CurrentUnitedHealthcarePolicy N/A

Prior authorization Individual Exchange plans

Defines prior authorization requirements and instructions for providers for UnitedHealthcare Individual & Family (ACA Marketplace) plans and lists codes and services requiring authorization for members in specified states.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization Individual Exchange plans

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal using the Prior Authorization and Notification tool.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+states listed

Portalsubmission channel

~200+codes listed

All statesprior auth required (some services)

Coverage criteria and services requiring prior authorization

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.

Providers must submit prior authorization requests using the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com).

When deciding coverage, reference the member-specific benefit plan document; prior authorization is not required for emergency or urgent care.

Site-of-service review may apply to many codes; Texas and Wisconsin require prior authorization for listed codes but are excluded from site-of-service review in several sections.

Certain specialty programs or COE requirements apply (for example, bariatric surgery may require a Center of Excellence); see the specific code sections for state exceptions.

Coverage criteria for outpatient supportive care injectables

Covered when prior authorization is obtained for outpatient administration of listed supportive-care injectables and anti-emetics.

Prior authorization is required for colony‑stimulating factors and bone‑modifying agents when administered in an outpatient setting for a cancer diagnosis (examples: J0897, J1442, J1447, J2506, J2820, Q5101, Q5110, Q5111, Q5120, Q5122).

Prior authorization is required for listed anti‑emetic injectable drugs (examples: Akynzeo J1454; Cinvanti J0185; Emend J1453; Sustol J1627).

Some J/Q codes listed above also require prior authorization for non‑oncology diagnoses; consult the injectable medications section for details.

Prior authorization requirements (excerpt)

The following items and services in these excerpts require prior authorization as indicated.

Carpal tunnel procedural codes (e.g., 29848, 64721) require prior authorization; site‑of‑service review may apply except Texas and Wisconsin where prior authorization is required but site‑of‑service review is excluded.

Inpatient video EEG procedures (e.g., 95700, 95711–95726) require prior authorization; outpatient/ASC video EEGs do not require prior authorization per the excerpt.

Chelation therapy (M0300, S9355) requires prior authorization.

Multiple chemotherapy and injectable drug J‑codes (examples: J0640, J0641, J0642, J1932, J1950, J1952, J9019, J9020) are listed as requiring prior authorization.

Prior authorization requirements (excerpt)

The document enumerates many drug, device, and procedure codes that require prior authorization; below are representative categories and notes.

Multiple anti‑emetic and chemotherapy J‑codes (e.g., J9058–J9098 series and extended J9xxx entries) require prior authorization as listed in the source.

Q‑codes and clinical trial procedure codes (Q2017, Q2043, Q2050, Q2055, Q5107; G0276, G0294, G2000, S9988, 69930) are listed and require prior authorization.

Cochlear implant device and related L‑codes (e.g., L8615–L8628, 69710) require prior authorization; state‑specific authorization exceptions are noted elsewhere.

CGM authorization criteria

Covered when prior authorization links device codes to qualifying diabetes diagnoses.

Continuous glucose monitoring devices and supplies (HCPCS examples A4238, A4239, A9276, A9277, A9278) require prior authorization.

Authorization is required only when accompanied by listed Type 2 or gestational diabetes diagnosis codes (numerous E11.xx and O24.xx codes are enumerated).

DME authorization criteria

Durable medical equipment items listed require prior authorization.

Prior authorization is required for numerous DME HCPCS codes enumerated in the source (examples include E0147, E2504, K‑series and other E‑codes listed).

Some K‑codes are flagged or masked in the source list; consult the full code list for specific K‑code authorization requirements.

Cosmetic/Reconstructive authorization criteria

Cosmetic procedures require prior authorization; reconstructive procedures are differentiated by medical necessity.

Cosmetic procedures that change or improve appearance without restoring physiologic function require prior authorization.

Reconstructive procedures that restore physiologic function also require authorization but are evaluated based on medical necessity; example CPTs listed include 15769, 15830, 21137.

Coverage criteria (partial)

Coverage criteria summarized for select service lines (partial).

Genetic and molecular testing including BRCA requires prior authorization/notification before DNA sequencing; payment is authorized only for CPT codes registered with the Genetic and Molecular Testing Prior Authorization/Notification Program. The ordering provider must notify the laboratory and the laboratory will notify UnitedHealthcare.

Foot surgery codes require prior authorization; site‑of‑service review may apply for all states except Texas and Wisconsin (which require prior authorization but are excluded from site‑of‑service review).

FESS (functional endoscopic sinus surgery) CPT codes listed (e.g., 31240, 31253–31259, 31267, 31276, 31287, 31288) require prior authorization.

Home health services require prior authorization; reference the member's benefit plan document to determine available coverage.

Hospice services require prior authorization; some market/state‑specific authorization exceptions are noted in the source.

Hysterectomy CPT codes listed (e.g., 58152, 58180, 58260, 58262, 58267, 58270, 58290, 58291–58294, 58541–58544) require prior authorization.

Experimental/Investigational

Certain codes are labeled experimental and investigational and require prior authorization (examples include 33477, 95966, 0253T, 0308T, 95965, 95967, 64722).

Infertility prior authorization criteria (partial)

Infertility services generally require prior authorization, with specified state exceptions.

Prior authorization is generally required for infertility diagnostic and treatment services and related CPT/HCPCS codes listed in the source.

State exceptions

Prior authorization is not required for certain infertility services in the following states: Alabama, Arizona, Florida, Georgia, Louisiana, Michigan, North Carolina, Oklahoma, Tennessee, Texas, Virginia and Washington.

Some infertility CPT/HCPCS codes require prior authorization only when accompanied by specified infertility diagnosis codes (see infertility diagnosis list in the source).

Injectables prior authorization

Injectable medications require prior authorization as listed.

Injectable medications and many specific HCPCS/J‑ and C‑codes listed in the source require prior authorization for administration; providers must consult the enumerated code lists in the document for applicable codes.

Examples of covered injectable drug codes are provided across multiple sections (see long J‑code listings in chunks 126–156); these entries are subject to prior authorization as indicated.

Injectable codes requiring prior authorization (list)

Extensive enumerated HCPCS J‑codes are listed and require prior authorization.

The source contains a long enumerated list of HCPCS J‑codes (see chunks 126–146) that are subject to prior authorization; use the document code lists for exact codes when submitting requests.

Prior authorization code list and submission instructions

Providers must follow the submission instructions and notifications in the document when requesting prior authorization for listed codes.

Submit prior authorization requests online via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com sign‑in with One Healthcare ID); phone support numbers are provided in specific sections for imaging and specialty inquiries.

The document lists many CPT/HCPCS codes that require prior authorization or notification; providers should reference the specific code entries in the source when preparing a request.

For injectable medication inquiries or questions about listed codes, contact the Optum Specialty Guidance Program as noted in the source (phone numbers provided in injectable sections).

Injectable medication prior authorization actions

Unclassified injectable codes require notification/prior authorization only for specified products; follow portal or SGP contact instructions.

For unclassified HCPCS codes J3490, J3590, C9167, C9168 (and related entries), notification/prior authorization is required only when billing for specified products (e.g., Adzynma®, Fylnetra®, Nulibry™, Omvoh®, Revcovi™).

Submit prior authorization requests for these items using the UnitedHealthcare Provider Portal Prior Authorization and Notification tool; for questions call the Optum Specialty Guidance Program at 888‑397‑8129.

Prior authorization code lists and notes (partial)

This document segment enumerates many additional injectable, L‑, Q‑ and supply codes requiring prior authorization (partial list).

A large set of J‑codes, Q‑codes, L‑codes and other HCPCS entries are listed across these chunks as subject to prior authorization; consult the full enumerated lists in the source for exact code detail when submitting requests.

Prior Authorization Requirements and Exceptions

Prior authorization is required for the listed pain injection and many procedural codes; site‑of‑service and state exceptions apply as noted.

Prior authorization is required for the listed pain injection codes (examples: 62291, 62292, 64620, G0259, G0260) and for many pain management procedure codes; this requirement applies for all states.

Site‑of‑service will be reviewed as part of prior authorization for many listed codes; Texas (and in some notes Wisconsin) are exceptions to site‑of‑service review for specified entries.

Flap repair exception

Flap repair CPTs (14020, 14021, 14061) will not require prior authorization when billed with skin cancer diagnoses in FL, IL, MD, MI, VA and WA.

Numerous HCPCS L‑codes and CPTs for injectable medications and supplies are enumerated and require prior authorization as listed in the source.

Prior authorization and conditional coverage rules

Prior authorization rules and conditional coverage criteria for radiation, proton therapy, private duty nursing and other services.

Standard (2D/3D) radiation therapy requires prior authorization only when billed with diagnosis codes in specified cancer ranges (C34.00–C34.92, C50.011–C50.929, C61, C79.51–C79.52, C84.7A).

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

Proton beam therapy (CPT/HCPCS codes 77520, 77522, 77523, 77525) requires prior authorization; indicate if performed as part of a clinical trial.

Prostate procedures (e.g., microwave and cryosurgical ablation CPTs 52441, 52442, 55873, 55874) require prior authorization.

Implantable beta‑emitting microspheres for treatment of malignant tumors require prior authorization; see clinical trials section for additional guidance.

Prior authorization criteria and operational steps

Operational steps: prior authorization is required for all states; providers must use portal or phone options and observe site‑of‑service rules.

Prior authorization is required for the listed codes and services for all states; site‑of‑service review will be applied as part of the prior authorization process for specified codes except in Maryland, Texas and Wisconsin.

Care providers ordering advanced outpatient imaging or other advanced outpatient procedures are responsible for notifying and requesting prior authorization before scheduling; submit requests via the UHC Provider Portal Prior Authorization and Notification tool or call the listed phone numbers (e.g., 866‑889‑8054) as provided in the source.

Site‑of‑service restriction

If the procedure is performed in an outpatient hospital setting or ambulatory surgery center, prior authorization is required; some office‑based procedures may be excluded in Texas and Wisconsin per the source.

Prior authorization criteria (excerpt)

Prior authorization requirements and common site/state exclusions summarized (excerpt).

Prior authorization is required when the procedure is performed in an outpatient hospital setting or ambulatory surgery center for the specified procedures.

Office‑based exclusion

Office‑based procedures may be excluded from prior authorization in Texas and Wisconsin; New Mexico is mentioned as excluded in specific entries—consult the applicable code notes.

Providers are responsible for notifying and requesting prior authorization before scheduling advanced outpatient procedures using the UHC Provider Portal or the phone contact provided in the source.

CPT, HCPCS and ICD-10 codes referenced

Examples of arthroplasty codes requiring prior authorizationCPTCovered

23470	Arthroplasty code listed as requiring prior authorization
23472	Arthroplasty code listed as requiring prior authorization
23473	Arthroplasty code listed as requiring prior authorization
23474	Arthroplasty code listed as requiring prior authorization
24360	Arthroplasty-related code
27120	Arthroplasty-related code

Examples of arthroscopy codes requiring prior authorizationCPTCovered

29826	Arthroscopy code requiring prior authorization
29843	Arthroscopy code requiring prior authorization
29871	Arthroscopy code requiring prior authorization
29805	Arthroscopy code requiring prior authorization
29806	Arthroscopy code requiring prior authorization
29807	Arthroscopy code requiring prior authorization

Examples of bariatric codes and notesCPTCovered

43644	Bariatric surgery code requiring prior authorization (may have COE requirement)
43645	Bariatric surgery code requiring prior authorization
43770	Bariatric surgery code requiring prior authorization
43860	Bariatric with diagnosis - authorization may not be required in some states

Bone growth stimulator codesmixedCovered

20974	Bone growth stimulator (electrical) requiring prior authorization
20975	Bone growth stimulator requiring prior authorization
E0747	Bone growth stimulator (device) requiring prior authorization

Bone marrow/stem cell codesCPTCovered

38204	Bone marrow/stem cell procedure requiring prior authorization
38232	Bone marrow/stem cell procedure requiring prior authorization

Breast reconstruction and related codesmixedCovered

15771	Breast reconstruction (non-mastectomy) requiring prior authorization
19316	Breast reconstruction code
19318	Breast reconstruction code
19325	Breast reconstruction code
L8600	Breast prosthesis HCPCS/L-code referenced

Selected HCPCS/J-codes for anti-emetics, bone-modifying agents, colony-stimulating factorsHCPCSCovered

J1454	Akynzeo (palonosetron/fosnetupitant)
J0185	Cinvanti (aprepitant)
J1453	Emend (fosaprepitant)
J1627	Sustol (granisetron extended release)
J0897	Denosumab (Prolia, Xgeva)
J1442	Filgrastim (Neupogen) / Filgrastim biosimilar

Selected ICD-10 diagnosis codes referencedICD-10

C50.011	Malignant neoplasm of nipple and areola, right female breast (example from list)
D05.90	Unspecified diagnosis from list (in situ neoplasms include D05 codes)

ICD-10 codes referencedICD-10

I70.533	ICD-10 diagnosis code present in list
I70.568	ICD-10 diagnosis code present in list
I72.3	ICD-10 diagnosis code present in list

Selected CPT procedure codesCPT

29848	Arthroscopic carpal tunnel release (example CPT) listed
64721	Neuroplasty/median nerve release code listed

Selected chemotherapy J-codesHCPCS

J9040	Chemotherapy drug J-code listed in excerpt
J9050	Chemotherapy drug J-code listed in excerpt
J9072	Chemotherapy drug J-code listed in excerpt
J9098	Chemotherapy drug J-code listed in excerpt

Anti-emetic and chemotherapy J-codes (partial)HCPCSCovered

J9058	Anti-emetic / injectable drug (as listed)
J9179	Chemotherapy/anti-emetic injectable drug (as listed)
J9999	Unspecified HCPCS code (listed)

Cochlear implant CPT/HCPCS/L-codesmixedCovered

L8615	Cochlear implant, internal device
L8616	Cochlear implant, internal device
69710	Cochlear implant procedure CPT

Clinical trial procedure codesHCPCSCovered

G0276	Clinical trial-related code
G0294	Clinical trial-related code
G2000	Clinical trial-related code

Continuous glucose monitoring HCPCSHCPCSCovered

A4238	CGM supplies
A4239	CGM supplies
A9276	CGM transmitter

Durable Medical Equipment HCPCSHCPCSCovered

E0147	Breathing equipment / DME example
E2504	DME example from list
K0005	Wheelchair component / DME example

Diabetes-related ICD-10 codes referenced for CGM prior authorizationICD-10Covered

E11.00	Type 2 diabetes mellitus without complications
E11.3211	Type 2 diabetes with specified complication (example)
O24.111	Gestational diabetes mellitus (example)

Durable Medical Equipment (partial list)HCPCSCovered

K0820***	DME/HCPCS code (masked)
K0821***	DME/HCPCS code (masked)
K0822***	DME/HCPCS code (masked)

Genetic and molecular testing (BRCA)CPTCovered

81162	BRCA genetic testing
81432	Genetic/molecular testing

Surgical procedures requiring prior authorizationCPTCovered

28285	Foot surgery
31240	FESS

Hospice HCPCSHCPCSCovered

G0299	Hospice-related HCPCS
G0300	Hospice-related HCPCS
G0493	Hospice-related HCPCS
G0494	Hospice-related HCPCS

IMRT codesmixedCovered

77385	IMRT planning/verification
77386	IMRT planning/verification
G6015	IMRT related HCPCS
G6016	IMRT related HCPCS

Selected injectable J/C codes (partial)HCPCSCovered

J0121	Injectable drug HCPCS/J-code (listed)
J0300	Injectable drug HCPCS/J-code (listed)

HCPCS J‑codes listedHCPCS

No codes listed

Unclassified injectable codes with limited prior authorization requirementsHCPCSCovered

J3490	Unclassified injectable code; prior authorization required only for specified products (Adzynma®, Fylnetra®, Nulibry™, Omvoh®, Revcovi™)
J3590	Unclassified injectable code; prior authorization required only for specified products (Adzynma®, Fylnetra®, Nulibry™, Omvoh®, Revcovi™)
C9167	Unclassified injectable code; prior authorization required only for specified products
C9168	Unclassified injectable code; prior authorization required only for specified products

Unclassified injectable codes (notification/prior authorization applies for specific products)HCPCS

J3490	Unclassified injectable medication
J3590	Unclassified injectable medication
C9167	Unclassified injectable medication
C9168	Unclassified injectable medication

Extensive J-code list for injectable medicationsHCPCS

J0121	Representative J-code from mapping sequences
J0470	Example listed J-code requiring prior authorization mapping
J1746	J1746 appears multiple times in the list (noted with *)

Sample injectable J-codes (partial list)HCPCS

J2426	Injectable medication HCPCS/J-code listed
J2427	Injectable medication HCPCS/J-code listed
J2430	Injectable medication HCPCS/J-code listed
J2440	Injectable medication HCPCS/J-code listed
J2469	Injectable medication HCPCS/J-code listed

Sample Q-codes (partial list)HCPCS

Q0144	HCPCS Q-code listed
Q0161	HCPCS Q-code listed
Q0220	HCPCS Q-code listed
Q3027	HCPCS Q-code listed

Sample A-, L- and CPT codes for supplies/devices/servicesmixed

A4557	Medical and surgical supplies (example A-code)
L0112	Orthotics/prosthetics L-code (example)
L5830	Orthotics/prosthetics L-code (example)
96130	Medicine services and procedures (neuropsych testing) - requires prior authorization

Selected HCPCS L-codes and CPTs requiring prior authorizationmixedCovered

L5683	Injectable medication HCPCS L-code (listed among many L-codes)
62291	CPT for injection/procedure (pain injection) requiring prior authorization
14020	Flap repair CPT (may be exempt for skin cancer diagnoses in some states)

Diagnosis ranges triggering prior authorization for standard radiation therapyICD-10

C34.00-C34.92	Lung cancer diagnosis code range mentioned for standard radiation therapy prior authorization condition
C50.011-C50.929	Breast cancer diagnosis code range mentioned for standard radiation therapy prior authorization condition
C61	Prostate cancer diagnosis code mentioned
C79.51-C79.52	Secondary malignant neoplasm codes mentioned
C84.7A	Specific lymphoma code range mentioned

Selected CPT/HCPCS codes requiring prior authorizationCPT | HCPCS

T1000	Private duty nursing
T1002	Private duty nursing
T1003	Private duty nursing
52441	Prostate procedure
55873	Cryosurgical ablation of prostate (referenced)
77520	Proton beam therapy
77522	Proton beam therapy
77523	Proton beam therapy
77525	Proton beam therapy

Selected imaging and radiology codes shown in this sectionCPT

78016
78430
78802
0633T
G0235

CT/MRI mapping examplesCPT

70450	Example CT sequence mapping listed
71250
74150

Office-based procedure examplesCPT

11402	Dermatologic
19000	General surgery
62270	Neurologic

Sample CPT codes mentionedCPT

29902	Arthroscopy / related (code shown in document)
25280	Body lengthening (code shown in document)
37761	Cardiovascular procedure code shown in document

Dermatologic / surgical codesCPT

11441	Dermatologic injectable procedure code
11443	Dermatologic injectable procedure code
11601	Surgical procedure code listed

Provider submission steps and operational notes

Note

Coverage decision note

When deciding coverage, reference the member-specific benefit plan document — terms vary by state. Site-of-service review may apply to certain codes on this list; prior authorization is not required for emergency or urgent care. Members have no non‑emergent out‑of‑network coverage or coverage outside the service area for these plans.

Submit prior authorizations using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) — sign in with One Healthcare ID. If you don’t have a One Healthcare ID, visit UHCprovider.com/access.
Prior authorization not required for emergency or urgent care.

Prior Authorization

Site of service review

Site of service (SOS) may be reviewed as part of the prior authorization process for many outpatient procedures. For certain CPT/HCPCS codes (for example arthroscopy, carpal tunnel, pain injections, select imaging and advanced procedures) prior authorization is required only when the service is requested in an outpatient hospital setting; Texas and Wisconsin frequently have exclusions. Providers ordering advanced outpatient imaging or office‑based procedures are responsible for notification and requesting prior authorization before scheduling.

Site‑of‑service review applies to many outpatient codes; prior authorization may be required only for outpatient hospital setting.
Texas and Wisconsin: several codes are excluded from SOS review (see code‑level guidance) — but prior authorization may still be required.
Care providers ordering advanced outpatient imaging must notify and request prior authorization before scheduling.

Prior Authorization

ICD‑10‑coded items requiring prior authorization (excerpt)

Some ICD‑10 diagnosis codes require prior authorization when linked to specific services. Prior authorization requirements depend on the member’s plan and state. Always verify the Dx to CPT/HCPCS linkage when submitting.

Examples of ICD‑10 code ranges that can trigger prior authorization for radiation and oncology services: C34.00‑C34.92, C50.011‑C50.929, C61, C79.51‑C79.52, C84.7A
Certain diabetes (E11.*) and gestational diabetes (O24.*) codes trigger prior authorization for continuous glucose monitoring devices.
Use the member benefit document to confirm which ICD‑10 codes require authorization.

Prior Authorization

Carpal tunnel prior authorization and site‑of‑service notes

Carpal tunnel procedures require prior authorization. Site‑of‑service review may also apply for all states except Texas and Wisconsin (those two states require prior authorization but are excluded from SOS review).

Affected CPT examples: 29848, 64721, 64722
Site‑of‑service review: may be applied for all states except Texas and Wisconsin
Prior authorization required in all listed states

Prior Authorization

Anti‑emetics and chemotherapy J‑codes requiring prior authorization (partial lists)

Many anti‑emetic and chemotherapy‑supportive drugs require prior authorization when billed as J‑ or Q‑codes. This includes an extensive list of J‑codes (partial list below) and several Q‑codes and L‑codes. Some colony‑stimulating factors and bone‑modifying agents require authorization for oncology and non‑oncology diagnoses.

Partial J‑code list (examples): J9015, J9017, J9020, J9051, J9058, J9060, J9070, J9080, J9179, J9200, J9201, J9206, J9208, J9210, J9212, J9214, J9218, J9223, J9226, J9245, J9250, J9255, J9260, J9261, J9270, J9271, J9272
Extended anti‑emetic / chemotherapy J‑codes (examples): J9179, J9181, J9185, J9190, J9196, J9198, J9200‑J9213, J9214‑J9229, J9245‑J9274, J9280‑J9281
Q‑code examples requiring authorization: Q2017, Q2043, Q2050, Q2055, Q5107, Q5110‑Q5119, Q5120, Q5122, Q5123, Q5126‑Q5130

Prior Authorization

Q‑code and unclassified injectable prior authorization notes

Certain Q‑codes and L‑codes related to injectables, and some unclassified J‑codes, require prior authorization or notification. For unclassified codes (J3490, J3590, C9167, C9168, C9151) notification/prior authorization is required only for specific products (e.g., Adzynma®, Fylnetra®, Nulibry™, Omvoh®, Revcovi™).

Q‑codes: Q2017, Q2043, Q2050, Q2055, Q5107, Q5110–Q5119, Q5120–Q5123, Q5126–Q5130
L‑codes: many cochlear and hearing device L‑codes (see cochlear implants callout)
Unclassified codes: J3490*, J3590*, C9167*, C9168* — notification/prior authorization required for listed specialty products

Prior Authorization

Cochlear implants and related device codes

Cochlear implants and external components require prior authorization in most markets; some authorizations are not required in specific states. Prior authorization applies to both surgical implantation CPT codes and device HCPCS/L‑codes.

Relevant CPT examples: 69710*, 69714*, 69930, 69930 (surgical codes)
Relevant HCPCS/L‑codes: L8615, L8616, L8617**, L8618, L8619, L8622, L8627, L8628, V5273
Market exceptions: Authorization not required in Alabama, Florida, Georgia, Kansas, Michigan, Mississippi and Ohio markets for some items; **Prior authorization required in Ohio for specific codes

Denial Risk

Experimental / investigational services requiring prior authorization

Experimental, investigational, or services linked to investigational procedures require prior authorization. Clinical trial‑related codes and services (for example G0276, G0294, G2000, S9988 and related trial codes) are subject to review and authorization.

Clinical trial codes requiring authorization/notification: G0276, G0294, G2000, S9988
Investigational procedures and associated services require prior authorization before scheduling or performance

Documentation Required

Notification or prior authorization for select treatment codes

Some procedures require notification only; others require prior authorization. For example, certain reconstructive, cosmetic‑adjacent, or soft‑tissue treatment codes may be 'Notification or prior authorization' depending on the code and setting. Providers should submit a notification or prior authorization via the portal when indicated.

Examples of codes requiring notification or prior authorization: 11980, 14000, 14001, 14041, 15734, 15738, 15750, 15757, 15758, 19303, 53410, 53430, 54125, 54520, 54660, 54690, 55175, 55180, 56625, 56800, 57110, 58661, 58720, 64856, 64892, 64896 (selection varies by state)
If a code is listed as 'Notification or prior authorization' confirm the member plan requirements before scheduling

Prior Authorization

Hearing services prior authorization / age and market notes

Hearing services and device coverage vary by state and member age. Prior authorization is commonly required for hearing device supplies and for members age thresholds specified by market.

Prior authorization required for certain hearing services and supplies; some CPT/HCPCS codes listed: V5095*, V5130*, V5140*, V5252*–V5260*, V5273, V5253–V5259 series
Operational note: Prior authorization required for members ages 21 and older in specified markets; some codes/exclusions vary by state

Prior Authorization

Home health prior authorization and benefit reference

Home health services require prior authorization when covered by the member’s benefit. The benefit plan document must be referenced to determine available coverage, covered visit types and applicable CPT/HCPCS codes. Laboratories or suppliers must follow the prior authorization/notification process on the portal.

Home health example codes: G0155, G0156, G0157, G0158, G0159, G0160, G0161, S9122, S9127, S9129, S9810, T1030, T1001, T1031, T1004
Reference the member‑specific benefit plan to confirm whether home health is a covered benefit and documentation requirements

Prior Authorization

Hospice prior authorization

Hospice services require prior authorization. Some hospice codes may be market‑specific exceptions (e.g., authorization not required in Alabama for certain items). Check member plan and state exceptions.

Hospice example codes: G0299, G0300, G0493, G0494, S9126, T2042, T2043*, T2044*, T2045, T2046
Note: Some codes may be excluded from authorization in specific markets (see plan/state‑level exceptions)

Prior Authorization

Hysterectomy prior authorization

Hysterectomy procedures require prior authorization. A range of CPT codes for abdominal, vaginal and laparoscopic hysterectomy are included — verify plan coverage prior to scheduling.

Example hysterectomy CPT codes: 58152, 58180, 58260, 58262, 58267, 58270, 58290, 58291, 58292, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573

Prior Authorization

Infertility services — prior authorization and state exceptions

Infertility diagnostic and treatment services require prior authorization regardless of diagnosis in most states, though some markets are excluded. State‑specific exceptions apply (e.g., prior authorization not required in certain states). When authorization is required, both diagnostic CPTs and selected treatment codes are subject to review.

Codes often requiring prior authorization include: 58760*, 89260*, 89261*, S0132* (examples)
State exceptions: Prior authorization not required in some states (Alabama, Arizona, Florida, Georgia, Louisiana, Michigan, North Carolina, Oklahoma, Tennessee, Texas, Virginia and Washington) — confirm member market

Prior Authorization

Injectable J‑codes (partial list)

This policy includes a broad set of injectable J‑codes that require prior authorization. The list in the policy is extensive; below are examples (partial) drawn from the full injectables section. Always submit prior authorization requests through the Provider Portal and include clinical justification and diagnosis linkage.

Partial injectable J‑code examples (not exhaustive): J0121, J0122, J0129, J0131‑J0133, J0135, J0153, J0171‑J0185, J0202, J0217‑J0225, J0248, J0256‑J0285, J0287‑J0330, J0348, J0360, J0401, J0456, J0461, J0470, J0475, J0490‑J0515, J0517, J0558, J0561, J0567, J0571‑J0599
Additional instruction: For unclassified J3490/J3590 and C91xx unclassified codes, notification/prior authorization is required for specific products as noted in the policy (e.g., Adzynma®, Fylnetra®, Nulibry™, Omvoh®, Revcovi™)

Prior Authorization

Injectable J‑codes (continued)

Additional injectable J‑codes continued (policy contains many more). Providers must use the portal for prior authorization and can contact Optum Specialty Guidance Program for specialty injectable questions.

Continued examples: J0630, J0636‑J0638, J0670, J0690‑J0706, J0712‑J0735, J0740‑J0795, J0801, J0834, J0840‑J0887, J0894‑J0896, J1000, J1020, J1030, J1040, J1050, J1071, J1095‑J1110, J1120, J1160‑J1212, J1230‑J1327, J1335, J1364, J1380, J1410‑J1459, J1551‑J1599, J1602‑J1745, J1750‑J2795, J2800‑J2999, J3000‑J3245 (this is illustrative — see full policy for complete list)
Operational contact: For prior authorization questions, use the Prior Authorization and Notification tool at UHCprovider.com or call the Optum Specialty Guidance Program at 888‑397‑8129

Prior Authorization

Specific S‑codes referenced for prior authorization

Several specific S‑codes and unclassified HCPCS S‑series items require prior authorization or notification; these often relate to supplies, home health, testing, or specialized injectable administration.

Example S‑codes referenced: S5570, S5571, S9122, S9126, S9127, S9129, S9340, S9341, S9342, S9810
Unclassified and S‑codes for lab/genetic testing and specialized supplies often require prior authorization — follow portal submission guidance

Prior Authorization

Prior authorization and site‑of‑service review notes

Prior authorization and site‑of‑service review notes: many procedures require prior authorization in all states; for some codes the authorization requirement is conditional based on place of service (outpatient hospital vs ASC or office). Verify state and site exceptions before scheduling.

Site‑of‑service review: applies to arthroscopy, pain injections, select imaging, and many interventional procedures — Texas and Wisconsin often have SOS exclusions
If a code is authorized only when performed in an outpatient hospital setting, the same code performed in an ASC or office may not need authorization (confirm with member benefits)

Prior Authorization

Proton beam therapy prior authorization

Proton beam therapy requires prior authorization. When proton therapy is part of a clinical trial, indicate that on the authorization request. CPT examples include 77520, 77522, 77523, 77525.

Proton beam therapy CPT codes: 77520, 77522, 77523, 77525
Indicate whether treatment is part of a clinical trial when submitting prior authorization

Prior Authorization

Radiation therapy prior authorization

Radiation therapy (standard, IGRT, IMRT and advanced techniques) requires prior authorization in many circumstances. Certain radiation CPT/HCPCS codes may be prior authorized only when associated with specified oncology diagnosis codes; others require authorization regardless of diagnosis.

Examples of radiation codes requiring authorization: 77014, 77371‑77373, 77385, 77386, 77387, 77401, 77402, 77407, 77412, G6001, G6015, G6016, G6017, 77470
Standard radiation (2D/3D) may require authorization only when billed with specific cancer diagnosis codes (see policy ICD‑10 ranges)

Prior Authorization

Prostate procedures prior authorization

Prostate procedures (including cryosurgical ablation and prostate microwave procedures) require prior authorization. Examples include CPT 52441, 52442, 55873, 55874.

Prostate example codes: 52441, 52442, 55873, 55874
Prior authorization required in all applicable states; verify member benefit and site‑of‑service rules

Prior Authorization

Implantable microspheres prior authorization

Implantable beta‑emitting microspheres for malignant tumors require prior authorization. These device‑based or implantable microsphere procedures are conditionally authorized and generally subject to review (see clinical trials section for related notes).

Device/procedure reference: implantable beta‑emitting microspheres for malignant tumors (see policy section)
Authorization required and may be reviewed in the context of clinical trials or investigational status

Definitions and term clarifications

Prior authorization required

DefinitionPrior authorization is required for listed procedures and codes; providers must reference member-specific benefit plans to determine coverage. Prior authorization is not required for emergency or urgent care.

How to submitSubmit requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) signed in with One Healthcare ID.

ScopeApplies to UnitedHealthcare Individual & Family (ACA Marketplace) plans for members in the states listed in the policy.

Center of Excellence (COE)

DefinitionCenter of Excellence (COE) — a coverage requirement for bariatric surgery and related services in specified situations.

ApplicationThe policy notes a COE requirement for coverage of bariatric surgery and services (e.g., CPT codes 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888).

State exceptionsSome bariatric authorizations are not required in specific states (e.g., South Carolina and Wisconsin as noted).

Prior authorization required for colony-stimulating factors and bone-modifying agents administered outpatient for cancer diagnosis

RequirementPrior authorization required for colony-stimulating factors and bone-modifying agents administered in an outpatient setting for a cancer diagnosis.

Example codesExamples include J0897, J1442, J1447, J2506, J2820 and Q5101/Q5110/Q5111/Q5120/Q5122 (some also require PA for non-oncology diagnoses).

ReferenceSee injectable medications section for codes that also require authorization for non-oncology diagnoses.

Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal to submit requests

Primary submission channelUse the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) and sign in with One Healthcare ID.

Alternative contactFor advanced outpatient imaging prior authorization, providers may call 866-889-8054 as listed in the document.

SupportFor injectable medication questions or specialty support, contact Optum Specialty Guidance Program at 888-397-8129 (as referenced elsewhere).

Inpatient video EEG prior authorization

RequirementInpatient video EEG (CPT 95700, 95711, 95712, 95713, 95720, 95722, 95724, 95726) requires prior authorization.

ExclusionOutpatient hospital and ambulatory surgical center video EEGs do not require prior authorization according to the excerpt.

ActionSubmit PA requests via the Provider Portal per general submission instructions.

Site-of-service note for carpal tunnel

RequirementCarpal tunnel procedure codes (e.g., 29848, 64721) require prior authorization.

Site-of-service reviewSite-of-service review may apply for these codes for most states; Texas and Wisconsin both require prior authorization but are excluded from site-of-service review.

SubmissionSubmit PA requests via the Provider Portal prior to scheduling when required.

Clinical trials

DefinitionClinical trials — a rigorously controlled study of a new drug, device or treatment on eligible human subjects; procedures/codes tied to clinical trials are noted as prior authorization required.

Example codesClinical trial procedure codes listed include G0276, G0294, G2000, S9988 and 69930 and are flagged for prior authorization.

NoteIf performed as part of a clinical trial, some therapies (e.g., proton beam) should indicate trial participation when requesting authorization.

Cochlear implant

RequirementCochlear implant procedures and device codes (e.g., CPT 69710, 69714, 69930; HCPCS/L-codes L8615–L8628, and others) require prior authorization.

Device definitionCochlear implant: a medical device within the inner ear with external components to assist persons with profound sensorineural deafness achieve conversational speech.

State exceptionsAuthorization not required in Alabama, Florida, Georgia, Kansas, Michigan, Mississippi and Ohio markets for certain cochlear implant items (state-specific notes in the source).

Cosmetic procedures

Cosmetic definitionCosmetic procedures change or improve physical appearance without significantly improving or restoring physiologic function and require prior authorization.

Reconstructive distinctionReconstructive procedures treat a medical condition or restore physiologic function; they also have authorization requirements but are evaluated for medical necessity.

Example CPTsExample cosmetic/reconstructive CPT codes listed include 15769, 15830 and 21137.

Reconstructive procedures

RequirementReconstructive and many surgical procedures (including broad lists of CPTs) require prior authorization for all states.

Flap repair exceptionFlap repair CPTs 14020, 14021 and 14061 will not require prior authorization when billed with skin cancer diagnoses in Florida, Illinois, Maryland, Michigan, Virginia and Washington.

ActionProviders should submit PA requests via the Provider Portal and reference applicable diagnosis codes to determine exceptions.

Genetic and Molecular Testing Prior Authorization/Notification Program

ProgramGenetic and Molecular Testing Prior Authorization/Notification Program requires prior authorization/notification for genetic testing including BRCA before DNA sequencing.

Payment conditionPayment is authorized only for CPT codes registered with the Genetic and Molecular Testing Prior Authorization/Notification Program.

ProcessThe ordering provider must notify the laboratory; the laboratory will notify UnitedHealthcare per the program instructions.

Site-of-service review for foot surgery

Foot surgery requirementFoot surgery CPT codes (examples include 28285, 28289, 28291–28299) require prior authorization.

Site-of-service reviewSite-of-service review may apply for these codes for all states except Texas and Wisconsin (those states require PA but are excluded from site-of-service review).

SubmissionSubmit PA requests via the UnitedHealthcare Provider Portal or call the listed PA phone number when applicable before scheduling advanced outpatient procedures.

Injectables

DefinitionInjectables — drugs administered via IV infusion, subcutaneously or intramuscularly; many injectable medications require prior authorization.

Large code listsExtensive HCPCS/J/C and L-code lists in the policy identify injectable drugs and biologics that require prior authorization (see code lists in source).

Unclassified codes noteUnclassified injectable codes (e.g., J3490, J3590, C9167, C9168) require notification/prior authorization only for specific products as listed (Adzynma®, Fylnetra®, Nulibry™, Omvoh®, Revcovi™).

Infertility with listed diagnosis

RuleInfertility diagnostic and treatment CPT/HCPCS codes generally require prior authorization; some codes require PA only when accompanied by listed infertility diagnosis codes.

State exceptionsSome infertility services do not require prior authorization in specified states (New Mexico excluded for certain entries; other market exceptions listed elsewhere).

Diagnosis linkageThe policy lists specific ICD-10 diagnosis codes (e.g., N46.*, N97.*, etc.) that, when present, condition PA requirements for certain infertility codes.

J‑code prior authorization listing

J‑code listingHCPCS J‑codes for injectable drugs are listed throughout the document and tied to prior authorization requirements; providers should reference the enumerated J-code blocks in the policy.

ExamplesRepresentative J-codes shown include J0202, J0217, J0289, J1454, J2506 among many others in the full list.

SubmissionSubmit PA requests for J‑coded injectables via the Provider Portal; specialty support contact information is provided for questions.

Unclassified injectable codes prior authorization note

Unclassified codes noteNotification/prior authorization applies to certain unclassified injectable codes (J3490, J3590, C9167, C9168) only when billed for specific products (Adzynma®, Fylnetra®, Nulibry™, Omvoh®, Revcovi™).

How to obtain PASubmit requests online via the Prior Authorization and Notification tool on the UHC Provider Portal; questions can be directed to Optum SGP at 888-397-8129.

Codes referencedSource lists the unclassified codes J3490, J3590, C9167, C9168 (and mentions C9151 in context) with product-specific PA applicability.

Notification/prior authorization required for specific unclassified codes and products

RequirementNotification or prior authorization is required for specific unclassified codes and products (e.g., Adzynma®, Fylnetra®, Nulibry™, Omvoh®, Revcovi™) when billed to codes J3490, J3590, C9167, C9168.

Submission detailsSubmit via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call Optum Specialty Guidance Program at 888-397-8129 for questions.

ScopeApplies only to the specified products for those unclassified codes; other uses of the codes may not require notification per the policy segment.

Prior authorization

DefinitionPrior authorization — a required review before certain services, procedures, supplies, devices or medications are provided; providers must obtain PA when indicated in the policy.

Universal requirementThe document indicates prior authorization is required for the listed services for all states unless a state-specific exception is noted.

ProcessProviders are responsible for requesting authorization via the UHC Provider Portal; site-of-service review may be part of the PA process for many codes.

Predetermination

DefinitionPredetermination — a form of prior review flagged for certain medications in addition to prior authorization (document notes some medications labeled 'Predetermination').

ImplicationMedications flagged as 'Predetermination' may require an additional or separate review process before payment authorization.

ReferenceSee the injectable medication sections in the policy for specific predetermination flags and instructions.

Site-of-service review exceptions note

General ruleSite-of-service review may be applied as part of the prior authorization process for listed codes; prior authorization is required for all states, and SOS review is performed except where state-specific exclusions apply.

Texas & WisconsinTexas and Wisconsin are noted as special: certain codes still require prior authorization but are excluded from site-of-service review; office-based procedure exclusions also apply in these states.

Provider actionIf service is scheduled in an outpatient hospital or ambulatory surgery center, submit PA via the Provider Portal; providers ordering advanced outpatient imaging must notify/request PA before scheduling.

Flap repair CPT exceptions for skin cancer diagnoses

ApplicabilityOtherwise, these flap repair CPTs are listed among procedures requiring prior authorization for all states.

ActionProviders should include diagnosis coding to determine exemption when submitting authorization requests for flap repair procedures.

Proton beam therapy

RequirementProton beam therapy requires prior authorization; providers should indicate if therapy is performed as part of a clinical trial.

Example codesRelevant CPT/HCPCS codes include 77520, 77522, 77523 and 77525 as referenced in the policy.

ContextProton beam therapy is treated as focused radiation therapy using proton beams and requires PA per the radiation therapy section.

Potentially cosmetic

FlagPotentially cosmetic — policy marks many diagnosis/code entries (C44/D04 ranges etc.) as 'Potentially cosmetic' indicating cosmetic exclusion or special handling may apply.

ImplicationWhen an item is marked 'Potentially cosmetic,' coverage depends on whether the procedure restores physiologic function or meets medical necessity criteria.

Provider actionInclude diagnosis and clinical justification with PA requests to demonstrate medical necessity when codes are potentially cosmetic.

Prior authorization

Primary instructionPrior authorization is required for the procedures and codes listed in this document; providers must submit requests via the UnitedHealthcare Provider Portal's Prior Authorization and Notification tool.

Emergency carePrior authorization is not required for emergency or urgent care situations.

Support contactsFor injectable specialty questions, the Optum Specialty Guidance Program phone number (888-397-8129) is provided in the policy segments addressing injectables and unclassified codes.

Office-based procedure exclusions (Texas and Wisconsin)

Texas & Wisconsin exclusionsOffice-based procedure exclusions apply in Texas and Wisconsin: prior authorization is required if performed in an outpatient hospital setting or ambulatory surgery center; office-based may be excluded in these states.

Provider responsibilityCare providers ordering advanced outpatient procedures must provide notification and request prior authorization before scheduling via the Provider Portal or by phone (866-889-8054).

Site-of-service ruleSite-of-service (SOS) rule: PA only required when requesting service in an outpatient hospital setting for specified procedures (see code-specific notes).

Site of service (SOS)

DefinitionSite of service (SOS) — indicates whether prior authorization is required based on the care setting; PA often required when service is performed in an outpatient hospital or ambulatory surgery center.

RulePrior authorization is required when the service is requested in an outpatient hospital setting for specified procedures; office-based exclusions apply in some states (TX, WI) as noted.

Provider actionProviders must confirm the intended site of service and submit PA requests via the Provider Portal when SOS triggers authorization requirements.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization Individual Exchange plans

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal using the Prior Authorization and Notification tool.

SourceLink

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