UnitedHealthcare Prior Auth — Individual Exchange

Coverage criteria and requirements

inv-01: Coverage criteria by service group

Prior authorization is required for the following service categories and listed codes; site-of-service review and some state-specific exceptions may apply.

Arthroplasty: Prior authorization required for the listed CPT/HCPCS codes (examples: 23470, 24360, 25441). Site-of-service review may apply for many states; Texas and Wisconsin require prior authorization but are excluded from site-of-service review.

Arthroscopy: Prior authorization required for listed CPT codes (examples: 29805, 29826, 29843, 29871, 29897-29916). Site-of-service review may apply for all states except Texas and Wisconsin (those two require prior authorization for all codes listed but are excluded from site-of-service review).

Bariatric surgery: Prior authorization required for listed CPT codes (examples: 43644, 43645, 43659, 43770–43775, 43842). Center of Excellence requirement may apply for coverage in certain circumstances; some state-specific exceptions where authorization is not required for select codes/diagnoses are noted in the document.

Body lengthening / Bone growth stimulator / Bone marrow/stem cell procedures: Prior authorization required for listed CPT/HCPCS codes (examples: 27685, 20974, 20975, 20979, E0747). Site-of-service review may apply for body lengthening except Texas and Wisconsin are excluded from site-of-service review.

Breast reconstruction (non‑mastectomy): Prior authorization required for listed CPT/HCPCS codes (examples: 15771, 19316, 19318, 19325, 19328, 19330, 19340, 19342). Mastectomy-related notifications/prior authorization guidance is referenced elsewhere in the document.

inv-02: Prior authorization criteria (partial)

Prior authorization requirements for outpatient cancer supportive medications and certain related codes.

Injectable supportive medications (colony‑stimulating factors and bone‑modifying agents): Prior authorization required when administered in an outpatient setting for a cancer diagnosis; example codes include J0897, J1442, J1447, J2506 and Q5101/Q5110/Q5111/Q5120/Q5122. Some of these codes also require prior authorization for non‑oncology diagnoses.

Anti‑emetics: Specific anti‑emetic HCPCS/J‑codes require prior authorization. Examples listed in the document include J1454 (Akynzeo), J0185 (Cinvanti), J1453 (Emend) and J1627 (Sustol).

inv-03: Prior authorization requirements (partial)

Prior authorization requirements and site‑of‑service notes (partial).

Chemotherapy agents and related services: Prior authorization required for many inpatient services and for numerous listed J‑codes (examples in document include J9015, J9042, J9051, J9070 and many others). Site‑of‑service rules may exempt outpatient hospital or ambulatory surgical centers in some cases; Texas and Wisconsin require prior authorization for all listed codes but are excluded from site‑of‑service review.

inv-04: Authorization and coverage criteria from chunks

Authorization and coverage notes extracted from the document sections.

Cochlear implants and auditory implants: Prior authorization required for listed CPT/HCPCS codes (examples: 69710, 69714, 69717, 69930 and device codes L8615–L8628). Some cochlear implant codes require prior authorization for members age 18 and older.

Continuous glucose monitoring (CGM): Prior authorization required for CGM device/supply codes when the diagnosis is type 2 diabetes or gestational diabetes (numerous E11.* and O24.* diagnosis codes listed). Prior authorization is not required for type 1 diabetes for the listed device codes (examples: A4226, A4238, A4239, A9276–A9278, E0787, E2102, E2103).

Clinical trials: Prior authorization required for clinical trial‑related services; example codes cited include G0276, G0293, G0294 and G2000.

Community support exclusions: Document lists specific state exclusions and indicates prior authorization is required for mapped community support services (codes referenced include H0037, H0040, T1024).

inv-05: Prior authorization coverage nodes (partial)

Services and codes in this excerpt require prior authorization or notification as indicated.

Cosmetic and reconstructive procedures: Prior authorization required for listed CPT codes (examples: 15769, 15830, 21137).

Durable medical equipment (DME): Prior authorization required for numerous HCPCS/E‑codes (examples in document: E0147, E0193, E0194, E0265 and many others).

Foot surgery: Prior authorization required for listed CPT codes (examples: 28285, 28289, 28291–28299). Site‑of‑service review may apply for most states except Texas and Wisconsin (those two require prior authorization but are excluded from site‑of‑service review).

Functional endoscopic sinus surgery (FESS): Prior authorization required for listed CPT codes (examples: 31240, 31253, 31254, 31255).

Gender dysphoria reassignment: Prior authorization required for listed CPT codes (examples: 55970, 55980, 57335). Some codes are excluded in South Carolina and Wisconsin as noted in the document.

inv-06: Prior authorization and state exceptions

Services and codes listed require prior authorization or notification as indicated; some services are subject to state‑level exceptions.

Genetic and molecular testing (including BRCA): Notification/prior authorization required before DNA sequencing; payment will be authorized only for CPT codes registered with the Genetic and Molecular Testing Prior Authorization/Notification Program (examples: 0055U, 0101U, 0179U, 0111U, 0209U, etc.).

Intensity‑modulated radiation therapy (IMRT): Prior authorization required for listed IMRT CPT/HCPCS codes (examples: 77385, 77386).

Infertility services: Infertility diagnostic and treatment services: Prior authorization generally required; however, prior authorization is not required for certain services in specified states/markets (Alabama, Arizona, Florida, Georgia, Louisiana, Michigan, North Carolina, Oklahoma, Tennessee, Texas, Virginia and Washington).

inv-07: Infertility prior authorization condition

Certain infertility procedure codes require prior authorization only when paired with specified infertility diagnosis codes.

Infertility procedures with listed diagnoses: The following procedure codes require prior authorization only when billed with a listed infertility diagnosis (examples of procedure codes: 54500, 54505, 55550, 58140, 58145, 58146, 58662, 58670, 58672, 58673; diagnosis codes listed in the document include N46.*, N46.01, N46.021–N46.025 and others).

inv-08: Injectables prior authorization

Injectable medications require prior authorization; numerous HCPCS/J and C codes are enumerated in the policy.

Injectable medications: Prior authorization required for the injectable medications and related CPT/HCPCS codes listed in the document (examples include CPT/HCPCS codes 90281, 90283–90284, 90378, A9607 and numerous J‑ and C‑codes such as J1120, J1160, C9046–C9084). Providers should follow the document instructions for how to obtain prior authorization for these injectable medications.

Cancer supportive and anti‑emetic injectables: Specific injectable supportive‑care and anti‑emetic J‑codes are listed and require prior authorization (see prior nodes referencing J1454, J0185, J1453, J1627, J0897, J1442 and many additional J‑codes enumerated in the injectables lists).

inv-09: Injectable J-code list

Listing of injectable HCPCS (J‑) codes with prior authorization guidance (document provides an extended enumerated list).

Examples from injectable J‑code list: Selected J‑codes shown in the document that require prior authorization or have 'how to obtain prior authorization' guidance include: J1120, J1160, J1162, J1165, J1170, J1190, J1200, J1201, J1212, J1230, J1240, J1245, J1250, J1265, J1270, J1290 and many additional J‑codes continuing throughout the policy.

inv-10: Unclassified codes PA procedure

Prior authorization/notification instructions for unclassified injectable codes and how to submit requests.

Unclassified injectable codes (J3490, J3590, C9151, C9167, C9168): Notification/prior authorization is required only when used for specific products (Fylnetra, Nulibry, Revcovi, Rivfloza). For prior authorization, submit requests online using the Prior Authorization and Notification tool on UHCprovider.com. For questions call the Optum Specialty Guidance Program (SGP) at 888‑397‑8129.

inv-11: Injectable medications — listing

This section enumerates J‑codes for injectable medications; the document lists many codes with instructions for obtaining prior authorization or predetermination.

Injectable listing examples: Examples from the injectable medications listing include J0630, J0636, J0637, J0650–J0699, and a broad continuation of J‑codes (see extended lists in the policy) that are identified with prior authorization instructions. The document does not include separate clinical coverage criteria for each listed code in this excerpt; follow the 'how to obtain prior authorization' guidance in the policy.

inv-12: Prior authorization criteria by code group

Prior authorization requirements organized by code groups (injectables, supplies, orthotics/prosthetics, etc.).

Injectable medication J‑code group: Many injectable J‑codes (examples shown include J3470, J3471, J3473, J3475 and others listed across the document) require prior authorization when used as described in the policy.

Medical and surgical supplies (A‑/A6‑/A9‑/A65‑ series): Prior authorization required for listed supply codes (examples: A4557, A6502, A6506, A6513, A9598, A4600, A6503, A6507, A9274).

Orthotics and prosthetics (L‑code group): Prior authorization required for listed L‑codes (examples and many L‑codes enumerated in the policy).

inv-13: Prior authorization criteria (excerpt)

Prior authorization requirements for pain injections and related procedures (excerpt).

Pain injections and pain management procedures: Prior authorization required for listed pain injection CPT/HCPCS codes for all states (examples: 62291, 62292, 64620, G0259, G0260 and numerous additional CPT codes such as 62281, 62320–62327, 62350–62369, 64405–64420, 64430–64451, 64483–64493, 64600–64635).

Site‑of‑service review for pain procedures: Site‑of‑service may be reviewed as part of the prior authorization process for these codes; Texas and Wisconsin require prior authorization for all listed codes but are excluded from site‑of‑service review in many sections of the document.

Orthotics/prosthetics L‑codes: Numerous L‑codes are listed with instructions 'how to obtain prior authorization' (examples in the document include L3961, L3967, L3971, L3973 and many others).

inv-14: Prior authorization and state-specific notes

Services in this excerpt require prior authorization unless an exception is noted; certain state‑specific rules apply.

State‑specific exceptions and notes: Certain procedures (for example flap repair CPTs 14020, 14021, 14061) will not require prior authorization when billed with skin cancer diagnoses — this exception applies only in specified states (Florida, Illinois, Maryland, Michigan, Virginia and Washington). Other state‑specific exclusions and requirements are noted throughout the policy.

Private duty nursing: Prior authorization required for private duty nursing codes (examples: T1000, T1002, T1003).

Proton beam and radiation therapy: Prior authorization required for proton beam therapy and radiation therapy services (examples: 77520, 77522–77525, 77385, 77386); indicate when performed as part of a clinical trial.

inv-15: Radiology prior authorization criteria

Prior authorization requirements and site‑of‑service rules for radiology and advanced imaging.

Radiology general requirement: Prior authorization is required for many radiology and advanced imaging procedures; the policy states prior authorization is required for all states for specified radiology services (examples and code ranges provided in the document).

Provider responsibility for advanced imaging: Care providers ordering advanced outpatient imaging procedures must notify and request prior authorization before scheduling; how to obtain prior authorization is via the Prior Authorization and Notification tool on UHCprovider.com or by phone at 866‑889‑8054.

Site‑of‑service rules: Site‑of‑service will be reviewed as part of the prior authorization process for many radiology codes; some outpatient hospital exclusions and state exceptions are noted (site‑of‑service prior authorization required if performed in outpatient hospital or ambulatory settings; not required if performed in an office).

inv-16: Site of service coverage and authorization

Coverage and authorization stance varies by site of service and specific state notes (Texas and Wisconsin highlighted).

Site‑of‑service authorization rule: Prior authorization is required when procedures are performed in an outpatient hospital or ambulatory setting; prior authorization is not required when the same procedures are performed in a provider office (document lists many CPT examples).

Texas and Wisconsin SOS note: For certain listed procedures the document specifically notes outpatient hospital exclusions for Texas and Wisconsin; those states require prior authorization for listed codes but may be excluded from site‑of‑service review or have 'authorization only required when requesting' language as noted in the policy.

Codes referenced (CPT/HCPCS/ICD-10) and code groups

Sample CPT/HCPCS codes requiring prior authorization (partial list)CPT

23470	Arthroplasty/shoulder
23472	Arthroplasty/shoulder
23473	Arthroplasty/shoulder
23474	Arthroplasty/shoulder
24360	Shoulder procedure
24361	Shoulder procedure
24362	Shoulder procedure
24363	Shoulder procedure
24365	Shoulder procedure
24370	Shoulder procedure

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Selected ICD-10 codes referencedICD-10

C50.019	Malignant neoplasm of unspecified site of breast
C50.011	Malignant neoplasm of nipple and areola, right female breast
C50.012	... left
C79.81	Secondary malignant neoplasm of breast
D05.90	Lobular carcinoma in situ of unspecified breast
Z85.3	Personal history of malignant neoplasm of breast
Z90.10	Acquired absence of breast

Selected HCPCS/J-codes for anti-emeticsHCPCSCovered

J1454	Akynzeo (palonosetron/fosnetupitant)
J0185	Cinvanti (aprepitant)
J1453	Emend (fosaprepitant)
J1627	Sustol (granisetron ER)

ICD-10 codes referenced for prior authorization (selected)ICD-10

E11.52	Type 2 diabetes mellitus with diabetic peripheral angiopathy
E11.00	Type 2 diabetes mellitus without complications
I70.533	Atherosclerosis of other native arteries of extremities
I77.77	Other specified disorders of arteries and arterioles
I96	Gangrene, not elsewhere classified

Chemotherapy J-codes (selection)HCPCSCovered

J9015	Chemotherapy agent
J9021	Chemotherapy agent
J9033	Chemotherapy agent
J9042	Chemotherapy agent
J9051	Chemotherapy agent
J9061	Chemotherapy agent
J9070	Chemotherapy agent
J9118	Chemotherapy agent
J9144	Chemotherapy agent
J9153	Chemotherapy agent

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Chemotherapy, related supplies, and clinical trial codesmixed

Q2017	Chemotherapy supply code
Q2043	Chemotherapy supply code
Q2050	Chemotherapy supply code
Q5107	Infusion pump related
Q5112	Infusion pump related
Q5113	Infusion pump related
Q5114	Infusion pump related
Q5115	Infusion pump related
Q5116	Infusion pump related

Cochlear implant procedure and device codesmixedCovered

69710	Cochlear implant procedure
69714	Cochlear implant procedure
69717	Cochlear implant procedure
69930	Cochlear implant procedure
L8615	Cochlear implant device
L8616	Cochlear implant device
L8617	Cochlear implant device
L8618	Cochlear implant device
L8619	Cochlear implant device
L8622	Cochlear implant device

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Continuous glucose monitoring device and supply codesHCPCS

A4226	CGM sensor, disposable
A4238	CGM transmitter
A4239	CGM transmitter
A9276	CGM supply
A9277	CGM supply
A9278	CGM supply
E0787	External glucose monitor
E2102	CGM system component
E2103	CGM system component

Diagnosis codes triggering CGM authorizationICD-10

E11.00	Type 2 diabetes mellitus without complications
E11.01	Type 2 diabetes mellitus with hyperglycemia
E11.21	Type 2 diabetes mellitus with diabetic nephropathy
E11.311	Type 2 diabetes mellitus with unspecified diabetic retinopathy
O24.111	Pre-existing diabetes mellitus in pregnancy, insulin controlled

Sample DME HCPCS/E-codesHCPCS

E0147	Walker, other
E0193	Other DME
E0194	Other DME
E0265	Pressure reducing overlay
E0266	Pressure reducing overlay
E0296	Therapeutic mattress replacement

Sample surgical CPT codesCPT

28285	Foot surgery
28289	Foot surgery
28291	Foot surgery
28292	Foot surgery
28295	Foot surgery
28296	Foot surgery

Selected surgical/procedure codesCPT

56800	Pelvic procedure
56805	Pelvic procedure
57110	Pelvic procedure
58140	Hysterectomy
58662	Infertility procedure
64856	Nerve repair

Genetic and molecular testing codes (BRCA and others)CPT

81162	BRCA1 and BRCA2 sequencing
81163	BRCA1/BRCA2 duplication/deletion
81432	Mol test panel
81439	Genetic testing
81455	Comprehensive genomic profiling
81471	Molecular test
81507	Molecular pathology procedure
87797	Infectious agent detection by nucleic acid

Injectable HCPCS/J and C codes (selection)HCPCS

J0121	Injection, vaccine
J0131	Injection
J0185	Aprepitant (Cinvanti)
J0640	Supportive care drug
J1442	Filgrastim
J0897	Denosumab
J3490	Unclassified drug code
J3590	Unclassified drug code
J9999	Compounded drug, not otherwise classified

Infertility CPT/S codes (selection)CPT

54500	Orchiectomy
54505	Orchiectomy
55550	Vasectomy
58140	Hysterectomy
58145	Hysterectomy
58146	Hysterectomy

Injectable J-codes (sample)HCPCS

J1120	Injection
J1160	Injection
J1162	Injection
J1170	Injection
J1190	Injection

Selected J-codes from injectable listHCPCS

J7301	Injection
J7303	Injection
J7304	Injection
J7307	Injection
J7311	Injection
J7312	Injection
J7313	Injection
J7320	Injection
J7330	Injection

Selected Q-codes from injectable listHCPCS

Q0138	Home infusion
Q0139	Home infusion
Q0144	Home infusion
Q0161	Home infusion
Q0162	Home infusion
Q0163	Home infusion
Q0220	Perfusion pump
Q0240	Home infusion
Q3027	Infusion

Unclassified injectable codesHCPCS

J3490	Unclassified drugs
J3590	Unclassified biologics
C9151	Unclassified
C9167	Unclassified
C9168	Unclassified

Examples from injectable listHCPCS

J0630	Injection
J0650	Injection
J0690	Injection
J0695	Injection
J3470	Injection
J3480	Injection

Sample J-codes for injectable medicationsHCPCS

J3470	Injection
J3471	Injection
J3485	Injection
J3489	Injection

Orthotics/Prosthetics L-codes (selection)HCPCS

L0622	Lower extremity orthosis
L0640	Lower extremity orthosis
L0999	Unlisted orthotic/prosthetic code
L1844	Prosthetic component
L3973	Prosthetic
L3961	Prosthetic

Pain injections codesCPTCovered

62291	Injection/epidural
62292	Injection/epidural
64620	Destruction of nerve, facet
G0259	Administration of anesthesia or similar

Procedure/CPT codes listed in excerptCPT

30460	Rhinoplasty
30462	Rhinoplasty
30540	Septoplasty
31295	Nasal/sinus endoscopy
54400	Penile prosthesis
67900	Eyelid procedure

Radiation/proton beam related codesCPT

77520	Proton beam therapy
77522	Proton beam therapy
77523	Proton beam therapy
77525	Proton beam therapy
77331	Radiation therapy planning
77399	Unlisted radiation procedure
77470	Radiation treatment delivery

Home health/private duty nursing codesHCPCS

T1000	Private duty nursing
T1002	Home health
T1003	Home health
G0235	Home oxygen

Radiology and advanced imaging codesCPT

78472	Myocardial perfusion imaging
78491	Myocardial imaging
78499	Unlisted nuclear medicine procedure
78597	Lymphoscintigraphy
78813	Other nuclear medicine
78830	Bone imaging
0609T	Radiology add-on
0633T	Radiology add-on

Listed CPT codes for SOS exclusions (selection)CPT

11402	Excision benign lesion
11420	Excision benign lesion
11424	Excision benign lesion
19000	Breast procedure
62270	Spinal injection
57460	Obstetric procedure
31579	Bronchoscopy
29900	Arthroscopy
29901	Arthroscopy
29902	Arthroscopy

Miscellaneous codes and notesmixed

S2095	Transportation/other service code (included per completeness review)
Y90	External cause code (included per completeness review)
Multiple nuclear medicine CPT codes	Various nuclear medicine CPT codes listed across radiology and nuclear medicine sections (e.g., 78472, 78491, 78499, 78597, 78608, 78813, 78830, 78831, 78832, 78814, 78815)

How to obtain authorization and provider responsibilities

Prior Authorization

Submission instructions and general authorization rules

Submit prior authorization requests using the UnitedHealthcare Provider Portal Prior Authorization and Notification tool at UHCprovider.com (Sign In with One Healthcare ID). Prior authorization is required for many services listed below; reference the member-specific benefit plan document and state-specific notes. Prior authorization is not required for emergency or urgent care.

Members in these plans have no non-emergent out-of-network coverage and no coverage outside the service area.
Site-of-service (SOS) review may apply to certain codes; where SOS applies it will be noted for the listed services and some states (notably Texas and Wisconsin) are excluded from SOS review for specific code sets.

Prior Authorization

Arthroplasty — prior authorization required

Arthroplasty (joint replacement): prior authorization is required for these codes and services in all listed states. Site-of-service review may apply.

Representative CPT codes (selection shown in source): 23470, 23472–23474, 24360–24363, 24365, 24370–24371, 25441–25442 (consult full list).
Prior authorization required for all states.
Site-of-service review may apply where noted elsewhere in this document.

Prior Authorization

Arthroscopy — prior authorization and site-of-service note

Arthroscopy procedures require prior authorization for all listed CPT codes. Site-of-service review may also apply for most states; Texas and Wisconsin are excluded from SOS review for arthroscopy (both still require prior authorization).

Representative CPT codes (selection): 29805–29808, 29819–29830, 29834–29840, 29843, 29844–29846, 29860–29863, 29870, 29873–29888, 29891–29899, 29914–29916.
Prior authorization is required for all states.
Site-of-service review may apply for all states except Texas and Wisconsin (those states still require prior authorization but are excluded from SOS review).

Prior Authorization

Bariatric surgery — prior authorization and Center of Excellence requirement

Bariatric surgery requires prior authorization. There is a Center of Excellence (COE) requirement for coverage of bariatric surgery and related services in certain markets. Authorization requirements and code exclusions vary by state.

Representative CPT codes (selection): 43644, 43645, 43659, 43770–43775, 43842–43848, 43860, 43865, 43886–43888 (consult full list).
COE requirement: coverage of bariatric surgery/services requires use of an approved Center of Excellence in markets where the COE requirement applies.
Authorization exceptions: Some codes/markets are excluded — e.g., authorization not required in South Carolina and Wisconsin for specific bariatric codes; some authorizations not required in select states (see state notes).
Prior authorization/notification required for specified diagnosis codes (for example: E66.01, E66.09, E66.1–E66.3, E66.8, E66.9, Z68.1, Z68.20–Z68.22, Z68.30–Z68.39, Z68.41–Z68.45) when applicable.

Prior Authorization

Body lengthening, bone growth stimulator, and bone marrow/stem cell — prior authorization

Procedures for body lengthening, bone growth stimulators, and bone marrow / stem cell procedures require prior authorization. Site-of-service review may apply for body lengthening codes (Texas and Wisconsin exclusions noted).

Body lengthening representative CPT code: 27685 (site-of-service may be reviewed for all states except Texas and Wisconsin; those states still require authorization but are excluded from SOS review).
Bone growth stimulator codes: 20974, 20975, 20979, HCPCS E0747 (prior authorization required).
Bone marrow / stem cell harvest/related codes: 38204–38205, 38211, 38230, 38232–38243 (prior authorization required).

Prior Authorization

Injectable medications and J‑code prior authorization (selection)

Many medications administered by injection or infusion require prior authorization. This includes oncology supportive agents, a broad J‑code list, and numerous other injectables and HCPCS codes. Unclassified injectable codes (J3490, J3590, and specific C‑codes) require notification/prior authorization only for specified products.

Cancer supportive care injectables (colony stimulating factors, bone‑modifying agents) require prior authorization — selected codes: J0897, J1442, J1447, J2506, J2820, Q5101–Q5122 (see full list).
Anti‑emetics requiring prior authorization include: J1454 (Akynzeo), J0185 (Cinvanti), J1453 (Emend), J1627 (Sustol) (see full list).
Unclassified injectable codes: J3490*, J3590*, C9151*, C9157*, C9167*, C9168* — prior authorization/notification required only for specified products (Fylnetra, Nulibry, Revcovi, Rivfloza); submit via the Provider Portal. For questions call Optum Specialty Guidance Program at 888‑397‑8129.
Representative J‑code selection (partial): J1120, J1160, J1162, J1165, J1170, J1190, J1200–J1306, J1322–J1439, J1442–J1459, J1551–J1602, J1610–J1744 (extensive list continues in source).
Operational note: For biologics / unclassified injectables, follow the portal submission process; specialty support phone numbers are provided in the source for selected cases.

Prior Authorization

Chemotherapy — prior authorization and site‑of‑service notes

Chemotherapy services require prior authorization. Site-of-service review may apply for many chemotherapy and infusion-related codes; inpatient chemotherapy often requires authorization.

Prior authorization required for many chemotherapy J‑codes and related services — representative codes appear in the injectable and chemotherapy lists (see source for full J‑code listing).
Prior authorization is required for inpatient chemotherapy services; prior authorization may not be required for outpatient hospital or ambulatory surgical center for some codes — check individual code notes.
Site-of-service review may apply for all states except Texas and Wisconsin for many chemotherapy codes (those two states may be excluded from SOS review but still require authorization).
Some chemotherapy and infusion procedure CPT/HCPCS codes: G0276, G0293, G0294, G2000 (clinical trial related codes) — see clinical trials note below.

Prior Authorization

Clinical trials — prior authorization / notification

Clinical trials (rigorously controlled studies of new drugs/devices/treatments under institutional oversight) may require prior authorization or special documentation. Indicate whether treatment is part of a clinical trial when requesting authorization for related services (e.g., proton therapy, certain chemotherapy codes).

Relevant CPT/HCPCS codes for clinical trial services include G0276, G0293, G0294, G2000.
When proton beam therapy or other advanced therapies are part of a clinical trial, indicate this on the prior authorization request (see proton beam therapy and radiation sections).

Note

Community support exclusions — state notes

Community support services (selected HCPCS H‑ and T‑codes) are excluded in specified states and/or require prior authorization; confirm state applicability before requesting authorization.

Community Support Exclusions: Alabama, Arizona, Florida, Georgia, Louisiana, Maryland, Michigan, North Carolina, Oklahoma, Tennessee, Texas (state list from source).
Representative codes referenced for community support exclusions: H0037, H0040, T1024 (verify code applicability in the full source).

Prior Authorization

Foot surgery — prior authorization and site‑of‑service note

Foot surgery procedures require prior authorization. Site-of-service review may apply for foot surgery codes for most states; Texas and Wisconsin are often excluded from SOS review (they still require authorization).

Representative CPT codes (selection): 28285, 28289, 28291–28299, 28295–28298 (consult full list).
Prior authorization required for all states; site-of-service review may apply for all states except Texas and Wisconsin (those states still require authorization but excluded from SOS review).

Prior Authorization

Genetic testing — prior authorization/notification

Genetic and molecular testing (including BRCA testing) requires prior authorization or notification per the Genetic and Molecular Testing Prior Authorization/Notification Program. The ordering provider must notify the laboratory and follow the program rules before performing DNA sequencing tests.

Payment will be authorized only for CPT codes registered with the Genetic and Molecular Testing Prior Authorization/Notification Program for each specified genetic test.
Notification/prior authorization is required for BRCA testing before DNA sequencing is performed; sample registered CPT codes include 0055U, 0101U, 0179U, 0111U, 0209U, 0216U, 0239U, 0288U, 0321U, 0341U, 0388U, 0398U, 0423U, 0448U, 0474U, 0129U, 0211U, 0217U, 0242U, 0289U, 0323U, 0094U (see source for full list).

Prior Authorization

Pain injections and pain management procedures — prior authorization

Pain injections and interventional pain management procedures require prior authorization. Site‑of‑service review may apply for many of these codes; Texas and Wisconsin are often excluded from SOS review in specific sections but still require authorization.

Representative pain injection and management CPT/HCPCS codes requiring authorization: 62291, 62292, 64620, G0259, G0260, 62281, 11981, 62320–62327, 62350–62369, 64405, 64408, 64415–64418, 64420, 64430, 64445–64451, 64483–64484, 64505–64520, 64600, 64633, 64635, E0782–E0786 (selection only).
Prior authorization is required for all states.
Site-of-service review may be performed for these services for all states except Texas and Wisconsin in some sections (those states still require authorization but may be excluded from SOS review).

Prior Authorization

Orthotics/prosthetics and injectable medication HCPCS L‑codes — prior authorization

Orthotics and prosthetics and related HCPCS L‑codes require prior authorization. Many individual L‑codes used for prosthetic components and custom devices are listed and require authorization.

Representative L‑codes requiring prior authorization include: L0112, L0220, L0452, L0482, L0484, L0486, L3961, L3967, L3971, L3973, L3975–L3978, L4030, L5010, L5050, L5060, L5105, L5150, L5160, L5210, L5230, L5250, L5280, L5301, L5321, L5530, L5535, L5540, L5590, L5610–L5616, L5639, L5649, L5651, L5673, L5681, L5683, L5703–L5728, L5795, L5814, L5818, L5824–L5848, L5857–L5961, L5966, L5973, L5976, L5979–L5988, L6010, L6020, L6026, L6055, L6120, L6130, L6205, L6310, L6320, L6360, L6370, L6400, L6570–L6588, L6590, L6615–L6638, L6693–L6697, L6880–L6895, L6900–L6975, L7007–L7045, L7170, L7181, L7185–L7186, L7191, L7259, L7499, L8629, L8699 (extensive list in source).
Operational note: Prosthetics are distinct from DME and follow orthotics/prosthetics authorization pathways.

Prior Authorization

Private duty nursing — prior authorization required

Private duty nursing services require prior authorization.

Representative CPT/HCPCS codes: T1000 (prior authorization required in many markets with some state-specific notes), T1002, T1003 (verify state applicability).
Follow state-specific rules noted elsewhere in the document for markets where authorization exceptions apply.

Prior Authorization

Radiation and proton beam therapy — prior authorization

Radiation therapy and proton beam therapy require prior authorization. Indicate on the request if proton beam therapy is being performed as part of a clinical trial.

Proton beam therapy CPT/HCPCS codes: 77520, 77522, 77523, 77525 (prior authorization required).
IMRT and advanced radiation therapy codes (for example 77385, 77387, G6001, G6002, G6017) require prior authorization.
When proton beam therapy or IMRT is part of a clinical trial, state this on the authorization request.

Note

State‑specific site of service exclusions and authorization notes

State‑specific site‑of‑service (SOS) exclusions and authorization notes: many services include SOS review language that may exclude Texas and Wisconsin from SOS review for specific code groups (those states often still require prior authorization). Other states have specific exclusions or authorization exceptions referenced in individual sections above; review the service‑level notes before submitting a request.

Common SOS pattern: "Site of service may also apply for all states except Texas and Wisconsin. Both states require prior authorization for all codes listed, but they're excluded from site of service review." — applies in multiple sections (arthroscopy, body lengthening, foot surgery, pain management, injectables).
Some services list state-specific authorization exceptions (e.g., bariatric codes excluded or not requiring authorization in South Carolina, Wisconsin, Alabama, Florida, Georgia, Louisiana, Oklahoma, etc.).
Care providers ordering advanced outpatient imaging procedures must provide notification and request prior authorization before scheduling; submit via the Provider Portal or call 866‑889‑8054.

Terms and quick references

Provider submission process

Primary submission methodUse the Prior Authorization and Notification tool on UHCprovider.com via One Healthcare ID

Alternative contactPhone numbers for PA requests provided elsewhere in policy (e.g., 866-889-8054 for imaging)

Reference for coverageMember-specific benefit plan document must be referenced when deciding coverage

Emergency/urgent care exception and benefit reference

Emergency/urgent carePrior authorization is not required for emergency or urgent care

Benefit referenceMember-specific benefit plan document must be referenced for coverage determinations

Network/area coverageMembers have no non-emergent out-of-network coverage and no coverage outside the service area for these plans

Cancer supportive care

DefinitionCancer supportive care: prior authorization required for colony-stimulating factors and bone-modifying agents administered in an outpatient setting for a cancer diagnosis

Non-oncology noteCodes J0897, J1442, J1447, J2506, J2820, Q5101, Q5110, Q5111, Q5120, Q5122 also require PA for non-oncology diagnoses (see injectables)

ActionSubmit PA via UnitedHealthcare Provider Portal

UnitedHealthcare Provider Portal submission

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

Access stepsSign in with One Healthcare ID; select Prior Authorization and Notification tab on dashboard

If no IDVisit UHCprovider.com/access to obtain a One Healthcare ID

Prior authorization

General PA rulePrior authorization is required for many chemotherapy, injectable and procedural services listed in this policy

Site-of-service noteSite-of-service review may apply; Texas and Wisconsin require PA for listed codes but are excluded from site-of-service review

Provider actionSubmit PA prior to scheduling when required; follow portal instructions

Clinical trials

RequirementClinical trials require prior authorization (codes referenced: G0276, G0293, G0294, G2000)

DefinitionClinical trials: rigorously controlled studies subject to institutional oversight

NoteIndicate if service is performed as part of a clinical trial when submitting PA

Cosmetic procedures

Cosmetic proceduresCosmetic procedures change/improve appearance without significantly improving/restoring physiological function

Reconstructive proceduresReconstructive procedures treat a medical condition or restore physiologic function

PA requirementPrior authorization required for listed cosmetic and reconstructive CPT codes

Reconstructive procedures

DefinitionReconstructive procedures: treat a medical condition or restore physiologic function

PA requirementPrior authorization required for listed reconstructive CPT codes

State notesSome mastectomy-related notifications/prior authorization guidance referenced elsewhere

Prior Authorization/Notification Program

ProgramGenetic and Molecular Testing Prior Authorization/Notification Program

BRCA testingNotification/prior authorization required for BRCA testing before DNA sequencing is performed

Payment conditionPayment authorized only for CPT codes registered with the program

BRCA testing requirement

BRCA testing requirementNotification/prior authorization is required for BRCA testing prior to DNA sequencing

Ordering provider actionOrdering provider must notify the laboratory conducting the test as part of the process

Registered CPTsPayment authorized for CPTs registered with the Genetic and Molecular Testing Prior Authorization/Notification Program

Injectables

Injectables definitionInjectables: drugs administered intravenously, subcutaneously, or intramuscularly; prior authorization required for listed injectables

PredeterminationSome injectable medications are subject to predetermination (policy labels 'Injectable medications Predetermination')

Unclassified codesUnclassified J-/C-codes are listed; special PA rules apply (see unclassified codes block)

Injectables

Common J-codesLarge lists of HCPCS J-codes are enumerated in the policy and require prior authorization (examples appear throughout chunks 126-145 and 128-130)

How to obtain PARequests should be submitted via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal

ScopeMany specific J-codes and continuations are provided in the policy; refer to full list when billing

Predetermination

Predetermination for unclassified codesFor unclassified codes J3490, J3590, C9151, C9167, C9168, notification/PA is required only for Fylnetra, Nulibry, Revcovi, Rivfloza

Submission methodSubmit PA online using the Prior Authorization and Notification tool on UHCprovider.com

SupportOptum Specialty Guidance Program (SGP) phone: 888-397-8129

Injectable medications

Injectable medications PAPrior authorization required for many injectable medications; policy enumerates extensive J-code lists

Unclassified examplesExamples of unclassified and other J-codes appear in chunks 157 and 162 (e.g., J0630, J0636, J0650, etc.)

SubmissionUse UnitedHealthcare Provider Portal Prior Authorization and Notification tool to request authorization

Prior authorization

Prior authorization generalPrior authorization required for chemotherapy, radiation and many specialty procedures listed in this policy

Clinical trials linkIf service is part of a clinical trial, indicate this on the PA request (clinical trial codes G0276, G0293, G0294, G2000)

Radiation/proton beamProton beam therapy and IMRT require prior authorization; indicate if performed in a clinical trial

Site-of-service review

Site-of-service reviewSite-of-service review may apply to listed codes; Texas and Wisconsin require prior authorization but are excluded from site-of-service review

Flap repair exceptionFlap repair CPTs 14020, 14021, 14061 will not require PA when billed with skin cancer diagnoses in FL, IL, MD, MI, VA, WA

Pain injectionsPain injection codes require prior authorization for all states; site-of-service review may apply except TX and WI

site_of_service_review

SOS outpatient hospital exclusionsCertain procedures require prior authorization when performed in an outpatient hospital or ambulatory setting but not when performed in an office

Example codesProcedures listed include dermatologic, general surgery, neurologic, OB/GYN and respiratory CPTs (examples shown in SOS lists)

State exceptionsSite-of-service outpatient hospital exclusions and related rules reference Texas and Wisconsin as special cases

prior_authorization_required

PA requiredPrior authorization required for many listed services and codes across the document (chemotherapy, injectables, procedures)

How to requestSubmit via UHCprovider.com Prior Authorization and Notification tool or by phone where indicated

Site-of-service implicationPA applicability can depend on site (outpatient hospital/ambulatory vs office)

Proton beam therapy

DefinitionProton beam therapy: focused radiation therapy that uses beams of protons

Prior authorizationPrior authorization required for proton beam therapy (codes include 77520, 77522, 77523, 77525)

Clinical trial noteIndicate if proton beam therapy is performed as part of a clinical trial when submitting PA

Flap repair prior authorization exception

Flap repair exceptionFlap repair CPTs 14020, 14021, 14061 will not require prior authorization when billed with skin cancer diagnoses — applies in FL, IL, MD, MI, VA, WA

ScopeThis is a state-limited exception; consult state notes in policy

Site-of-serviceSite-of-service review may apply to related codes except TX and WI exclusions noted elsewhere

Proton beam

Proton beamProton beam therapy is classified as focused radiation using protons and requires prior authorization

Related codesIncludes CPTs 77520, 77522-77525 and related radiation codes (77385, 77386, 77470)

SRS/SBRT cross-referenceStereotactic radiosurgery/SBRT (SRS/SBRT) are also listed and require PA (see SRS/SBRT codes)

SRS/SBRT

SRS/SBRTStereotactic radiosurgery/stereotactic body radiation therapy (SRS/SBRT) require prior authorization

Example codesSRS/SBRT codes include 77371, 77372, 77373, G0339, G0340

Related guidanceSubmit PA and indicate if treatment is part of a clinical trial

Site of service (SOS) outpatient hospital exclusions

SOS outpatient hospital exclusionsCertain procedures when performed in outpatient hospital or ambulatory settings require prior authorization; office setting does not require prior authorization

Example servicesIncludes dermatologic, general surgery, neurologic, OB/GYN and respiratory procedures listed in SOS tables

State calloutTexas and Wisconsin are specifically referenced regarding SOS outpatient hospital exclusions and site-of-service review

OpenPayer

Prior authorization — Individual Exchange plans

Coverage criteria and requirements

Codes referenced (CPT/HCPCS/ICD-10) and code groups

How to obtain authorization and provider responsibilities

Terms and quick references