UnitedHealthcare Prior Auth Requirements (TX)

Prior Authorization Coverage Criteria

Coverage criteria by service category

The document enumerates services and codes that require prior authorization; some items include effective dates or diagnostic code notes.

Behavioral Health services: many benefit plans provide coverage through a designated behavioral health network; refer to the behavioral health network and call 888-887-9003 when referring for mental health and substance use services.

Breast reconstruction (non-mastectomy) codes (examples: 19316, 19325, 19355, 19318, L8600): prior authorization is not required for these codes when submitted with Breast Reconstruction diagnosis codes; PA required when submitted with other diagnosis codes.

Cochlear and auditory implants and related device codes (examples listed under cochlear implant entries): prior authorization applies with specified effective dates for some items (example: prior authorization effective Jan. 1, 2023 for cochlear implants).

DME and prosthetics: prior authorization is required for many DME and prosthetic items regardless of billed amount; specific HCPCS/E/K codes are listed in the table and some entries include effective dates.

Bone growth stimulator codes (examples: 20974–20979, 20975) and other device codes: listed and require PA where indicated in the table.

Prior authorization coverage criteria (excerpt)

Coverage stance and criteria as presented in these chunks

Prior authorization is required regardless of billed amount for numerous listed codes and services.

DME cumulative rental cost: cumulative rental cost of more than $1,000 requires prior authorization for listed DME codes.

Injectable medications and medication J-codes: have specified prior authorization effective dates (examples include Feb. 1, 2025 for Injectable Medications and Oct. 1, 2024 for Medications entries); follow the effective-date notes in the table for each listed drug code.

Post-acute joint replacement authorization

Post-acute inpatient admissions for joint replacement and specified facilities require prior authorization/notification.

Joint replacement (total hip and knee) post-acute inpatient admissions (example codes: 23470–23472, 27120, 27412): prior authorization and notification of admission date required for post-acute inpatient services provided by acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long-term acute care hospitals, and skilled nursing facilities.

Submission method: submit prior authorization requests through naviHealth as part of the Continued Care program; phone 855-851-1127, fax 844-244-9482.

Ambulance and potentially unproven services

Ambulance transport and potentially unproven services have prior authorization requirements and specified effective dates.

Non-emergent ambulance and air ambulance transport codes (examples: A0430, A0431, A0436, J7330): prior authorization required with effective date Jan. 1, 2015.

Ground ambulance Texas mandate codes (examples listed under TX MANDATE): prior authorization required with effective date April 1, 2016.

Potentially unproven services and linked codes (examples: 33289, C2624): prior authorization required with effective date April 1, 2023.

Therapy prior authorization rules

Therapy codes require prior authorization for re-evaluations; initial evaluations generally do not require prior authorization (exceptions noted).

Therapy re-evaluations and other listed therapy codes (examples include 97112, 97139, 97530, G0152 and numerous S9128-associated codes): prior authorization is required for all re-evaluations and for the other therapy codes listed.

Initial evaluations: initial evaluations do not require prior authorization except where specifically noted; follow the table entries for any exceptions.

Submission method: prior authorization requests for therapy re-evaluations should be submitted online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal per the table instructions.

Orthotics and prosthetics prior authorization

Orthotics and prosthetics require prior authorization when cost thresholds are exceeded.

Orthotics (examples: L3020, L1846): prior authorization is required when retail purchase or cumulative rental cost is more than $1,000; effective date shown Jan. 1, 2015 for orthotics entries.

Prosthetics (examples: L5795, L5818, L5973, L5987 and other L-codes listed): prior authorization is required for prosthetic codes listed when retail purchase or cumulative rental cost is more than $1,000; some prosthetic entries reference effective dates (examples include July 1, 2017).

Extracted prior authorization notes and criteria (fragmentary)

Where present, prior authorization effective dates and provider responsibilities are noted for certain services.

Psychological testing codes: 96116 and 96121 show prior authorization effective Oct. 1, 2019 (the table notes fragment 'Prior authorization will not...'); other psychological testing codes show date-based notes (examples: service on or after March 1, 2022).

Advanced outpatient imaging codes (examples: 78431–78433, 78830–78832): include prior authorization effective dates (examples: Jan. 1, 2020; Jan. 1, 2021) and state that care providers ordering an advanced outpatient imaging procedure are responsible for providing notification/prior authorization information.

Device codes (examples: HCPCS E0747/E0748 for stimulators): listed with a prior authorization field present though some fragments do not include an explicit effective date; follow the specific table entry for the device code in question.

Prior authorization coverage criteria (excerpt)

Prior authorization is required for listed transplants, CAR T-Cell therapies, VADs, and certain implantable devices; specific effective dates and contact methods are provided for many entries.

Transplant and CAR T-Cell therapies (examples include J3490/J3590/C9399 entries and listed CAR-T agents such as Abecma®, Breyanzi®, Kymriah™, Yescarta™): prior authorization is required; some therapies include specified effective dates (examples: July 1, 2024; April 1, 2024; Jan. 1, 2022; Oct. 1, 2021) and contact instruction to call the Community and State Transplant Case Management team (888-936-7246) or use the notification number on the member ID.

Ventricular Assist Device (VAD) procedures (example codes: 33927, 33928, 33929, 33975, 33976, 33982, 33983): prior authorization is required; entries list Jan. 1, 2018 (and other dates) and instruct providers to call the notification number on the member's health plan ID and to fax forms to the Optum VAD Case Management team (contact numbers provided in the table).

Implantable stimulators/neurostimulators (examples: E0747–E0760, L8682/L8683 and related codes): listed with prior-authorization effective dates varying by code (examples in table include Jan. 1, 2015; July 1, 2018; July 1, 2021); follow the table entry for submission instructions.

Vein procedures including saphenous vein ablation and varicose vein treatments (examples: 36473, 36475, 36479, 37735, 37785): prior authorization is required with effective dates shown in examples (Oct. 1, 2018; July 1, 2021; Jan. 1, 2015); some fragments reference additional contact instructions.

Prior authorization instructions and codes (incomplete)

This section provides codes and contact instructions for obtaining prior authorization for inpatient post-acute services; specific clinical criteria are not present in these chunks.

Prior authorization contact: for certain procedures that 'restore normal blood flow' and related inpatient post-acute services the table repeatedly lists contact phone/fax 855-282-8929 for additional information/how to obtain prior authorization.

Listed procedure codes in this section include examples such as 33983, 36473, 36475 and 37765; clinical criteria and complete PA steps are not specified in these fragments — providers should use the listed contact (855-282-8929) to obtain PA instructions.

Partial/incomplete prior authorization entries — saphenous vein procedures

No complete criteria provided in this fragment. References to prior authorization are present but actionable elements (diagnosis codes, clinical criteria, steps to obtain authorization) are missing or blank.

Saphenous vein procedures (examples: CPT 36473, 36475) are listed in the post-acute/inpatient admissions section; the entries in this fragment reference these CPT codes but do not include diagnosis codes, clinical criteria, or operational PA steps in the excerpt.

Action required: providers should contact the prior authorization resource indicated elsewhere in the table (for inpatient/post-acute services) to obtain the necessary clinical criteria and submission instructions for these vein procedures.

Codes and Billing Thresholds

Examples of listed CPT/HCPCS codesmixed

20974-20979, 20975	Bone growth stimulator codes referenced
81163-81164	BRCA genetic testing codes referenced
19316,19325,19355,19318,L8600	Breast reconstruction (non-mastectomy) codes referenced

Hearing/cochlear implant codesmixed

69729-69730,69710-69711,69714,69799,69930,92601-92604,L8614,L8619,L8690,L8691,L8692

Cochlear and auditory implant and related device codes

Various reconstructive/cosmetic procedure codes listed across sectionsmixed

11950-11954,15775-15793,15820-15839,17106-17108,17380,17999,19300,21172-21275,21740-21743,28344,30120,30540-30560,30620,40500,67900-67950,69090,69300,69320,Q2026

Assorted reconstructive/cosmetic and surgical procedure codes

DME/prosthetics codesHCPCSCovered

E0766,E2617,E1239,E2609,E8001,K0813-K0899,E0466,E1230,E2310,E2311,E2321,K0800-K0885

DME/prosthetic HCPCS/E/K codes with PA requirement regardless of billed amount

Enteral ServicesHCPCSCovered

B4100	Enteral nutrition product (Enteral Services)
B4103	Enteral nutrition product (Enteral Services)

Selected CPT and surgical/procedure codesCPT

29914	Femoroacetabular Impingement (arthroscopic) code
29915	Femoroacetabular Impingement (arthroscopic) code
14000	Listed surgical CPT code
15734	Listed surgical CPT code

Specialty and injectable medication HCPCS/J-codesHCPCS

J0223	Givlaari (injectable specialty drug)
J0896	Reblozyl
J3399	Zolgensma (listed as J3399)
J0222	Onpattro
J1303	Ultomiris
J1300	Soliris
J0584	Crysvita
J3398	Luxturna
J1301	Radicava
J2326	Spinraza

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Therapy evaluation and re-evaluation codesCPTCovered

97112	Therapy/rehabilitation codes (examples listed)
97139	Therapeutic procedure
97530	Therapeutic activities
G0152	Home health therapy codes

Prosthetics HCPCS L-codesHCPCSCovered

L5795	Prosthetic HCPCS/L-codes (examples)
L5818	Prosthetic HCPCS/L-codes
L5973	Prosthetics cont.
L5987	Prosthetics cont.

Prosthetics (sample)HCPCS

L5973	Prosthetics-related code listed
L5976	Prosthetics-related code listed
L5980	Prosthetics-related code listed

Spinal surgery and instrumentation codesCPT

22100	Spinal surgery / fusion related CPT code
22526	Spinal surgery code set
22630	Spinal surgery code set
22804	Spinal instrumentation/fusion related code

Neurosurgery / spine procedure codesCPT

63001	Neurosurgery/craniotomy-related CPT code
63030	Spine surgery CPT code
63101	Cranial/neurosurgery CPT code

Radiology / advanced imaging codesCPT

78431	Nuclear medicine cardiac imaging codes (example)
78830	Molecular imaging / PET-type code

Selected neurosurgery/spine and cranial procedure codes (partial list)CPT

63250
63265
63268
61850

Transplant / CAR-T related HCPCS/J-codesHCPCS

J3490	Unclassified drugs (used here for CAR-T and transplant agents)
C9399	Unclassified biologics
J3590	Unclassified drug code (listed)

Vein and VAD codes (examples)CPT

36473	Venous ablation
33927	VAD procedures

Listed procedure codes in post-acute inpatient admissions sectionCPT

33983	Procedure code listed in section (context not fully specified in this chunk)
36475	Procedure code repeatedly listed (appears associated with saphenous vein/venous procedures and other contexts)
36473	Procedure code appearing in vein-related entries
37765	Procedure code appearing once in this chunk

Referenced CPT codesCPT

36473	CPT code listed in fragment (procedure on saphenous veins)
36475	CPT code listed in fragment (procedure on saphenous veins)

inv-29: Billed amount threshold — PA required regardless of billed amount for many prosthetics/DME items

ScopePrior authorization is required for many durable medical equipment (DME) and prosthetics items regardless of billed amount.

Examples of affected code setsMultiple HCPCS/E/K codes listed across the prosthetics/DME sections (see prosthetics DME code lists).

Effective dates contextSome prosthetics/DME entries include effective dates (examples shown: July 1, 2017; July 1, 2021; Jan. 1, 2015 in fragments).

How to Submit Prior Authorization and Provider Responsibilities

Prior Authorization

Advanced Outpatient Imaging — Ordering Provider Responsibility

Prior authorization is required for advanced outpatient imaging. The ordering provider is responsible for obtaining prior authorization or notification before the service is performed.

Advanced imaging examples include nuclear medicine and other advanced outpatient imaging CPT codes listed in the Radiology section (effective dates Jan. 1, 2020 and Jan. 1, 2021).

Prior Authorization

Q‑code Therapies / Transplants — Prior Authorization and Contact

Certain Q-code services, transplant services and CAR T‑Cell therapies require prior authorization. Contact UnitedHealthcare’s transplant/CAR T specialty teams for authorization and case management.

Q‑codes and related services (for example Q2054, Q2053, Q2042, Q2041) require prior authorization — call the Community and State Transplant Case Management team at 888-936-7246.
For CAR T‑Cell therapies (including Abecma®, Breyanzi®, Kymriah™, Yescarta™, Tecartus™, etc.) follow the listed prior authorization effective dates and contact the UnitedHealthcare specialty team as indicated.

Definitions and Terms

inv-53: Prior authorization — definition and submission methods summary

DefinitionPrior authorization (PA): a review requirement for certain services before they are performed or billed; emergency and urgent care are excluded.

Submission methodsSubmit via UnitedHealthcare Provider Portal Prior Authorization and Notification tool (One Healthcare ID), 24/7 chat on the Contact Us page, or fax to 877-940-1972.

Out-of-network requestsOut-of-network requests must be made by a network care provider.

Form availabilityThe prior authorization request form is available at Prior Authorization Forms (per document).

inv-54: Service coordinator — contact role for incontinence supplies when not using designated vendor

RoleService coordinator: the contact for obtaining incontinence supplies when not using the designated vendor (Tenderheart Health Outcomes).

Quick Reference: Codes, Thresholds, and Submission Methods

Key thresholds & contact callouts

Note

How to submit prior authorization requests

Note

Incontinence supplies routing

Note

Post-acute joint replacement submission

Note

VAD / cardiac device contact

Top code groups (examples)

OpenPayer

Prior authorization requirements for UnitedHealthcare Connected (Medicare‑Medicaid Plan) Texas

Prior Authorization Coverage Criteria

Codes and Billing Thresholds

How to Submit Prior Authorization and Provider Responsibilities

Definitions and Terms

Quick Reference: Codes, Thresholds, and Submission Methods