CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Ohio Medicaid

Lists services, CPT/HCPCS codes, and procedures that require prior authorization for UnitedHealthcare Community Plan of Ohio participating providers; includes submission methods and exceptions for emergency/urgent care.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Ohio Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on UHCprovider.com or call 877-842-3210.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Jul. 1, 2024effective date

UHCprovider.comonline portal

877-842-3210phone

J9000-J9999injectable chemo range

Cochlear/CGMdevice categories

$500

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Services and Coverage Criteria Requiring Prior Authorization

This section lists services, medication categories, and specific CPT/HCPCS codes that require prior authorization or notification. Consolidated entries below include cancer supportive care injectable drugs and medications, broader lists of services and procedures requiring authorization, and operational instructions for submitting authorizations.

Criteria group: Prior authorization required for outpatient cancer supportive care medications and related services when billed for a cancer diagnosis. This includes colony-stimulating factors, erythropoiesis-stimulating agents, bone-modifying agents, injectable chemotherapy and select anti-emetic and supportive drugs. See code groups below for specific HCPCS/J-codes.

Criteria group: Prior authorization required for injectable colony-stimulating factors (white blood cell growth factors) administered outpatient for oncology: J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125, J1449 (Eflapegrastim - Rolvedone), Q5125 (Filgrastim-ayow - Releuko), J1447 (Tbo‑filgrastim - Granix), other filgrastim biosimilars (Q510* series) — authorization required for oncology diagnoses; Q5120/Q5122/Q5125 require authorization for both oncology and non-oncology (see routing notes).

Criteria group: Prior authorization required for bone-modifying agent Denosumab J0897 (outpatient cancer use) and erythropoiesis-stimulating agents J0885 (ESAs) when used for oncology diagnosis; J0897 requires prior authorization for non-oncology diagnoses.

Criteria group: Prior authorization required for outpatient injectable chemotherapy drugs (J9000–J9999), leucovorin J0640, levoleucovorin J0641/J0642, Lupron Depot J1950, leuprolide J1952 and related agents for cancer treatment.

Criteria group: Prior authorization required for select anti-emetic and supportive oncology agents such as fosaprepitant (Emend) and trilaciclib (Cosela) and extended-release granisetron (Sustol) when billed outpatient for cancer supportive care.

Criteria group: Prior authorization required for inpatient services as noted (see transplant/CAR T-cell routing) — inpatient authorizations handled separately; notification required for certain admissions and post-acute facilities.

Criteria group: Prior authorization required for the following service categories and representative CPT/HCPCS codes: advanced outpatient radiology (CT/MRI/PET) per Radiology Prior Authorization Program; radiation therapy (specific RT codes and diagnoses ranges require PA, see Standard Radiation Therapy list); transplants and CAR T‑cell therapy — call Transplant Case Management at 888-936-7246; ventricular assist devices — contact notification number on member ID and fax to Optum VAD Case Management at 855-282-8929; joint replacement, bariatric surgery, cochlear implants, continuous glucose monitors, enteral nutrition supplies, genetic/BRCA testing (notification/PA before sequencing), orthotics/prosthetics with retail purchase or cumulative amounts, private duty nursing, selected outpatient procedures and site-of-service outpatient hospital cases.

Criteria group: Prior authorization required for vein procedures (e.g., 36473, 36475, 36478, 37700, 37718, 37722, 37765, 37766, 37780) and other specified procedural codes.

Criteria group: Operational routing and submission instructions: submit requests online via the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal (UHCprovider.com) > Prior Authorization and Notification tile, or call 888-397-8129 (general PA). For non-oncology use of certain colony-stimulating Q-codes submit via Provider Portal or call 877-842-3210. For Radiology PA call 866-889-8054. For Solaris medication notification use OptumRx at 800-310-6826. For Unclassified J-code (C9399,J3490,J3590) PA applies only to specific products (e.g., Elevidys, Eylea HD, Nulibry, Rivfloza).

note':'All items above consolidate requirements from the provider-facing code lists and coverage-category entries. Providers must verify diagnosis-specific PA applicability (oncology vs non-oncology) and follow special routing instructions where indicated.'

CPT / HCPCS / ICD-10 Codes and Coding Rules

Cancer supportive care — Selected HCPCS/J-codes requiring prior authorization (covered)HCPCSCovered

J1745	Injection, infliximab, biosimilar (per product)
J9334	Injection, pembrolizumab, 1 mg
J1449	Pegfilgrastim-cbqv (Rolvedon)

Injectable medications — Selected J-codes (covered)HCPCSCovered

J1745	Infliximab (referenced product-specific PA applies)
J9334	Pembrolizumab (per mg) — prior authorization required for oncology administration
J2506	Pegfilgrastim (Neulasta)

Cancer supportive care — procedure & diagnosis codes (neutral listing)ICD-10

C43.10	Malignant melanoma of unspecified part of trunk
C44.01	Basal cell carcinoma of skin of lip
M86.051	Acute osteomyelitis of right shoulder

Infectious/septic and device-related diagnosis codes (neutral)ICD-10

T82.818A	Other mechanical complication of other cardiac and vascular devices, implants and grafts, initial encounter
S91.301A	Open wound of right great toe with damage to nail, initial encounter
M86.151	Chronic osteomyelitis of right shoulder

Malignant melanoma and other skin cancer diagnosis codes (neutral)ICD-10

C43.111	Malignant melanoma of right ear and external auricular canal
C44.101	Basal cell carcinoma of skin of unspecified eyelid, including canthus

Skin / cancer diagnosis codes (neutral)ICD-10

C44.1921	Squamous cell carcinoma of skin of right eyelid, including canthus
C44.392	Other specified malignant neoplasm of skin
C43.31	Malignant melanoma of right lower limb
C43.9	Malignant melanoma, unspecified

DME HCPCS codes (neutral)HCPCS

E0194	Compression garments, trunk
E0277	Compression garment, custom-fit
E0457	CPAP interface, replacement

Genetic / molecular testing CPT codes (neutral)CPT

81162	BRCA1 and BRCA2 full sequence analysis
81479	Unlisted molecular pathology procedure
81445	Oncology panel

Genetic / molecular and referenced CPT codes (covered)CPTCovered

81432	BRCA1/BRCA2 targeted genomic sequence analysis
81433	Comprehensive genomic profiling
0022U	Molecular pathology procedure (new technology)

Selected injectable HCPCS/J-codes (covered)HCPCSCovered

J3262	Tocilizumab
J0801	Acthar Gel (repository corticotropin)
J1745	Infliximab — included where PA applies

HCPCS codes mentioned (neutral)HCPCS

J1932

Pegvisomant — referenced; see provider portal for PA rules

Ambiguous mentions — J1932 (neutral)HCPCS

J1932

Lanreotide (mentioned multiple times)

Selected HCPCS J- and A- codes listed (covered)HCPCSCovered

J0174	Leqembi
J1306	Leqvio
J1745	Infliximab (added to ensure completeness)
J9334	Pembrolizumab (per mg) — PA required for oncology use

Orthognathic surgery CPT codes (partial list) (covered)CPTCovered

21196	Orthognathic surgery, mandibular osteotomy
21206	Orthognathic surgery, complex
21215	Mandibular osteotomy with bone graft
21244	Maxillary osteotomy

Orthotics & prosthetics HCPCS codes (partial list) (covered)HCPCSCovered

L0480	Foot orthosis, non-molded, off-the-shelf
L1834	Upper limb prosthesis, myoelectric
L3900	Lower extremity prosthesis
L6940	Orthotic, wrist/hand

Outpatient therapy CPT codes (partial list) (covered)CPTCovered

97110	Therapeutic exercises
97112	Neuromuscular reeducation
97530	Therapeutic activity
97761	Prosthetic training

Prostate and radiation therapy codes (covered)CPTCovered

37243	Transcatheter therapy, prostate
77014	Radiation therapy simulation
77387	Radiation treatment device
77470	Radiation therapy management
77525	External beam radiation

IMRT codes (neutral)CPT

77385	IMRT planning, complex
77386	IMRT secondary plan

Proton beam therapy codes (neutral)CPT

77520	Proton beam radiation therapy, simple
77522	Proton beam radiation therapy, complex

Respite service codes (covered)HCPCSCovered

H0045	Respite care, per 15 minutes
S5150	Respite care services
S5151	Respite care services - other

Ophthalmology / radiation therapy codes (covered)CPTCovered

67228	Radiation procedure for retina
67311	Repair of retinal tear
67312	Retinal detachment repair

Cell and gene therapy / drug codes (covered)HCPCSCovered

J1428	Exondys 51
J3398	Luxturna
C9399	Unclassified biologics (PA only for specified products)

Vein procedure CPT codes (covered)CPTCovered

36473	Injection of sclerosing agent
37718	Excision of varicose veins
36475	Venous ablation
37722	Ligation and stripping
36478	Endovenous ablation
37765	Repair of varicose veins
33927	Cardiac assist device procedure
33976	VAD implantation

VAD procedure and related codes (covered)CPTCovered

33928	Ventricular assist device insertion
33979	VAD removal
Q0507	VAD supply code
Q0508	VAD supply code 2
Q0509	VAD supply code 3

How Providers Request Prior Authorization and Important Operational Steps

Prior Authorization

How to request prior authorization

Submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) with your One Healthcare ID and password, or call 877-842-3210. Prior authorization is not required for emergency or urgent care; out-of-network providers must request authorization for all procedures and services (excluding emergent/urgent care).

Prior Authorization

Procedures requiring prior authorization (sample codes)

Prior authorization is required for selected procedures including abortion/pregnancy termination (e.g., 59840, 59841, 59850–59857), bariatric surgery (e.g., 43644, 43645, 43659, 43770, 43775, 43842–43848, 43860) and breast reconstruction (non-mastectomy) CPT codes (e.g., 11971, 19316–19318, 19328–19380).

Prior Authorization

Medications requiring prior authorization — cancer supportive care

Key Terms and Definitions

inv-85: Prior authorization definition

DefinitionPrior authorization is the process of obtaining approval from UnitedHealthcare before providing certain services or medications, except in emergency or urgent care situations.

When not requiredPrior authorization is not required for emergency or urgent care services.

Submission methodsRequests can be submitted via the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone (see contact info).

inv-86: Cancer supportive care (outpatient)

IncludesColony‑stimulating factors, erythropoiesis‑stimulating agents and bone‑modifying agents administered in an outpatient setting for a cancer diagnosis require prior authorization.

Example agents/codesExamples include pegfilgrastim/filgrastim products and denosumab (e.g., J1442, J1449, J2506, J0897 as listed in the cancer supportive care section).

Important Contact Numbers, Portals, and Designated Vendors

inv-85: Provider portal and phone contacts for prior authorization and notification

PortalOnline: Submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal at UHCprovider.com (sign in with One Healthcare ID).

PhonePhone option for prior authorization: call 877‑842‑3210 (policy also references alternate numbers for some services).

NotePrior authorization is not required for emergency or urgent care; out‑of‑network providers must still request authorization for non‑emergent services.

inv-51: DME vendor instruction — Edgepark

Vendor instructionIncontinence supplies are a benefit only when provided through Edgepark Medical Supplies.

Phone

Policy Version and Revision Timeline

2024-07-01effective_dateLatest

Policy effective date established for UnitedHealthcare prior authorization requirements for Ohio Medicaid.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Ohio Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on UHCprovider.com or call 877-842-3210.

SourceLink

On This Page

Cancer supportive care medications administered in the outpatient setting for a cancer diagnosis require prior authorization, including colony-stimulating factors, pegfilgrastim products, sargramostim, tbo-filgrastim, trilaciclib and denosumab.

Examples: J1449, J1442, Q5110, J2506, Q5122, Q5120, J1447, J1448, J0897

Prior Authorization

Chemotherapy injectable drugs - prior authorization required

Injectable chemotherapy drugs (J9000–J9999) and specified injectable supportive agents (e.g., leucovorin J0640, levoleucovorin J0641–J0642, Lupron Depot J1950, leuprolide J1952) administered in an outpatient setting require prior authorization.

Includes intravenous, intravesical and intrathecal administrations.

Prior Authorization

Cochlear implants - prior authorization required

Cochlear implants and other auditory implant procedures require prior authorization for the listed CPT codes.

CPT examples: 69710, 69714, 69930

Prior Authorization

Continuous glucose monitors - prior authorization required

Continuous glucose monitor (CGM) device HCPCS/CPT codes require prior authorization.

Examples: A4226, A4239, E0787, E2102, E2103

Prior Authorization

Inpatient video EEG - prior authorization

Prior authorization is required for inpatient cerebral seizure monitoring (video EEG) CPT codes when provided as inpatient services.

CPT examples: 95700, 95711, 95712, 95713

Prior Authorization

Cosmetic and reconstructive procedures - prior authorization

Various cosmetic and reconstructive procedures listed require prior authorization; refer to the CPT codes enumerated in the policy for applicability and any notes on exceptions.

Sample CPTs: 11960, 14020, 14021, 14061, 15830, 15847, 17106–17108, 21137–21184, 21230, 21235, 21256, 21275

Prior Authorization

Drug screening prior authorization

Drug screening services require prior authorization; G0483 is cited repeatedly for drug screening.

Procedure code: G0483

Prior Authorization

DME prior authorization and vendor instructions

Durable medical equipment (DME) requires prior authorization; incontinence supplies are a benefit only when provided through Edgepark Medical Supplies and must be requested by calling the designated vendor.

Edgepark phone: 844-564-1008
Some DME requires PA regardless of billed amount; certain items require PA only if retail purchase or cumulative rental cost exceeds $500.

Prior Authorization

Enteral and in-home nutritional therapy prior authorization

Enteral services and in‑home nutritional therapy, including gastrostomy tube supplies, require prior authorization.

Examples: B4034, B4035, B4036, B4100, B4102–B4104, B4150–B4159, B4152, B4153, B4155, B4159

Prior Authorization

Genetic and molecular testing prior authorization

Genetic and molecular testing, including BRCA and a wide range of genomic/molecular CPT, HCPCS and PLA codes, requires prior authorization and must include laboratory/test identification as part of the authorization process.

Examples: 81162–81164, 81228–81229, 81400–81465, 81521–81599, 87505–87507, various PLA/U codes (e.g., 0175U, 0215U)

Prior Authorization

Procedure-level prior authorization

Specific procedures and procedure groups are flagged as requiring prior authorization at the procedure level (e.g., experimental/investigational services, femoroacetabular impingement procedures, FESS, gender dysphoria treatments).

Examples: 33477, 36514, 64722, 66180 (experimental/investigational entries); FAI 29914, 29916; FESS 31240–31288; gender dysphoria 55970, 55980

Prior Authorization

Prior authorization and notification requirements

Certain genetic/molecular tests (including BRCA) and specified home health outpatient services and hysterectomy procedures require prior authorization or notification prior to the service.

Home health codes: G0151–G0153, G0156, G0299–G0300; Hysterectomy examples: 58150, 58152, 58180, 58260–58292, 58541–58573

Prior Authorization

Injectable medication prior authorization

A broad list of injectable medications require prior authorization; see the policy's injectable medication list and J/Q codes for applicable products.

Selected examples from the list: Q5121, J0490, J0597, J0585–J0588, J1551, J1951, J9210, J1932

Prior Authorization

HCPCS code referenced for prior authorization

Lanreotide is referenced with HCPCS code J1932 and is listed repeatedly in the policy as a code requiring authorization handling.

HCPCS: J1932 (Lanreotide)

Note

Repeated HCPCS code mentions (J1932)

The policy text repeats references to J1932 (Lanreotide) and mentions J1932 alongside Lemtrada in multiple entries; review the J1932 listing in the injectable medications section for product-specific requirements.

Repeated entries reference J1932 and 'J1932 Lemtrada'.

Prior Authorization

How to submit prior authorization

Submit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool at UHCprovider.com or by calling the number listed in the policy (alternate phone provided in the submission section).

Portal instructions: Sign in with One Healthcare ID and select the Prior Authorization and Notification tile; alternate call number: 888-397-8129 (as listed).

Prior Authorization

Colony-stimulating factors authorization notes

Authorization is required for white blood cell colony‑stimulating factors Q5120, Q5122 and Q5125 for both oncology and non‑oncology diagnoses; oncology DX follows the cancer supportive care section, and non‑oncology requests may be submitted via the Provider Portal or by calling 877-842-3210. Prior authorization is not required for ESRD diagnosis.

Codes: Q5120, Q5122, Q5125
Note: J0897 requires prior authorization for non‑oncology diagnoses

Prior Authorization

Unclassified code PA requirement

Unclassified codes C9399, J3490 and J3590 require prior authorization only when used for specified products (Elevidys, Eylea HD, Nulibry, Rivfloza).

Codes: C9399, J3490, J3590 — PA limited to listed products

Prior Authorization

Facility and procedure prior authorization requirements

Facilities providing post‑acute inpatient services must obtain prior authorization and notify UnitedHealthcare of the admission date; prior authorization is also required for listed joint replacement CPTs and for non‑emergent air ambulance transports.

Facility types: acute care hospitals, inpatient rehabilitation, critical access hospitals, LTACHs
Non‑emergent air ambulance example codes: A0430, A0431, A0435, A0436

Documentation Required

New-to-market medications recommendation

Predetermination is highly recommended for medications listed on the Review at Launch for New to Market Medications list; consult the Review at Launch policy at UHCprovider.com for newly approved drugs.

Check the Review at Launch for New to Market Medications policy for current guidance.

Prior Authorization

Orthotics and Prosthetics prior authorization note

Prior authorization is required for orthotics and prosthetics only when obtained via retail purchase or when cumulative purchase/rental thresholds apply.

Sample HCPCS L-codes listed (e.g., L0170, L0480, L0631, L5610)

Prior Authorization

Out-of-network referral prior authorization

Prior authorization is required for referrals to out‑of‑network providers who are not contracted with UnitedHealthcare.

Prior Authorization

Outpatient therapy prior authorization

Outpatient therapy services require prior authorization; multiple CPT codes for speech, occupational and physical therapy are listed in the policy.

Examples: 92507, 97110, 97530, 97750, 97010–97039 series

Prior Authorization

Private duty nursing prior authorization

Private duty nursing services require prior authorization before service.

Example code: T1001

Prior Authorization

Prostate procedures prior authorization

Prior authorization is required for specified prostate procedures listed in the policy.

Examples: 37243, 52441, 52442, 53850

Prior Authorization

Radiation therapy prior authorization

Radiation therapy services require prior authorization; the policy includes IMRT and proton beam therapy codes and additional instructions.

Examples: IMRT codes 77385, 77386; proton beam codes 77520, 77522; imaging 77014

Prior Authorization

Radiology prior authorization and notification

Care providers ordering advanced outpatient imaging must provide notification prior to scheduling and submit prior authorization requests via the Provider Portal or by calling the radiology prior authorization phone number.

Radiology prior authorization phone: 866-889-8054; submit via UHCprovider.com Prior Authorization and Notification tile

Prior Authorization

Respite services prior authorization

Respite services require prior authorization for the listed HCPCS codes.

Codes: H0045, S5150, S5151

Prior Authorization

Site-of-service prior authorization rule

Site‑of‑service prior authorization is required only when the listed services are performed in an outpatient hospital setting; the same services are not subject to PA when performed at a participating Ambulatory Surgery Center (ASC).

Prior Authorization

Standard Radiation Therapy diagnosis-limited PA

Standard Radiation Therapy (2D/3D) prior authorization is required only when the service is associated with specified diagnosis codes (examples include C34.00–C34.92, C50.011–C50.929, C61, etc.).

Relevant RT codes: 77525, 77470, 77387

Prior Authorization

Sleep apnea procedures — prior authorization

Sleep apnea and maxillomandibular procedures require prior authorization.

Examples: 21685, 41599, 42145

Prior Authorization

Spinal surgery — prior authorization

Spinal surgery CPT codes listed in the policy require prior authorization before the service is provided.

Sample codes include: 22100–22102, 22110–22114, 22206–22207, 22510–22515, 22600–22612, 22800–22861, 63001–63191, 63200–63308

Prior Authorization

Stimulators/device implantation — prior authorization

Implantation of neurostimulators and related device procedures require prior authorization.

Examples: 64553, 64555, 64568, 64570, 64590, 61863–61868, 61885–61886, 63650, 63655, 63685

Prior Authorization

Transplants and CAR T-Cell therapy — prior authorization/notification

Transplants and CAR T‑Cell therapies require prior authorization/notification and coordination with UnitedHealthcare Community and State Transplant Case Management; call the Transplant Case Management team for instructions.

Call: UnitedHealthcare Community and State Transplant Case Management at 888-936-7246

Prior Authorization

Vein procedures — prior authorization

Vein procedures for removal and ablation of saphenous trunks and named branches require prior authorization; the policy lists applicable CPT/HCPCS codes.

Examples: 36473, 36475, 36478, 37700, 37718, 37722, 37765, 37766, 37780

Prior Authorization

VAD — notification and prior authorization

Ventricular assist devices (VAD) require prior authorization and notification; providers must call the notification number on the member's health plan ID card and fax the required form to Optum VAD Case Management.

Fax Optum VAD Case Management at 855-282-8929 after calling the notification number on the member's ID card.
Sample VAD codes: 33927, 33976, 33983, 33928, 33979, Q0507, 33929, 33981, Q0508, 33975, 33982, Q0509

Prior Authorization

Code-specific prior authorization note (38232)

Prior authorization for code 38232 is required only in specified circumstances as noted in the policy.

38232 — PA required only for specified indications (see policy details).

Prior Authorization

CAR T-Cell and related codes — prior authorization

CAR T‑Cell therapy and associated temporary and Q-codes require prior authorization.

Examples: temporary codes 0537T–0540T, Q2041–Q2056

Prior Authorization

Vein procedures prior authorization

Vein procedure prior authorization — removal and ablation of main trunks and named branches of the saphenous veins for venous disease/varicose veins of the extremities requires prior authorization; CPT/HCPCS codes are provided in the policy.

Codes listed: 36473, 37718, 36475, 37722, 36478, 37765, 37700, 37766, 37780

Prior Authorization

VAD prior authorization (contact and fax instructions)

VAD prior authorization — prior authorization is required for VAD placement; call the notification number on the member's ID card and fax the required form to Optum VAD Case Management at 855-282-8929.

Optum VAD Case Management fax: 855-282-8929

Prior Authorization

Transplants and specified gene therapies — prior authorization

Certain transplants and specified gene therapies (Amtagvi, Lantidra, Skysona, Zynteglo) require prior authorization; an oncology diagnosis is referenced for obtaining prior authorization for these therapies.

Gene therapies listed: Amtagvi, Lantidra, Skysona, Zynteglo

Non‑oncology notesSome Q‑codes (Q5120, Q5122, Q5125) also require authorization for non‑oncology diagnoses per policy guidance.

inv-87: Injectable chemotherapy

Code rangeInjectable chemotherapy drugs (J9000–J9999) administered in an outpatient setting require prior authorization.

Included agentsAlso lists leucovorin/levoleucovorin (J0640, J0641, J0642) and select leuprolide/Lupron Depot products (J1950, J1952).

SettingsApplies to outpatient intravenous, intravesical and intrathecal administration for oncology indications.

inv-88: Prior authorization required (general)

RequirementPrior authorization (payer authorization) must be obtained before the listed service or device will be covered by UnitedHealthcare.

Submission optionsSubmit via the Prior Authorization and Notification tool on UHCprovider.com using One Healthcare ID or call the specified phone numbers per policy instructions.

Out‑of‑network providersOut‑of‑network physicians, facilities and other health care professionals must request authorization for all procedures and services (excluding emergent/urgent care).

inv-89: Edgepark Medical Supplies

DesignationEdgepark Medical Supplies is the designated vendor for incontinence supplies for this benefit.

PhoneTo request incontinence supplies, call Edgepark Medical Supplies at 844‑564‑1008.

Coverage conditionIncontinence supplies are a benefit only when provided through Edgepark Medical Supplies per the policy note.

inv-90: Genetic/molecular testing submission requirements

Submission detailGenetic/molecular testing prior authorization requires indication of the laboratory and the test name as part of the authorization/notification process.

Codes referencedIncludes molecular CPT/HCPCS/PLA codes such as 81420, 81431–81440, 81443–81465 and others listed in the genetic testing section.

BRCA specificBRCA testing (e.g., 81162–81164, 81228–81229) requires notification/prior authorization before DNA sequencing is performed.

inv-91: BRCA/genetic and molecular testing

RequirementBRCA and other genetic/molecular testing require notification or prior authorization before testing is performed.

Process noteThe ordering provider must notify the laboratory conducting the test; the lab will notify UnitedHealthcare as part of the process.

Relevant codesBRCA/test codes include 81162–81164, 81228–81229 and multiple molecular CPT/PLA codes listed in the policy.

inv-92: Home health care (prior auth scope)

ScopePrior authorization for home health care is required when services are provided in outpatient settings, including the member's home.

Codes examplesHome health/outpatient codes referenced include G0151, G0299, G0152, G0300 and related HCPCS codes.

ExemptionEmergency/urgent care remains exempt from prior authorization requirements.

inv-93: J1932

CodeJ1932 — HCPCS code referenced in the document associated with lanreotide.

RepetitionJ1932 (lanreotide) is repeatedly referenced in the injectable medication section of the policy.

ActionFollow standard PA submission instructions when requesting authorization for J1932 (lanreotide).

inv-94: Prior authorization (general term)

TermPrior authorization — a payer authorization that must be obtained before the listed service or device will be covered.

How to obtainSubmit requests via UHCprovider.com Prior Authorization and Notification tool or call the designated phone number per policy.

Emergency care noteNot required for emergency or urgent care situations.

inv-95: Proton Beam Therapy

DefinitionProton Beam Therapy — focused radiation therapy that uses beams of protons (tiny particles with a positive charge).

CodesAssociated CPT/Codes: 77520, 77522 are listed for proton beam therapy in the policy.

PA notePrior authorization is required for radiation therapy services per radiation section guidance.

inv-96: IMRT

DefinitionIMRT — Intensity‑Modulated Radiation Therapy.

CodesIMRT planning/delivery codes include 77385 and 77386 as listed in the policy.

PA notePrior authorization applies to radiation therapy codes as specified in the radiation therapy section.

inv-97: IMRT codes 77385, 77386

CodesIMRT codes: 77385, 77386 are referenced for prior authorization requirements.

ContextThese codes are listed under radiation therapy services and require authorization per the radiation therapy criteria.

Provider actionInclude diagnosis and clinical justification when submitting PA for IMRT codes.

inv-98: Proton Beam Therapy codes 77520, 77522

CodesProton Beam Therapy codes: 77520, 77522 are listed and require prior authorization per radiation therapy guidance.

DefinitionFocused proton beam delivery and planning codes for proton therapy.

Submission tipFollow radiation therapy PA process and include diagnosis codes as required (see Standard Radiation Therapy diagnosis‑limited guidance).

inv-99: VAD — definition

DefinitionVentricular assist device (VAD) — a mechanical pump that takes over the function of a damaged ventricle and restores normal blood flow.

PA requirementVAD placement requires prior authorization; follow the VAD notification and fax instructions to Optum VAD Case Management.

Contact processCall the notification number on the member's health plan ID card, then fax the required form to Optum VAD Case Management at 855‑282‑8929.

inv-100: Transplant / CAR T-Cell therapy

ExamplesCAR T‑Cell therapy examples include Abecma, Breyanzi, Kymriah, Tecartus and Yescarta; these services require prior authorization.

CoordinationProviders must contact UnitedHealthcare Community and State Transplant Case Management for authorization and coordination (see contact).

Contact numberTransplant/CAR T‑Cell therapy prior authorization contact: 888‑936‑7246.

inv-101: VAD — mechanical pump definition and function

FunctionA VAD is a mechanical pump that assists or replaces the function of a damaged ventricle to restore normal blood flow.

PA and notificationPrior authorization required; providers must call the notification number on the member's ID and fax documentation to Optum VAD Case Management (855‑282‑8929).

Related codesVAD procedure and Q‑codes are listed in the policy (see VAD codes section for specifics).

To request incontinence supplies, call Edgepark Medical Supplies at 844‑564‑1008.

PA noteDME generally requires prior authorization; confirm whether a specific DME item requires PA regardless of billed amount or only above the retail/rental threshold.

inv-79: VAD prior auth contact — Optum VAD Case Management fax

Contact methodFax required VAD documentation to Optum VAD Case Management at 855‑282‑8929 as part of the authorization/notification process.

Initial stepCall the notification number on the member's health plan ID card before faxing the form to Optum VAD Case Management.

PurposeOptum VAD Case Management coordinates clinical review and authorization for ventricular assist device services.

inv-10: Transplant / CAR T-Cell prior auth contact

ContactTransplant and CAR T‑Cell therapy prior authorization: call UnitedHealthcare Community and State Transplant Case Management at 888‑936‑7246.

Coordination requirementThese services require prior authorization and coordination with the Transplant Case Management team before scheduling and delivery of services.

Notification optionAlternatively, use the notification number on the back of the member's health plan ID card as instructed in the policy.