CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Kentucky Medicaid

List of services and CPT/HCPCS/ICD-10 codes that require prior authorization for UnitedHealthcare Community Plan of Kentucky providers, and how to submit prior authorization requests.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Kentucky Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID or by phone at 877-842-3210.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2024-09-01policy effective date

UHCprovider.comportal

877-842-3210PA phone

Yesemergency exempt

$500CGM threshold

multiple

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.

Services and Coverage Criteria Requiring Prior Authorization

inv-01: Services requiring prior authorization (partial list)

The document lists specific service categories and associated CPT/HCPCS codes that require prior authorization.

Arthroplasty — Prior authorization required for listed arthroplasty CPT codes (examples: 23470, 23472, 23473, 23474).

Arthroscopy — Prior authorization required for listed arthroscopy CPT codes (examples: 29884–29916 series).

Bariatric surgery — Prior authorization required (see bariatric code listings).

Body lengthening — Prior authorization required for listed CPT codes (examples: 25280, 27685).

Bone growth stimulators — Prior authorization required for CPT/HCPCS codes (20974, 20975, 20979, E0747).

Bone marrow / stem cell procedures — Prior authorization required for listed CPT codes (examples: 38204, 38205, 38211, 38230, 38232, 38243).

Breast reconstruction (including non-mastectomy reconstruction) — Prior authorization required for listed CPT codes (examples: 19316, 19318, 19325, 19328).

inv-02: Prior authorization criteria and submission instructions

Covered when prior authorization is obtained using the specified submission methods; operational submission notes included.

Injectable cancer supportive care drugs administered in an outpatient setting require prior authorization (intravenous, intravesical, intrathecal).

Anti-emetic and supportive oncology products listed (examples: Akynzeo J1454, Cinvanti J0185, Emend J1453, Nyvepria) require prior authorization; to submit prior authorization for these outpatient injectable cancer supportive care drugs, call 888-397-8129 or use the Provider Portal as directed.

Call 888-397-8129 for specified cancer supportive care drug authorizations; other authorizations may be submitted via UHCprovider.com (One Healthcare ID).

Cardiology outpatient and office-based procedures (diagnostic catheterizations, electrophysiology implants, stress echocardiograms) require prior authorization; submit via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 866-889-8054.

inv-03: Stated prior authorization requirements

Coverage actions and requirements as stated for the listed services and device entries.

Cartilage implants — Prior authorization required (CPT mappings listed, e.g., 29848 → 27412).

Injectable chemotherapy agents administered in outpatient settings — Prior authorization required; some codes restricted to cancer diagnosis (multiple J-codes listed).

Cochlear implants and other auditory implants — Prior authorization required regardless of cost; L-codes and CPT codes provided (examples: 69710, 69930, L8619).

Congenital heart disease–related services (including pre-treatment evaluation) — Prior authorization required; numerous CPT codes enumerated (examples include 33251, 33404).

inv-04: Prior authorization criteria by service

Prior authorization requirements shown by service category and code.

Congenital heart disease services — Prior authorization required for congenital heart disease–related services including pre-treatment evaluation as listed by CPT codes (e.g., 33251, 33254–33261, 33404, 33414–33417).

Continuous glucose monitoring (CGM) — Prior authorization required when the billed amount or cumulative rental cost is more than $500; listed CPT/HCPCS examples include 95250, 95251, A9276, A9277, A9278.> $500

Durable medical equipment (DME) and orthotics/prosthetics — Many DME and orthotics/prosthetics entries require prior authorization; some DME are noted as 'DME Regardless of Cost.'

inv-05: Selected coverage requirements

Selected coverage requirements and notable excerpts.

Enteral and parenteral in‑home nutritional therapy — Prior authorization required for listed codes; procedures performed through a gastrostomy tube are noted as experimental/investigational and prior authorization is required.

Gender reassignment genetic and molecular testing (including BRCA) — Prior authorization required; providers requesting laboratory testing must complete the prior authorization/notification process.

Some CPT procedures associated with gastrostomy tube use are labeled experimental/investigational in the document excerpt — prior authorization still required.

inv-06: Prior authorization and notification requirements (selected)

Prior authorization and notification rules in the genetic testing, home health/hospice, hearing and injectable medication sections.

Genetic and molecular testing (including BRCA) — Prior authorization/notification required before DNA sequencing; the ordering provider must notify the laboratory performing the test and the laboratory will notify UnitedHealthcare as part of the program.

Home health and hospice services and certain hearing services — Prior authorization required for listed G- and V-code services (see respective code lists).

Injectable medications — Prior authorization required for listed injectable drugs (examples provided) and unclassified/temporary injectable codes require prior authorization (see unclassified/temporary codes list).

inv-07: Injectable medications — prior authorization listing

Listed injectable medications and unclassified/temporary injectable codes designated as prior authorization required.

Specific injectable medications (examples include Cosentyx J0598, J3247 Cortrophin Gel, J0802 Crysvita, J0584 Cutaquig, J0589 Daxxify) are included on the prior authorization listing.

Unclassified or temporary injectable medication codes (examples: C9094, J3490, J3590) are explicitly noted as requiring prior authorization.

inv-08: Orthotics and prosthetics coverage requirement

Orthotics and prosthetics entries that require prior authorization and related code examples.

Orthotics and prosthetics — Prior authorization required for many HCPCS L‑codes listed (examples: L0220, L2520, L3913, L5679, L6615, L6895, L8629).

inv-09: Procedure code listings

Procedure categories with example CPT codes that are listed in the policy and require prior authorization.

Mastectomy — CPT 19300 listed (prior authorization instructions referenced in surrounding policy).

Neurostimulator implantation — CPT examples listed (64553, 64595, 64555, 64568) and require prior authorization for implantation procedures.

Maxillofacial treatment and related reconstructive procedures — Various CPT codes listed; prior authorization required as indicated in the surgery sections.

inv-10: Prior authorization criteria (codes and cost threshold)

Orthotics/prosthetics cost-based prior authorization threshold and related HCPCS L-code references.

Orthotics and prosthetics with a billed amount or cumulative rental cost of more than $500 require prior authorization (threshold applies to listed L‑codes).> $500

Examples of L‑codes referenced under the cost threshold requirement include L8629, L0631, L0632, L0634 (multiple L‑codes are listed throughout the section).

inv-11: Coverage notes (codes only)

This section contains code listings without explicit medical necessity criteria; operational note to obtain prior authorization is provided.

Code listings only — The section enumerates HCPCS L‑codes (for example L0629, L0631, L0632, L0634) and instructs providers to obtain prior authorization for items listed; no additional medical necessity criteria are specified in this excerpt.

inv-12: Authorization and coverage requirements (partial section)

Selected authorization and coverage requirements with examples.

Outpatient therapy (physical, occupational, speech) — Prior authorization required for outpatient therapy services (examples: CPT 97110, 97129, 97130, 92507).

Pain injections and spine injection procedures — Prior authorization required for listed pain injection CPT codes (examples: 62280, 64416–64421 series).

Orthotics and prosthetics rental/cost threshold — Orthotics/prosthetics with a billed amount or cumulative rental cost over $500 require prior authorization (see L‑code listings).> $500

inv-13: Prior authorization and exemption criteria (excerpt)

Selected prior authorization rules and specified exemptions or listings.

Specific CPT/HCPCS codes require prior authorization as indicated — examples include pain injection codes, specified device HCPCS codes, and PPEC codes (T1025, T1026).

EXEMPTION: Diagnosis-based exemption: Some codes are not subject to prior authorization when billed with specified ICD-10 diagnosis codes (see the listed ICD-10 codes in the policy excerpt).

Therapy and procedure CPT codes are enumerated; providers must refer to the full policy for precise prior authorization instructions and submission processes.

inv-14: Prior authorization criteria (service-level summary)

Service-level summary of prior authorization rules by category.

Advanced outpatient imaging (CT/MRI/MRA/PET/nuclear medicine) — Care providers must provide notification prior to scheduling and submit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool.

Sleep studies (laboratory polysomnography) — Prior authorization required; excludes home sleep studies (lab-based polysomnography codes include 95805, 95807, 95808, 95810).

Spinal cord stimulators — Prior authorization required for spinal cord stimulator procedures and implantation (example CPT codes: 63650, 63663, 63655, 63661, 63662).

Transplant services (including CAR T-cell therapy) — Prior authorization required for transplant or transplant-related services prior to pre-treatment or evaluation (examples and products listed).

CPT / HCPCS / ICD-10 Codes Subject to Prior Authorization

Genetic / Molecular Testing CPT/HCPCS (Prior Authorization/Notification required)mixed

81163	BRCA1/BRCA2 - Partial or targeted testing (see program)
81164	BRCA1/BRCA2 - Full gene sequencing (see program)
81432	Cancer susceptibility panel, somatic and germline (multi-gene)
81228	BRCA1 (full gene)
81400	Molecular pathology procedure level I
81405	Molecular pathology procedure level II
81410	Molecular pathology procedure level III
81229	BRCA2 (full gene)
81401	Molecular pathology procedure add-on
81406	Molecular pathology procedure add-on

Genetic / Molecular Testing (Unlisted / Proprietary U-codes requiring PA)HCPCS

0006M	Genetic test (proprietary)
0007M	Genetic test (proprietary)
0018U	Genetic test (proprietary)
0022U	Genetic test (proprietary)
0055U	Genetic test (proprietary)
0087U	Genetic test (proprietary)
0088U	Genetic test (proprietary)
0111U	Genetic test (proprietary)
0129U	Genetic test (proprietary)
0154U	Genetic test (proprietary)

Home Health / Therapy HCPCS (Prior Authorization required)HCPCS

G0155	Services of physical therapist in home health setting
G0156	Services of occupational therapist in home health setting
G0162	Services by clinical psychologist or clinical social worker
G0299	Direct skilled nursing services
G0300	Physician certifying plan of care
G0495	Home health aide services
S5108	Home infusion service code
S5109	Home infusion supply code
S9122	Home health aide visit

Injectable / Specialty Drug J‑codes (Prior Authorization required)HCPCS

J3262	Acthar Gel
J0801	Cimzia or similar (refer to specific drug mapping)
Q5124	Cerezyme (drug-specific Q-code)
J1786	Drug-specific injectable
Q5128	Product-specific Q-code
J0717	Injection, palivizumab or similar mapping
J2786	Cinryze
J0598	Cimerli (or similar)
J0586	Dysport / botulinum toxin mapping
J1743	Elaprase

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1/2

Pain Management / Spine Injection CPT Codes (Prior Authorization required)CPT

62367	Injection(s), single level; lumbar or sacral (epidural)
62368	Injection(s), each additional level
62369	Injection(s), continuous infusion catheter placement or management
62370	Injection(s), epidural catheter for infusion

How Providers Submit Prior Authorization Requests and Operational Requirements

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal at UHCprovider.com using your One Healthcare ID and password. If you do not have a One Healthcare ID, visit UHCprovider.com/access. Alternatively, call 877-842-3210. Prior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for non‑emergent services.

Prior Authorization

Services requiring prior authorization (examples)

Obtain prior authorization for services explicitly marked "Prior authorization required," such as body lengthening, bone growth stimulators, and bone marrow/stem cell procedures.

Body lengthening (e.g., CPT 25280, 27685) — Prior authorization required
Bone growth stimulators (e.g., 20974, 20975, 20979, E0747) — Prior authorization required
Bone marrow / stem cell procedures (e.g., 38204, 38205, 38211) — Prior authorization required

Definitions and Key Terms

Prior authorization definition

DefinitionPrior authorization: a payer review process required for specified procedures and services before provision

Emergency carePrior authorization is not required for emergency or urgent care

Submission methodsRequests submitted via UnitedHealthcare Provider Portal (One Healthcare ID) or by phone (877-842-3210)

Behavioral health network requirement

CoverageMany behavioral health services are covered only through a designated behavioral health network

Provider actionFor specific behavioral health prior authorization requirements, call the number on the member's ID card

Policy Revision History

2024-09-01policy_effectiveLatest

Policy effective date published in header: Effective Sept. 1, 2024.

2024-09-01publication

UnitedHealthcare Community Plan of Kentucky prior authorization requirements document published with effective date Sept. 1, 2024.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Kentucky Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID or by phone at 877-842-3210.

SourceLink

On This Page

Prior Authorization

Cancer supportive care prior authorization

Prior authorization is required for injectable cancer supportive care drugs administered in an outpatient setting, including specified anti‑emetics and colony stimulating factors.

Examples: Akynzeo (J1454), Cinvanti (J0185), Emend (J1453), Nyvepria

Prior Authorization

Submit prior authorization for outpatient injectable cancer supportive care

To request prior authorization for outpatient injectable cancer supportive care drugs, use the Provider Portal for general authorizations or call the dedicated line 888-397-8129 for specified cancer supportive care drug requests.

Submit other prior authorizations via the Prior Authorization and Notification tool on UHCprovider.com.
Call 888-397-8129 to submit prior authorization for the listed cancer supportive care injectables.

Prior Authorization

Cardiology outpatient procedures prior authorization

Participating physicians must obtain prior authorization for outpatient and office‑based diagnostic catheterizations, electrophysiology implants and stress echocardiograms before performance; submit via the Provider Portal or by phone.

Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-889-8054 for cardiology prior authorizations.

Prior Authorization

Phone submission for certain drug prior authorizations

Certain injectable drug prior authorizations must be submitted by phone to the designated number.

Call 888-397-8129 to submit prior authorization for specified injectable drugs.

Prior Authorization

Prior authorization required for listed services

Obtain prior authorization for specified services listed in the policy, including cartilage implants and monitoring/seizure monitoring procedures marked as requiring prior authorization.

Cartilage implants — Prior authorization required
Cerebral seizure monitoring and related monitoring CPTs — Prior authorization required

Prior Authorization

Chemotherapy prior authorization

Prior authorization is required for injectable chemotherapy drugs administered in an outpatient setting; some chemotherapy codes are limited to cancer diagnoses.

Examples of chemotherapy J‑codes listed (e.g., J0594, J0640) — Prior authorization required

Prior Authorization

Cochlear implants prior authorization

Providers must obtain prior authorization for cochlear implants and other auditory implants regardless of cost.

Cochlear implant examples: CPT 69710, 69714, 69717, 69930 and HCPCS L8619, L8627, L8628, L8692 — Prior authorization required

Prior Authorization

Congenital heart disease services prior authorization

Prior authorization is required for congenital heart disease–related services, including pre‑treatment evaluation; multiple CPT codes are listed and must be authorized prior to service.

Examples of listed CPT codes: 33251, 33254–33261, 33404, 33414–33417, 33476, 33478, 33502–33507 — Prior authorization required

Prior Authorization

Cochlear and auditory implants - prior authorization

Cochlear and other auditory implants require prior authorization; related L‑code mappings are provided in the document.

See L‑code and CPT mappings (e.g., L8619, L8627, L8628) in the cochlear implant entries — prior authorization required regardless of cost

Prior Authorization

Congenital heart disease services - prior authorization

Congenital heart disease–related services (including pre‑treatment evaluation) list numerous CPT codes; obtain prior authorization before providing these services.

Extensive CPT code list provided for congenital heart disease procedures — all require prior authorization

Prior Authorization

Continuous glucose monitoring and related DME - prior authorization

Continuous glucose monitoring equipment and related supplies require prior authorization when the billed amount or cumulative rental cost is more than $500.

Relevant codes include CPT 95250, 95251 and HCPCS A9276–A9278; prior authorization required when billed amount or cumulative rental cost exceeds $500

Prior Authorization

Durable medical equipment / Orthotics & Prosthetics - prior authorization

Durable medical equipment and orthotics/prosthetics HCPCS/L‑codes listed throughout require prior authorization; note rental/cost thresholds trigger authorization.

Many DME and O&P codes (examples: A5500 series, E‑series) are listed as requiring prior authorization
Orthotics/prosthetics entries further reference specific L‑codes that require authorization

Prior Authorization

Enteral/parenteral in-home nutritional prior authorization

Enteral and parenteral in‑home nutritional services require prior authorization; related procedures performed through a gastrostomy tube are noted as experimental/investigational and prior authorization is required.

Relevant codes include V2623, V2627 and B4150–B4160 — Prior authorization required

Prior Authorization

Gender reassignment genetic/molecular testing prior authorization

Gender reassignment genetic and molecular testing, including BRCA testing, requires prior authorization; providers requesting laboratory testing must complete the prior authorization/notification process.

BRCA and related genetic test codes (e.g., 81163, 81164, 81432) — Prior authorization required
Ordering provider must complete prior authorization/notification when requesting laboratory testing

Prior Authorization

Genetic and molecular testing (BRCA) prior authorization

Prior authorization is required for genetic and molecular testing including BRCA; care providers must complete the prior authorization/notification process before testing.

Laboratory testing codes listed (e.g., 81228, 81400–81410) — prior authorization/notification required prior to DNA sequencing

Prior Authorization

Hearing services prior authorization

Hearing services identified by V‑codes listed in the policy require prior authorization.

Examples: V5014, V5050, V5060, V5130, V5140 — Prior authorization required

Prior Authorization

Home health and hospice prior authorization

Home health and hospice services listed with G‑codes require prior authorization.

Home health examples: G0155, G0156, G0162; Hospice examples: G0493, G0494, Q5001 — Prior authorization required

Prior Authorization

Injectable medications prior authorization

Injectable medications shown in the document require prior authorization; examples include Actemra, Acthar Gel and listed J‑codes such as J3262 and J0801.

Examples: Actemra, Acthar Gel, J3262, J0801, and other J‑codes listed in the injectable medications sections — Prior authorization required
Many specific product names are paired with HCPCS codes in the listing

Documentation Required

Laboratory notification requirement for genetic testing

When ordering genetic/DNA sequencing tests (including BRCA), the ordering care provider must notify the laboratory performing the test; the laboratory will notify UnitedHealthcare under the prior authorization/notification program.

Provider notification of the laboratory is required before DNA sequencing is performed.
Laboratory will notify UnitedHealthcare as part of the program.

Prior Authorization

Prior authorization required — unclassified/temporary injectable codes

Unclassified or temporary injectable medication codes (for example, C9094, J3490, J3590) are explicitly identified as requiring prior authorization.

C9094, J3490, J3590 — Prior authorization required for unclassified/temporary injectable codes

Prior Authorization

Listed injectable medications requiring prior authorization

Multiple specific HCPCS drug codes and associated product names are listed as requiring prior authorization; consult the injectable medications sections for exact code‑to‑product mappings.

Examples shown: J0598 (Cosentyx), J3247 (Cortrophin Gel), J0802 (Crysvita), J0584 (Cutaquig), J0589 (Daxxify) — Prior authorization required

Documentation Required

Procedure code listed (mastectomy)

The mastectomy CPT code 19300 is listed in the document and the prior authorization instructions apply.

CPT 19300 (mastectomy) appears in the code listings — obtain prior authorization as indicated

Prior Authorization

Orthotics and prosthetics prior authorization

Many HCPCS L‑codes used for orthotics and prosthetics in the policy require prior authorization; providers must obtain authorization before billing/obtaining these items.

Examples: L0220, L2520, L6895, L6616, L8629 and numerous other L‑codes listed — Prior authorization required

Prior Authorization

Mastectomy and medicine services prior authorization

Prior authorization is required for mastectomy and related medicine service CPTs listed in the document; follow the standard submission instructions to request authorization.

CPT examples: 19300 (mastectomy), 96130, 96131 — obtain prior authorization per policy

Prior Authorization

Neurostimulator implantation prior authorization

Prior authorization is required for neurostimulator implantation procedures; the CPT implantation codes are enumerated in the policy and must be authorized prior to implantation.

Examples: CPT 64553, 64595, 64555, 64568 — Prior authorization required for neurostimulator implantation

Prior Authorization

Prior authorization requirement for listed HCPCS L‑codes

Orthotics and prosthetics items with a billed amount or cumulative rental cost of more than $500 require prior authorization; several specific HCPCS L‑codes are listed in this context.

Threshold: billed amount or cumulative rental cost > $500 triggers prior authorization
Referenced L‑codes include L8629 and others listed in the orthotics/prosthetics entries

Prior Authorization

HCPCS codes referenced for prior authorization

The policy lists HCPCS codes L0629, L0631, L0632 and L0634 among L‑codes associated with prior authorization; obtain authorization when these codes apply.

L0629, L0631, L0632, L0634 — listed as HCPCS L‑codes related to prior authorization

Prior Authorization

HCPCS L-codes referenced for prior authorization

Additional HCPCS L‑codes referenced in the document are associated with prior authorization; consult the L‑code listings when planning services or equipment procurement.

Multiple L‑codes are repeated in the general information and orthotics sections as requiring prior authorization

Prior Authorization

HCPCS codes requiring prior authorization (listed)

Specific HCPCS L‑codes (for example L0629, L0631, L0632, L0634) are repeated in the policy as codes requiring prior authorization; ensure authorization is in place when billing these codes.

L0629, L0631, L0632, L0634 — cited multiple times as requiring prior authorization

Prior Authorization

Outpatient therapy prior authorization

Outpatient physical, occupational and speech therapy services require prior authorization as indicated in the policy.

Examples of therapy CPTs: 97150, 97530, 97535, 97542, 92507 — Prior authorization required for outpatient therapy

Prior Authorization

Orthotics/prosthetics rental cost threshold

For orthotics/prosthetics provided on a rental basis, a cumulative rental cost of more than $500 triggers the requirement for prior authorization.

Cumulative rental cost threshold: > $500 requires prior authorization

Prior Authorization

Pain injection prior authorization

Pain injection procedures listed in the policy require prior authorization before service.

Examples of pain injection CPTs requiring prior authorization include 62280 and 64416–64420, 64430, 64445–64447, etc.

Prior Authorization

Pain injections prior authorization (code list)

Pain injection CPT codes enumerated in the document must have prior authorization as indicated.

CPT examples: 62280, 62281, 62282, 62291, 62292 and multiple 644xx series — obtain prior authorization

Prior Authorization

Device prior authorization

Certain specified device HCPCS codes require prior authorization; consult the device listings in the policy for code‑specific authorization requirements.

Device examples shown in the document are listed with HCPCS codes and marked as prior authorization required

Prior Authorization

PPEC prior authorization

Prescribed pediatric extended care services (PPEC) require prior authorization; the policy lists relevant HCPCS/T‑codes.

Examples: T1025, T1026 — Prior authorization required for PPEC

Note

Diagnosis-based prior authorization exemption

Some codes are exempt from prior authorization when billed with specified ICD‑10 diagnosis codes; check the diagnosis‑based exemption list before submitting an authorization request.

Prior authorization not required when billed with the listed diagnosis codes (see policy ICD‑10 list)

Prior Authorization

Advanced outpatient imaging prior authorization and submission method

Care providers ordering advanced outpatient imaging procedures (CT, MRI, MRA, PET, nuclear medicine) must provide notification prior to scheduling and submit prior authorization requests via the UnitedHealthcare Provider Portal.

Use the Prior Authorization and Notification tool on UHCprovider.com to submit requests and provide required notification before scheduling

Prior Authorization

Sleep studies and spinal cord stimulator prior authorization

Laboratory‑assisted sleep studies (polysomnography) and spinal cord stimulator procedures require prior authorization before performance.

Sleep study CPTs include 95805, 95811, 95807, 95808, 95810 — Prior authorization required
Spinal cord stimulator CPTs include 63650, 63663, 63655, 63661, 63662 — Prior authorization required

Prior Authorization

Transplant services prior authorization

Transplant and transplant‑related services (including CAR T‑cell therapy) require prior authorization before pre‑treatment or evaluation.

Transplant and CAR T‑cell therapy services (examples: Abecma, Breyanzi) — Prior authorization required before pre‑treatment/evaluation

ScopeThis applies to mental health and substance use services per the policy section

Cancer supportive care drugs

DefinitionCancer supportive care drugs: injectable supportive agents administered in outpatient settings (IV, intravesical, intrathecal)

ExamplesAnti‑emetics listed include Akynzeo (J1454), Cinvanti (J0185), Emend (J1453); colony stimulating factors like Nyvepria are included

RequirementPrior authorization required for these outpatient injectable cancer supportive care drugs

Provider Portal prior authorization

ToolPrior Authorization and Notification tool on the UnitedHealthcare Provider Portal (access via UHCprovider.com using One Healthcare ID)

Alternate submissionPhone submission is available (877-842-3210); some services reference other contact numbers in specific sections

NotePortal is the primary method for prior authorization and notification submissions

Cochlear implants and other auditory implants

DefinitionCochlear implants and other auditory implants: medical devices within the inner ear with an external portion to assist persons with profound sensorineural deafness

RequirementPrior authorization required regardless of cost (section states 'Regardless of Cost')

CodesMultiple cochlear implant CPT/HCPCS codes are listed in the cochlear implants section

Durable Medical Equipment (DME) prior auth rule

RuleDurable medical equipment (DME) — many entries state 'DME Regardless of Cost' and require prior authorization

ContextDME listings include prosthetics and orthotics and often reference separate rules for prosthetics vs DME

ActionProviders should obtain prior authorization for DME items as indicated, even if below cost thresholds in some entries

CGM prior authorization threshold

ThresholdCGM devices and related supplies with a billed amount or cumulative rental cost greater than $500 require prior authorization

Codes citedExamples in the CGM listing: CPT 95250, 95251 and HCPCS A9276, A9277, A9278

Related noteSection explicitly marks 'Prior authorization required' for continuous glucose monitoring when cost threshold exceeded

Prior authorization

NotePrior authorization: payer review required for specified services before provision

ExceptionNot required for emergency or urgent care

SubmissionRequests via Provider Portal or phone (877-842-3210)

Experimental/investigational

DefinitionExperimental/investigational: services or procedures described in the policy as experimental and investigational (example entries in that section include codes like 95965)

ContextSome procedures performed through a gastrostomy tube are noted as experimental/investigational in the enteral/parenteral section

ActionRefer to the policy's experimental/investigational notes when determining prior authorization necessity or coverage

Ordering care provider notification

Provider responsibilityOrdering care provider must notify the laboratory conducting DNA sequencing/BRCA testing as part of the prior authorization/notification program

Laboratory roleThe laboratory will notify UnitedHealthcare under the Genetic and Molecular Testing Prior Authorization/Notification Program

When requiredNotification/prior authorization is required before DNA sequencing is performed

Unclassified/temporary injectable codes

DefinitionUnclassified/temporary injectable codes: codes without standard permanent HCPCS descriptors (examples: C9094, J3490, J3590)

RequirementThese unclassified/temporary injectable codes explicitly require prior authorization per the document

ExamplesC9094, J3490, J3590 listed in the unclassified/temporary injectable codes section

Prior authorization

NotePrior authorization is a payer review process required for specified services prior to provision

Emergency careEmergency or urgent care is exempt from prior authorization requirements

SubmissionUse Provider Portal (One Healthcare ID) or phone 877-842-3210 to submit requests

prior authorization threshold

Threshold definitionPrior authorization threshold is met when billed amount or cumulative rental cost exceeds $500

Applies primarily toOrthotics and prosthetics HCPCS L-codes and similar rental items

DocumentationMultiple sections repeat the > $500 cumulative rental cost threshold for PA

HCPCS L‑codes (prior authorization)

DefinitionHCPCS L‑codes: orthotics/prosthetics codes referenced in the policy (examples include L0113, L0456, L0457, L0462, L0480, L0629, L0631-L0634, L6895)

UseMultiple L‑codes are listed across orthotics/prosthetics sections as subject to prior authorization rules

ActionRefer to L‑code listings in the orthotics/prosthetics section when preparing prior authorization requests

HCPCS L-codes

DefinitionHCPCS L‑codes: repeated list of L0629, L0631, L0632, L0634 and related L‑series codes in the policy

ContextThese L‑codes are associated with prior authorization in the general information sections

Provider actionObtain prior authorization for items billed with these L‑codes as indicated

General information

NoteGeneral information header used throughout the document to introduce code listings and prior authorization notes

PurposeStructures repeated code lists and PA instructions across service sections

Provider tipUse the General Information entries to find specific PA instructions for each code group

Threshold for prior authorization of orthotics/prosthetics

Threshold detailOrthotics and prosthetics require prior authorization when the cumulative rental cost exceeds $500

ExamplesSections reference specific L-codes (e.g., L0456, L0457, L0480, L0113) alongside the cumulative rental cost threshold

RepetitionThe > $500 threshold is reiterated across multiple orthotics/prosthetics entries in the document

Diagnosis-based prior auth exemption

Exemption ruleSome codes are exempt from prior authorization when billed with specified ICD‑10 diagnosis codes listed in the policy

ExamplesDiagnosis codes listed include many C43.* (melanoma) and D04.* entries shown in the exemption lists

ActionVerify diagnosis codes on the claim to determine if prior authorization is required

PPEC

DefinitionPPEC (Prescribed Pediatric Extended Care services): specialized pediatric extended care services

RequirementPPEC services require prior authorization (codes such as T1025, T1026 are listed)

CodesT1025, T1026 referenced in the PPEC section

Advanced outpatient imaging

DefinitionAdvanced outpatient imaging: certain CT, MRI, MRA, PET and nuclear medicine procedures

Provider responsibilityProviders must provide notification prior to scheduling and submit prior authorization requests via the Provider Portal

Submission methodUse Prior Authorization and Notification tool on UnitedHealthcare Provider Portal for these imaging procedures

Sleep studies (lab-based)

DefinitionSleep studies (lab-based): laboratory-assisted polysomnography procedures to diagnose sleep disorders (excludes home sleep studies)

RequirementPrior authorization required for laboratory-assisted sleep studies (CPT examples: 95805, 95811, 95807, 95808, 95810)

ExclusionHome sleep studies are excluded from this requirement