CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida

Lists prior authorization requirements and submission instructions for participating providers in the Preferred Care Network and Preferred Care Partners of Florida plans; affects in-network providers serving members of the listed groups and plans.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone to the listed network numbers.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2ways to submit prior authorization

2025-01-01policy effective date

multipleplan groups listed

$1,000orthotics PA threshold

requiredinjectable chemo notification

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.

Prior Authorization Coverage Criteria

Orthotics — Prior Authorization and Notification Requirements

Prior authorization and notification rules for orthotics, prosthetics, and related durable medical equipment (DME). Consolidated guidance and thresholds from the source.

Prior authorization is required for orthotics when the retail purchase price or the cumulative rental cost exceeds $1,000.

All requests for durable medical equipment (including orthotics and prosthetics) should be directed to a health plan contracted vendor. For more information, call the number on the member's health plan ID card.

Prior authorization is required for prosthetics and certain HCPCS codes as noted in plan-specific vendor guidance (example codes in source: L5301, L5987, L5856, L5968, L5981).

Advance notification is required when a network provider directs a member to an out-of-network facility, physician, or other care provider and the member's benefit plan does not include out-of-network benefits; this may affect coverage for orthotics/DME.

Certain complex services and technologies (e.g., cellular and gene therapy, transplant-related services, unclassified/temporary codes) may require prior authorization; when orthotics are part of such services, follow the specific authorization process referenced for those services.

Some orthotics/prosthetics-related items or procedures (including select CPT/HCPCS/unclassified codes and certain transplant-related codes) have specific prior authorization requirements or exceptions — contractors should verify code-specific rules via the plan's prior authorization vendor or the Optum notification numbers where provided.

When orthotics are provided via rental, cumulative rental cost should be tracked; prior authorization is required once the cumulative rental exceeds $1,000.

For ventricular assist devices (VAD) and other high-cost devices/procedures that may interact with orthotic/prosthetic care, contact the designated case management or notification teams (e.g., Optum VAD Case Management at 888-936-7246) to obtain authorization and coordination.

Operational note: Your agreement with Preferred Care Network or Preferred Care Partners may include additional restrictions on referring members outside the network; using in-network providers helps members avoid higher out-of-pocket costs.

CPT/HCPCS/ICD-10 and Drug Codes

Spinal surgery — Covered CPTCPTCovered

20930	Allograft, morselized or placement of osteopromotive material, for spine surgery
20931	Allograft, structural, for spine surgery
20939	Packing of bone graft substitute, spine
22854	Insertion of interbody biomechanical device(s) (e.g., structural allograft) with integral anterior instrumentation for spine

How Providers Must Submit and Notify

Prior Authorization

Online submission — Use UHC Provider Portal

Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) by signing in with a One Healthcare ID and selecting the Prior Authorization and Notification tab.

Go to UHCprovider.com, click Sign In, use One Healthcare ID.
Select the Prior Authorization and Notification tab on your dashboard.

Prior Authorization

Phone submission — Network contact numbers

Submit prior authorization requests by phone using the numbers provided for each network: Preferred Care Network at 866-273-9444 and Preferred Care Partners at 800-995-0480.

Preferred Care Network: Call 866-273-9444
Preferred Care Partners: Call 800-995-0480

Definitions and Reference Notes

Prior authorization

DefinitionPrior authorization: a health plan process requiring providers to obtain plan approval before delivering specific services or supplies listed in this policy.

When requiredRequired for services and codes enumerated in this document except where the policy explicitly states 'no prior authorization required' (for example emergency/urgent care).

How to submitSubmit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone using the numbers listed in this policy.

Plans with referral requirements — 'Referral Required'

ID card indicatorIf a member's health plan ID card states 'Referral Required', certain services may also require a PCP referral in addition to prior authorization.

Where to find details

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone to the listed network numbers.

SourceLink

On This Page

Prior Authorization

Emergency/urgent care — No prior authorization required

Prior authorization is not required for emergency or urgent care services; do not submit routine prior authorization for these encounters.

Prior Authorization

WellMed submission for select groups

For the specified WellMed groups, submit prior authorization requests via the WellMed provider portal (eprg.wellmed.net) or by calling 877-299-7213, 8 a.m.–5 p.m. ET, Monday–Friday.

WellMed provider portal: eprg.wellmed.net
Phone: 877-299-7213 (8 a.m.–5 p.m. ET, M–F)

Documentation Required

Referral requirement — PCP referral may also be needed

If a member’s ID card indicates 'Referral Required', some services may also require a PCP referral in addition to prior authorization; follow the UnitedHealthcare Care Provider Administrative Guide for referral details.

Check the member’s health plan ID card for 'Referral Required'.
Obtain PCP referral when required in addition to prior authorization.

Prior Authorization

Cardiology services — Mixed prior authorization status

Cardiology entries in this document show mixed authorization status: some cardiology services are noted 'Prior authorization no longer required' while other cardiology or vascular procedures (and diagnosis-linked items) still require prior authorization.

Some cardiology services: 'Prior authorization no longer required'.
Other cardiology/vascular procedures and diagnosis-linked items remain subject to prior authorization.

Note

Diagnosis and CPT/HCPCS placeholders — Preferred Care Partners

The Preferred Care Partners section lists numerous ICD‑10 diagnosis codes alongside placeholders for CPT or HCPCS procedure codes to be used in prior authorization processing (e.g., I70.239, I70.241, I70.242).

Diagnosis code examples: I70.239, I70.241, I70.242 appear with CPT/HCPCS placeholders.
Use the documented ICD‑10 entries when submitting authorizations for Preferred Care Partners.

Note

Additional diagnosis codes — Preferred Care Partners

Additional ICD‑10 diagnosis codes are listed in the Preferred Care Partners entries and are shown in proximity to CPT/HCPCS placeholders for authorization (see I70.235, I70.238/I70.243 examples).

Example additional codes: I70.235, I70.238, I70.243.
These diagnosis codes are presented alongside procedure code placeholders for PA processing.

Note

Diabetes-related ICD-10 codes — Linked to peripheral vascular codes

Diabetes-related ICD‑10 codes for peripheral angiopathy (E08.52, E09.52, E10.52, E11.52, E13.52) appear in the document near peripheral vascular/I70.* codes and should be used when linking diagnoses to prior authorization submissions.

Diabetes with peripheral angiopathy codes: E08.52, E09.52, E10.52, E11.52, E13.52.
These are listed in proximity to I70.x peripheral vascular diagnosis codes.

Note

Diagnosis code references — Preferred Care Partners (partial)

Preferred Care Partners entries reference multiple ICD‑10 diagnosis codes (partial listing shown in this extract) and reference CPT/HCPCS groupings; use the ICD‑10 list when preparing prior authorization requests for these groups.

Partial ICD‑10 examples included: I70.233, E09.52, E10.52, I70.222, I70.231.
CPT/HCPCS groupings are indicated as placeholders in the extract.

Note

Cardiovascular diagnosis groupings — I70.* listings

An extensive set of I70.* cardiovascular diagnosis codes is enumerated in the Preferred Care Partners section and is associated with related CPT/HCPCS groupings for prior authorization purposes; include the appropriate I70.x code when applicable.

Examples include I70.249, I70.261–I70.269, I70.321–I70.345, I70.348–I70.449 (and others listed).
These I70.* codes map to cardiovascular/peripheral vascular services in the authorization listings.

Documentation Required

Injectable chemotherapy — Outpatient notification required

Notification is required for outpatient-administered injectable chemotherapy drugs billed under J‑codes (J9000–J9999), leucovorin/levoleucovorin (J0640/J0641/J0642), Q‑codes, or miscellaneous HCPCS when unassigned.

Chemotherapy injectable drugs (J9000–J9999) require notification.
Leucovorin/levoleucovorin (J0640/J0641/J0642) and Q‑coded or misc. HCPCS injectables also require notification.

Prior Authorization

ESRD/dialysis — Advance notification required

Advance notification is required for end‑stage renal disease (ESRD) and outpatient dialysis services; contact the Kidney Resource Service to enroll or refer Medicare members as directed (phone: 866-561-7518).

ESRD/outpatient dialysis services require advance notification.
Kidney Resource Service phone: 866-561-7518 (for Medicare member enrollment/referral).

Prior Authorization

Gender dysphoria — Prior authorization/notification required

Prior authorization is required for gender dysphoria treatments and for specified CPT/HCPCS procedure codes when submitted with diagnosis codes F64.* or Z87.890; notification or prior authorization applies as listed.

Gender dysphoria treatments: Prior authorization required.
Certain procedure codes also require notification or prior authorization when submitted with F64.* or Z87.890.

Billing Rule

DME routing — Use contracted vendor and ID card number

All requests for durable medical equipment (DME) must be directed to a health plan contracted vendor; call the number on the member’s health plan ID card for vendor and routing information.

Direct all DME requests to a contracted vendor.
Call the number on the member’s ID card for more information.

Prior Authorization

Procedure PA requirements — Reconstructive/cosmetic procedures

Many reconstructive and cosmetic procedures, and numerous CPT/HCPCS codes listed across this document, require prior authorization — follow the listed 'how to obtain prior authorization' notes for each procedure.

Reconstructive procedures that treat a medical condition require prior authorization as noted.
Refer to the specific CPT/HCPCS 'how to obtain prior authorization' entries in the document.

Prior Authorization

Procedure and DME PA notes — Hysterectomy and DME exceptions

Certain procedures and DME have specific prior authorization notes in the document (for example, listed inpatient vaginal hysterectomy codes apply to inpatient only and outpatient vaginal hysterectomies do not require prior authorization).

Inpatient vaginal hysterectomy codes listed for inpatient prior authorization; outpatient vaginal hysterectomies: no prior authorization required.
DME prior authorization applies only for members residing and receiving services in Alabama and Georgia as noted.

Billing Rule

Injectable medication codes — Use listed HCPCS/J‑codes

Additional injectable medication codes and line‑items are listed in the document (see J1302 and the broader HCPCS/J‑code lists) — include the exact HCPCS/J code when submitting an authorization for injectable medications.

Example listed injectable code: J1302.
Refer to the HCPCS/J‑code lists in the injectable medications section when submitting prior auth.

Prior Authorization

How to submit prior authorization — Portal or phone

To submit a prior authorization, use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (select Prior Authorization then Specialty Pharmacy) or call 888-397-8129; naviHealth manages certain authorizations (Phone: 855-851-1127; Fax: 844-244-9482).

Provider Portal: uhcprovider.com → Prior Authorization → Specialty Pharmacy
Phone for submissions: 888-397-8129
naviHealth contact: Phone 855-851-1127, Fax 844-244-9482

Prior Authorization

Admission and out‑of‑network notification — Post‑acute services

Notification and prior authorization of the admission date is required for post‑acute inpatient services (acute care hospitals, acute inpatient rehabilitation, LTAC, critical access hospitals, and skilled nursing facilities); advance notification is also required when directing a member to an out‑of‑network provider.

Post‑acute inpatient admissions require notification and PA of admission date.
Advance notification required if a network provider directs a member to an out‑of‑network provider or to request in‑network cost sharing due to no available in‑network providers.

Prior Authorization

Orthotics — PA required over $1,000

Prior authorization is required for orthotics when the retail purchase or the cumulative rental cost exceeds $1,000.

Threshold: retail purchase or cumulative rental cost > $1,000 triggers PA requirement.

Prior Authorization

Non‑emergency air transport — Prior authorization required

Prior authorization is required for non‑emergency air transport and non‑urgent ambulance transportation by air; the document lists related codes (e.g., A0430–A0436) and indicates PA is required.

Non‑emergency air transport requires prior authorization.
Example HCPCS codes listed: A0430, A0431, A0435, A0436.

Prior Authorization

Orthotics — PA threshold reminder

Orthotics prior authorization threshold reiterated: prior authorization is required for retail purchases or cumulative rental costs exceeding $1,000.

PA threshold: > $1,000 retail or cumulative rental cost.

Prior Authorization

Proton beam therapy — PA required (listed codes)

Proton beam therapy requires prior authorization; example CPT codes listed include 77520, 77522, 77523, and 77525.

Proton beam therapy CPT codes: 77520, 77522, 77523, 77525.
Prior authorization required for proton beam therapy.

Prior Authorization

Radiation therapy — Prior authorization no longer required (selected codes)

The document notes a change for radiation therapy where prior authorization is no longer required for certain radiation therapy services (examples: IGRT codes 77014, 77387, G6017 and IMRT references).

Radiation therapy example codes: IGRT 77014, 77387, G6017.
Entry records 'Prior authorization no longer required' for radiation therapy in this section.

Prior Authorization

Neurostimulator/device implantation — PA and vendor routing

Implantation of neurostimulators and related devices that send electrical impulses requires prior authorization and requests should be directed to a health plan contracted vendor; multiple neurostimulator procedure codes (e.g., 61850, 61863, 61864, 61867) and equipment HCPCS (E0748, E0749, E0760) are listed.

Contact the contracted vendor (phone number on member’s ID card) for device/implant requests.
Example procedure codes: 61850, 61863, 61864, 61867; equipment codes: E0748, E0749, E0760.

Prior Authorization

Transplant services — Mixed prior authorization status

Transplant services entries show mixed authorization status: several transplant‑related services are noted 'Prior authorization no longer required' while other transplant codes remain listed and, in some entries, prior authorization is required.

Some transplant entries: 'Prior authorization no longer required.'
Other transplant-related codes remain listed and may require prior authorization per entry-specific notes.

Prior Authorization

Pain management — PA required for listed codes

Pain management procedures (for example codes 62350–62361, 62360, 62351) require prior authorization as listed in the document.

Pain management example codes: 62350–62361, 62360, 62351.
Prior authorization required for these pain management procedure codes.

Note

Transplant code notes — Follow code‑specific PA annotations

Selected transplant-related codes include entries annotated both 'Prior authorization no longer required' and 'Prior authorization required' — follow the code‑specific notes in the document when preparing authorizations.

Examples of codes with 'no longer required' notes: entries around 64568/64590.
Examples of codes annotated as 'Prior authorization required': S2061, 38242 and others.

Prior Authorization

Transplant codes — Examples annotated as PA required

Several transplant‑related CPT codes are explicitly annotated as requiring prior authorization (for example 32853, S2061, 38242 in entries shown); always check the entry-specific requirement.

Listed examples annotated as requiring PA: 32853, S2061, 38242.
Verify the code‑specific annotation before submission.

Prior Authorization

Cellular and gene therapy — PA reference and code guidance

The document references cellular and gene therapy services and lists specific temporary and permanent codes for which prior authorization is required; follow the cellular/gene therapy entries when submitting authorizations.

Cellular/gene therapy example codes: 0537T, 0538T, 0539T, 0540T, C9098 and various Q‑codes.
Code 38232 noted to require PA only for an oncology diagnosis.

Billing Rule

Orthotics — Code list reference (repeat listings)

Orthotics codes and related CPT/HCPCS procedure codes are repeatedly listed throughout the section (examples include 32855, 33933, 38208–38214); include the specific CPT/HCPCS code when requesting prior authorization or submitting claims.

Frequent orthotics procedure examples: 32855, 33933, 38208–38214.
Use the specific listed codes when preparing PA requests or claims.

Billing Rule

Orthotics — CPT/HCPCS codes for PA and billing

Orthotics-related CPT/HCPCS codes appear as examples and are used to determine prior authorization and claims submission (listed codes include 32855, 33933, 38208, 38209, 38210).

Examples: 32855, 33933, 38208, 38209, 38210.
These codes are referenced when determining PA and billing for orthotics.

Billing Rule

HCPCS S‑codes — S2060/S2061 usage

Commonly referenced HCPCS S‑codes (for example S2061 and S2060) are listed multiple times in the orthotics/device sections; include the correct HCPCS S‑code on authorizations and claims.

HCPCS S‑codes referenced frequently: S2061, S2060.
Use these HCPCS S‑codes where applicable on PA submissions and claims.

Prior Authorization

Procedure codes — Follow 'how to obtain prior authorization' notes

Various CPT/HCPCS procedure codes in this section include 'how to obtain prior authorization' notes; follow the listed instructions for those specific codes when requesting prior authorization.

Examples with PA instructions: 38215, 38232 (38232 requires PA only for an oncology diagnosis), 44137, 44715, 47133, 50325.
For cellular and gene therapy codes, follow the 'Cellular and gene therapy' PA instructions.

Prior Authorization

Unclassified drug codes & vein procedures — PA required

Unclassified drug codes (e.g., C9399, J3490, J3590) and vein procedure codes (e.g., 37243, 37799) are flagged as prior authorization required; vein removal/ablation procedures specifically require prior authorization.

Unclassified drug codes listed: C9399, J3490, J3590 (used for certain cellular/gene therapies).
Vein procedure examples requiring PA: 37243 (ablation) and 37799 (removal/other).

Prior Authorization

VAD — Contact Optum VAD Case Management for PA

Ventricular assist devices (VAD) prior authorization/management requires contacting the Optum VAD Case Management team at 888-936-7246 or using the notification number on the back of the member’s health plan ID card.

Optum VAD Case Management: 888-936-7246
Also use the notification number on the member’s health plan ID card.

See the UnitedHealthcare Care Provider Administrative Guide for referral process details for commercial and Medicare Advantage plans.

ImplicationTreating physician must obtain prior authorization and, when required, the PCP referral before performing certain in-network services.

Cardiology services

ScopeCardiology services: the document lists numerous cardiovascular diagnoses (I70.*) and related entries mapped to cardiology/vascular procedures for Preferred Care Partners.

Variation in PA statusSome cardiology services are annotated as 'Prior authorization no longer required' while other cardiology services or diagnosis-linked procedures require prior authorization.

Coding examplesCPT examples such as 37224 and 37228 appear alongside I70.* diagnosis groupings in the cardiology entries.

CPT/HCPCS placeholders — usage

PurposeCPT/HCPCS placeholders indicate locations in the document where specific procedure (CPT) or supply (HCPCS) codes should be listed alongside ICD-10 diagnosis codes for prior authorization processing.

UsagePlaceholders are used repeatedly in the Preferred Care Partners sections to map diagnosis code groupings to the CPT/HCPCS code lists used for authorization decisions.

NoteThe extract contains many placeholders but not all specific CPT codes are present in this partial document segment.

Diabetes with peripheral angiopathy — referenced ICD-10 codes

Codes listedE09.52, E10.52, E11.52, E13.52

ContextThese ICD-10 codes represent diabetes with peripheral angiopathy and are referenced in proximity to I70.* peripheral vascular diagnoses in the Preferred Care Partners entries.

ImplicationWhen these diabetes secondary codes are present with listed vascular diagnoses, authorization status for related vascular procedures may be affected as noted in the policy.

Preferred Care Partners

LabelPreferred Care Partners (plan reference)

UseDenotes the plan group for which the listed prior authorization requirements and code mappings apply in this document extract.

Relation to codesPreferred Care Partners sections enumerate ICD-10 and CPT/HCPCS groupings used for prior authorization processing for those plan groups.

Advance notification

DefinitionAdvance notification: providers must notify the health plan in advance for specified services (for example, end-stage renal disease/outpatient dialysis services).

Distinction from PAAdvance notification is separate from prior authorization and applies when the plan requires the health plan to be informed before services (e.g., ESRD/dialysis).

ContactTo enroll or refer a Medicare member to the Kidney Resource Service, call 866-561-7518 as noted in the policy.

Chemotherapy notification (outpatient injectable chemotherapy)

DefinitionChemotherapy notification: outpatient-administered injectable chemotherapy drugs billed under J-codes (J9000-J9999), Q-codes, or miscellaneous HCPCS require notification to the health plan.

ExamplesIncludes leucovorin (J0640) and levoleucovorin (J0641, J0642) and other injectable chemotherapy agents listed in the J-code ranges.

Submission instructionFor prior authorization or notification, submit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by the phone numbers provided.

DME prior authorization geographic limitation

Geographic limitationPrior authorization for durable medical equipment (DME) is required only for members residing in and receiving services in Alabama and Georgia.

RoutingAll DME requests must be directed to a health plan contracted vendor; call the number on the member's health plan ID card for details.

ReferencePolicy notes show DME routing and geographic PA limitation in the DME section of the document.

Hysterectomy prior authorization note

RuleOutpatient vaginal hysterectomies do not require prior authorization.

ScopeThe listed hysterectomy CPT codes in the document (for example 58180, 58541, 58260 series) apply to inpatient vaginal hysterectomy entries only.

ImplicationWhen submitting authorizations or claims, do not request PA for outpatient vaginal hysterectomy procedures per this policy excerpt.

Prior Authorization and Notification tool (UnitedHealthcare Provider Portal)

Tool namePrior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com).

How to accessSign in with One Healthcare ID, then select the Prior Authorization and Notification tab on the portal dashboard to submit requests.

Alternate phonePhone submission options (see policy) are available for plan-specific contacts and specialty lines when noted.

Post-acute inpatient services

Included servicesPost-acute inpatient services requiring notification or authorization include: acute care hospitals, acute inpatient rehabilitation (AIR), critical access hospitals, long-term acute care hospitals (LTAC), and skilled nursing facilities (SNF).

Admission requirementNotification and prior authorization of the admission date are required for these post-acute inpatient facilities as noted in the policy.

ExclusionsCertain plans (UnitedHealthcare Assisted Living Plans and UnitedHealthcare Nursing Home plan) are excluded from the SNF prior authorization requirement as listed.

Contracted vendor referral for device requests

DirectionRequests for certain devices and implantable neurostimulators should be directed to a health plan contracted vendor; contact number is on the member's health plan ID card.

Neurostimulator noteImplantation of devices that send electrical impulses (neurostimulators) requires prior authorization and routing to the contracted vendor as indicated in the orthotics/device entries.

Where to callUse the vendor contact number printed on the back of the member's ID card for device/implant requests.

Out-of-network advance notification

When requiredAdvance notification is required when a network provider directs a member to an out-of-network provider and the member's benefit plan does not include out-of-network benefits, or when requesting in-network cost sharing due to no available in-network provider.

PurposeAdvance notification helps determine coverage and potential out-of-pocket costs for members directed to out-of-network care.

Relation to admissionsAdvance notification requirement appears alongside post-acute inpatient admission and out-of-network service rules in the policy.

Cellular and gene therapy services

Category referenceCellular and gene therapy services are identified in the code lists as a category for which prior authorization is required (examples include temporary and T-code listings shown).

How listedSpecific CPT/HCPCS and temporary codes (e.g., 0537T–0540T, C9098, J3393/J3394, Q2041–Q2056) are called out under the cellular and gene therapy entries.

ImplicationProviders must follow the policy's prior authorization instructions for cellular and gene therapy codes when submitting requests.

Orthotics code list — repeated CPT/HCPCS codes

Section purposeOrthotics code list: this section enumerates repeated CPT/HCPCS codes associated with orthotics and related procedures across the policy extract.

RepetitionCodes such as 32855, 33933, 38208–38214 appear repeatedly in the orthotics entries, indicating a raw code listing rather than narrative criteria.

UsageThese code lists are used to determine when orthotics-related prior authorization is required per the policy's monetary threshold and other rules.

Orthotics codes (shorthand reference)

ShorthandOrthotics codes — refers to the repeated listing of specific CPT/HCPCS procedure and supply codes (examples: 32855, 33933, 38209, 38214).

FunctionServes as a shorthand reference within the orthotics section to the detailed code lists repeated throughout the document.

Cross-referenceUse this shorthand when checking the orthotics monetary threshold and PA requirements elsewhere in the policy.

CPT/HCPCS codes — orthotics section

DefinitionCPT/HCPCS codes: procedure and supply codes cited throughout the orthotics section to identify billable services and items requiring authorization.

ExamplesExamples include 32855, 33933, 38208–38214, and HCPCS S‑codes such as S2060/S2061 referenced in orthotics contexts.

RoleThese codes drive prior authorization determination, claims processing, and routing to contracted vendors when applicable.

Ventricular assist devices (VAD)

DefinitionVentricular assist devices (VAD): a mechanical pump that takes over the function of the damaged ventricle of the heart; entries for VAD require special prior authorization contact procedures.

How to obtain authorizationPlease call the Optum VAD Case Management team at 888-936-7246 or the notification number on the back of the member's health plan ID card for VAD prior authorization/management.

Codes referencedVAD-related CPT/HCPCS codes (for example entries include 33975, 33976, 33979, 33981–33983) are listed in the orthotics/device sections and tied to the special contact requirement.

Unclassified drug codes**

NoteUnclassified drug codes: the policy flags unclassified/temporary drug codes (for example C9399, J3490, J3590) and indicates they are subject to prior authorization handling.

ContextThese unclassified codes are listed in the orthotics/cellular/gene therapy sections where miscellaneous or not-yet-assigned agents may be billed under J3490/J3590/C9399.

ImplicationWhen a drug lacks an assigned permanent code, providers should follow the policy's instruction to submit PA requests for unclassified codes as noted.