CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP

Lists services, procedures and drugs that require prior authorization for participating providers in the UnitedHealthcare Community Plan of Pennsylvania CHIP and explains how to submit requests; applies to inpatient and outpatient participating and out-of-network providers.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb. 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, by phone (800-600-9007), or by fax (877-310-3826).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-02-01effective date

portal/phone/faxsubmission methods

>$500DME PA threshold

888-936-7246transplant contact

manycode examples

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.

Coverage criteria and services requiring prior authorization

Prior authorization criteria examples

Selected services and medications explicitly noted as requiring prior authorization in this section.

Abortion procedures require prior authorization; example CPT codes include 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, 59866.

Bariatric surgery and specific obesity-related services require prior authorization; example CPT codes include 43644, 43645, 43659.

Behavioral health services: for specific codes requiring prior authorization, providers should call the number on the back of the member's health plan ID card when referring for mental health and substance use services.

Cancer supportive care injectable drugs (colony-stimulating factors and bone-modifying agents) administered in an outpatient setting for a cancer diagnosis require prior authorization; example J/Q codes: J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125. These codes also require prior authorization when used for non‑oncology diagnoses (see Injectable medications section).

Bone growth stimulators (electrical stimulation/ultrasound to heal fractures) require prior authorization (example CPT codes 20975, 20979).

BRCA genetic testing requires prior authorization (example CPT code 81162).

Extracted coverage criteria (partial)

Prior authorization requirements shown for specific inpatient and outpatient services.

Cerebral seizure monitoring — inpatient video (e.g., CPT 95700, 95711–95713): prior authorization required for inpatient services.

Chemotherapy — injectable chemotherapy drugs administered in an outpatient setting for a cancer diagnosis: prior authorization required.

Cochlear implants and other auditory implants require prior authorization; examples include CPT/HCPCS 69710, 69714, 69930, L8619, L8690, L8691; submission via portal or phone is indicated.

Continuous glucose monitor (CGM) supplies/devices require prior authorization when used with a type 2 diabetes diagnosis; example HCPCS codes include A4226, A9278, A4239, E0787, A9276, E2102.

Cosmetic procedures that change or improve appearance without medical benefit require prior authorization; reconstructive procedures that treat a medical condition are listed with CPT codes and prior authorization guidance.

Antiemetics prior authorization code list (partial)

This section lists codes and notes on how to obtain prior authorization for antiemetics and related reconstructive procedures; additional information fields are blank in this extract.

Reconstructive / antiemetic‑related procedure codes referenced with prior authorization guidance include: 21230, 21256, 21280, 21282, 21295, 21740. (Entries in this extract repeat and some fields are incomplete.)

Coverage criteria (partial)

Coverage actions and requirements shown in this partial section

Durable medical equipment (DME): prior authorization is required for the listed DME codes when the retail purchase or cumulative rental cost exceeds $500 (example codes A9279, A9280, A9900, E0194, E0265–E0277, E0300, E0328–E0329, E0445, E0457, E0460, E0465, E0466, E0470–E0471, E0483, E0486, etc.).

Prosthetics are not considered DME; see orthotics and prosthetics guidance for applicable prior authorization rules (orthotics/prosthetics threshold applies separately).

Prior authorization criteria (partial)

Services listed below require prior authorization or notification per UnitedHealthcare Community Plan policies as indicated.

Enteral services and in‑home nutritional therapy (example HCPCS B4034, B4035, B4036, B4100, B4102–B4104, B4149–B4161, B9002) require prior authorization; gastrostomy tube codes are listed.

Genetic and molecular testing performed in outpatient settings requires prior authorization/notification (example codes 0018U, 0022U, 81163, 81164, 81439–81448, 81460, 81465, 81479, 81518–81522, 81546, 81595, 81599, 87505–87507, S3870); BRCA testing specifically requires notification/prior authorization before DNA sequencing and the ordering provider must notify the laboratory.

Durable medical equipment (listed V‑series codes e.g., V5269, V5274, V5281, V5282, V5283, V5286) require prior authorization as indicated.

Prior authorization and notification requirements

Prior authorization is required for listed injectable medications and select procedures; providers must follow code-specific prior authorization instructions where given.

Injectable medications: a broad list of J/Q HCPCS codes require prior authorization (examples include J3262, J0801, J7207, J7171, J7210, J1931, J7186, J7193, J7201, J7214, J1426, J0225, J0739, J0256, J0881, J2793, J3145, Q5121, J7195, and many others listed throughout the injectable medications sections).

Home health and hospice services delivered in outpatient/home settings require prior authorization (example G0156, G0162, G0299, G0300, G0493–G0496, S9122–S9124, S9474, T2045).

Hysterectomy procedures (CPT codes listed under the hysterectomy section) require prior authorization.

BRCA/genetic testing requires notification/prior authorization before DNA sequencing; the ordering provider and laboratory must notify UnitedHealthcare.

Prior authorization and notification criteria (selected from this extract)

This section enumerates procedures, transports, and orthotics/prosthetics that require prior authorization or notification.

Joint replacement procedures (total hip and knee and related codes) require prior authorization (examples appear in the joint replacement entries).

Non‑emergent air ambulance transport requires prior authorization (example codes A0430, A0431, A0435, A0436, S9960, S9961).

Orthotics and prosthetics: prior authorization is required only for orthotics/prosthetic codes with a retail purchase or cumulative rental cost greater than $500 (example L‑codes such as L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631, etc.).

Notification/authorization is required for inpatient admissions to post‑acute facilities (acute care hospital, acute inpatient rehab, critical access hospital, LTACH, skilled nursing facility) — facilities must notify and obtain authorization as indicated.

Unclassified/temporary codes C9399, J3490, J3590 require prior authorization only for specific products (Amtagvi, Lantidra, Lenmeldy, Skysona, Tecelra); CPT code 38232 requires prior authorization only for an oncology diagnosis per the transplants section.

Partial coverage criteria and submission instructions

Coverage stance and requirements noted in this section (partial):

Pediatric day services (PDHC) require prior authorization (example code T1024).

Private duty nursing requires prior authorization (example codes T1000, T1002, T1003).

Potentially Unproven Services and certain prostate procedures require prior authorization (examples shown).

Proton beam therapy requires prior authorization (example CPT codes 77520, 77522, 77523, 77525).

Providers should submit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com) or by phone (866‑889‑8054) as noted in this section; see Radiology Prior Authorization and Notification for radiology CPT/HCPCS guidance and site‑of‑service rules.

Prior authorization requirements (excerpt)

Services explicitly marked as requiring prior authorization in this excerpt:

Sleep apnea procedures and surgeries require prior authorization (example CPTs 21685, 41599, 42145).

Spinal surgery procedures require prior authorization (examples include CPTs 22100, 22101, 22102, 22110, 22112, 22114, 22206, 22207, 22210, 22212, 22214, 22220, 22224, 22510–22515, 22532–22533, etc.).

Transplant and drug-code special conditions

Transplants and certain codes:

Transplant‑related drugs and codes are subject to prior authorization; example transplant drug J3392–J3394 are listed and specific process notes apply.

CPT code 38232 will require prior authorization only for an oncology diagnosis (per the transplants section).

Unclassified codes C9399, J3490, J3590 require prior authorization for specific products (Amtagvi, Lantidra, Lenmeldy, Skysona, Tecelra) as noted.

For transplant and CAR T‑cell therapy services, 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 obtain authorization/notification guidance.

Device and procedure prior authorization

Device and procedure authorizations:

Stimulator implantation (including bone growth stimulators and neurostimulators) requires prior authorization (implantation device entries and related CPT/HCPCS references).

Ventricular assist devices (VAD) require prior authorization; providers should call the notification number on the back of the member's ID card and then fax the form provided by the nurse to Optum VAD per the instructions.

Wound vacuum therapy (wound VAC) requires prior authorization; device code E2402 is listed among wound vac entries.

Vein procedure prior authorization

Vein procedures:

Removal and ablation of the main trunks and named branches of the saphenous veins for venous disease/varicose veins requires prior authorization; listed CPT codes include 36468, 36473, 36475, 36478, 37700, 37718, 37722, 37765.

CPT, HCPCS, ICD-10 and other code lists

Covered CPT Codes (examples requiring prior authorization)CPTCovered

59840	Abortion procedure
59841	Abortion procedure
59850	Abortion procedure

Covered HCPCS/J-codes - Antiemetics & Colony-Stimulating FactorsHCPCSCovered

J1453	Fosaprepitant, 1 mg (Emend for Injection)
J1454	Fosnetupitant 235 mg and palonosetron 0.25 mg
J1627	Granisetron, extended-release
J1449	Eflapegrastim-xnst (Rolvedon)
J1442	Filgrastim (Neupogen)

ICD-10 Diagnosis Codes (mapped for antiemetics/related items)ICD-10

I74.3	Embolism and thrombosis of arteries of lower extremities
I74.4	Embolism and thrombosis of arteries of upper extremities
I74.5	Embolism and thrombosis of arteries, unspecified
I74.8	Other arterial embolism and thrombosis
I74.9	Arterial embolism and thrombosis, unspecified
I75.021	Atherosclerosis of native arteries of the extremities with rest pain, right leg
I75.022	Atherosclerosis... left leg

Example CPT/HCPCS Codes (mixed examples)mixed

69710	Cochlear implant related procedure
69714	Cochlear implant procedure
69930	Cochlear implant procedure
L8619	Cochlear implant external part (HCPCS L-code)
11960	Blepharoplasty, upper; repair of eyelid
15820	Blepharoplasty, lower; repair of eyelid
A4226	Replacement pump, insulin infusion
A9278	Continuous glucose monitor supply

Referenced CPT/HCPCS-like procedure codesCPT

21230	Reconstruction procedure (example)
21256	Reconstruction procedure
21740	Reconstructive procedure
21280	Reconstructive tissue transfer
21282	Reconstructive procedure
21295	Reconstructive procedure

Antiemetics CPT/HCPCS (selected)CPT

21280	Reconstructive tissue transfer (appears in antiemetics section)
21282	Reconstructive procedure
21295	Reconstructive procedure
21740	Reconstructive procedure

ICD-10 Mappings and Conversions (selected series)ICD-10

C43.0	Melanoma of skin, unspecified (mapped to detailed C43.x codes)
C44.01	Basal cell carcinoma of skin of lip (source) - mapped to C44.02/C44.09 etc.
C44.02	Basal cell carcinoma of skin of unspecified lip
C44.09	Basal cell carcinoma of skin of other lip sites
C44.101	Basal cell carcinoma of skin of unspecified eyelid, including canthus

E-series HCPCS Examples (DME/orthotics)HCPCS

E0194	Patient lift, fixed or mobile
E0265	Seat/positioning accessory
E0300	Manual wheelchair

Genetic / Molecular Testing Codes (require prior authorization)CPTCovered

0018U	Genetic/molecular test (example)
0022U	Genetic/molecular test (example)
81163	Genetic testing; therapeutic mutation analysis

Selected Injectable Drug HCPCS/J-codes (require prior authorization)HCPCSCovered

J7203	Rebinyn
J0896	Reblozyl
J3489	Reclast, Zoledronic Acid
Q5125	Releuko (filgrastim-ayow)
J1745	Remicade
Q5106	Retacrit
J1449	Rolvedon (eflapegrastim-xnst)
J2506	Pegfilgrastim (Neulasta)
Q5101	Filgrastim-sndz (Zarxio)
Q5108	Pegfilgrastim-jmdb (Fulphila)

Colony Stimulating Factors (require prior authorization)HCPCSCovered

J1449	Eflapegrastim-xnst (Rolvedon)
J1442	Filgrastim (Neupogen)
J1447	Tbo-filgrastim (Granix)
J2506	Pegfilgrastim (Neulasta)

Covered CPT/HCPCS Codes - Prior Authorization ExamplesCPTCovered

23470	Shoulder arthroplasty code (example)
24360	Shoulder procedure
27120	Total hip arthroplasty
27412	Knee procedure
29866	Arthroscopy procedure

Additional HCPCS / L-codes and drug J-codes listed (covered/neutral)HCPCSCovered

L0112	Orthotic/prosthetic code (example)
L0170	Orthotic/prosthetic code
L0456	Orthotic/prosthetic code
L0462	Orthotic/prosthetic code
L1755	Orthotic/foot insert

Orthotics / Prosthetics L-code examplesHCPCS

L5610	Prosthetic component
L5639	Orthotic component
L5640	Orthotic component
L5673	Prosthetic component
L5682	Prosthetic component
L5683	Prosthetic component

Selected Service Codes (PDHC, Private Duty Nursing, Potentially Unproven)HCPCS

T1024	Pediatric day health care (PDHC)
T1000	Private duty nursing
T1002	Private duty nursing
33289	Potentially Unproven Service example
C2624	Potentially Unproven Service example
S2112	Implantable device supply

Proton Beam Therapy CPT CodesCPT

77520	Proton beam therapy delivery
77522	Proton beam therapy delivery
77523	Proton beam therapy delivery
77525	Proton beam therapy delivery

Radiology / Advanced Imaging Codes (see Radiology Prior Authorization and Notification)CPT

30420	Rhinoplasty-related code (placeholder - see Radiology prior auth)
30430	Facial procedure code (placeholder)
30400	Cleft lip/palate code (placeholder)

Gynecologic / Female Genital System CodesCPT

57240	Vaginal suspension (example)
57250	Vaginal procedure
57461	Hysteroscopy procedure
57520	Uterine procedure
58561	Laparoscopic sterilization or other gyn procedure

Musculoskeletal / Arthroscopy CodesCPT

20552	Injection(s); single tendon sheath, or ligament, or ganglion cyst
20553	Similar injection(s)
29822	Arthroscopy, shoulder
29806	Arthroscopy, knee

Selected Spinal Surgery CPT Codes (partial list)CPTCovered

22100	Spinal fusion procedure example
22101	Spinal surgery code
22510	Spinal instrumentation
22630	Lumbar fusion
22800	Application of spinal instrumentation

Device, Transplant and CAR T/Gene Therapy Related CodesmixedCovered

63302	Neurosurgical procedure
0098T	Neuromodulation/implant code
Q2041	Transplant related HCPCS
C9399	Unclassified drug code (requires prior auth for certain therapies)
J3490	Unclassified drug code (requires prior auth for Amtagvi, others)

How providers obtain prior authorization and required notifications

Prior Authorization

How to submit prior authorization requests

Prior authorization is required for a number of provider actions and services. Submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal at UHCprovider.com (Sign in with your One Healthcare ID). If you do not have a One Healthcare ID, visit UHCprovider.com/access. You may also call 866-889-8054 (or 800-600-9007 for some services) 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. For inpatient admissions, notification of the admission date is required; prior authorization and admission date notification are required for acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long-term acute care hospitals and skilled nursing facilities.

Online: Prior Authorization and Notification tool on UHCprovider.com
Phone: 866-889-8054 or 800-600-9007 (as indicated)
Fax: 877-310-3826
Emergency/urgent care: prior authorization not required
Out-of-network providers: must request prior authorization

Prior Authorization

Definitions and explanatory notes

Prior authorization required

DefinitionPrior authorization is a pre-service approval process for listed services and codes; it is not required for emergency or urgent care.

Who must complyParticipating and out-of-network providers (out-of-network providers must request prior authorization for all procedures and services).

Submission methodsRequests may be submitted via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by phone, or by fax.

Cochlear implants and other auditory implants

DefinitionCochlear implants and other auditory implants: a medical device within the inner ear with an external portion to help persons with profound sensorineural hearing loss.

Codes shown as examples

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb. 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, by phone (800-600-9007), or by fax (877-310-3826).

SourceLink

On This Page

Site‑of‑service rule: prior authorization is required only when requesting certain services in an outpatient hospital setting; radiology prior authorization guidance applies as indicated.

Cardiology prior authorization requirement

Cardiology services performed in outpatient and office-based settings require prior authorization for certain procedures. This includes diagnostic cardiac catheterizations, electrophysiology (EP) procedures and implantable cardiac devices, and stress echocardiography when indicated. For details and the complete list of CPT/HCPCS codes requiring authorization, submit requests via the Prior Authorization and Notification tool on UHCprovider.com or call 888-397-8129 (Cardiology contact).

Prior authorization required for outpatient and office-based diagnostic catheterizations, electrophysiology implants and stress echoes
How to obtain: Prior Authorization and Notification tool at UHCprovider.com or call 888-397-8129
See Cardiology Prior Authorization and Notification for full CPT/HCPCS code list

Prior Authorization

Cerebral seizure monitoring - inpatient video

Prior authorization is required for inpatient video cerebral seizure monitoring (continuous inpatient EEG/video monitoring). Include the applicable CPT codes when requesting authorization.

Inpatient video cerebral seizure monitoring: prior authorization required
Example CPT codes: 95700, 95711, 95712, 95713

Prior Authorization

Chemotherapy (injectable outpatient)

Prior authorization is required for injectable chemotherapy drugs administered in an outpatient setting for a cancer diagnosis. This includes intravenous, intravesical and intrathecal administrations. Submit requests via the Provider Portal or call the prior authorization number indicated for injectable medications.

Outpatient injectable chemotherapy (IV, intravesical, intrathecal) for cancer diagnosis: prior authorization required
How to obtain: Prior Authorization and Notification tool at UHCprovider.com

Prior Authorization

Cosmetic and reconstructive procedures

Cosmetic procedures that change or improve physical appearance without significantly improving function require prior authorization. Reconstructive procedures performed to treat a medical condition or restore function also require prior authorization when indicated. Refer to the CPT/HCPCS codes below when submitting requests.

Cosmetic procedures (appearance-focused): prior authorization required
Example cosmetic CPT codes: 11960, 14020**, 14021**, 14061**, 15820, 15821, 15822, 15823, 15830, 15877, 15878*, 15879*
Reconstructive procedures (medical indication/function restoration): prior authorization required
Example reconstructive CPT codes: 21181, 21182, 21183, 21184, 21230, 21256, 21295, 21280, 21282, 21247, 21248, 21249

Prior Authorization

Additional procedure/Q-codes

Certain additional procedures and Q-codes require prior authorization. For many of these services, use the Provider Portal or call the prior authorization number listed. Examples include ophthalmologic and other procedure-specific codes — see the applicable specialty prior authorization pages for full code lists.

Additional procedure/Q-codes: prior authorization required as indicated
Example device/supply HCPCS: A4226, A9278, A4239, A9276, A9277
How to obtain: Prior Authorization and Notification tool at UHCprovider.com or call the specialty contact number

Prior Authorization

Procedures and surgical prior authorization

Many surgical procedures and specialty interventions require prior authorization. This includes, but is not limited to, spinal surgeries, sleep apnea surgeries, maxillofacial/jaw treatments for functional impairment, prostate procedures, femoroacetabular impingement surgery, functional endoscopic sinus surgery (FESS), and stimulator implantations. Verify the specific CPT codes and obtain authorization prior to scheduling.

Procedures and surgical services: prior authorization required (examples)
Spinal surgery: prior authorization required (example CPTs: 22100–22533 series as applicable)
Sleep apnea procedures and surgeries: prior authorization required
FESS (functional endoscopic sinus surgery) CPTs: 31240, 31253–31259 require prior authorization
Stimulator implantation: prior authorization required (example CPTs: 63655, 63685, 64553, 64555, 64568, 64570, 64590; device HCPCS L8680, L8682, L8685)

Prior Authorization

Home health and hospice prior authorization

Home health and hospice services require prior authorization. For home health in outpatient settings (including services provided in the member's home), obtain prior authorization before initiation. Hospice services also require prior authorization. Include the appropriate G- and S-codes when requesting authorization.

Home health services (outpatient/home): prior authorization required
Example home health codes: G0156, G0162, G0299, G0300, G0493–G0496
Hospice: prior authorization required (example code: T2045)
How to obtain: Prior Authorization and Notification tool at UHCprovider.com

Prior Authorization

Prior authorization for injectable medications

Many injectable medications and biologics require prior authorization prior to administration. This includes a comprehensive list of J- and Q-codes for specialty and supportive drugs. Use the Provider Portal to submit prior authorization requests or call 888-397-8129 when noted. Note special instructions for certain unclassified/temporary codes and product-specific exceptions.

Injectable medications (biologics, specialty drugs): prior authorization required
Examples (not exhaustive): J3262 (Actemra®), J0801 (Acthar®), J0881 (Aranesp), J1745 (Remicade®), J9312 (Rituxan®), Q5125 (Releuko®), J3489 (Reclast/Zoledronic Acid), J0896 (Reblozyl®), J7203 (Rebinyn)
How to obtain: Prior Authorization and Notification tool at UHCprovider.com or call 888-397-8129

Prior Authorization

Inpatient admission notification/authorization

Notification is required for hospital inpatient admissions. For certain post-acute inpatient facilities, both prior authorization and notification of the admission date are required. Verify and submit inpatient notifications/authorizations before or at the time of admission as applicable.

Inpatient admission: notification required for admissions
Prior authorization and admission date notification required for: acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long-term acute care hospitals, skilled nursing facilities
How to obtain: Provider Portal Prior Authorization and Notification tool or the inpatient notification phone numbers

Prior Authorization

Special notes on unclassified/temporary codes and J0897

Special notes apply to unclassified and temporary HCPCS/CPT codes and certain generic J-codes. Prior authorization is required for unclassified/temporary codes C9399, J3490 and J3590 only when used for specific products (for example, Nulibry™, Rivfloza, Revcovi, Amtagvi, Lantidra, Lenmeldy, Skysona, Tecelra, etc.). For J0897, prior authorization is required when used for non-oncology indications. Review the Review at Launch for New to Market Medications policy and the Review at Launch Medication List for up-to-date requirements; predetermination is highly recommended for new-to-market drugs.

Unclassified/temporary codes (C9399, J3490, J3590): prior authorization required only for specified products (e.g., Nulibry™, Rivfloza, Revcovi, Amtagvi, Lantidra, Lenmeldy, Skysona, Tecelra)
J0897: prior authorization required for non-oncology indications
See Review at Launch for New to Market Medications policy and Review at Launch Medication List
Predetermination recommended for drugs on the Review at Launch list

Prior Authorization

Site of service prior authorization note

Site-of-service rules may affect whether prior authorization is required. For some services, prior authorization is required only when the service is requested in an outpatient hospital setting (site-of-service (SOS) outpatient hospital). If the service is performed at a participating ambulatory surgery center (ASC) or other non-hospital setting, prior authorization may not be required. Check specialty prior authorization pages (for example Radiology Prior Authorization and Notification) for SOS-specific rules and code lists.

Prior authorization may be site-specific (required only when requested in an outpatient hospital setting)
Example: certain radiology procedures require authorization only when performed in an outpatient hospital — see Radiology Prior Authorization and Notification
Confirm site of service when submitting authorization requests

Prior Authorization

Transplant/CAR T-cell prior authorization contact

Transplant and CAR T-cell therapy services require coordination with UnitedHealthcare's transplant case management. Prior authorization and specialized case management are required. Providers should call the UnitedHealthcare Community and State Transplant Case Management Team per instructions on the member's identification card and follow the submission process provided by the transplant team.

Transplants and CAR T-cell therapy: prior authorization required
How to obtain: Call the UnitedHealthcare Community and State Transplant Case Management Team (see member ID card notification number) to initiate authorization and case management

Prior Authorization

Vein procedures and wound vac — prior authorization

Vein procedures (removal/ablation of saphenous trunks and named branches) and wound vacuum (wound vac) therapy require prior authorization. Example CPT codes for vein procedures include 36468, 36473, 36475, 36478, 37700, 37718, 37722, 37765. Wound vac therapy and related supplies (for example E2402) require prior authorization. Ventricular assist devices (VAD) also require prior authorization; follow the notification process on the member's ID card and fax required forms to Optum VAD as directed.

Vein procedures (saphenous removal/ablation): prior authorization required
Example CPTs for vein procedures: 36468, 36473, 36475, 36478, 37700, 37718, 37722, 37765
Wound vac therapy: prior authorization required (example HCPCS: E2402)
Ventricular assist devices (VAD): prior authorization required — call notification number on member ID card and fax Optum VAD forms

Example CPT/HCPCS entries associated with cochlear implants include 69710, 69714, 69930 and HCPCS L8619, L8690, L8691.

AuthorizationCochlear implants require prior authorization; portal submission is indicated in the policy.

Continuous glucose monitor

DefinitionContinuous glucose monitor (CGM): device and supplies listed with sample HCPCS codes (examples include A4226, A9278, A4239, E0787, A9276, E2102, A9277, E2103).

Prior authorization triggerPrior authorization required when used for Type 2 diabetes diagnosis (policy notes PA required with Type 2 diabetes).

CodesPolicy lists multiple CGM supply/device HCPCS codes as examples in the CGM section.

Antiemetics

DefinitionAntiemetics: entries in the policy reference antiemetic-related procedures and codes, often linked with reconstructive procedures and coding notes.

Coding contextPolicy lists multiple CPT/HCPCS procedure codes (e.g., 21230, 21256, 21280, 21282, 21295, 21740) in antiemetics/reconstructive sections.

DocumentationMany antiemetics entries include repeated 'how to obtain prior authorization' lines though additional fields are blank in the extract.

Antiemetics prior authorization listing

Listing notePolicy entries indicate CPT or HCPCS codes and 'how to obtain prior authorization' for antiemetics; several additional information fields are blank or repeated in the extract.

Example codesCodes repeatedly shown include 21280, 21282, 21295, 21740 among others.

Actionable guidanceFollow the policy's code-specific 'how to obtain prior authorization' directions where provided; some antiemetics entries may require portal submission per code instructions.

Prosthetics vs DME

DistinctionProsthetics are explicitly noted as not being classified as Durable Medical Equipment (DME) in this policy.

ImplicationProsthetic items follow orthotics/prosthetics guidance (separate threshold/PA rules) rather than DME rules.

Cross-referenceSee orthotics and prosthetics section for applicable PA thresholds and code lists.

Genetic/molecular testing prior authorization

RequirementGenetic and molecular testing performed in outpatient settings requires prior authorization or notification.

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

Coding examplesPolicy lists many U‑codes and molecular/genetic CPT/HCPCS codes (e.g., 0018U, 81163, 81445, 81439, 81440, 81445) associated with testing.

Enteral services prior authorization

Services coveredEnteral services and in-home nutritional therapy require prior authorization.

Example codesExamples of enteral and in-home nutrition codes listed include B4034, B4035, B4036, B4100, B4102, B4103, B4104, B4149, B4150 and others.

Gastrostomy noteGastrostomy tube codes (e.g., B4149, B4150) are included in the enteral services PA requirements.

BRCA testing notification

RequirementBRCA testing requires notification or prior authorization before DNA sequencing is performed.

ProcessThe ordering care provider must notify the laboratory conducting the test, and the laboratory will notify UnitedHealthcare per the policy.

Associated codesPolicy references BRCA-related molecular/genetic codes (e.g., 81439, 81440, 81445) in the genetic testing section.

Home health prior authorization

RequirementPrior authorization is required for home health services when provided in outpatient settings including the member's home.

Example codesListed home health codes include G0156, G0162, G0299, G0300, G0493–G0496 and S9122–S9124 among others.

Hospice noteHospice services also require prior authorization (e.g., T2045 listed).

Predetermination recommendation for Review at Launch Medication List

RecommendationPredetermination is highly recommended for drugs on the Review at Launch Medication List (per the Review at Launch policy).

Where to checkSee the Review at Launch for New to Market Medications policy for the most up-to-date list of newly approved FDA drugs included on the Review at Launch Medication List.

PurposePredetermination helps confirm coverage and PA requirements for new-to-market medications prior to prescribing/dispensing.

Review at Launch

DefinitionReview at Launch: the policy that contains the most up-to-date information on newly approved FDA drugs included on the Review at Launch Medication List.

Relation to PADrugs on the Review at Launch list may have specific prior authorization or predetermination guidance; check the Review at Launch policy for details.

ActionProviders should consult the Review at Launch policy before requesting prior authorization for new medications.

Proton beam therapy

DefinitionProton beam therapy: focused radiation therapy using beams of protons (tiny particles with a positive charge).

Prior authorizationPrior authorization is required for proton beam therapy and associated CPT codes (e.g., 77520, 77522, 77523, 77525).

Coding examplesPolicy explicitly lists CPT codes 77520, 77522, 77523, 77525 for proton beam therapy prior authorization.

Prior Authorization and Notification tool

ToolPrior Authorization and Notification tool: online submission tool on the UnitedHealthcare Provider Portal (UHCprovider.com) used to submit PA requests.

Alternate contactsPhone numbers referenced in the policy for PA submission/assistance include 800-600-9007, 888-397-8129 and 866-889-8054 (context-dependent in different sections).

Portal instructionsSign in with One Healthcare ID at UHCprovider.com and select the Prior Authorization and Notification tab on the dashboard to submit requests online.

Site of service (SOS)

DefinitionSite of service (SOS): the location category where a service is delivered (policy emphasizes outpatient hospital settings for certain PA requirements).

PA rule tied to SOSPrior authorization is only required when requesting certain services in an outpatient hospital setting; radiology PA/notification guidance applies for advanced outpatient imaging.

ExamplesPolicy lists SOS‑specific CPTs under outpatient hospital (e.g., gynecologic procedures) and refers to Radiology Prior Authorization and Notification for imaging codes.

Prior authorization

DefinitionPrior authorization required indicates that the listed procedure or code must be authorized by UnitedHealthcare prior to service.

ExamplesMany procedures and device codes in the policy are explicitly labeled 'Prior authorization required' (e.g., vein procedures, VADs, transplants, spinal surgery).

Provider actionProviders must obtain authorization before scheduling or delivering listed services unless the situation is emergent or urgent.

Transplant/CAR T-cell notification

Notification contactTransplant and CAR T‑cell therapy services require contacting the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 (or the notification number on the member's ID card).

ScopeThis applies to CAR T‑cell therapies and transplants listed in the policy (examples include Abecma®, Breyanzi®, Kymriah™, Tecartus™, Yescarta™).

ProcessProviders should call the transplant case management team for notification and authorization prior to providing transplant/CAR T‑cell services.