CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida

Lists prior authorization requirements and submission instructions for participating Preferred Care Network and Preferred Care Partners of Florida providers, including portals, phone numbers, and plan groups; applies to inpatient and outpatient services and excludes emergency/urgent care.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call Preferred Care Network 866-273-9444 / Preferred Care Partners 800-995-0480.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2024-10-01policy effective date

WellMed portalWellMed portal option

Multipleinjectable J/Q codes

Requiredchemotherapy notification

Advance notice

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.

naviHealthnaviHealth contact

Services and Codes Requiring Prior Authorization / Notification

inv-01: Prior authorization requirements and exceptions

The document lists services and specific codes that require prior authorization; some services (e.g., cardiology) note that prior authorization is no longer required. Cancer supportive care drugs and colony‑stimulating factors administered outpatient generally require prior authorization.

Covered when listed procedures, devices or drugs are submitted with prior authorization as specified in the sections below; emergency and urgent care do not require prior authorization.

Examples of items that require prior authorization

Bone growth stimulators — CPT 20974, 20975, 20979 (prior authorization required).
Breast reconstruction (non‑mastectomy) — CPT 19316, 19318, 19325 and prosthetic implant L8600 (prior authorization required).
Cancer supportive care / antiemetics and colony‑stimulating factors — multiple J/Q codes including J1454, J1442, J1447, Q5108, Q5122, J2506, J2820, J0897, J1456, J1449, J0885 (prior authorization required).
Erythropoiesis‑stimulating and other injectable biologics listed in the policy (see injectable medication lists) — prior authorization required per entries.
Note: Cardiology services section indicates 'Prior authorization no longer required' for cardiology services. Verify cardiology codes against that note before requesting prior authorization.

Submit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by calling the numbers provided for the plan groups; follow the submission instructions in the Provider Actions section.

inv-02: selected_service_authorization_rules

Selected services require either prior authorization or notification as specified below.

Injectable chemotherapy drugs administered in an outpatient setting (intravenous, intravesical, intrathecal) require notification: J9000–J9999 and related miscellaneous/Q‑coded chemo agents; leucovorin/levoleucovorin (J0640, J0641, J0642). Submit via Provider Portal or phone as directed.

Notification (not full prior authorization) is required for outpatient chemotherapy injectable drugs per the policy.

End‑stage renal disease (ESRD) and dialysis services require advance notification for inpatient or outpatient dialysis; exception: advance notification is not required when a Medicare member travels outside the service area.

Gender dysphoria treatment requires prior authorization; certain CPT codes listed (examples include 55970, 55980 and a broader set of CPT codes listed) require notification or prior authorization depending on diagnosis codes (F64.x, Z87.890).

All durable medical equipment (DME) requests must be directed to a health plan contracted vendor; contact number is on the member's ID card. This routing applies regardless of PA requirement for specific DME items.

inv-03: Hysterectomy authorization criteria

Hysterectomy and related surgical procedures

Prior authorization is required for many abdominal and laparoscopic hysterectomy CPT codes listed (examples: 58150, 58152, 58180, 58541, 58552, 58543, 58544, 58550, 58552, 58553, 58554, 58570).

Inpatient vaginal hysterectomy CPT codes (e.g., 58260, 58262, 58263, 58267, 58290, 58291, 58292) indicate prior authorization required. Outpatient vaginal hysterectomies may not require prior authorization for outpatient vaginal procedures (policy notes exception).

inv-04: Home health authorization criteria

Home health services

Prior authorization is required for home health services only for members who reside in and receive services in Alabama and Georgia; all requests should be directed to a health plan contracted vendor and the member's ID card used for contact.

inv-05: DME and injectable medication listing

DME, procedure, and injectable medications

The policy lists numerous DME/procedure CPT mappings and many injectable HCPCS J‑codes; presence in these lists indicates the item may be subject to prior authorization per the broader policy. Refer to the specific code lists in the coding section when determining PA requirements.

Selected injectable and biologic examples from the list

Adakveo — J0791 (listed).
Aduhelm — J0172 (listed).
Givlaari — J0223; Hemgenix — J1411; Evkeeza — J1305 (listed among injectable medications).
Colony‑stimulating factors and pegfilgrastim biosimilars — J1442, J1447, J1449, Q5108, Q5122, etc. (listed) — generally require prior authorization per cancer supportive care entries.

inv-06: Prior authorization criteria by service group

Services and codes requiring prior authorization or notification as listed below.

Post‑acute inpatient admissions: prior authorization and notification of admission date required for acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long‑term acute care hospitals and skilled nursing facilities; certain plans are excluded from the SNF PA requirement (UnitedHealthcare Assisted Living Plans and UnitedHealthcare Nursing Home plan).

Non‑emergency air transport requires prior authorization — specific transport HCPCS codes A0430, A0431, A0435, A0436 are listed.

Orthognathic, maxillofacial, spine and joint surgeries: prior authorization required for multiple CPT ranges and specific codes listed (examples include many spine and orthopedic CPT codes shown in the policy).

inv-07: Authorization and coverage criteria — excerpt

Coverage/authorization stance for several categories in this section (excerpt).

Out‑of‑network referrals: advance notification is required when a network provider directs a member to an out‑of‑network provider; members may have increased out‑of‑pocket costs or no coverage. Prior authorization requirements and network restrictions in provider agreements may apply.

Orthotics/Prosthetics: prior authorization is required for prosthetics/orthotics when the retail purchase or cumulative rental cost exceeds $1,000. Specific HCPCS L‑codes are referenced in the prosthetics listing.

Radiation and proton beam therapy

Proton beam therapy requires prior authorization (codes include 77520, 77522, 77523, 77525).
Some radiation therapy entries include a statement that prior authorization is no longer required for certain radiation services (verify specific radiation codes against the policy).

inv-08: Authorization stance for listed out-of-network procedures

Vein procedures and select therapies require prior authorization or case management notification as listed.

Vein procedures: removal and ablation of the main trunks and named branches of the saphenous veins (treatment of venous disease/varicose veins) require prior authorization — policy specifically notes prior authorization required for these vein procedures (e.g., code 37243 referenced).

Case management contacts: certain listed therapies and related out‑of‑network coordination reference case management and oncology diagnostic coding requirements when obtaining prior authorization for specialty products (see policy for detailed instructions).

Code Lists (CPT / HCPCS / ICD-10 / J‑codes) Referenced

Selected injectable medications (J‑codes) — included/require prior authorizationHCPCSCovered

J0791	Adakveo
J0172	Aduhelm
J7171	Adzynma
J0225	Amvuttra
J0585-J0589	Pegfilgrastim biosimilars range (examples)
J3111	Bone density agent (example)
J0897	Denosumab (Prolia, Xgeva)
J2329	Therapeutic biologic (example)
J1442	Colony-stimulating factor
J1447	Colony-stimulating factor

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Cardiovascular ICD-10 codesICD-10

I70.244	Atherosclerosis of native arteries of right leg with rest pain
I70.245	Atherosclerosis of native arteries of left leg with rest pain
I70.248	Atherosclerosis of native arteries of unspecified leg with rest pain

Osteomyelitis ICD-10 codesICD-10

M86.051	Acute hematogenous osteomyelitis, right shoulder
M86.052	Acute hematogenous osteomyelitis, left shoulder

Assorted CPT / HCPCS examples (mixed)mixed

27415	Osteotomy, knee; 1st
69714	CPT example listed in source
69930	CPT example listed in source
L8690	Prosthetic device example
11960	Soft tissue repair example

Gender dysphoria and related procedure/DME codesCPT

57106	Gender dysphoria related procedure example
64856	Nerve procedure example
L5987	Prosthetic code example (mapped in prosthetics section)

DME / procedure code mappings (examples)HCPCS

L5301	Prosthetic mapping for 52441
L5856	Prosthetic mapping for 52442
L5968	Prosthetic mapping for 55874

Enumerated injectable medication J‑codes (selected list)HCPCSCovered

J0791	Adakveo
J0172	Aduhelm
J7171	Adzynma
J0225	Amvuttra
J1454	Akynzeo (palonosetron/fosnetupitant)
J1456	Antiemetic drugs
J1442	Colony-stimulating factor
J1447	Colony-stimulating factor
J1449	Colony-stimulating factor
Q5108	Pegfilgrastim-jmdb (Fulphila) Q-code

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Selected injectable medications (highlighted) — coveredHCPCSCovered

J1442	Colony-stimulating factor
J1447	Colony-stimulating factor
J1449	Colony-stimulating factor
Q5108	Pegfilgrastim-jmdb (Fulphila)

Additional injectable biologics and therapiesHCPCSCovered

J3247	Therapeutic biologic (example)
J0584	Crysvita (listed J-code)
J1413	Elevidys
J1302	Enjaymo
J3380	Entyvio
J1305	Evkeeza
J0223	Givlaari
J1411	Hemgenix

Therapeutic radiopharmaceuticalsHCPCSCovered

A9513	Radiopharmaceutical
A9590	Radiopharmaceutical
A9699	Radiopharmaceutical
J9381	Tzield

Miscellaneous J‑codes listedHCPCS

J2507	Krystexxa
J0174	Leqembi
J1437	Intravenous iron product
J1439	Intravenous iron product

Selected spinal CPT codes (examples)CPT

22819	Spinal fusion, anterior
22830	Posterior instrumented fusion
22849	Spinal instrumentation (example)
22850	Spinal instrumentation (example)

Proton beam therapy codesCPT

77520	Proton beam therapy, simple
77522	Proton beam therapy, intermediate
77523	Proton beam therapy, complex

Radiation therapy G-codesCPT

G6017	IGRT related G-code
G6001	Radiation therapy G-code example

Selected listed CPT/HCPCS codes — consolidated examplesmixed

J3399	Zolgensma (example miscellaneous J-code)
J3393	HCPCS J3393 (example)
J3394	HCPCS J3394 (example)
J9999	Miscellaneous drug code
C9098	CAR T-cell related code
Q2041	Prosthetic related Q-code
Q2042	Prosthetic related Q-code
Q2053	Prosthetic related Q-code
Q2054	Prosthetic related Q-code
Q2055	Prosthetic related Q-code

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Part B Step Therapy Program — markermixed

Note	Drugs marked with ** in source are also included in the Part B Step Therapy Program

Orthotics/Prosthetics prior authorization thresholdmixed

PolicyNote

Retail purchase or cumulative rental cost > $1,000 requires prior authorization for orthotics/prosthetics

Conditional prior authorization notemixed

38232

Code 38232 will only require prior authorization for an (conditional) scenario per source notes

Submission, Notification, and Case-Management Contacts

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests using the UnitedHealthcare Provider Portal Prior Authorization and Notification tool: sign in at UHCprovider.com with your One Healthcare ID, then select Prior Authorization and Notification. Phone options: Preferred Care Network: 866-273-9444; Preferred Care Partners: 800-995-0480. For naviHealth-managed inpatient/post-acute authorizations: Phone 855-851-1127, Fax 844-244-9482. For specialty pharmacy/Prior Authorization submissions for certain drugs you may also call 888-397-8129.

Provider portal: UHCprovider.com > Prior Authorization and Notification tab (One Healthcare ID required).
Phone: Preferred Care Network 866-273-9444; Preferred Care Partners 800-995-0480.
naviHealth (manages in-scope PA): Phone 855-851-1127, Fax 844-244-9482.
Specialty pharmacy / certain drug PAs: call 888-397-8129.

Prior Authorization

WellMed submission option for specific groups

WellMed-specific groups may submit prior authorization requests through the WellMed provider portal or by phone during business hours.

Key Terms and Definitions

Prior authorization — short definition of prior authorization

DefinitionPrior authorization is the process by which certain services must be approved by the plan before they are rendered; not required for emergency or urgent care.

How to requestSubmit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by the listed phone numbers.

Referral Required plans — referral and PA interplay definition

Referral Required plansWhen a member's ID card indicates 'Referral Required,' some services may require both a referral from the member's primary care provider and prior authorization obtained by the treating physician.

Interaction with PAReferral and prior authorization requirements are distinct but may both be required before services are provided.

Supplementary Coding Notes and Program Flags

Part B Step Therapy Program drugs marker (repeat to surface in coding extras)

Part B Step Therapy marker (coding)Items marked with ** in the injectables/drug listing indicate inclusion in the Part B Step Therapy Program.

Orthotics/Prosthetics prior authorization threshold (repeat for emphasis in coding section)

Orthotics/Prosthetics PA threshold (coding)Prior authorization required when retail purchase or cumulative rental cost exceeds $1,000; applies to referenced L‑codes.

Coding noteVerify the HCPCS L‑code when submitting authorization for prosthetics/orthotics exceeding the threshold.

Conditional PA note for 38232 (coding exception flag)

Conditional PA flag for 38232 (coding)

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2024

Next Review DateN/A

SourceLink

On This Page

Spinal surgery and neurostimulators: spinal surgeries and implantation of neurostimulator devices require prior authorization; device requests should be directed to a plan‑contracted vendor. Numerous spinal CPT codes and device/device L‑codes are listed.

Transplant and CAR T‑cell services: organ/tissue transplants and transplant‑related services require prior authorization and notification; for coordination call Optum Transplant Case Management at 888‑936‑7246 per the policy. Specific cellular therapies and CAR T products are listed.

WellMed provider portal: eprg.wellmed.net.
Phone: 877-299-7213, 8 a.m.–5 p.m. ET, Monday–Friday.
Applicable groups: Preferred Care Network MedicareMax (HMO) groups 98151, 98152; MedicareMax Chronic (HMO C-SNP) group 90215; MedicareMax Plus (HMO D-SNP) groups 98153, 98154, 98155.

Prior Authorization

Examples of codes and products that commonly require prior authorization

Examples of services, procedures and injectable medications that require prior authorization or notification. This list is illustrative — verify code-specific rules before billing.

Bone growth stimulators: CPT/HCPCS 20974, 20975, 20979 (PA required).
Cancer supportive care anti-emetics: J1454 (Akynzeo), J1456 (other anti-emetics) — some agents require PA.
Colony-stimulating factors and related biologics: J1442, J1447, J1449, Q5108, Q5110, Q5122, Q5125, Q5127, Q5130, J2506, J2820, J1447, etc. (PA required).
Selected injectable medications listed: J0584 (Crysvita), J1413 (Elevidys), J1302 (Enjaymo), J3380, J1305 (Evkeeza), J0223 (Givlaari), J1411 (Hemgenix), J9332, J9334, J3399, J1748, J0585–J0589 (botulinum toxins), J3111/J0897 (bone density agents), and others — many require PA.
Colony-stimulating factors examples: filgrastim (Neupogen), pegfilgrastim (Neulasta) and biosimilars (Q-codes listed) — PA required.
Certain procedures and devices (e.g., cartilage and cochlear implants, prosthetics, many reconstructive procedures) require prior authorization.
This list also includes many CPT/HCPCS codes for procedures (examples in source). Confirm code-level requirements on the portal prior to submission.

Note

Cardiology services prior authorization status

Cardiology services: as noted in source material, prior authorization is no longer required for general cardiology services. However, code-level exceptions may exist for vascular/interventional procedures — verify specific CPT/HCPCS codes before submission.

General cardiology services: Prior authorization no longer required (confirm per benefit).
Interventional vascular codes (examples in source such as 37220–37228) may still have PA requirements — check code-specific guidance.

Prior Authorization

Injectable chemotherapy notification and prior authorization

Notification is required for outpatient injectable chemotherapy administration for a cancer diagnosis; some chemotherapy and supportive oncology injectables require prior authorization.

Notification required for outpatient injectable chemotherapy drugs (HCPCS J9000–J9999 range) and chemotherapy Q‑codes.
Specific listed drugs and codes requiring notification/PA include Leucovorin J0640, Levoleucovorin J0641/J0642, and miscellaneous/unassigned chemotherapy billed under miscellaneous HCPCS.
Submit chemotherapy prior authorizations via the Provider Portal Prior Authorization and Notification tool or call 888-397-8129 as applicable.

Prior Authorization

Gender dysphoria treatment prior authorization requirements

Gender dysphoria treatments require prior authorization or notification depending on the service and diagnosis code; many surgical and related CPT/HCPCS codes are listed and must be submitted when applicable.

Gender dysphoria treatment: Prior authorization required (notification or PA depending on service).
When submitted with diagnosis codes F64.0, F64.1, F64.2, F64.8, F64.9 or Z87.890, specific CPT codes require notification/PA.
Example surgical and procedure codes included in the source: 55970, 55980, 57106, 57110, 57291, 57292, 57295, 57296, 57335, 57426, 58661, 58720, 58940, 64856, 64892, 64896, 92507, 92508 (confirm full list on portal).
Durable medical equipment related to gender dysphoria and related services may have separate vendor routing — follow DME vendor direction.

Prior Authorization

Hysterectomy prior authorization requirements

Hysterectomy: abdominal and laparoscopic hysterectomies require prior authorization. Outpatient vaginal hysterectomies generally do not require prior authorization; some inpatient vaginal hysterectomy codes may be exceptions — confirm per code and setting.

Abdominal and laparoscopic hysterectomy CPT codes with PA: 58150, 58152, 58180, 58541, 58552, 58543, 58544, 58550, 58553, 58554, 58570.
Vaginal hysterectomy outpatient codes (no PA for outpatient vaginal hysterectomy): 58571, 58572, 58573 (outpatient vaginal hysterectomy typically not subject to PA).
Inpatient vaginal hysterectomy codes that may require PA or have special rules: 58260, 58262, 58263, 58267, 58290, 58291, 58292 (verify submission requirements).

Prior Authorization

DME, procedure, and injectable medication prior authorization direction

Durable Medical Equipment (DME), certain procedures, and many injectable medications must be routed as specified and often require prior authorization. DME must be requested from a contracted vendor; confirm codes and drug lists before submission.

All DME requests should be directed to a health plan–contracted vendor; call the number on the member's health plan ID card for vendor details.
Selected J‑codes and injectable medication examples requiring PA include (non‑exhaustive): J0584, J0585–J0589, J0897, J1442, J1447, J1449, J2506, J2820, J9332, J9334, J3399, J1748, J3380, J1305, J0223, J1411, J1302, J1413.
Bone density agents and colony-stimulating factors (examples J3111, J0897, J1442, J1447, Q5108, Q5122) are included in PA lists.
For DME and device implantation requests, follow vendor routing and portal submission — some devices require separate vendor approval.

Prior Authorization

Radiation and proton beam therapy authorization

Proton beam therapy requires prior authorization. Radiation therapy (therapeutic/IMRT/IGRT) in many cases no longer requires prior authorization, but specific proton beam CPT codes do require PA.

Proton beam therapy CPT/HCPCS codes: 77520, 77522, 77523, 77525 — Prior authorization required.
Radiation therapy (IMRT/IGRT and many therapeutic radiology services): Prior authorization no longer required in many cases — verify per code and benefit.
When in doubt for radiation or proton therapy, submit via the Provider Portal or contact the plan for code‑level confirmation.

Prior Authorization

Stimulators and device implantation prior authorization

Neurostimulators, device implantation procedures and other implantable stimulators require prior authorization. Direct device and implantation requests to the plan or contracted vendor for review.

Stimulators and implantable neurostimulator codes (examples in source include 61850, 61863, 61864, 61867, 61868, 61885, 61886, 63650, 63655, 63685, 64555, 64568, 64590, L8682, L8683) require prior authorization.
Bone growth stimulators (E0749, E0760) also require PA.
All device implantation requests should be routed per plan/vendor instructions; call the number on the member's ID or the plan contact for details.

Prior Authorization

Transplant authorization and notification

Transplant and CAR T-cell therapy require prior authorization and coordination with Optum Transplant Case Management. Contact the transplant case management team before requesting transplant‑related services.

Organ/tissue transplant and transplant‑related services: Prior authorization required; request prior to pre‑treatment or evaluation.
CAR T therapies and specific products (Abecma, Breyanzi, Carvykti, Kymriah, Lyfgenia, Tecartus, Yescarta, Zynteglo) require coordination — call Optum Transplant Case Management.
Optum Transplant Case Management phone: 888-936-7246 (also listed as the notification number on the back of the member's health plan ID card).

Note

Transplant / CAR T and VAD case management contacts

For CAR T and other transplant coordination, use the Optum Transplant Case Management contact. For ventricular assist devices (VADs), contact Optum VAD Case Management.

Optum Transplant Case Management: 888-936-7246 (use before transplant or CAR T-cell therapy services).
Optum VAD Case Management: 888-936-7246 (contact for VAD coordination and notification; also refer to notification number on member ID card).

Prior Authorization

Vein procedures prior authorization

Vein procedures (removal/ablation of saphenous trunks and named branches for venous disease/varicose veins) require prior authorization. Submit these requests via the Provider Portal and verify the specific CPT codes being used.

Vein procedures requiring PA include ablation/removal of saphenous trunks/branches — PA required.
Example related CPT codes include 37243 and others related to venous procedures — confirm codes on the portal.
Submit PA requests via the Prior Authorization and Notification tool on UHCprovider.com or contact the plan for code‑specific instructions.

notification — definition regarding injectable chemotherapy notification vs PA

Notification vs PA for injectable chemotherapyNotification is required when injectable chemotherapy drugs (J9000–J9999, J0640–J0642 and Q‑coded chemo agents) are administered in an outpatient setting; prior authorization may still be required for other listed services.

SubmissionSubmit via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone per instructions.

advance notification — ESRD/dialysis advance notification definition and exceptions

Advance notification for ESRD/dialysisAdvance notification is required for inpatient or outpatient dialysis services and for treatment of end-stage renal disease (ESRD); exception: not required when a Medicare member travels outside the service area.

Referral and vendor routingUse an in-network dialysis center when possible to avoid higher member cost‑sharing; contact details on the member's ID card.

Prior authorization process note — high-level description of PA process and applicability

PA process overviewPrior authorization requires submission to the plan (online via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by phone) and plan approval before non‑urgent services are rendered.

ApplicabilityApplies to specified procedures, DME, injectable medications, inpatient/post‑acute admissions and other services listed in the policy; emergency/urgent care is excluded.

Vendor routingMany DME and device requests must be directed to a plan‑contracted vendor as noted in the policy.

Prior Authorization submission via Provider Portal or phone — specialty pharmacy PA submission note

Specialty pharmacy PA submissionTo submit specialty pharmacy prior authorization, use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (select Specialty Pharmacy) or call 888‑397‑8129.

naviHealthnaviHealth manages prior authorization for in‑scope membership; phone 855‑851‑1127, fax 844‑244‑9482.

Admission notification — notification required for admission date

Admission notification requirementPrior authorization and notification of the admission date are required for acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long‑term acute care hospitals and skilled nursing facilities.

ExclusionsCertain plans (UnitedHealthcare Assisted Living Plans and UnitedHealthcare Nursing Home plan) are excluded from SNF prior authorization requirement.

Out-of-network services — brief definition and implications

Out‑of‑network services — definitionOut‑of‑network services are care provided by hospitals, physicians or other providers not contracted with Preferred Care Network and/or Preferred Care Partners; such referrals may increase members' out‑of‑pocket costs or be non‑covered.

Advance notificationAdvance notification is required when a network provider directs a member to an out‑of‑network provider.

Proton beam therapy — definition of proton beam therapy

Proton beam therapy — definitionProton beam therapy is focused radiation therapy using beams of protons (positively charged particles).

Authorization noteProton beam therapy requires prior authorization per the policy.

Ventricular assist devices (VAD) — VAD definition and coordination note

Ventricular assist device (VAD) — definitionA ventricular assist device (VAD) is a mechanical pump that takes over the function of a damaged ventricle and restores normal blood flow.

Coordination/contactFor VAD authorization/notification and coordination, call the Optum VAD Case Management team at 888‑936‑7246 or the notification number on the member's health plan ID card.

CAR T-cell therapy — CAR T-cell therapy definition and coordination requirement

CAR T‑cell therapy — definitionCAR T‑cell therapy and related services are cellular therapies listed in the policy (e.g., codes 0537T–0540T, C9098 and related Q codes) that require coordination with case management.

Coordination requirementContact Optum Transplant Case Management at 888‑936‑7246 (or the notification number on the member's ID card) for transplant and CAR T‑cell therapy coordination.

Code 38232 is flagged as conditionally requiring prior authorization; confirm specific circumstances before submitting authorization requests.

Policy repetitionThe document repeats that 38232 will only require prior authorization in specified circumstances—treat as a conditional exception.