UnitedHealthcare Oxford Prior Auth Policy Update

Prior authorization examples

Examples of services, procedures and drug classes that require prior authorization. This list consolidates categories, notable drug codes, procedure groups, and special-case rules (diagnosis-based exceptions and age/service setting notes).

Cancer supportive care: Prior authorization required for colony-stimulating factor drugs and bone-modifying agents administered in an outpatient setting for a cancer diagnosis. Notable HCPCS/J-codes subject to authorization: J0897, J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125 (also require PA for non-oncology DX). Eflapegrastim-xnst (Rolvedon®) and other agents require PA; see Specialty Pharmacy Transactions for submission.

Bone-modifying agents: Denosumab products (Prolia®, Xgeva®) — J0897* require prior authorization.

Erythropoiesis-stimulating agents: Epoetin alfa — J0885 requires prior authorization (both oncology and non-oncology DX; PA not required for ESRD diagnosis per policy notes).

Chemotherapy injectables: Notification/prior authorization required for injectable chemotherapy drugs administered in outpatient settings for cancer diagnoses. Includes chemotherapy J-codes (J9000-J9999), leucovorin (J0640), levoleucovorin (J0641, J0642), leuprolide (J1950/J1952), lanreotide (J1932), Q-coded chemotherapy injectables, and miscellaneous unassigned HCPCS billed under miscellaneous codes.

Injectable specialty medications: Many injectable medications (including select unclassified/temporary codes C9399, J3490, J3590) require notification/prior authorization when they correspond to specific branded therapies (e.g., Nulibry™, Rivfloza™, Revcovi™) — check Specialty Pharmacy Transactions tile or call the specialty pharmacy help line.

Cardiology and selected imaging/procedures managed by eviCore: Notification/prior authorization required for both participating and non-participating providers through eviCore for listed cardiology and related procedure codes (examples include 75557, 75559, 75561, 75563, 75571-75574, 75580, 78451-78452, 93460-93461 and select CPT/052* / 0571T codes). Submit via eviCore or Provider Portal; providers may also call 1-877-PRE-AUTH or the phone numbers listed.

Cartilage implants and select musculoskeletal procedures: Prior authorization required for adults (18+) for listed cartilage implant and related codes (examples: 27412, 27415, 27416, 29866) — see Congenital Heart Disease section for pediatric exceptions.

Cerebral seizure monitoring (inpatient video EEG): Prior authorization required for inpatient services and for patients ages 18 and older for listed EEG codes (e.g., 95700-95718 variants).

Congenital heart disease: Prior authorization required. For prior authorization call 888-936-7246 or use the notification number on the member ID card.

Continuous glucose monitors (CGM): Prior authorization required when billed with Type 2 diabetes and gestational diabetes diagnosis codes. Prior authorization is not required when billed with Type 1 diabetes diagnosis codes. Example HCPCS: A4226, A4238, A4239, A9276, A9277.

Cosmetic and reconstructive procedures: Prior authorization required for many CPT codes describing cosmetic or reconstructive procedures; examples include 11950-11952, 11954, 11960, 11970-11971, 11980, 14020**, 14021**, 14061**, 14302, 15570/15572/15574, 15730, 15733, 15740, 15756, 15769, 15775-15776 and others listed in the cosmetic/reconstructive section. (See exceptions below for diagnosis-driven exemptions.)

Diagnostic and therapeutic procedures and selected genetic testing / lab services: Prior authorization required for many listed diagnostic/therapeutic CPT/HCPCS and molecular/genetic test codes performed in outpatient settings (examples: 29799, 32601, 32662, 36512-36522, 80145, 80230, 80280, 81490, 81493, 83695, 81162-81164, 81432, 81202, 81228-81229, 81277). Care providers requesting laboratory/genetic testing will be required to complete the prior authorization/notification process.

Durable medical equipment (DME): Notification/prior authorization required for listed DME codes and for DME with retail purchase or cumulative rental cost over specified thresholds (examples: A6550, A7025, A7026, A9272, A9279, A9282, A9999, B9999, E0328-E0329, E0466, E0481 — prior authorization required when retail/cumulative rental cost exceeds $500).

Eye, ear, nose and throat (ENT) and functional endoscopic sinus surgery (FESS): Prior authorization required for many ENT procedures and for FESS (example CPTs: 30117, 31237, 31240, 31253-31255, 44388*, 44392*, 44403, 45379*, 45384*, 45389). Site of service will also be reviewed as part of the prior authorization.

Gastroenterology: Prior authorization required for participating physicians for selected EGDs, capsule endoscopies, diagnostic and surveillance colonoscopies and for specified CPT codes (e.g., 44388*, 44392*, 44403, 45379*, 45384*, 45389, and codes listed on the Gastroenterology PA list accessed via Provider Portal).

Gender dysphoria treatment: Prior authorization required for numerous procedure codes when submitted with gender dysphoria diagnosis codes (F64.0, F64.1, F64.2, F64.8, F64.9, Z87.892). Examples of codes requiring PA when submitted with those diagnoses include 55970, 55980, 14001, 14041, 15734, 15738, 15750, 15757-15758, 19303, 53410, 53430, 54125, 54520, 54660, 54690, 55175, 55180, 56625, 56800 and many other listed CPTs — verify specific CPT/diagnosis pairings on Provider Portal.

Genetic testing and lab services: Prior authorization required for many outpatient genetic and molecular tests (BRCA panels and specific CPTs such as 81162-81164, 81432, 81202, 81228-81229, 81277, 81490, 81493). Providers must supply required documentation to complete the PA/notification process.

Hysterectomy and laparoscopic surgeries: Prior authorization required for specified inpatient procedures (inpatient vaginal hysterectomies require PA). Outpatient vaginal hysterectomies may not require PA; check code-level guidance. Examples of laparoscopic CPTs under review include 58150, 58152, 58180, 58292, 58541-58544, 58550.

Home health care: Prior authorization required only in outpatient settings (including the member's home) for listed home health HCPCS (examples: S9335, S9339, S9355, S9562, T1000-T1003).

Infertility and injectable therapies: Selected infertility services and injectable specialty drugs require prior authorization (examples: infertility codes 58770, 89398; injectable therapy J-codes such as J0896, J1437, J1439 and Q0138). Submit requests via the Specialty Pharmacy Transactions tile or specialty phone lines.

Inpatient admissions and post-acute services: Prior authorization and notification of admission date required for specified post-acute inpatient facilities (acute care hospitals, acute inpatient rehab, critical access hospitals, long-term acute care, skilled nursing facilities) prior to admission when applicable.

Pain management and potentially unproven services: Prior authorization required for many pain management procedures (examples: 0278T, 62320-62327, 62350, 64451, 64454, 64484, 64520, 64620, 64640, G0260) and for potentially unproven services (examples: 20985, 22505, 25259, 26340, 27275, 27860, 28446, 28890, 31634, 31660).

Physical, occupational, speech & respiratory therapy: Prior authorization required; Optum Physical Health-contracted providers must submit an initial Patient Summary Form (PSF) within 3 days of initiating treatment and receive authorization within 10 days of the initial visit. Examples of therapy CPTs: 97010, 97124, 97533, 97537, 94060, 97172, S5181, 97169, S5150, S8990, 97170, S5151, S9125, 97171, S5180.

Radiation therapy: Prior authorization required for listed radiation therapy modalities and codes (IGRT, IMRT, proton beam, select CPT/HCPCS such as 77014, 77385, 77387, 77401-77412 and G60xx series). Standard radiation therapy PA required only when obtained with certain cancer diagnosis ranges (e.g., C34.00-C34.92, C50.011-C50.929, C61, C79.51-C79.52, C84.7A, D05.00-D05.92).

Radiology services managed by eviCore: Prior authorization/notification required for certain CT, MRI, MRA, PET scans and other radiology services; submit via Provider Portal or eviCore per cardiac/radiology transaction instructions.

Durable rules and site-of-service review: Many procedures and DME authorizations include site-of-service review — inpatient vs outpatient determinations may affect PA requirements (e.g., hysterectomy site-specific guidance).

Out-of-network services: Prior authorization required for certain out-of-network referrals or for directing members to non-contracted providers; patients using non-network providers may face increased out-of-pocket costs or no coverage.

Examples are illustrative, not exhaustive: Providers must consult UnitedHealthcare Provider Portal (Prior Authorization and Notification tool), eviCore where managed, or designated phone numbers (e.g., 800-666-1353, 877-842-3210, 888-936-7246) for complete, code-level PA requirements and submission instructions.

Authorization and submission requirements (partial)

Authorization and submission requirements: how to obtain prior authorization or provide required notifications for the services and codes listed above.

Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com). Click the UnitedHealthcare Provider Portal button and select the appropriate tile (Radiology/Cardiology/Oncology Transactions or Specialty Pharmacy Transactions) on your Provider Portal dashboard.

Specialty pharmacy and injectable drugs: For non-oncology indications, submit online via UHCProvider.com > Provider Portal > Specialty Pharmacy Transactions or call 877-842-3210 for assistance. For oncology DX, follow the Cancer Supportive Care section guidance.

eviCore-managed cardiology and radiology services: Notification/prior authorization required for participating and non-participating providers through eviCore. Providers may submit via the eviCore web portal, the Prior Authorization and Notification App, or call 1-877-PRE-AUTH. Some code groups also allow prior authorization via the UnitedHealthcare Provider Portal tile linked to eviCore transactions.

Phone-based submissions: For certain programs or service lines (e.g., congenital heart disease prior auth) call the designated numbers (examples: 888-936-7246; general authorization assistance: 800-666-1353).

Prior authorization is required; obtain via Provider Portal or phone.

Prior authorization is required; obtain via the Provider Portal or by phone where specified. Key operational notes for providers:

Use the UnitedHealthcare Provider Portal Prior Authorization and Notification tool for most PA submissions. Select the appropriate transaction tile on your dashboard (Radiology/Cardiology/Oncology Transactions or Specialty Pharmacy Transactions).

If a service is eviCore-managed (noted in the listing), follow eviCore submission channels; phone option: 1-877-PRE-AUTH. For specialty pharmacy or injectable meds, call 877-842-3210 when applicable.

When PA is required by diagnosis and CPT pairing (for example gender dysphoria treatment CPTs submitted with F64.x or Z87.892), ensure the correct diagnosis codes are on the request to avoid denials.

Authorizations are often site- and age-specific; confirm whether the PA requirement applies only to inpatient, outpatient, adult (18+) or pediatric settings and include that information in the submission.

Prior authorization/notification requirements and noted exceptions

Prior authorization/notification requirements and noted exceptions for diagnosis-driven exemptions, age and setting-specific exceptions, and selected service categories.

Prior authorization exceptions by diagnosis: Certain procedures (particularly many cosmetic/reconstructive CPTs) are exempt from prior authorization when billed with specific diagnosis codes that support medical necessity (extensive ICD-10 lists provided in source). Examples include multiple C43/C44 skin cancer codes and D04.* series codes — when billed with qualifying malignant or in-situ skin cancer diagnoses PA is not required. Providers must validate specific diagnosis code mappings on the Provider Portal.

Age-based exceptions: Some services (e.g., cartilage implants, inpatient EEG monitoring) require PA for patients ages 18 and older; pediatric cases may be handled under the Congenital Heart Disease section or other pediatric-specific criteria.

Cosmetic/reconstructive procedures: Many cosmetic and reconstructive CPT codes require prior authorization unless billed with a diagnosis that justifies medical necessity (see diagnosis-driven exemptions). Examples of commonly managed CPTs that generally require PA: 11950-11952, 11954, 11960, 11970-11971, 11980, 14020**, 14021**, 14061**, 14302, 15570/15572/15574, 15730/15733/15740/15756/15769/15775-15776, 15738/15750/15757-15758, 19303 (breast-related procedures), 14001/14041/15734, and multiple others listed in cosmetic/reconstructive procedure lists.

Prior authorization exemptions by diagnosis

Prior authorization exemptions when billed with listed diagnosis codes — diagnosis-driven PA waiver examples (partial).

Skin cancer and related excisions: Numerous ICD-10 C43.* and C44.* codes (detailed list in policy) exempt certain reconstructive/cosmetic procedure PA when the service is billed with these malignant or in-situ skin cancer diagnoses.

In-situ and malignant skin neoplasms: D04.* and D05.* series codes (e.g., D04.62, D04.70-D04.72, D04.8, D04.9, D05.00-D05.92) are cited as diagnoses which, when present, may eliminate the need for PA for related reconstructive procedures; confirm the exact CPT/diagnosis pairing on the Provider Portal.

ESRD drug exceptions: For some injectable oncology/supportive care drugs (e.g., J0885), prior authorization is not required when billed with an ESRD diagnosis — verify per-code exceptions on the portal.

CGM exceptions: Prior authorization is not required for CGM items when billed with Type 1 diabetes diagnosis codes; PA is required for Type 2 and gestational diabetes diagnosis codes.

Prior authorization required for cosmetic/reconstructive procedures

Prior authorization required for many cosmetic and reconstructive CPT codes listed; codes shown are representative but not exhaustive. When billed with medically necessary diagnoses (e.g., cancer resection, congenital anomalies, trauma), PA may be waived per diagnosis-driven exceptions.

Representative cosmetic/reconstructive CPTs that typically require prior authorization: 11950-11952, 11954, 11960, 11970-11971, 11980, 14020**, 14021**, 14061**, 14302, 15570, 15572, 15574, 15730, 15733, 15734, 15738, 15740, 15750, 15756, 15757, 15758, 15769, 15772, 15774, 15775, 15776, 19303, 14001, 14041, 14302 and related codes listed under the Cosmetic and Reconstructive section.

HCPCS/Q-codes relevant to reconstructive supplies or implants (examples referenced): Q2026 and other Q-/S- codes listed in the policy require PA where noted; some may be exempt when billed with specific diagnoses.

Provider action: Submit PA with complete clinical documentation demonstrating medical necessity when the indication is reconstructive or follows malignancy, trauma, infection, or congenital defect. If billed with an exempting diagnosis code as listed in the policy, PA may not be required — confirm via Provider Portal.

Prior authorization and code listing (partial)

Prior authorization and code listing (partial): sample grouped code entries and notable special-case codes requiring PA or notification.

Cardiology imaging and procedures (examples): 75557, 75559, 75561, 75563, 75571-75574, 75580, 78451-78452, 93460-93461, 0571T. eviCore-managed codes require submission through eviCore or the Provider Portal eviCore tile.

Radiation therapy (examples): 77014, 77385, 77387, 77401-77412, IGRT/IMRT codes, G6003/G6007/G6011 and other G60xx/Y90/S2095 entries; PA conditional on diagnosis ranges for standard radiation therapy (see prior item).

Therapy and rehabilitation codes (examples): 97010, 97124, 97533, 97537, 94060, 97169, 97170, 97171, 97172, S5150, S5151, S5180, S5181, S8990, S9125 — Optum Physical Health-contracted providers follow PSF submission rules.

DME examples: A6550, A7025, A7026, A9272, A9279, A9282, A9999, B9999, E0328, E0329, E0466, E0481, S8131 — PA required only for listed DME codes or when cost thresholds are exceeded.

Genetic and molecular test examples: BRCA panel entries and CPTs 81162-81164, 81202, 81228-81229, 81277, 81432, 81490, 81493 — PA required for many outpatient genetic tests.

Authorization criteria

Authorization criteria and operational notes (partial): what reviewers will evaluate when assessing prior authorization requests.

Medical necessity: Requests must demonstrate that the requested service/procedure/drug is medically necessary for the member's condition and not investigational for the indicated use.

Prior conservative management: For many surgical, interventional, or device-based therapies, reviewers expect documentation of prior conservative treatments, failed alternatives, or trial therapies where clinically appropriate.

Diagnostic confirmation: Provide relevant imaging, lab results, biopsy/pathology, or genetic test results to support the diagnosis and need for the requested service (e.g., tumor site and staging for radiation therapy; genetic test reports for genetic testing authorizations).

Procedure-specific criteria: Some codes (e.g., gender dysphoria procedures, cartilage implants, advanced radiology or cardiology imaging) have defined criteria or age thresholds that must be met; include applicable clinical notes, prior authorizations, consult notes, and operative reports.

Prior authorization and notification requirements (partial)

Prior authorization and notification requirements (partial) with procedural and administrative submission guidance.

Use Provider Portal first: The UnitedHealthcare Provider Portal Prior Authorization and Notification tool is the primary submission channel for most requests. Select the appropriate transaction tile (Radiology/Cardiology/Oncology Transactions or Specialty Pharmacy Transactions) to initiate an authorization.

eviCore and delegated vendors: For services managed by delegated vendors (eviCore for certain cardiology/radiology services, Optum for therapy), follow delegated vendor procedures for submission, authorization lookup, and appeals.

Telephone support: For questions or where online submission is not feasible, call the numbers listed in the policy (examples: general assistance 800-666-1353, specialty pharmacy 877-842-3210, congenital heart disease 888-936-7246).

Notification vs PA distinction: Confirm whether an item requires notification-only or a formal prior authorization. Notification may be sufficient for some DME, inpatient admission dates, or other programs but does not substitute for PA when PA is required for coverage.

Partial coverage/authorization rules (by category)

Partial coverage/authorization rules (by category) — highlights and conditional scenarios where PA may be required or waived.

Radiation therapy: Standard radiation therapy PA is required only when obtained with certain cancer diagnoses (e.g., ranges C34.*, C50.*, C61, C79.51-C79.52, C84.7A, D05.*); other radiation therapy modalities may have different requirements.

Chemotherapy and supportive oncology drugs: Many chemotherapy injectables require PA/notification in outpatient settings for cancer DX; certain supportive agents and bone-modifying agents have separate PA rules for oncology vs non-oncology diagnoses.

DME cost thresholds: DME authorizations may be triggered when retail purchase or cumulative rental costs exceed plan thresholds (example: $500) or when codes are explicitly listed as requiring PA.

Therapy services: Optum-managed therapy visits (PT/OT/ST/RT) require PA and PSF submission for initial evaluation and ongoing services per Optum rules; timing requirements for PSF submission are strict (within 3 days, received within 10 days).

Prior authorization and documentation criteria

Prior authorization and documentation criteria — provider responsibilities to reduce delays and avoid denials.

Complete coding and diagnosis pairing: Ensure CPT/HCPCS and ICD-10 codes are accurate and that any diagnosis-driven PA exceptions are clearly supported by the submitted diagnosis codes.

Attach supporting clinical documentation: Include recent clinical notes, imaging, lab/pathology results, prior treatment history, consult notes, and operative reports where relevant.

Follow delegated vendor forms and templates: Use eviCore, Optum, or specialty pharmacy-specific forms and submission templates when applicable; missing or improper forms can delay decisions.

Timely submissions: Submit requests prior to the service date where required. For retrospective or urgent requests follow the Provider Portal guidance and include justification for retrospective review.

Appeals and reconsideration: If an authorization is denied, follow UnitedHealthcare's appeals and reconsideration process as outlined on the Provider Portal and in plan materials.

Code Lists and Examples (CPT / HCPCS / ICD-10)

Selected arthroplasty CPT codesCPTCovered

23470	Arthroplasty-related CPT code listed
27130	Arthroplasty-related CPT code listed

Selected bariatric surgery CPT codesCPTCovered

43644	Bariatric surgery CPT code listed
43886	Bariatric surgery CPT code listed

Cancer supportive care HCPCS/NDC codesHCPCSCovered

J1454	Akynzeo (palonosetron/fosnetupitant) HCPCS J-code
J0897	Denosumab (Xgeva/Prolia) HCPCS J-code
J1449	Eflapegrastim-xnst (Rolvedon) J-code
Q5120	Ziextenzo (pegfilgrastim-bmez) Q-code

Cancer supportive care drugsHCPCSCovered

J1449	Eflapegrastim-xnst (Rolvedon)
J1448	Trilaciclib (Cosela)
Q5108	Fulphila (Pegfilgrastim-jmdb)
J1447	Granix (Tbo-filgrastim)
J2820	Leukine (Sargramostim)
J2506	Neulasta (Pegfilgrastim)
Q5110	Nivestym (Filgrastim-aafi)
Q5122	Nyvepria (Pegfilgrastim-apgf)

Cardiology CPT/HCPCS codes requiring eviCore authorizationCPTCovered

75557	Cardiology imaging/procedure code listed for eviCore management
93460	Cardiology catheterization/angiography code
33206	Cardiac device procedure

Sample ICD-10 diagnosis codes referencedICD-10

I70.644	ICD-10 code listed in cardiovascular system section
I72.3	ICD-10 code listed
I73.00	ICD-10 code listed

Additional ICD-10 diagnosis codesICD-10

L03.115	ICD-10 code listed
M86.051	ICD-10 code listed

Procedure/device-related ICD-10 codesICD-10

T82.312A	ICD-10 code listed
T82.818A	ICD-10 code listed

Congenital heart disease procedure codes (partial list)mixedCovered

33250-33390, 33404, 33414-33417, 33465-33478, 33500-33507, 33600-33697, 33702-33788, 33802-33895, 33897, 33917-33926

Extensive list of congenital heart disease-related CPT/HCPCS procedure codes for which prior authorization is listed

Chemotherapy injectablesHCPCSCovered

J9000-J9999

Chemotherapy injectable drugs

Selected CPT/HCPCS codes (cosmetic/reconstructive and others)CPT | HCPCS | mixed

11950	Cosmetic and reconstructive procedure code listed
11951	Cosmetic and reconstructive procedure code listed
11952	Cosmetic and reconstructive procedure code listed
15775	Cosmetic procedure code listed
15823	Reconstructive procedure code listed
17380	Procedure code listed
Q2026	HCPCS code referenced in list

Cosmetic and reconstructive codes (partial)ICD-10

C44.601	Listed under cosmetic and reconstructive prior authorization entries
C44.602	Listed under cosmetic and reconstructive prior authorization entries
C44.609	Listed under cosmetic and reconstructive prior authorization entries

Diagnostic and therapeutic CPT codes (partial)CPT

29799	Diagnostic and therapeutic procedure code listed
32601	Diagnostic and therapeutic procedure code listed
32662	Diagnostic and therapeutic procedure code listed

Durable medical equipment / DME (partial)HCPCS

A6550	Durable medical equipment code listed
A7025	Durable medical equipment code listed
E0481	DME examples listed; threshold note applies

Sample DME HCPCS codesHCPCSCovered

E0941	DME HCPCS code listed for prior authorization
E1003	DME HCPCS code listed for prior authorization
E1811	DME HCPCS code listed for prior authorization

ENT, FESS, Colonoscopy codesCPTCovered

30117	ENT CPT code requiring prior authorization
31240	FESS CPT code requiring prior authorization
G0105	Colonoscopy - Screening (SOS applies) CPT/HCPCS

Specific gender dysphoria/related procedure codesCPTCovered

55970	Code requiring prior authorization regardless of diagnosis
55980	Code requiring prior authorization regardless of diagnosis

CPT/HCPCS codes mentionedCPT

14000
14001
14041
15734
55970
55980

Procedure codes requiring prior authorization when linked to gender dysphoria treatmentCPTCovered

55970
55980

High-frequency prior auth proceduresCPTCovered

55970	Procedure code repeatedly referenced as requiring prior authorization
55980	Procedure code repeatedly referenced as requiring prior authorization

Genetic/molecular testing codesCPT | mixedCovered

81162-81420	Range of genetic testing/molecular CPT codes referenced
0005U-0398U	Multiple proprietary/temporary (U) genetic/molecular codes listed

Assorted U- and S-codes and other HCPCS/CPT codesmixed

0308U	Listed HCPCS/CPT-like code in segment
0336U	Listed HCPCS/CPT-like code in segment
S3870	HCPCS code listed

Injectable drug J-codesHCPCSCovered

J0896	Injectable drug code (anemia)
J1437	Injectable drug code
J3385	Erythropoiesis stimulating agent

Erythropoiesis Stimulating AgentsHCPCSCovered

J3385

Erythropoiesis Stimulating Agent (listed repeatedly)

Unclassified and temporary codesHCPCS

C9399	Unclassified/temporary code (see Review at Launch guidance)
J3490	Unclassified drug code (see Review at Launch guidance)
J3590	Unclassified drug code (see Review at Launch guidance)

Integumentary CPT codesCPT

11042	Debridement or integumentary procedure code listed
11043	Debridement or integumentary procedure code listed
11044	Debridement or integumentary procedure code listed
12031	Integumentary procedure (asterisk noted)

Medical and surgical supplies (A-codes)HCPCS

A2001	Medical and surgical supplies
A2002	Medical and surgical supplies
A2004	Medical and surgical supplies
A2005	Medical and surgical supplies

Orthotics and prosthetics L-codesHCPCS

L0112	Orthotics/prosthetics HCPCS L-code
L0113	Orthotics/prosthetics HCPCS L-code
L0460	Orthotics/prosthetics HCPCS L-code
L0464	Orthotics/prosthetics HCPCS L-code

Orthotics/prosthetics and drug-related HCPCS codes (partial)HCPCS

L5968	HCPCS code listed in section (partial)
L5973	HCPCS code listed in section (partial)
L5979	HCPCS code listed in section (partial)

Pain management and potentially unproven services CPT/T codes (partial)CPT | HCPCS

0278T	Pain management CPT/HCPCS code (partial list)
62320	Pain management CPT code
64451	Pain management CPT code

Representative CPT/HCPCS codes referencedmixed

97010	Physical therapy modality
97124	Physical therapy — massage
97533	Therapeutic activities
77401	Radiation treatment delivery
71271	CT chest with contrast (noted with asterisk in document)
70480	CT head/brain or similar radiology codes listed

Prior authorization contact

Provider Portal (online)Use Authorization/Notification Transactions on your Provider Portal dashboard (UHCprovider.com/priorauth)

PhoneCall 800-666-1353 to submit notification/prior authorization

Portal navigationSelect the Prior Authorization and Notification or Radiology/Cardiology/Oncology/Radiation Oncology Transactions tile on Provider Portal dashboard

Age threshold for adult prior authorization

Adult age thresholdPrior authorization required for patients ages 18 and older for many listed services

Pediatric exceptionsSee Congenital Heart Disease section for patients under age 18 (certain services have pediatric-specific rules)

Service examplesApplies to inpatient video EEG (cerebral seizure monitoring) and cartilage implants among others

DME purchase/rental cost threshold

DME cost thresholdNotification/prior authorization required when retail purchase or cumulative rental cost exceeds $500

DME code scopeRequirement applies only to listed DME codes; examples include E0328, E0329, E0466, E0481

Home health exceptionSome home health care services may qualify under DME requirement but are not subject to the $500 threshold

How to Submit Authorizations and Operational Notes

Prior Authorization

How to Submit Authorizations and Operational Notes

This list contains notification/prior authorization review requirements for health care professionals. Notification/prior authorization can be submitted online via UHCprovider.com > Prior Authorization and Notification (Provider Portal) or by phone at 800-666-1353. Notification/prior authorization is not required for emergency or urgent care.

Online: Sign in at UHCprovider.com/priorauth and use the Prior Authorization and Notification tool (select the appropriate tile on your Provider Portal dashboard: Radiology/Cardiology/Oncology/Radiation Oncology/Gastroenterology Endoscopy or Specialty Pharmacy Transactions as applicable).
Phone: 800-666-1353 (or specialty numbers where noted, e.g., eviCore-managed cardiology via 1-877-PRE-AUTH; Optum specialty pharmacy questions 888-397-8129; Specialty Pharmacy Transactions tile or 877-842-3210 for certain non-oncology specialty drugs).
For oncology supportive care and many chemotherapy/specialty drug requests, submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or the Specialty Pharmacy Transactions tile on your Provider Portal dashboard. Pre-determination is highly recommended for new-to-market medications listed on the Review at Launch Medication List (see Review at Launch policy at UHCprovider.com > Menu > Policies and Protocols > Commercial Policies > Medical & Drug Policies and Determination Guidelines).

Note

Site-of-service Review

Site of service will be reviewed as part of the prior authorization process for certain procedures (for example, selected arthroscopy and skilled nursing facility entries). Follow instructions on the Provider Portal and include site-of-service information when submitting requests.

Site-of-service review applies to selected arthroscopy CPT/HCPCS codes (e.g., 29914, 29915, 29916) and other codes designated with SOS notes.
Site-of-service review may affect authorization decisions for inpatient vs outpatient or facility choice.

Prior Authorization

Chemotherapy and Cancer Supportive Care Prior Authorization

For prior authorization of cancer supportive care agents and selected chemotherapy/specialty injectable drugs administered in outpatient settings, submit requests online through the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or the Specialty Pharmacy Transactions tile. For questions about the online specialty pharmacy authorization process contact Optum at 888-397-8129.

Selected chemotherapy/supportive care HCPCS/J-codes requiring prior authorization include: J8501, Q2049, J9219, J9274, J9298 and chemotherapy injectable drugs billed J9000–J9999; leucovorin J0640; levoleucovorin J0641/J0642; leuprolide acetate J1950/J1952; lanreotide J1932; Q-codes for pegfilgrastim/filgrastim biosimilars (e.g., Q5101, Q5111, Q5120, Q5125) and other Q-codes listed on the portal.
Unclassified/temporary codes (C9399, J3490, J3590) require prior authorization only for specified products (e.g., Nulibry™, Rivfloza™, Revcovi™).
Codes J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125 require prior authorization for both oncology and non-oncology diagnoses; J0885 requires prior authorization for both oncology and non-oncology DX.

Prior Authorization

Digestive System Prior Authorization

Digestive system procedures (including many diagnostic and therapeutic endoscopy codes) require prior authorization. For gastroenterology and endoscopy authorizations, submit requests online via the Prior Authorization and Notification tool on the Provider Portal (select the Radiology/Cardiology/Oncology/Radiation Oncology/Gastroenterology Endoscopy tile) or call 877-773-2884 when indicated.

Prior authorization is required for select EGD, colonoscopy and capsule endoscopy codes (examples include 44388*, 44392*, 44402, 45378*, 45379*, 45382, 45384*, 45388, 45389, 45398* and EGD codes 43200–43270 series as listed on the portal).
Some codes are subject to site-of-service review (marked SOS on the portal).
For full code lists and SOS details visit UHCprovider.com > Prior Authorization > Gastroenterology.

Prior Authorization

DME Prior Authorization / Notification

Durable medical equipment (DME) may require notification or prior authorization when specific DME codes are billed or when retail purchase or cumulative rental costs exceed plan thresholds. Submit DME prior authorization requests via the Provider Portal or call the standard prior authorization line.

DME codes listed that require notification/prior authorization include A6550, A7025, A7026, A9272, A9279, A9279, A9282, A9999, B9999 and specific equipment codes (E0328, E0329, E0466, E0481, E0744, E0769, E1701, E1702, E1831, etc.).
Prior authorization required when retail purchase or cumulative rental cost exceeds $500 (or other plan-specific thresholds).
For submission instructions use the Prior Authorization and Notification tool on the Provider Portal or call 800-666-1353.

Prior Authorization

Prior Authorization — Gender Dysphoria Procedures

Prior authorization is required for many gender dysphoria–related procedures when submitted with gender dysphoria diagnosis codes (F64.0, F64.1, F64.2, F64.8, F64.9, Z87.892). Submit requests online via the Provider Portal Prior Authorization and Notification tool or by calling the specified authorization number.

Codes requiring prior authorization when billed with gender dysphoria diagnosis codes include a broad list of surgical and procedural CPT codes (examples shown on the portal include 14001, 14041, 15734, 15738, 15750, 15757, 15758, 19303, 53410, 53430, 54125, 54520, 54660, 54690, 55175, 55180, 56625, 56800 and the recurrently listed codes 55970 and 55980).
Also see gastroenterology/EGD and other specialty code subsets noted to require prior authorization regardless of diagnosis (e.g., 55970, 55980 are explicitly listed).
For full lists and guidance visit UHCprovider.com > Prior Authorization and select the appropriate specialty tile, or call 877-773-2884 as directed.

Note

Review at Launch / New-to-market Medications Prior Authorization Guidance

Review at Launch (New-to-Market Medications) guidance: UnitedHealthcare maintains a Review at Launch for New to Market Medications policy and a Review at Launch Medication List. Pre-determination is highly recommended for drugs on the list. Check the Review at Launch policy on UHCprovider.com for the most current requirements.

Access the policy at UHCprovider.com > Menu > Policies and Protocols > Commercial Policies > Medical & Drug Policies and Determination Guidelines for UnitedHealthcare Commercial Plans.
For unclassified/temporary codes (C9399, J3490, J3590) and certain temporary/new codes, prior authorization may be required only for specific products—see the Review at Launch policy and Medication List.
Pre-determination is recommended for newly FDA-approved drugs included on the Review at Launch Medication List.

Prior Authorization

How to Obtain Prior Authorization (Specialty Drugs)

Specialty drug prior authorization instructions: For many specialty pharmacy and non-oncology specialty drugs, submit requests via the Specialty Pharmacy Transactions tile on the Provider Portal dashboard. For oncology vs non-oncology distinctions, follow the portal directions (some codes require different submission paths). Contact numbers are provided for specialty workflows.

For oncology supportive care and oncology-designated drugs follow the Cancer Supportive Care section and submit via the Prior Authorization and Notification tool on the Provider Portal.
For non-oncology specialty drugs and certain J-codes submit via the Specialty Pharmacy Transactions tile on the Provider Portal or call 877-842-3210 (or the number shown on the portal) as directed.
For questions about the online specialty pharmacy authorization process contact Optum at 888-397-8129.

Key Terms and Tools

Notification/prior authorization — definition

DefinitionA required review/notification process for specified services before provision (not required for emergency or urgent care).

ScopeApplies to listed inpatient and outpatient services for Oxford commercial plans

PurposeEnsures services meet plan requirements prior to delivery to avoid coverage risk

UnitedHealthcare Provider Portal

NameUnitedHealthcare Provider Portal — Prior Authorization and Notification tool

AccessGo to UHCprovider.com and click the UnitedHealthcare Provider Portal button; select the Prior Authorization and Notification tile on the dashboard

Use casesSubmit prior authorization requests for cancer supportive care, cardiology (when not managed by eviCore), radiology and other services listed

eviCore (cardiology/radiology UM vendor)

VendoreviCore — utilization management vendor managing prior authorization/notification for specified cardiology and certain radiology services

Submission optionsSubmit via Provider Portal radiology/cardiology/oncology transactions tile, call 1-877-PRE-AUTH, or use the eviCore website/App

ScopeApplies to participating and non-participating providers for listed cardiology CPT/HCPCS codes (examples: 75557, 93460, 71271) and certain CT/MRI/PET scans

How to Obtain Prior Authorization

Primary methodsUse Authorization/Notification Transactions on your Provider Portal dashboard to request authorization/notification

Phone alternativeCall 800-666-1353 to obtain prior authorization if not using the Portal

eviCore/CardsFor cardiology/radiology managed by eviCore, providers may call 1-877-PRE-AUTH or use eviCore website/App as noted on Provider Portal

Continuous glucose monitor — CGM prior authorization

CGM prior auth rulePrior authorization required for continuous glucose monitor (CGM) supplies when used for Type 2 and gestational diabetes; not required for Type 1 diabetes

Relevant HCPCS codesExamples include A4226, A4238, A4239, A9276–A9278, E0787, E2102–E2103

Diagnosis linkageAuthorization required only when billed with qualifying Type 2 or gestational diabetes diagnosis codes (see Provider Portal guidance)

Injectable chemotherapy drugs — prior authorization scope

ScopeNotification/prior authorization required for injectable chemotherapy drugs administered in outpatient settings for a cancer diagnosis (includes J9000–J9999 range and specified J/Q codes)

Examples of codesIncludes J9000-J9999, J0640-J0642 (leucovorin), J1932 (lanreotide) and selected J-/Q-codes listed in the chemotherapy section

Submission for specialty injectablesSome injectable medications should be submitted via the Provider Portal Specialty Pharmacy Transactions tile; questions: Optum 888-397-8129

Eflapegrastim-xnst (Rolvedon)

ProductEflapegrastim-xnst (Rolvedon) referenced in coding and prior authorization lists

HCPCS/J-codeListed as J1449 in the document's drug code listings

ContextAppears among cancer supportive care agents requiring prior authorization/submission via Provider Portal

DME threshold exception for certain home health services

ExceptionSome home health care services may qualify under the DME requirement but are not subject to the $500 retail purchase or cumulative rental cost threshold

Where notedSee Durable medical equipment — DME section and Home Health Services entries for specific exceptions

ExamplesOrthotics/prosthetics and power mobility/device codes may be listed under DME but handled per home health guidance

Durable medical equipment (DME)

DefinitionDurable medical equipment (DME) — items billed with DME HCPCS codes that require notification/prior authorization when listed

Examples of DME codesExamples shown: A6550, A7025, E0481, E0941, E1003, E1811 and multiple K-series power mobility codes

Authorization thresholdDME authorization applies to listed codes and is triggered when retail purchase or cumulative rental cost exceeds $500 (exceptions apply)

Functional endoscopic sinus surgery (FESS)

ProcedureFunctional endoscopic sinus surgery (FESS) — CPT 31240, 31253, 31254, 31255

RequirementPrior authorization required; site of service will also be reviewed as part of prior authorization

Related notesFESS entries are listed with other ENT and GI procedures where prior authorization may apply

Gender dysphoria diagnosis codes referenced

Diagnosis codesGender dysphoria diagnosis codes referenced: F64.0, F64.1, F64.2, F64.8, F64.9, Z87.892

UseThese diagnosis codes are used to determine when specific procedure CPT codes require prior authorization

Repeated referenceDocument repeatedly notes prior authorization required when listed codes are submitted with these diagnoses

Gender dysphoria diagnosis codes (explicit list)

Codes listF64.0, F64.1, F64.2, F64.8, F64.9, Z87.892

ContextThese are the explicit diagnosis codes called out in the gender dysphoria sections for authorization determination

ActionWhen these codes accompany specified CPT procedures, prior authorization is required

Genetic testing/notification requirement

RequirementGenetic and molecular testing performed in an outpatient setting requires prior authorization/notification

BRCA/DNA sequencingOrdering provider must notify prior to DNA sequencing (BRCA) as specified in the document

Representative codesExamples include CPT codes 81162, 81163, 81164, 81432 and a broader range 81162–81420 and related molecular codes

Gender dysphoria procedure prior authorization

Procedure prior authSpecific gender dysphoria procedure CPT codes are listed as requiring prior authorization when submitted with gender dysphoria diagnosis codes

Examples of CPT codesIncludes many codes such as 14001, 14041, 15734 and an extended list of surgical CPT codes shown in gender dysphoria sections

Codes always requiring authCodes 55970 and 55980 are repeatedly listed as requiring prior authorization in gender dysphoria context

Specialty Pharmacy Transactions tile

Portal tileSpecialty Pharmacy Transactions tile on Provider Portal — use to submit specialty drug prior authorization requests (non-oncology and oncology per guidance)

Phone for specialty drugsFor non-oncology specialty pharmacy prior authorization call 877-842-3210; for Portal questions call Optum 888-397-8129

When to useUse Specialty Pharmacy Transactions tile for listed injectable and specialty medications as instructed in drug sections

Prior authorization required — example categories

Examples of categoriesPrior authorization required for categories including genital organ procedures, hemic and lymphatic procedures, infertility services, home health care in outpatient settings

Broad applicationMultiple specific CPT/HCPCS codes within these categories are listed throughout the document as requiring prior authorization

Submission noteSubmit via Provider Portal or designated vendor (eviCore/Optum) depending on service category

Review at Launch / specialty drug prior auth guidance

Review at LaunchCheck the Review at Launch for New to Market Medications policy for up-to-date guidance; pre-determination recommended for listed drugs

Unclassified/temporary codesNotification/prior authorization only required for specific products billed under C9399, J3490, J3590 (e.g., Nulibry™, Rivfloza™, Revcovi™)

Dual-diagnosis drug authCertain codes (e.g., J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125) require prior authorization for both oncology and non-oncology diagnoses

Site of service review

Site-of-service reviewSite of service will be reviewed as part of the prior authorization process for certain services (e.g., skilled nursing facility entries, FESS, arthroscopy)

Inpatient/post-acute noteAdmission date notification/prior authorization required for facilities providing post-acute inpatient services (acute care hospitals, acute inpatient rehab, critical access hospitals)

Out-of-network impactPrior authorization required for out-of-network services; using non-contracted providers may increase member cost or result in no coverage

Out-of-network services

DefinitionOut-of-network services — services provided by physicians or facilities not contracted with the health plan; may result in increased member out-of-pocket expenses or no coverage

Authorization requirementPrior authorization required for many out-of-network services; recommendation to non-contracted providers may affect coverage

Related categoriesIncludes pain management and potentially unproven services listed with numerous CPT/T codes

Potentially unproven services

DefinitionPotentially unproven services — services determined to have insufficient clinical evidence in prevailing peer-reviewed literature; prior authorization required for listed codes

ExamplesIncludes multiple T-codes and CPT codes such as 20985, 22505, 25259, 26340, 27275, 27860, 28446

Decision basisDetermination made when there is insufficient high-quality clinical evidence (RCTs/cohort studies) to support effectiveness

PSF — Patient Summary Form timing requirement

PSF timingPatient Summary Forms (PSFs) should be sent within 3 days of initiating a member's treatment and must be received within 10 days from the initial date

ApplicabilityApplies to therapy visits performed by Optum-contracted care professionals (PT/OT/ST/RT) requiring prior authorization

Representative codesExamples include 97010, 97124, 97533, 97537, 97169, 97170, 97171

eviCore — radiology prior authorization manager

eviCore roleeviCore is the vendor managing prior authorization for certain radiology services for participating and non-participating providers

Examples of managed servicesCertain CT, MRI, MRA and PET scans and specified radiology/cardiology CPT/HCPCS codes are managed by eviCore

Submission optionsSubmit via Provider Portal transactions tile or follow eviCore submission/call instructions as provided

OpenPayer

Prior authorization requirements for Oxford plans

Services and Codes Requiring Prior Authorization

Code Lists and Examples (CPT / HCPCS / ICD-10)

How to Submit Authorizations and Operational Notes

Key Terms and Tools