CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Pennsylvania CHIP Medicaid

Lists services and codes that require prior authorization for participating providers in UnitedHealthcare Community Plan Pennsylvania CHIP, and explains how to request authorization (online, phone, fax). Applies to in-network and out-of-network providers except for emergency/urgent care.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Pennsylvania CHIP Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, or call 800-600-9007, or fax 877-310-3826.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Online, phone, faxauthorization request methods provided

Emergency/urgent care excludedsituations not requiring prior authorization

>$500DME PA threshold

Multiplecategories requiring PA

manyinjectable medication codes listed

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Prior Authorization Coverage Criteria

Coverage stance for listed codes

Covered services that require prior authorization for UnitedHealthcare Community Plan (Pennsylvania CHIP). Providers must request prior authorization via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call the numbers listed below where noted. Prior authorization is not required for emergency or urgent care.

all criteria must be met:

1. Prior authorization is required for the following categories and specific services/codes:

- Cardiology outpatient and office-based diagnostic catheterizations, electrophysiology implants, and stress echocardiograms (see Cardiology prior-authorization resources at UHCprovider.com/PAcommunityplan). Codes range in the 397–8129 series; call 866-889-8054 for prior authorization.

- Chemotherapy: injectable chemotherapy drugs administered in outpatient settings (J9000-J9999 range), including specified agents such as Leucovorin (J0640/J0641/J0642) and Lupron Depot (J1950).

- Cancer supportive care injectable colony-stimulating factors and related agents (examples: J1449 Rolvedon, J1442 Neupogen/filgrastim, Q5110 Nivestym, Q5125 Releuko, J2506 Neulasta/pegfilgrastim and biosimilars, J2820 Sargramostim, J1448 Trilaciclib, J0897 Denosumab, J0885 ESAs).

- Injectable medications: specified high-cost/managed injectables require prior authorization (examples include J0217 Lamzede, J1306 Leqvio, J2778 Lucentis, J1950 Lupron Depot, J1300 Soliris, J0897 Prolia, J2507 Krystexxa, J1745 Renflexis, Q5104 Q5106 biosimilars, J2326 Spinraza, J3358 Stelara, and many others listed under Injectable medications — contact portal or clinical review).

- Transplants and CAR T‑cell therapy: prior authorization required; providers must call the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 (see transplant/CAR T guidance for codes including 0537T–0540T, Q2041–Q2056, C9400, J3490/J3590 as applicable).

- Implantable devices and stimulators: prior authorization required for implantation procedures and device codes (examples: stimulators CPT 64553, 64555, 64568, 64570, 64590 and device HCPCS L8680–L8688; bone growth stimulators E0747–E0749).

- Ventricular assist devices (VAD): prior authorization required; contact the notification number on the member ID card and follow Optum VAD instructions. Relevant CPT codes: 33927, 33928, 33929, 33975–33982.

- Advanced radiology/imaging: certain outpatient CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures require prior authorization; contact 866-889-8054 or use the provider portal and refer to Radiology Prior resources.

- Proton beam therapy: prior authorization required (CPT codes 77520, 77522, 77523, 77525).

- Joint replacement, spinal surgery, orthognathic surgery, FESS, sleep apnea surgeries, and other specified surgical categories require prior authorization (see specific CPT lists and specialty resources).

- Enteral services and in-home nutritional therapy: prior authorization required for supplies and services (examples: B4034–B4036, B4100–B4149, B4150–B4161, B9002, B9998).

- Durable medical equipment (DME), orthotics and prosthetics: prior authorization required for listed codes with retail purchase or cumulative rental cost over $500 (examples include A9279, A9280, A9900, E0194, E0265–E0277, E0300, E0328–E0329, E0445, E0457, E0465–E0471; orthotics/prosthetics L0112, L0170, L0456, L0462, L0464, L0480–L0484, L0486, L0624, L0629, L0631–L0637, L8040–L8047, L8499, L8609, L8610, L8612, L8631, L8659).

- Wound vacuum therapy: prior authorization required (example HCPCS E2402).

2. Special instructions and contacts:

- Submit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal at UHCprovider.com (select Prior Authorization and Notification on the dashboard).

- Phone numbers where provided in the categories: general PA tool and clinical lines (e.g., 866-889-8054 for radiology/cardiology/advanced imaging and prior auth help; 800-600-9007 for Community Plan general PA support; transplant case management 888-936-7246).

- For Ventricular Assist Devices, follow the notification number on the member's ID card and fax the form provided by the nurse to Optum VAD per instructions.

3. Code- and service-level detail:

- Many categories list specific CPT/HCPCS ranges and individual codes that require prior authorization (examples above). Providers must consult the online Prior Authorization and Notification Resources pages for full, up-to-date code lists (Cardiology Prior, Radiology Prior, Injectable medications list, Transplant/CAR T guidance, etc.).

4. Exceptions and notes:

- Prior authorization is not required for emergency or urgent care.

- Some codes (e.g., unclassified codes C9399, J3490, J3590) may require prior authorization when used for specific gene or cellular therapies per the transplant/gene therapy guidance.

- DME and orthotics/prosthetics prior authorization thresholds apply only to listed codes when retail or cumulative rental cost exceeds $500.

Operational note: Use the provider portal first for submission; when in doubt about whether a specific code requires prior authorization, confirm via the portal resource pages or call the listed prior authorization phone lines.

Code Lists (CPT, HCPCS, ICD-10, L-codes)

Breast surgery CPT codesCPTCovered

19325	Breast reconstruction, partial or total reconstruction of the breast
19328	Breast reconstruction, including latissimus dorsi flap
19330	Immediate insertion of breast prosthesis following mastectomy
19340	Breast reconstruction, reconstruction of nipple
19342	Breast reconstruction, areola reconstruction
19357	Breast reconstruction revision
19361	Breast reconstruction, secondary or delayed
19364	Breast reconstruction, adjunct procedures
19367	Breast reconstruction, adjacent tissue transfer or rearrangement
19368	Breast reconstruction, augmentation with prosthesis

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How Providers Request Authorization & Operational Notes

Prior Authorization

Request prior authorization via portal, phone, or fax

To request prior authorization submit online via the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal (UHCprovider.com), or call 800-600-9007, or fax 877-310-3826. Prior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all procedures and services except emergent/urgent care.

Online: Use the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal (UHCprovider.com)
Phone: 800-600-9007
Fax: 877-310-3826

Prior Authorization

Route cardiology authorizations via portal or 866-889-8054

Cardiology outpatient and office-based diagnostic catheterizations, electrophysiology implants and stress echoes require prior authorization. Providers may submit requests via the Prior Authorization and Notification tool or call 866-889-8054; see UHCprovider.com/PAcommunityplan > Prior Authorization and Notification Resources > Cardiology Prior for CPT details.

Key Definitions and Thresholds

Prior authorization

DefinitionA requirement to obtain approval from UnitedHealthcare before performing non-emergent services so that the service will be covered.

Submission methodsRequests may be submitted online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by phone (800-600-9007), or by fax (877-310-3826).

ExceptionPrior authorization is not required for emergency or urgent care.

Emergency or urgent care

CoverageEmergency or urgent care is excluded from prior authorization requirements.

Behavioral health routingBehavioral health services may be covered through a designated behavioral health network; for specific codes call the number on the back of the member's ID card.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Pennsylvania CHIP Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, or call 800-600-9007, or fax 877-310-3826.

SourceLink

On This Page

Use the Prior Authorization and Notification tool on the Provider Portal or call 866-889-8054

Refer to UHCprovider.com/PAcommunityplan > Prior Authorization and Notification Resources > Cardiology Prior for CPT codes

Prior Authorization

Refer behavioral health authorizations to behavioral network/ID-card number

Behavioral health services may be covered through a designated behavioral health network; for specific codes that require prior authorization call the number on the back of the member's ID card when referring for mental health and substance use services.

When referring for mental health or substance use services, call the number on the member's health plan ID card for authorization routing

Prior Authorization

Use Provider Portal to request authorization for listed services

Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal. Specific services shown (for example, chemotherapy injectable drugs J9000-J9999, cochlear implants, continuous glucose monitors) require prior authorization as listed.

Use the Prior Authorization and Notification tool on UHCprovider.com to submit requests
Examples of services requiring authorization in this excerpt include chemotherapy injectable drugs (J9000-J9999) and listed device/drug HCPCS/CPT codes

Prior Authorization

EEG — outpatient no PA; inpatient monitoring requires PA

Electroencephalogram (EEG) — prior authorization is not required for outpatient hospital or ambulatory surgical center EEGs; inpatient cerebral seizure monitoring/inpatient video services do require prior authorization.

Outpatient EEG (hospital or ASC): no prior authorization required
Inpatient cerebral seizure monitoring / inpatient video EEG: prior authorization required

Prior Authorization

DME prior authorization threshold: > $500

Durable medical equipment (DME): prior authorization is required only for the DME codes listed with a retail purchase or cumulative rental cost of more than $500.

PA required when retail purchase or cumulative rental cost for listed DME codes exceeds $500

Prior Authorization

Enteral services require prior authorization for listed B‑codes

Enteral services require prior authorization for the listed HCPCS B‑codes (for example B4034, B4035, B4036, B4100 and related B‑codes).

Submit prior authorization for enteral nutrition and related enteral supply HCPCS B‑codes via the Provider Portal

Prior Authorization

Experimental/investigational procedures require prior authorization

Specific procedure codes designated as experimental and investigational are noted and require prior authorization (examples listed include 33477, 36514, 64722 and others).

If a procedure is listed as experimental/investigational in the document, obtain prior authorization before proceeding

Prior Authorization

Obtain prior authorization for listed surgical procedures (e.g., FAI, FESS)

Prior authorization is required for listed surgical procedures shown in the document, including femoroacetabular impingement syndrome procedures and multiple FESS CPT codes (e.g., 29916, 31240, 31253–31259, 31267, 31276, 31287–31288).

Obtain PA for femoroacetabular impingement procedures (29916)
Obtain PA for functional endoscopic sinus surgery codes (31240, 31253–31259, 31267, 31276, 31287–31288)

Prior Authorization

Gender dysphoria services require prior authorization

Gender dysphoria services and the related CPT and diagnosis codes listed (e.g., 55970, 55980; diagnoses F64.x) require prior authorization.

Prior authorization required for procedures and services for gender dysphoria as listed (CPT 55970, 55980; ICD‑10 F64.0–F64.2 indicated)

Prior Authorization

Surgical procedures in list require PA — submit via portal

Prior authorization is required for the listed surgical procedures referenced elsewhere in the document (for example: femoroacetabular impingement 29916 and multiple FESS codes). Submit requests via the Provider Portal.

Use the Prior Authorization and Notification tool on UHCprovider.com to submit surgical PA requests
Example codes requiring PA include 29916 and the FESS CPTs listed

Prior Authorization

Genetic/molecular testing and BRCA sequencing require PA/notification

Genetic and molecular testing require prior authorization/notification; BRCA testing specifically requires notification/prior authorization before DNA sequencing — the ordering provider must notify the laboratory and the laboratory will notify UnitedHealthcare.

Obtain prior authorization/notification for listed genetic/molecular tests (U‑codes and CPTs shown)
For BRCA sequencing, ordering provider must notify the lab and the lab will notify UnitedHealthcare before sequencing

Prior Authorization

Home health and hospice require prior authorization

Home health services provided in outpatient/home settings and hospice require prior authorization as listed (examples include G‑ and S‑codes for home health and T2045 for hospice).

Home health prior authorization is required for outpatient/home settings (e.g., G0156, G0162, G0299, G0300, G0493‑G0496)
Hospice (T2045) requires prior authorization

Prior Authorization

Injectable medications (listed J/Q codes) require prior authorization

An extensive list of injectable medications (HCPCS/J‑codes and Q‑codes) included in the document require prior authorization; providers must obtain prior authorization for these drugs before administration.

Many biologic and specialty injectable J‑codes (examples in the list such as J7170 Hemlibra, J1411 Hemgenix, J0897 Prolia, J3399 Zolgensma) require PA
Submit PA via the Provider Portal for listed injectable medications

Prior Authorization

Obtain PA for listed J‑codes via Provider Portal (examples: J1290, J2840)

Follow the general guidance in the document for obtaining prior authorization for listed HCPCS J‑codes (example entries show Kalbitor J1290, Kanuma J2840 and other named products); submit via the Provider Portal as directed.

Use the Prior Authorization and Notification tool on UHCprovider.com for listed J‑codes
Examples in the document include J1290 (Kalbitor) and J2840 (Kanuma)

Prior Authorization

Obtain PA/notify for inpatient and post‑acute admissions

Prior authorization and notification of admission date are required for admissions to post‑acute inpatient facilities including acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long‑term acute care hospitals and skilled nursing facilities; general inpatient admission notification is required.

Notification required for inpatient admissions
Prior authorization and admission-date notification required for specified post‑acute inpatient facility types

Prior Authorization

Refer to injectable medication code lists — PA required

Numerous injectable medications listed by HCPCS/J‑code in the document require prior authorization (see the extensive J/Q‑code lists provided in the injectable medications sections).

Refer to the document's injectable medication code lists to determine which J/Q‑codes require PA
Submit PA requests via the Provider Portal for those medications

Prior Authorization

Total joint (hip/knee) replacement requires prior authorization

Joint, total hip and knee replacement procedures require prior authorization as indicated in the document (joint replacement codes are listed under the joint replacement entries).

Obtain prior authorization for total joint hip and knee replacement procedures per the listed CPT codes

Prior Authorization

Air and ambulance transport require prior authorization

Non‑emergent air ambulance transport and ambulance transport require prior authorization; example air ambulance codes include A0430, A0431, A0435 and A0436.

Obtain prior authorization for non‑emergent air ambulance transports (A0430, A0431, A0435, A0436)
Ambulance transport entries S9960/S9961 also indicate authorization requirements

Prior Authorization

Inpatient admissions: notification required; PA for post‑acute facilities

Inpatient admissions require notification; for certain post‑acute inpatient facilities prior authorization and notification of admission date are required (see facility list).

Notification required for all inpatient admissions
PA + admission‑date notification required for acute care hospitals, acute inpatient rehab, critical access hospitals, LTACHs, and skilled nursing facilities

Prior Authorization

Orthognathic surgery requires prior authorization

Orthognathic surgery and treatment of maxillofacial/jaw functional impairment require prior authorization; examples of CPT codes listed include 21121, 21123, 21125, 21127 and related codes.

Obtain PA for orthognathic surgery CPTs listed (e.g., 21121, 21123, 21125, 21127, 21141–21145)

Prior Authorization

Orthotics/prosthetics PA required when cost threshold met

Orthotics and prosthetics require prior authorization only for the codes listed that meet the retail purchase or cumulative rental cost threshold (document lists many L‑codes subject to this rule).

PA required only for orthotics/prosthetics L‑codes that exceed the specified retail purchase or cumulative rental cost threshold
Refer to the listed L‑codes in the document to determine PA applicability

Prior Authorization

Radiology advanced outpatient imaging requires notification/PA

Advanced outpatient imaging (certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures) require prior authorization/notification; providers should notify prior to scheduling and can request authorization via the Provider Portal or by calling 866-889-8054.

Care providers must provide notification prior to scheduling advanced outpatient imaging
Request PA via the Prior Authorization and Notification tool or call 866-889-8054

Prior Authorization

Private duty nursing requires prior authorization

Private duty nursing services (T1000, T1002, T1003) require prior authorization.

Obtain PA for private duty nursing codes T1000, T1002, T1003

Prior Authorization

Pediatric day services (PDHC T1024) require prior authorization

Pediatric day health care (PDHC) services (T1024) require prior authorization.

Obtain PA for pediatric day services code T1024

Prior Authorization

Potentially unproven services require prior authorization

Services marked as 'Potentially Unproven Services' in the document require prior authorization (examples listed include codes such as 33289 and C2624).

If a service/code is listed under Potentially Unproven Services, obtain prior authorization before proceeding

Prior Authorization

Rhinoplasty/septoplasty for functional nasal treatment requires PA

Rhinoplasty and septoplasty for nasal functional treatment require prior authorization; example CPTs listed include 30400, 30435, 30465 and related codes.

Obtain PA for rhinoplasty/septoplasty CPTs listed (e.g., 30400, 30435, 30465)

Documentation Required

Site‑of‑service (SOS): PA required for outpatient hospital setting only

Site‑of‑service prior authorization is required only when requesting the service in an outpatient hospital setting; prior authorization is not required if the procedure is performed at a participating ambulatory surgical center for certain services.

When requesting service in an outpatient hospital setting, obtain PA if indicated
Services performed at participating ambulatory sites may not require PA under the SOS rule

Prior Authorization

Sleep apnea procedures require prior authorization

Sleep apnea procedures and related surgeries require prior authorization as listed in the document (sleep/apnea CPTs and mapping examples are provided).

Obtain PA for sleep apnea procedures and surgeries listed
Refer to the CPT mappings in the document for specific codes requiring PA

Prior Authorization

Spinal and related surgeries require prior authorization

Spinal surgery and many listed spinal/neurosurgery CPT codes require prior authorization; the document provides multiple CPT examples and mappings that must be authorized before performance.

Obtain PA for the listed spinal/neurosurgery CPTs (examples include 22100, 22514, 22802, 63030)

Prior Authorization

Stimulator/device implantation requires prior authorization

Implantation of stimulators and related device codes (examples: E0747–E0749, L8680 range, and CPT neurostimulator codes such as 64553, 64555) require prior authorization.

Obtain PA for device implantation and stimulator CPT/HCPCS codes listed (e.g., E0747, E0748, E0749, 64553, 64555, L8680)

Prior Authorization

Transplant and CAR T‑cell therapy require PA — call Transplant Case Management Team

Transplant and CAR T‑cell therapy services require prior authorization; providers must call the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 (or the notification number on the member's ID card) to initiate authorization.

Call UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 for transplant/CAR T authorization routing
Follow notification instructions on the member's ID card as directed

Prior Authorization

Gene therapy/CAR T and special/unclassified codes require prior authorization

Gene therapy, CAR T and certain unclassified or special codes require prior authorization; note code 38232 requires prior authorization only for an oncology diagnosis and unclassified codes (C9399, J3490, J3590) require authorization for specific therapies listed (e.g., Casgevy, Lantidra, Lyfgenia, Skysona, Zynteglo).

Code 38232: PA required only for oncology diagnoses
Unclassified codes C9399/J3490/J3590 require PA for specified gene therapies (Casgevy, Lantidra, Lyfgenia, Skysona, Zynteglo)

Prior Authorization

VAD, wound vac and vein procedures require PA; follow VAD notification process

For specific VAD, wound vac and vein procedure CPT/HCPCS codes listed, prior authorization is required. For ventricular assist devices (VADs), call the notification number on the back of the member's ID card and fax the form provided by the nurse to Optum VAD as instructed.

Obtain PA for listed VAD, wound vac (E2402) and vein procedure codes (36468, 36473, 36475, 36478)
For VADs: call the notification number on the member's ID card and fax the nurse‑provided form to Optum VAD

Documentation Required

Codes and special notes: unclassified/special codes require PA per document

Multiple CPT/HCPCS and miscellaneous codes are listed with special notes indicating that certain unclassified codes (e.g., C9399, J3490, J3590) will require prior authorization for specific gene/cell therapies; code‑specific exceptions and instructions are provided in the document.

Review document code list and special notes for unclassified/special‑code handling before submitting PA
Unclassified codes may require PA only for specified therapies or diagnoses (see code 38232 note)

General noteOut-of-network providers must request prior authorization for all procedures and services except emergent/urgent care.

Prior Authorization and Notification tool on UnitedHealthcare Provider Portal

Portal toolSubmit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com).

Phone and portal alternativesProviders may also call specialty numbers (e.g., 866-889-8054 for radiology/cardiology routing) or general phone/fax per portal instructions.

How to accessGo to UHCprovider.com, click the UnitedHealthcare Provider Portal button, then select Prior Authorization and Notification on the dashboard.

DME prior authorization threshold

Threshold statementPrior authorization is required only for the DME codes listed with a retail purchase or cumulative rental cost of more than $500.

Representative codesExamples in the DME list include A9279, A9280, A9900, E0194, E0265, E0300, E0445 and others subject to the threshold.

Classification noteProsthetics are explicitly noted as not DME in this section.

Experimental/investigational

DefinitionServices designated as experimental and investigational require prior authorization.

ExamplesDocument lists specific procedure codes flagged as experimental/investigational (e.g., 33477, 36514, 64722, 65765, 65767, 66180).

ActionProviders must obtain prior authorization for listed experimental/investigational procedures before performing the service.

BRCA testing prior authorization/notification

BRCA testing requirementNotification/prior authorization is required for BRCA testing before DNA sequencing is performed; the ordering provider must notify the laboratory and the laboratory will notify UnitedHealthcare.

Related testingGenetic and molecular testing more broadly require prior authorization/notification; many U- and molecular CPT codes are listed in the document.

Provider actionObtain required notification/prior authorization prior to sequencing to ensure coverage and compliance.

Home health prior authorization

RequirementHome health services require prior authorization when provided in outpatient/home settings (including the member's home).

Example G-codesListed home health codes include G0156, G0162, G0299, G0300, G0493, G0494, G0495, G0496.

ScopeApplies to home health and hospice services when delivered in outpatient/home settings per the document guidance.

General Information — prior authorization entries

How to obtain prior authorizationSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, or call 800-600-9007, or fax 877-310-3826.

Use for listed servicesThis process applies to multiple listed services (injectable medications, surgeries, DME, genetic tests, etc.) as shown in the document code lists.

Out-of-network providersOut-of-network providers must request prior authorization for all procedures and services except emergent/urgent care.

Inpatient admission / notification

Notification requirementNotification is required for inpatient admissions.

Post-acute facilitiesPrior authorization and notification of admission date are required for acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long-term acute care hospitals, and skilled nursing facilities.

Provider actionObtain prior authorization and notify UnitedHealthcare of the admission date for services at the listed post-acute facilities.

post-acute inpatient services — includes acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long-term acute care hospitals, skilled nursing facilities

ScopeIncludes acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long-term acute care hospitals, and skilled nursing facilities for post-acute inpatient services.

Admission handlingProviders must obtain prior authorization and notify UnitedHealthcare of the admission date for these facility types.

Related servicesJoint replacement and other major inpatient procedures listed elsewhere also require prior authorization for these settings.

Advanced outpatient imaging notification

Notification responsibilityCare providers ordering advanced outpatient imaging procedures are responsible for providing notification prior to scheduling the procedure.

How to requestRequest prior authorization via the Prior Authorization and Notification tool on the Provider Portal or call 866-889-8054.

More infoFor details and CPT codes that require prior authorization, visit UHCprovider.com/PAcommunityplan > Prior Authorization and Notification Resources > Radiology Prior.

Site of service (SOS) prior authorization

SOS ruleSite-of-service prior authorization is required only when requesting the service in an outpatient hospital setting; it is not required when the same service is performed at a participating ambulatory surgical center in some cases.

ExamplesDocument cites procedures (e.g., CPT 69205, 36590, 64721, 36832) with SOS applicability noted.

Provider actionConfirm the service location; if outpatient hospital setting, obtain prior authorization per SOS guidance.

*SOS

SOS applies noteCertain CPT codes are marked '*SOS also applies' indicating site-of-service prior authorization considerations for those procedures.

ExamplesSleep apnea and related procedure codes are among those noted with SOS applicability in the document.

ImplicationWhen '*SOS' is shown, providers should verify whether the outpatient hospital site triggers prior authorization.

Transplant Case Management Team

Team contactFor transplant and CAR T-cell therapy services, call the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246.

ScopeIncludes transplant and CAR T-cell therapy services listed (e.g., ide-cel, liso-cel, tisagenlecleucel, brexucabtagene autoleucel, axicabtagene ciloleucel).

AlternativeAlso use the notification number on the member's ID card as indicated in the document.

VAD

VAD requirementVentricular assist devices (VAD) require prior authorization; providers must call the notification number on the member's ID card and fax the form provided by the nurse to Optum VAD.

Representative CPTsDocument lists VAD procedure codes such as 33927, 33928, 33929, 33975-33982.

Provider actionFollow the call-and-fax notification process described for authorization of VAD services.

Wound vac

Wound vac requirementWound vacuum therapy (wound vac) requires prior authorization; the device is listed as HCPCS E2402.

CodeWound vac device HCPCS code E2402 is specifically cited.

ActionObtain prior authorization prior to obtaining/using the wound vac device per the document instructions.