UnitedHealthcare Prior Auth & Notification Policy Update

Policy Snapshot & Scope

This guidance applies to UnitedHealthcare's participating Preferred Care Network and Preferred Care Partners providers delivering inpatient and outpatient services in FL and AL. It summarizes when plan approval, advance notification, or other submission steps are required for covered services and includes where to submit requests and plan-specific phone contacts.

Quick facts — overview_card

submission methods availablePhone & online

service types listed (e.g., oncology supportive care, cardiology, reconstructive, cochlear)Multiple service categories

ICD-10 and CPT/HCPCS codes included for many categoriesExtensive code lists

CPT/HCPCS procedure codes mentioned in this part40+ codes

state with explicit special prior authorization requirement for home healthAlabama

contact for cellular/gene therapy & VAD case managementOptum Case Management 888-936-7246

Applies toPreferred Care Network & Preferred Care Partners

Prior Authorization and Notification Criteria

Many services in this part require either prior authorization or advance notification before care is provided. Providers should submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) with a One Healthcare ID or by phone to the plan-specific numbers; WellMed groups may use the WellMed portal (eprg.wellmed.net) or call 877-299-7213. Examples of groups that commonly require PA or notification include outpatient colony‑stimulating factors and certain antiemetics for cancer supportive care, injectable/chemotherapy drugs (notification for J9000–J9999 and leucovorin/levoleucovorin), many surgical procedures (including spinal and reconstructive categories), transplant and VAD/cellular and gene therapies, and advance notification for ESRD/dialysis services.

Code Lists and Billing Categories

Bone growth stimulatorCPT|HCPCSCovered

20974	Electrical stimulation/ultrasound to heal (bone growth stimulator)
20975	Electrical stimulation/ultrasound to heal (bone growth stimulator)
20979	Electrical stimulation/ultrasound to heal (bone growth stimulator)

Breast reconstruction - non-mastectomy and following mastectomy (diagnosis list)CPT|HCPCS|ICD-10Covered

19316	Breast reconstruction (CPT)
19318	Breast reconstruction (CPT)
19325	Breast reconstruction (CPT)
L8600	Breast prosthesis (HCPCS)
C50.019	Malignant neoplasm of unspecified site of right female breast (ICD-10) - example from list
C50.011	Malignant neoplasm of nipple and areola, right female breast (ICD-10)
C50.012	Malignant neoplasm of central portion of right female breast (ICD-10)
Z85.3	Personal history of malignant neoplasm of breast (ICD-10)
D05.90	Unspecified carcinoma in situ of breast (ICD-10)

Cancer supportive care – drugs requiring prior authorization (outpatient)HCPCS|CPTCovered

J1454	Akynzeo (palonosetron/fosnetupitant) (HCPCS)
J0185	Cinvanti (aprepitant) (HCPCS)
J1453	Emend (fosaprepitant) (HCPCS)
J1627	Sustol (granisetron extended release) (HCPCS)
J1442	Filgrastim (Neupogen) (HCPCS) - requires PA for oncology; note: also requires PA for some non-oncology Dx (marked with *)
Q5110	Filgrastim-aafi (Nivestym) (Q-code) - requires PA
Q5101	Filgrastim-sndz (Zarxio) (Q-code)
J2506	Pegfilgrastim (Neulasta) (HCPCS)
Q5122	Pegfilgrastim-apgf (Nyvepria) (Q-code) - requires PA
Q5111	Pegfilgrastim-cbqv (Udenyca) (Q-code) - requires PA

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Chemotherapy (injectable) notificationHCPCS

J9000-J9999	Range for chemotherapy injectable drugs (require notification)
J0640	Leucovorin (HCPCS) - notification
J0641	Levoleucovorin (HCPCS) - notification
J0642	Levoleucovorin (HCPCS) - notification

Cardiovascular / Cardiology procedural codes (examples requiring prior auth unless flagged)CPT|ICD-10Covered

37254	Endovascular procedure (CPT) - listed
37256	Endovascular procedure (CPT) - listed
37258	Endovascular procedure (CPT) - listed
37260	Endovascular procedure (CPT) - listed
37263	Endovascular procedure (CPT) - listed
37265	Endovascular procedure (CPT) - listed
37267	Endovascular procedure (CPT) - listed
37269	Endovascular procedure (CPT) - listed
37271	Endovascular procedure (CPT) - listed
37273	Endovascular procedure (CPT) - listed

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Cardiovascular related diagnosis codes (ICD-10) referencedICD-10Covered

I70.221	Atherosclerosis of native arteries of extremities
I70.222	Atherosclerosis of native arteries of extremities
I70.223	Atherosclerosis of native arteries of extremities
I70.228	Atherosclerosis (other sites)
I70.229	Atherosclerosis (other sites)
I70.321	Atherosclerosis
I73.00	Raynaud's disease
I73.01	Other peripheral vascular diseases
I73.1	Thromboangiitis obliterans

Cartilage implantsCPTCovered

27415	Cartilage implant procedure (CPT)
27416	Cartilage implant procedure (CPT)

Cochlear and auditory implantsCPT|HCPCSCovered

69714	Cochlear implant procedure (CPT)
69930	Cochlear implant procedure (CPT)
L8614	Cochlear implant internal device (HCPCS)
L8619	Cochlear implant (HCPCS)
A4238	External sound processor (HCPCS)
A4239	External sound processor (HCPCS)
E2102	External auditory device (HCPCS)
E2103	External auditory device (HCPCS)

Cosmetic and reconstructive procedure examples (CPT)CPTCovered

11960	Injection for cosmetic (CPT)
11971	Injection/implant (CPT)
15820	Skin graft (CPT)
15821	Skin graft (CPT)
17107	Destruction benign lesion (CPT) - listed under 'Achieve conversational speech' group
21175	Reconstruction facial bones (CPT)
21182	Reconstructive (CPT)
21230	Reconstructive (CPT)
21255	Reconstructive (CPT)
21263	Reconstructive (CPT)

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Reconstructive procedures / improving or restoring physiologic functionCPT|HCPCS

31295
31296
31297
67902
67903
67904
67906
67908
67909
67912

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Durable medical equipment (DME)HCPCS

E0470
E0651
E0660
E0669
E0675
E0652
E0665
E0472
E0655
E0667

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End-stage renal disease / Dialysis servicesmixed

Advance notification required for outpatient dialysis; contact Kidney Resource Service 866-561-7518 for Medicare member enrollment/referral

Gender dysphoria treatment - surgical procedures requiring notification/prior authorizationCPT

55970	Requires notification or prior authorization regardless of diagnosis
55980	Requires notification or prior authorization regardless of diagnosis
14000
14001
14041
15734
15738
15750
15757
15758

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Hysterectomy (abdominal and laparoscopic) and vaginal hysterectomy codesCPT

58150
58542
58552
58571
58152
58543
58553
58180
58544
58554

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Injectable medications and specialty J-codes (selected examples)HCPCS

J0896	Reblozyl
J0174	Leqembi
J0175	Kisunla
J2786	Cinqair
J0517	Fasenra
J2182	Nucala
J2356	Tezspire
J0223	Givlaari
J1299	Soliris (category)
J1302	Enjaymo

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Gene therapies and other Q/J codes (selected examples)HCPCS

J1411	Hemgenix
J1412	Roctavian
J1413	Elevidys
J3392	Beqvez
J3401	Vyjuvek
J3398	Luxturna
J3399	Zolgensma
Q5136	Jubbonti
Q5151	Epysqli
Q5152	Bkemv

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Botulinum toxinsHCPCS

J0585	Botox
J0586	Dysport
J0587	Myobloc
J0588	Xeomin
J0589	Daxxify

Intravenous ironHCPCS

J1437	Monoferric
J1439	Injectafer

White blood cell colony stimulating factors (examples)HCPCS

J1442	Neupogen
J1447	Granix
J1449	Rolvedon
J2506	Neulasta

Rituximab and biosimilars (examples)HCPCS

J9311	Rituxan Hycela
J9312	Rituxan
Q5123	Riabni
Q5119	Ruxience
Q5115	Truxima

Ophthalmologic VEGF and related agentsHCPCS

J0177	Eylea HD
J0178	Eylea
J0179	Beovu
J2777	Vabysmo
J2778	Lucentis
J2779	Susvimo
Q5124	Byooviz
Q5128	Cimerli
Q5147	Pavblu

Hyaluronic acid polymers (viscosupplementation)HCPCS

J7320	Genvisc 850
J7321	Hyalgan/Supartz/Visco-3
J7322	Hymovis
J7323	Euflexxa
J7324	Orthovisc
J7326	Gel-One
J7327	Monovisc
J7329	TriVisc
J7331	Synojoynt
J7332	Triluron

Examples of service categories mapped to internal request codesmixed

A0430	Example internal mapping for J3490/J3590/C9399/C9305 group associated with inpatient admissions (AIR/LTAC/SNF) per document fragment
A0431	Example internal mapping for J3590 group associated with inpatient admissions (fragmented)
A0435	Example internal mapping (document fragment)
A0436	Example internal mapping (document fragment)
21121	Mapping referenced in transport (non-urgent air ambulance) section for specific code group
21122	Mapping referenced in transport section
21123	Mapping referenced in transport section
21125	Orthognathic/ maxillofacial surgery mapping (document fragment)
21127	Orthognathic mapping (document fragment)
21141	Orthognathic/ maxillofacial mapping

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HCPCS / J-codes mentionedHCPCS

J3490	Unclassified drug, miscellaneous J-code referenced for prior authorization
J3590	Unclassified biologics/other miscellaneous J-code referenced for prior authorization
C9399	Unclassified professional service or product (C-code) referenced
C9305	Specific C-code referenced

CPT procedure codes referencedCPT

22558	Spinal procedure range start referenced
22590	Spinal procedure code referenced
22595	Spinal procedure code referenced
22600	Spinal procedure code referenced
22610	Spinal procedure code referenced
22612	Spinal procedure code referenced
22630	Spinal procedure code referenced
22633	Spinal procedure range end referenced

General codes referenced for prior authorization / advance notificationCPT|HCPCS

J3490	Unclassified drugs (HCPCS) - referenced for how to obtain prior authorization
J3590	Unclassified biologics (HCPCS) - referenced for how to obtain prior authorization
C9305	HCPCS code referenced multiple times in document
C9399	HCPCS unclassified miscellaneous code (referenced)

Spine / orthopaedic and related surgical CPT codes (examples listed)CPT

22558	Arthrodesis procedures (listed multiple times)
22590	Spinal code referenced
22595	Spinal code referenced
22600	Arthrodesis, posterior or posterolateral technique
22610	Arthrodesis, posterior interbody technique
22630	Arthrodesis, posterior or posterolateral technique (lumbar)
22633	Arthrodesis, combined posterior and anterior technique

Large list of surgical procedure codes requiring advance notification / prior authorization (excerpts)CPT

22800	Initial spinal instrumentation (example mapping to level-specific codes 22802, 22804, 22808)
22802	Spinal instrumentation, level 1 (mapping example)
22804	Spinal instrumentation, level 2 (mapping example)
22808	Spinal instrumentation, level 3 (mapping example)
22810	Spinal instrumentation (mapping to 22812, 22818, 22819)
22812	Spinal instrumentation mapping example
22818	Spinal instrumentation mapping example
22819	Spinal instrumentation mapping example
22830	Other spinal instrumentation codes (mapped to 22849, 22850, 22852)
22849	Spinal instrumentation mapping example

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Pain management and related CPT codesCPT

62350	Epidural injection (listed as requiring prior authorization for pain management)
62351	Epidural injection, other (listed)
62360	Spinal injection (listed)
62361	Spinal injection (listed)

Potentially unproven / investigational service examplesCPTNot Covered

28890	Listed under potentially unproven services (prior auth required)
33289	Listed under potentially unproven services (prior auth required)
36514	Listed under potentially unproven services (prior auth required)
64405	Listed under potentially unproven services (prior auth required)
64722	Listed under potentially unproven services (prior auth required)
64744	Listed under potentially unproven services (prior auth required)
66180	Listed under potentially unproven services (prior auth required)
95965	Listed under potentially unproven services (prior auth required)
95966	Listed under potentially unproven/investigational linked services (prior auth required)
C2624	HCPCS listed under investigational/linked services

Radiation therapy / proton beam / radiosurgery codesCPT|HCPCS

77520	Proton beam therapy - listed as prior authorization required
77522	Proton beam therapy - listed
77523	Proton beam therapy - listed
77525	Proton beam therapy - listed (duplicate entries present)
77331	Radiation therapy code referenced
77370	Radiation therapy code referenced
77399	Radiation therapy code referenced
77470	Radiation code referenced
77387	Image guided radiation therapy (IGRT) / IMRT referenced
77372	Stereotactic radiosurgery referenced

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RhinoplastyCPT

30400	Rhinoplasty - prior authorization required
30410	Rhinoplasty - prior authorization required
30420	Rhinoplasty - prior authorization required
30430	Rhinoplasty - prior authorization required

Sleep apnea surgical procedures / maxillomandibular advancementCPT

21685	Maxillofacial procedure referenced (sleep apnea surgeries)
42145	Pharyngeal/oral procedure referenced
41512	Upper airway/oral procedure referenced
41530	Upper airway/oral procedure referenced
41599	Unlisted procedure code for maxillomandibular surgeries

Selected spine surgery related CPT exampleCPT

20939

Spinal surgery / grafting code referenced (listed multiple times)

Spinal surgery (advance notification / prior authorization)CPT|HCPCS

20930	Spinal surgery - listed in document as requiring prior auth/advance notification
20931	Spinal surgery - listed in document as requiring prior auth/advance notification
20939	Spinal surgery - listed in document as requiring prior auth/advance notification
22854	Spinal surgery - listed in document as requiring prior auth/advance notification
22858	Spinal surgery - listed in document as requiring prior auth/advance notification

Transplant and transplant-related services (prior authorization / notification)CPT|HCPCS

61868
61885
63655
64590
63685
L8682
A9590
A9699

Cellular and gene therapy / related codesCPT|HCPCS|J-code|Q-code|T-code

0537T	listed with related transient codes 0538T, 0539T, 0540T
C9098	mapped to J3387/J3389/J3391 per document
J3392	mapped to J3393/J3394/J3402
J9999	mapped to Q2041/Q2042/Q2053
Q2054	mapped to Q2055/Q2056/Q2057
Q2058
J3387
J3389
J3391

Bone marrow harvest and related (CPT series and mappings)CPT

38240	bone marrow harvest; mapped to 38241/38242/...
38241
38242
38208
38209
38210
38212
38213
38214
38215	mapped to 38232* and others per document

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Ventricular assist devices (VAD) and cardiac proceduresCPT|HCPCS

33927
33928
33929
33930
33933
33940	mapped to 33944/33945 per document
33944
33945
33975
33976

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Other codes appearing in this partCPT|HCPCS

50300	kidney related mapping to 50320/50323/50340
50320
50323
50340
50360	mapped to 50365/50370/50547
50547
32850	lung related mapping to 32851/32852/32853
32851
32852
32853

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Overall this section establishes billing rules for participating network providers: it lists which services require prior authorization, which require notification or advance notification, and groups related codes and programs to guide billing and clinical operations. Related entries are organized by service category (for example, cancer supportive care drugs, chemotherapy injectable notification, inpatient admissions, spinal and other surgical groups) to help providers route requests and include required authorization numbers on claims.

What Providers Must Do

Prior Authorization

How to submit prior authorization

Submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID, or by phone to the plan-specific numbers. WellMed groups use the WellMed provider portal (eprg.wellmed.net) or call 877-299-7213.

Prior Authorization

Plan-specific phone numbers

Plan-specific phone contact numbers for prior authorization and support are listed below.

Preferred Care Network: 866-273-9444
Preferred Care Partners: 800-995-0480
WellMed support: 877-299-7213 (8 a.m. - 5 p.m. ET, Mon-Fri)

Key Terms

Defined terms

Prior authorizationApproval obtained from UnitedHealthcare before certain services are provided to ensure coverage under the member's plan.

NotificationAdvance notice to UnitedHealthcare that a service/drug will be administered; required for certain chemotherapy injectables administered outpatient.

Advance notificationA required notice to the plan for certain services (e.g., ESRD/dialysis) prior to referral or enrollment; may reduce member cost-sharing when in-network providers are used.

Preferred Care PartnersInternal UnitedHealthcare designation referenced throughout the document (context: contracted vendors/providers managed through the plan).

Preferred Care Network / Preferred Care PartnersUnitedHealthcare network entities referenced in this part for which advance notification/prior authorization rules apply.

Optum Transplant/VAD Case Management

Policy Update Changes

2024-04-12document_publicationLatest

Clinical quick reference guidance for Preferred Care Network/Preferred Care Partners (Florida) listing prior authorization and notification requirements and submission instructions.

OpenPayer

Prior authorization and notification requirements for Preferred Care Network and Preferred Care Partners (Florida)

Policy Snapshot & Scope

Prior Authorization and Notification Criteria

Code Lists and Billing Categories

What Providers Must Do

Key Terms

Policy Update Changes

Prior authorization and notification requirements for Preferred Care Network and Preferred Care Partners (Florida)

Policy Snapshot & Scope

Prior Authorization and Notification Criteria

Code Lists and Billing Categories

What Providers Must Do

Key Terms

Where to Get More Information

Policy Update Changes