UnitedHealthcare Prior Auth Requirements PA Medicaid

Coverage Criteria and Authorization Rules

Selection of coverage criteria from document

Prior authorization required for certain outpatient drugs and services:

Colony-stimulating factor drugs and bone-modifying agents require prior authorization when administered in an outpatient setting for a cancer diagnosis.

Specific injectable CSF and related J-/Q-codes (examples: J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125, J1449, J2820) require prior authorization; some listed codes also require prior authorization for non‑oncology diagnoses.

Requests for prior authorization for these agents should be submitted using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (instructions provided in the document).

Prior authorization coverage criteria (section excerpts)

Coverage stance and requirements for prior authorization by service category (examples from this section):

Injectable chemotherapy drugs (including J9000–J9999, J0640–J0642, J1950, Q‑codes and miscellaneous/unassigned injectable chemotherapy HCPCS) require prior authorization when administered in an outpatient setting for a cancer diagnosis.

Injectable colony-stimulating factor drugs require prior authorization; associated ICD-10 diagnosis code listings are provided in the document.

Cochlear implants and other auditory implants require prior authorization (representative CPT/HCPCS codes provided).

Exceptions: Electroencephalogram (EEG) outpatient hospital or ambulatory surgical center services do not require prior authorization.

Continuous glucose monitoring supplies/devices require prior authorization when indicated (e.g., with Type 2 Diabetes diagnosis); HCPCS codes are listed.

Many cosmetic and reconstructive procedure CPTs listed in the document require prior authorization; reconstructive procedures that treat a medical condition are included in the authorization requirements.

Prior authorization code and exception rules (partial)

Codes and rules for prior authorization in this section (partial list):

A wide range of CPT and HCPCS procedure codes tied to listed services require prior authorization (examples in the document include 15879, 17106–17108, 17999, 21137–21138, 21141–21147, 21299, 67900–67966, Q2026 and others).

The document lists numerous diagnosis codes for which prior authorization is not required when billed with the specified diagnosis codes (exception/diagnosis lists shown in the source).

Durable medical equipment (DME) HCPCS codes listed require prior authorization only when the retail purchase or cumulative rental cost for the listed codes exceeds $500; prosthetics are explicitly not classified as DME in this context.

Gender dysphoria note: Gender dysphoria may apply to select procedure codes (noted next to some codes such as 67966).

Prior authorization administrative criteria (listed)

Administrative prior authorization requirements by service category and codes

Enteral services listed (examples: B4034, B4035, B4036) require prior authorization.

Experimental and investigational services listed in the document require prior authorization (examples: 33477, 36514, 64722, 65765, etc.).

Genetic and molecular testing CPT/U codes require notification or prior authorization per the document (examples: 81479, 81518–81522, 81546, 81595, 81599, 87505–87507); BRCA testing requires laboratory notification to UnitedHealthcare before sequencing.

Home health services (examples: G0156, G0162, G0299, G0300 and related codes) require prior authorization; some home health entries note outpatient‑setting specifics.

Hysterectomy CPT codes listed (examples: 58150, 58152, 58180, 58260–58263, 58267, 58270, 58290–58292, 58542–58544, 58550, 58552–58553, 58570–58571) require prior authorization.

Prior authorization requirements

This document section enumerates injectable medications (by name and HCPCS/J-code) and procedure codes that require prior authorization.

Listed injectable medications and specialty drugs (numerous J- and Q-codes shown in the document) require prior authorization prior to coverage; examples appear throughout the injectable medication lists.

Listed CPT/HCPCS procedure codes and services in the document require prior authorization where indicated (examples and long code lists are provided in the source).

Service examples: Home health, hospice (T2045), hysterectomy and human milk bank services are specifically noted as requiring prior authorization where indicated in the list.

Authorization and notification requirements

Coverage-related authorization requirements in this section:

Inpatient admissions: notification is required for admissions; prior authorization and notification of the admission date are required for facilities providing post-acute inpatient services (acute care hospitals, acute inpatient rehabilitation, critical access hospitals).

Joint replacement (total hip and knee) procedures listed require prior authorization; pre-determination is highly recommended for drugs on the Launch Medication List.

Non‑emergent air ambulance transport HCPCS codes (examples: A0430, A0431, A0435, A0436) require prior authorization.

Authorization criteria for listed CPT/HCPCS codes

Authorization criteria and notes for listed services and codes.

Orthognathic surgery CPT codes listed in the document (examples: 21121, 21123, 21125, 21127, 21141–21147, 21159–21299 range entries shown) require prior authorization.

Orthotics and prosthetics: prior authorization is required only for the listed orthotics/prosthetic HCPCS (L‑codes) when the retail purchase or cumulative rental cost for the listed code(s) exceeds $500.

Prior authorization criteria (partial) — orthotics and prosthetics

Prior authorization criteria for orthotics and prosthetics in this section (partial content):

Prior authorization is required for orthotics and prosthetic HCPCS L‑codes listed in the document only when the retail purchase or cumulative rental cost for the listed code(s) is more than $500.

The document provides multiple L‑code examples (e.g., L1720, L1730, L1755, L1820, L1950, L1970, L2000, L2005 and many others) subject to the PA threshold noted above.

Prior authorization criteria and process (partial)

Prior authorization requirements and site-of-service considerations for listed codes

Certain services explicitly indicate 'Prior authorization required' (examples in the document include pediatric day services T1024, private duty nursing T1000/T1002/T1003, proton beam therapy 77520–77525, rhinoplasty/septoplasty 30400–30462 and others).

To request prior authorization providers should use the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call the telephone number provided (document gives call center instructions and number such as 866-889-8054 for some services and 800-600-9007 for general PA submissions).

Site‑of‑service note: Some CPTs require prior authorization only when performed in an outpatient hospital setting; other entries indicate no prior authorization required depending on site and procedure context (site-of-service rules shown in the source).

Prior authorization criteria (partial list)

Prior authorization requirements for specified services and codes

Transplants and CAR T‑cell therapy services require prior authorization; providers are instructed to contact the UnitedHealthcare Community and State Transplant Case Management Team or Optum Transplant as noted in the document.

Spinal surgery and related procedural codes listed in the source require prior authorization.

Ventricular assist devices (VAD) and related services require prior authorization; the document instructs providers to call the notification number on the member's ID card and fax specified forms to the Optum VAD case team.

Wound VAC services and codes (examples: 33983, Q0507–Q0509, E2402) require prior authorization.

Vein procedures for removal and ablation (example CPTs provided) require prior authorization; certain unclassified drug codes (C9399, J3490, J3590) for specified therapies require prior authorization through Optum Transplant.

Code Lists and Coding Notes

Selected CPT/HCPCS codes noted in this portionCPT | HCPCS

59840	Abortion procedure code listed as requiring prior authorization
59841	Abortion procedure code listed as requiring prior authorization
59850	Abortion procedure code listed as requiring prior authorization
20975	Bone growth — requires prior authorization
20979	Bone growth — requires prior authorization
81162	BRCA genetic testing — requires prior authorization
81432	BRCA genetic testing — requires prior authorization
81433	BRCA genetic testing — requires prior authorization
19316	Breast reconstruction-related CPT code listed
19318	Breast reconstruction-related CPT code listed

1–10 of 16

1/2

Selected ICD-10 codes (example)ICD-10

I70.533	Referenced ICD-10 code in injectable colony-stimulating factors list
I70.534	Referenced ICD-10 code in injectable colony-stimulating factors list
I70.535	Referenced ICD-10 code in injectable colony-stimulating factors list

Chemotherapy HCPCS/J-codesHCPCSCovered

J9000-J9999	Chemotherapy injectable drugs range
J0640	Leucovorin
J0641	Levoleucovorin

Example procedure/device codesCPT | HCPCSCovered

95700	Inpatient video cerebral seizure monitoring
95711	Cerebral seizure monitoring
A4226	Continuous glucose monitor supplies

Representative procedure/HCPCS codesCPT | HCPCS | mixedCovered

Q2026	HCPCS code listed in the procedure list
67966	CPT code listed in the procedure list

Diagnosis codes (examples)ICD-10

C43.0	Diagnosis codes listed as exceptions where prior authorization is not required when billed with these diagnosis codes
C44.01	Example listed diagnosis code

Sample HCPCS/CPT/U codes mentionedmixed

B4034	Enteral services
B4100	In-home nutritional
0018U	Genetic/molecular test (example U-code)
81479	Genetic testing CPT example

Selected injectable J-codesHCPCS

J3262	Actemra
J0801	Acthar
J3262	Actemra (listed)

Selected injectable and specialty drug HCPCS/CPT codes appearing in this sectionHCPCS

J1930	Somatuline® Depot (listed as injectable medication)
J2326
J1747
J3241	Tepezza®
J3121	Tezspire™
A9607	Therapeutic radiopharmaceuticals
90378	Synagis
J1429	Vyondys 53®
J9332	Vyvgart™
J9334	Vyvgart Hytrulo

1–10 of 22

1/3

Selected example CPT/HCPCS codesmixedCovered

21121	Orthognathic surgery CPT code (listed as requiring prior authorization)
L0112	Orthotic/prosthetic HCPCS code (listed)

HCPCS L-codes (partial list)HCPCS

L1720	Orthotics and prosthetics (listed example)
L1730	Orthotics and prosthetics (listed example)
L1820	Orthotics and prosthetics (listed example)

Orthotics and prosthetics (sample codes listed)HCPCS

L6882	Orthotics and prosthetics (continued)
L6895	Orthotics and prosthetics (continued)
L6900	Orthotics and prosthetics (continued)

Selected service codes with prior auth notesmixed

T1024	Pediatric day services (PDHC)
T1000	Private duty nursing
33289	Potentially unproven services (example CPT)
77520	Proton beam therapy

Rhinoplasty/septoplasty CPTsCPT

30400	Rhinoplasty/septoplasty
30410	Rhinoplasty/septoplasty
30420	Rhinoplasty/septoplasty

Ophthalmology and misc (partial list)CPT

65730
65855
66170
66761
67028

Spinal surgery codes (partial)CPT

22100	Spinal surgery (example)
22514	Spinal surgery (listed with asterisk in source)
22850
63003

Device/implant codes (partial)HCPCS

E0747	Implantation device code (listed)
E0748	Implantation device code (listed)
L8680	Device supply codes (listed)

CAR T/Gene therapy code mappingsCPT | HCPCS

0537T	CAR T-Cell therapy related T-codes mapping
0538T
Q2041

DME prior auth financial threshold

DME PA financial thresholdPrior authorization required only for listed DME codes when retail purchase or cumulative rental cost is more than $500.

Example DME codes subject to thresholdA9279, A9280, A9900, E0194 (listed DME HCPCS examples).

Prosthetics noteProsthetics are not classified as DME for this prior authorization list; see Orthotics and Prosthetics section for guidance.

Launch Medication List pre-determination recommendation

Pre-determination recommendationPre-determination is highly recommended for drugs on the Launch Medication List.

Where to find Review at Launch policySee Review at Launch for New to Market Medications policy at UHCprovider.com under Community Plan Policies (Medical & Drug Policies and Coverage Determination Guidelines).

Context of useRecommendation applies when requesting prior authorization or planning treatment involving Launch-listed medications (e.g., joint replacement medication planning, air ambulance references).

Orthotics/prosthetics PA cost threshold

Orthotics/prosthetics PA cost thresholdPrior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500.

Representative L-codes referencedExamples include L0112, L0170, L0456, L0462, L1720, L1730, L1755, L1820 (multiple L-codes listed in orthotics/prosthetics section).

Pre-determination notePre-determination is recommended and the Launch Medication List reference appears alongside orthotics/prosthetics entries in the document.

Prior authorization cost threshold

General PA cost thresholdPrior authorization is required when the retail purchase or cumulative rental cost exceeds $500.

Applies toDocument applies this $500 threshold to listed DME, orthotics and prosthetics codes as noted in the respective sections.

How threshold is expressed in policyStated as 'retail purchase or cumulative rental cost of more than $500' in multiple sections (DME and orthotics/prosthetics).

Oncology-specific prior authorization for 38232

38232 oncology-specific PA ruleCPT code 38232 will only require prior authorization when billed for an oncology diagnosis.

Related gene therapy/unclassified code noteUnclassified codes (C9399, J3490, J3590) and certain gene therapies require prior authorization through Optum Transplant; referenced near the 38232 entry.

Instruction sourcePolicy text explicitly states the oncology-only PA requirement for code 38232 and links to surrounding transplant/Optum Transplant guidance.

How Providers Request Prior Authorization and Operational Notes

Prior Authorization

How to request prior authorization

To request prior authorization, submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com), or by phone 800-600-9007 or fax 877-310-3826. Prior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all non‑emergent procedures and services.

Prior Authorization

Cardiology prior authorization instructions

Cardiology outpatient and office-based diagnostic catheterizations, electrophysiology implants and stress echocardiography require prior authorization. Submit requests via the UnitedHealthcare Provider Portal or call 866-889-8054; see UHCprovider.com/PAcommunityplan → Prior Authorization and Notification Resources → Cardiology Prior for CPT/HCPCS details.

Prior Authorization

Cancer supportive care drugs requiring prior authorization

Colony‑stimulating factor drugs and bone‑modifying agents administered in an outpatient setting for a cancer diagnosis require prior authorization. Specific HCPCS/J‑codes are listed in the document (examples include J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125).

Prior Authorization

How to obtain prior authorization (portal-focused)

For most services requiring prior authorization, submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com). The portal is the primary submission method referenced throughout this list.

Prior Authorization

Seizure monitoring / EEG prior auth notes

Prior authorization is required for inpatient video cerebral seizure monitoring (CPT 95700, 95711–95713). EEG performed in an outpatient hospital or ambulatory surgical center does not require prior authorization.

Prior Authorization

Continuous glucose monitor prior authorization

Continuous glucose monitor supplies and systems require prior authorization when used for members with Type 2 Diabetes; applicable HCPCS codes include A4226, A9277, A4238, A9278, A4239, E0787, A9276 and related codes listed.

Prior Authorization

Chemotherapy injectable drugs prior authorization

Injectable chemotherapy drugs administered in an outpatient setting for a cancer diagnosis (including J9000–J9999, J0640–J0642, J1950, Q‑codes and miscellaneous HCPCS for unassigned drugs) require prior authorization. Submit requests via the Provider Portal.

Prior Authorization

Cochlear implants prior authorization

Cochlear implants and other auditory implants require prior authorization. Representative CPT/HCPCS codes listed include 69710, 69714, 69930 and device L‑codes such as L8619, L8691, L8614, L8692.

Prior Authorization

Cosmetic and reconstructive procedures prior authorization

Many cosmetic and reconstructive CPT codes listed require prior authorization; reconstructive procedures that treat a medical condition or restore function are included. Examples in the list include CPTs 11960, 14020, 15820–15879, 17106–17108, 17999, and 21137–21183.

Prior Authorization

Prior authorization for listed procedures (reconstructive examples)

Numerous specific procedures are tied to prior authorization—examples include CPT 15879, 17106–17108, 17999 and 21137–21139 (reconstructive procedure examples). Verify the full code list before scheduling and submit authorization via the Provider Portal.

Billing Rule

DME prior authorization threshold (provider action)

Durable medical equipment (DME) codes listed require prior authorization only when the retail purchase or cumulative rental cost for the listed codes exceeds $500.

Billing Rule

Authorization identifiers for injectable colony-stimulating factors

Injectable colony‑stimulating factor items reference authorization identifiers for DME-like entries: K0008, K0013, K0108 and K0812 appear as authorization identifiers associated with these items.

Billing Rule

Authorization identifiers and HCPCS codes for DME, enteral and nutritional services

The document lists numerous HCPCS codes and authorization identifiers for durable medical equipment, enteral and in‑home nutritional services (examples include K0830–K0891 series, B4034–B4036, V5281–V5290 and others) and notes prior authorization is required for enteral services.

Prior Authorization

Procedures and experimental/investigational codes requiring prior authorization

Various procedures and services labeled experimental/investigational require prior authorization; examples include CPT 33477, 36514, 64722, 65765 and other listed codes—confirm authorization prior to providing these services.

Prior Authorization

Gender dysphoria and related procedure codes requiring prior authorization

Gender dysphoria treatments and related procedures require prior authorization; the policy lists numerous associated ICD‑10 codes (e.g., F64.0–F64.9) and multiple CPT codes spanning reconstructive and surgical services that must be authorized.

Prior Authorization

Genetic and molecular testing codes and prior authorization/notification requirements

Genetic and molecular testing CPT/U codes require prior authorization or notification for many tests (examples include 0018U, 0022U, 81163, 81400–81417, 81479, and BRCA testing which requires lab notification to UnitedHealthcare).

Prior Authorization

Home health and hospice codes requiring prior authorization

Home health services (e.g., G0156, G0162, G0299, G0300, G0493–G0496) and hospice (T2045) require prior authorization as noted; home health prior authorization applies to outpatient settings per the list.

Prior Authorization

Hysterectomy codes requiring prior authorization

Hysterectomy CPT codes listed (for example 58150, 58152, 58180, 58260–58292, 58542–58571) require prior authorization according to the document.

Prior Authorization

Obtain prior authorization (summary for multiple services)

Prior authorization is required for the HCPCS/CPT codes and services listed throughout the document (including home health, hospice, hysterectomy and human milk bank entries); submit requests via the Provider Portal or applicable phone numbers.

Prior Authorization

Inpatient admission notification and prior authorization

Notification is required for inpatient admissions; for post‑acute inpatient services (acute care hospitals, acute inpatient rehabilitation, critical access hospitals) prior authorization and notification of the admission date are required.

Prior Authorization

Joint replacement prior authorization

Joint, total hip and knee replacement procedures listed require prior authorization (multiple CPT/HCPCS codes enumerated). Pre‑determination is highly recommended for drugs on the Launch Medication List.

Prior Authorization

Air ambulance prior authorization

Non‑emergent air ambulance transports (HCPCS A0430, A0431, A0435, A0436 and S9960) require prior authorization before transport.

Prior Authorization

Orthognathic surgery prior authorization

Orthognathic surgery for treatment of maxillofacial/jaw functional impairment requires prior authorization for the listed CPT codes (examples include 21121, 21123, 21125, 21127, 21141–21155 and others).

Documentation Required

Air ambulance and medication pre-determination

For non‑emergent air ambulance and certain specialty medications, pre‑determination is recommended; the document references pre‑determination for drugs on the Launch Medication List and the same submission pathways for air ambulance authorization.

Prior Authorization

Orthognathic surgery CPT codes and PA

Orthognathic surgery CPT codes are listed in detail (including 21121–21127, 21141–21155, 21159–21161, 21206–21210, 21240, etc.) and require prior authorization prior to performance.

Billing Rule

Orthotics & Prosthetics HCPCS codes and PA threshold

Orthotics and prosthetics HCPCS L‑codes are listed; prior authorization is required only when the retail purchase or cumulative rental cost for the listed orthotics/prosthetic codes exceeds $500.

Prior Authorization

Prior authorization requirement and how to obtain (orthotics/prosthetics)

Prior authorization is required for orthotics and prosthetic codes listed only when the retail purchase or cumulative rental cost is more than $500; the policy also references how to obtain authorization and recommends pre‑determination.

Documentation Required

Pre-determination recommendation / Review at Launch reference

The document references the Review at Launch for New to Market Medications policy on UHCprovider.com and states pre‑determination is highly recommended for drugs on the Launch Medication List.

Prior Authorization

How to obtain prior authorization (phone and portal)

Prior authorization requests may also be obtained by phone at 866-889-8054 or submitted online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com → Provider Portal → Prior Authorization and Notification).

Prior Authorization

Services noted as prior authorization required (examples)

The document marks multiple services explicitly as 'Prior authorization required,' including pediatric day services (T1024), private duty nursing (T1000/T1002/T1003), potentially unproven services (e.g., 33289) and proton beam therapy (77520–77525).

Prior Authorization

Site of service prior authorization notes

Some CPTs require prior authorization only when performed in an outpatient hospital site of service; other entries note that authorization is not required depending on procedure and site—confirm site‑specific notes in the code list.

Prior Authorization

Transplant prior authorization instruction

Transplant services (including CAR T‑cell therapy where applicable) require prior authorization; contact the UnitedHealthcare Community and State Transplant Case Management Team as directed in the policy for coordination.

Prior Authorization

VAD prior authorization instruction

Ventricular assist devices (VAD) and related services require prior authorization. Call the notification number on the member's ID card and fax the form provided by the nurse to the Optum VAD Case as instructed.

Prior Authorization

Procedure prior authorization requirement (spinal surgery, wound vac, vein procedures)

Procedures such as spinal surgery, wound VACs and vein procedures are listed as requiring prior authorization; wound VAC examples include CPT/HCPCS 33983, Q0507–Q0509 and E2402—obtain authorization before providing these services.

Key Definitions and Terms

Prior authorization definition

Prior authorization (definition)A required approval obtained before certain services are performed; not required for emergency or urgent care.

How to requestRequests may be submitted online via the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal, by phone, or by fax (specific contact details are provided elsewhere in the document).

Out-of-network requirementOut-of-network providers must request prior authorization for all procedures and services excluding emergent or urgent care.

Colony-stimulating factor and bone-modifying agents definition

DefinitionColony-stimulating factor and bone-modifying agents: drugs administered in an outpatient setting for a cancer diagnosis that require prior authorization.

Example HCPCS/J-codesCodes listed include J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125 (document lists these and notes some also need PA for non-oncology diagnoses).

How to obtain PA for these agentsRefer to the injectable medications section for how to obtain prior authorization; specific authorization identifiers are noted elsewhere in the document.

Cosmetic and reconstructive definition (cosmetic)

Cosmetic procedure definitionCosmetic procedures change or improve physical appearance without significantly improving or restoring physiological function.

Reconstructive procedure definitionReconstructive procedures treat a medical condition or improve or restore physiological function (distinguished from cosmetic procedures).

PA implicationPrior authorization is required for many listed cosmetic and reconstructive CPT codes; reconstructive procedures that treat medical conditions may also require authorization.

Cochlear implant definition

Cochlear implant definitionA cochlear implant is a medical device within the inner ear with an external portion to help persons with profound hearing loss; CPT/HCPCS codes and PA instructions are provided (example how to obtain PA = 69930, L8691, L8614, L8692).

PA requirementCochlear implants and other auditory implants require prior authorization as listed in the document.

Representative codesRepresentative codes and how to obtain PA are provided in the cochlear implant entries (see injectable/implant sections).

Reconstructive vs cosmetic distinction

DistinctionReconstructive procedures treat medical conditions or restore physiological function; cosmetic procedures are intended to change or improve appearance without significant functional benefit.

Policy impactThe distinction guides prior authorization decisions — reconstructive services addressing medical need may still require PA but are clinically distinguishable from elective cosmetic services.

ExamplesDocument lists multiple CPT codes under 'Cosmetic and reconstructive' to indicate where PA is required depending on clinical intent (e.g., 11960, 14020, 15879, 17106–17108, 17999, 21137–21138).

Prosthetics/DME distinction

Distinction between prosthetics and DMEProsthetics are not classified as DME for this prior authorization list; orthotics and prosthetics are handled in their own section.

Related PA thresholdDME codes are subject to the $500 retail purchase or cumulative rental threshold; orthotics/prosthetics have a parallel threshold when treated as PA-applicable items.

Representative codesDME examples include A9279, A9280; orthotics/prosthetics include many L-codes (L0112, L1720, L1730, etc.).

Prior authorization (general note)

General note on prior authorizationPrior authorization indicates the payer requires approval before coverage for listed medications or services; not required for emergency or urgent care.

Submission methodsRequests may be submitted online via the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal, by phone, or by fax as provided in the document.

Provider applicabilityOut-of-network providers must request prior authorization for all procedures and services excluding emergent or urgent care.

Experimental and investigational definition

Experimental & investigational definitionServices or procedures labeled 'Experimental and investigational' in the document require prior authorization (the policy explicitly states 'Prior authorization required' for these entries).

Example codesExamples listed under experimental/investigational include CPT 33477, 36514, 64722, 65765 and others in that section.

ImplicationClaims for procedures designated experimental/investigational should be submitted only after obtaining required prior authorization per the listed codes and instructions.

Prior authorization required indicates payer approval needed

Meaning of 'Prior authorization required'Indicates the payer requires approval before coverage for the listed injectable medications or services; entries flagged this way must have approval obtained prior to service provision or billing.

Where usedThis designation appears throughout the document for injectables, DME, home health, hospice, hysterectomy, and other services.

Exception noteEmergency and urgent care remain exceptions where prior authorization is not required.

Review at Launch

Review at Launch referenceSee 'Review at Launch for New to Market Medications' policy for up-to-date information on newly FDA-approved drugs; referenced in the document alongside Launch Medication List entries.

PurposeUsed to guide PA and pre-determination decisions for new-to-market medications included on the Launch Medication List.

Where to accessAvailable at UHCprovider.com under Community Plan Policies (Medical & Drug Policies and Coverage Determination Guidelines).

Launch Medication List

Launch Medication List definitionA referenced list of medications for which pre-determination (pre-authorization review) is highly recommended; tied to the Review at Launch policy.

Operational guidanceProviders are advised to pre-determine coverage for Launch-listed drugs via the Provider Portal or by phone/fax per standard PA submission processes.

Where referencedLaunch Medication List appears throughout sections on inpatient admission, joint replacement, air ambulance, and orthognathic surgery as a pre-determination recommendation context.

Orthotics and prosthetics PA threshold (definition)

Orthotics & prosthetics PA threshold (definition)Prior authorization is required only for orthotics and prosthetic HCPCS L-codes listed when the retail purchase or cumulative rental cost is more than $500.

ScopeApplies to the L-code series enumerated in the orthotics/prosthetics sections (many L-codes listed across chunks 118–132).

Related processEntries reference how to obtain prior authorization and recommend pre-determination where applicable.

Prior authorization threshold (definition)

Prior authorization threshold (definition)The policy defines the financial PA threshold as retail purchase or cumulative rental cost greater than $500 for listed items.

Applies toUsed for DME, orthotics and prosthetics entries as the cutoff determining when PA is required for listed codes.

Stated wordingExpressed in the document as 'retail purchase or cumulative rental cost of more than $500'.

Prior authorization (duplicate reference)

Prior authorization (reference)A payer requirement for approval before coverage; the document repeatedly flags services and codes as 'Prior authorization required' with submission instructions provided.

Submission methodsOnline via the Provider Portal Prior Authorization and Notification tool, by phone, or fax as listed in the general information and specific sections.

Non-emergency exceptionEmergency and urgent care do not require prior authorization per the general information section.

Provider Portal prior auth tool (definition)

Provider Portal prior auth toolThe Prior Authorization and Notification tool on UnitedHealthcare Provider Portal (UHCprovider.com) is the primary online method to submit prior authorization requests.

How to accessGo to UHCprovider.com, click the UnitedHealthcare Provider Portal button, then select Prior Authorization and Notification on the Provider Portal dashboard.

Alternative submission methodsPhone and fax contact information is provided in the document for providers who do not use the portal.

Optum Transplant (definition/reference)

Optum Transplant (definition)Optum Transplant is the program used for prior authorization of certain unclassified codes and specialized therapies (e.g., Amtagvi, Casgevy, Lantidra, Lenmeldy, Skysona) that require authorization through Optum Transplant.

Contextual useReferenced where unclassified drug codes (C9399/J3490/J3590) and certain gene therapies are listed as requiring Optum Transplant authorization.

How providers are directedEntries instruct providers to use Optum Transplant processes for these specific therapies as noted in the policy text.

Ventricular assist device (VAD) definition

Ventricular assist device (VAD) definitionA ventricular assist device (VAD) is a mechanical pump that takes over the function of the damaged ventricle and restores normal blood flow; prior authorization is required for VADs and related services.

How to obtain PA for VADProviders should call the notification number on the member's ID card and fax the form provided by the nurse to the Optum VAD Case as instructed in the document.

PA requiredThe policy explicitly states prior authorization is required for VAD procedures and related services.

OpenPayer

Prior Authorization Requirements for Pennsylvania Medicaid

Coverage Criteria and Authorization Rules

Code Lists and Coding Notes

How Providers Request Prior Authorization and Operational Notes

Key Definitions and Terms