The following coverage rules summarize orthotics/prosthetics/stimulators and associated coding references and prior authorization requirements. Consolidated coding lists below are extracted from the source and indicate services that typically require prior authorization or notification. When a retail purchase or cumulative rental cost exceeds $1,000 prior authorization is required. For device implantations and neurostimulators, refer requests to the health plan contracted vendor or the phone numbers listed on the member's ID card.
Orthotics/prosthetics prior authorization threshold: Prior authorization is required for orthotics and prosthetics when the retail purchase or cumulative rental cost is > $1,000. (See member ID card phone number for plan-specific submission instructions.)
Durable medical equipment (DME): All requests for DME should be directed to a health plan contracted vendor. For more information call the number on the member's health plan ID card. Advance notification is required for out-of-network dialysis referrals and for certain inpatient/outpatient admissions related to ESRD.
Neurostimulators and implanted devices: Implantation of neurostimulator devices (codes include 61850, 61863, 61864, 61867) and similar implanted stimulators should be directed to a health plan contracted vendor; prior authorization is required for many stimulators (including bone growth stimulators 20974, 20975, 20979).
Ventricular assist devices (VADs): Prior authorization/notification required. Contact Optum VAD Case Management at 888-936-7246 or the notification number on the member's ID card for authorization and case management. Relevant procedure codes include 33975, 33976, 33979, 33981, 33982, 33983, 33927-33929.
Prosthetics coding references: Examples of prosthetic HCPCS/Codes called out include L5301, L5987, L5856, L5968, L5981; prior authorization required when purchase/rental threshold exceeded.
Orthotics / surgical implant code references: Source lists numerous surgical and implant-related codes referenced in orthotics/related services including 20931, 20939, 22854, 64590, 63650, and others; when these services involve prosthetic/orthotic devices or implants, prior authorization or vendor coordination may be required.
Cellular and gene therapies and unclassified/temporary codes: Many cellular and gene therapies and unclassified codes require prior authorization; referenced codes include 0537T, 0538T, 0539T, 0540T, C9098, J3393, J3394, J9999, Q2041-Q2056, C9399, J3490, J3590 (see notes that certain codes such as 38232 require prior auth only for oncology diagnoses).
Vein and vascular procedures: Vein procedures such as saphenous vein ablation/removal (e.g., 37243, 37799) require prior authorization. Cardiology/vascular services may have mixed prior authorization stance depending on diagnosis codes; consult plan-specific lists and diagnosis-driven rules.
How to obtain prior authorization: For most items submit requests through the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call the phone number on the member's health plan ID card. WellMed groups use the WellMed provider portal (eprg.wellmed.net) or specified WellMed phone numbers for listed groups.