CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements and how to obtain prior authorization (UnitedHealthcare Colorado Rocky Mountain Health Plan)

Lists services and CPT/HCPCS/J codes that require prior authorization and provides provider submission instructions; emergency and urgent care are exempt. Applies to providers serving members of the referenced plan.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements and provider instructions for Rocky Mountain Health Plans / UnitedHealthcare Colorado

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests and supporting documentation online (or to eviCore where indicated) prior to scheduling non-emergent services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

manyCode entries

EnteralEnteral services require prior auth

J9000-J9999Chemo injectables

Online / eviCoreAuthorization channel

Jan 1, 2024Daxxify temp code date

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Services Requiring Prior Authorization

Prior authorization coverage stance

Prior authorization required for the following service categories and specific codes as listed; emergency and urgent care are exempt.

Prior authorization is required for the service categories and codes enumerated in this document (examples include arthroplasty/arthroscopy, bariatric, breast reconstruction, cardiology procedures, injectable chemotherapy drugs, continuous glucose monitors).

Providers must submit prior authorization requests through the channels specified (UHCprovider online portal for Rocky Mountain Health Plans providers; non‑participating providers may fax; eviCore for certain services).

Prior authorization is not required for emergency or urgent care services.

Prior authorization code requirements (partial)

Codes and items listed below are identified as requiring prior authorization in the document extract.

Prior authorization required for the enumerated procedural CPT codes (examples shown in the list: 91112, 91132, 41120, 41512).

Prior authorization required for the enumerated HCPCS/DME E‑codes and other durable medical equipment codes (examples shown in the list: A0110, A9520, E0170, E0194, E0625–E0657 series).

Operational clarification: prosthetics are explicitly noted as not being categorized as DME; authorization requirements for prosthetics/orthotics are listed separately where applicable.

Partial prior authorization criteria from section

Prior authorization requirements and special routing notes (partial):

Enteral services and in‑home nutritional therapy require prior authorization when billed with the corresponding B‑series codes (examples: B4149, B4150, B4152–B4168, B4180, B4199).

Codes C9762, C9763 and S8080 must be authorized through eviCore; submit requests online to eviCore prior to service as indicated in the list.

Specified surgical CPT codes for gender dysphoria treatment require prior authorization when billed with the listed diagnosis codes (see gender dysphoria DX codes).

Also noted: Various DME K‑codes and other procedure code groups are listed as requiring prior authorization (partial lists shown).

Prior authorization requirements (partial)

Prior authorization is required for the listed services when billed with the specified diagnosis codes or when the specific CPT/HCPCS/genetic test codes are used.

Prior authorization required for surgical codes associated with gender dysphoria when billed with diagnosis codes F64.0, F64.1, F64.2, F64.8, F64.9 and 287.890.

Prior authorization required for the enumerated surgical CPT codes shown in the gender dysphoria and related sections (examples include 15769, 15771–15776, 15780–15793, 15819, and others listed).

Prior authorization required for a wide range of genetic/molecular test codes and lab services (examples include OO01U, 0013M, OO04M, 81415–81417, 81419, 81422–81437 and many additional codes), with some genetic tests routed to eviCore for review.

Prior authorization requirement

Prior authorization requirement for listed services

For the listed genetic test and temporary CPT/HCPCS codes shown in the genetic tests/lab services segments, prior authorization is required and providers should submit requests online as instructed in the list.

Prior authorization required

The following services and code groups require prior authorization per this section:

ONE of: Prior authorization required for hyperbaric treatment (G0277).

ONE of: Prior authorization required for hysterectomy procedures (examples: 58578, 58579, 58679).

ONE of: Prior authorization required for infusion and injection services and the listed injectable medication HCPCS/CPT/Q codes (examples: 90291, Q0515, Q2028, Q2041–Q5122 series).

ONE of: Prior authorization required for medical and surgical supplies; effective Jan 1, 2024 Daxxify uses temporary code C9160 mapped to multiple Q‑codes as noted.

Prior authorization requirements (partial)

Codes listed below are associated with prior authorization requirements as noted.

Prior authorization required for many medical and surgical supplies and mapped temporary codes (e.g., C9160 for Daxxify mapped to Q‑codes) as specified in the supplies section.

Prior authorization required for listed musculoskeletal/wound care and related procedure codes (examples: 97602, 97605–97608, 99500, 20957).

Prior authorization required for orthotics and certain prosthetics/orthotic L‑codes where indicated (examples: L1499, L3649, L4000, L5010, L5020, etc.).

Prior authorization coverage stance

Services requiring prior authorization as indicated in this section:

Psychological testing (codes 96112, 96113) requires prior authorization.

Advanced outpatient imaging (certain CT, MRI, MRA, PET and nuclear medicine procedures) requires prior authorization; participating physicians should obtain authorization/notification via eviCore as indicated.

Extensive orthotics/prosthetics L‑code lists are provided; CPT/HCPCS codes listed include instructions to obtain prior authorization where applicable.

Prior Authorization Coverage Criteria

Prior authorization requirements for listed procedures and codes

Care providers ordering advanced outpatient imaging procedures are responsible for providing notification/requesting prior authorization before scheduling; requests submitted online to eviCore or by phone as directed.

Prior authorization required for radiation therapy procedures and listed radiation CPT/HCPCS codes (examples include 77373, 77435 and related codes).

Prior authorization required for surgical procedures including rhinoplasty, sinuplasty, spine surgery and various stimulators; providers must obtain authorization via eviCore prior to scheduling these procedures.

Coverage stance by service group

Prior authorization/notification requirements by service group

Transplants (listed transplant CPT codes such as 32850–32856, 33927–33935) require prior authorization; submit notification/prior authorization as instructed.

Unlisted and surgery/unlisted CPT codes (many 77xxx, 91xxx, 99xxx series) require prior authorization; providers must request authorization for unlisted procedures as noted.

Urological procedures (examples: 54400–54417 series) require prior authorization when listed in this section.

Vein procedures and ablation (examples: 36465–36475, 36476–36479) require prior authorization as listed.

Codes and Code Groups Mentioned

HCPCS DME / E-codesHCPCS

E2222	(listed in source)
E2372	(listed in source)
E0762	Nerve stimulator related HCPCS
E0170	(listed in source)
E0193	(listed in source)
E0946	(listed in source)
E1625	(listed in source)
E2322	(listed in source)
E2323	(listed in source)
E2324	(listed in source)

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1/4

HCPCS K-codes (DME - K series)HCPCS

K0838	(listed in source)
K0839	(listed in source)
K0840	(listed in source)
K0841	(listed in source)
K0842	(listed in source)
K0843	(listed in source)
K0848	(listed in source)
K0849	(listed in source)
K0850	(listed in source)
K0851	(listed in source)

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1/4

Enteral & Gastrostomy HCPCSHCPCS

B4178	Gastrostomy tube (listed in source)
B4149	(listed in source)
B4150	(listed in source)
B4152	(listed in source)
B4153	(listed in source)
B4154	(listed in source)
B4155	(listed in source)
B4157	(listed in source)
B4158	(listed in source)
B4159	(listed in source)

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1/3

Genetic / Molecular CPT & Temp CodesCPT

81162	(listed in source)
81163	(listed in source)
81164	(listed in source)
81165	(listed in source)
81166	(listed in source)
81167	(listed in source)
81173	(listed in source)
81174	(listed in source)
81185	(listed in source)
81186	(listed in source)

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1/6

Temporary / Category III / Other Temp Codesmixed

0337U	(listed in source)
0338T	(listed in source)
0338U	(listed in source)
0339T	(listed in source)
0342T	(listed in source)
0342U	(listed in source)
0344U	(listed in source)
0345T	(listed in source)
0625T	(listed in source)
0626T	(listed in source)

1–10 of 18

1/2

Physical Medicine / Therapy CPTsCPT

97537	Community/work-related rehabilitation (listed)
97542	Wheelchair management training (listed)
97602	Negative pressure wound therapy (listed in source)
97546	(

Other CPTs / Procedures / Stimulators / Surgical / TransplantCPT

20972	Nerve grafting/related (listed in source)
22533	Spine surgery (listed in source)
41820	Stimulator procedure (listed in source)
61850	Stimulator intracranial (listed in source)
64553	Peripheral nerve interface (listed in source)
32851	Transplant-related code (listed in source)
38205	Hematopoietic progenitor cell collection (listed in source)
37718	Vein procedure (listed in source)
61630	Neurosurgical procedure (listed in source)

How Providers Must Request Prior Authorization

Prior Authorization

How to obtain prior authorization

Rocky Mountain Health Plans providers must submit prior authorization requests and supporting documentation online at UHCprovider.com/priorauth > Advance Notification and Plan Requirement Resources and select the appropriate Plan Type. Non‑participating providers may fax requests and documentation to 800‑262‑2567 or 970‑255‑5681. For services routed to eviCore, submit requests online at www.evicore.com or call 800‑792‑8750. Prior authorization is not required for emergency or urgent care. Out‑of‑network providers must request prior authorization for all non‑emergent services.

Behavioral health services: call 888‑282‑8801
Notification by admitting facility: phone 800‑416‑2157 (option 4) or 970‑248‑5197
eviCore (advanced imaging, certain genetic tests, and other services): www.evicore.com or 800‑792‑8750

Prior Authorization

Prior authorization required — Enteral and in‑home nutritional therapy

Enteral services and in‑home nutritional therapy (enteral or other home nutrition) require prior authorization. Submit authorization requests and clinical documentation prior to delivery or initiation of therapy.

Terms and Operational Notes

Prior authorization definition

DefinitionPrior authorization is the process where health care providers seek approval before rendering a service; advance notification is required so UnitedHealthcare can perform prospective, concurrent and retrospective review.

When not requiredPrior authorization is not required for emergency or urgent care.

Submission channelsRocky Mountain Health Plans providers: UHCprovider.com prior auth resources; non‑participating providers: fax 800-262-2567 or 970-255-5681.

Behavioral healthBehavioral health prior authorization: call 888-282-8801.

Admitting facility notificationNotification by admitting facility: phone 800-416-2157 (option 4) or 970-248-5197.

Prosthetics vs DME

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements and provider instructions for Rocky Mountain Health Plans / UnitedHealthcare Colorado

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests and supporting documentation online (or to eviCore where indicated) prior to scheduling non-emergent services.

SourceLink

On This Page

Authorization for unclassified/temporary codes (C9399, J3490, J3590, Q5123) is required only for a specified list of drugs as described in the document.

Enteral HCPCS: B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158
In‑home nutritional therapy HCPCS: B4159, B4160, B4161, B4162, B4164, B4168
Authorization reference: E2362

Prior Authorization

Prior authorization required — ENT and V‑codes

Procedures and supplies related to the ear, nose and throat (ENT), as well as services billed with V‑codes listed in this policy, require prior authorization. Providers must submit requests and supporting clinical information before scheduling the service.

Sample ENT CPT codes requiring prior authorization: 65770, 65785, 66989, 66991, 68816, 68841
Sample V‑codes requiring prior authorization: V5090, V5160, V5171, V5172, V5181, V5190, V5200, V5253–V5267, V5266–V5267
Some ENT and V‑code authorizations are routed through eviCore — verify routing at www.evicore.com

Denial Risk

Denial risk / Prior authorization requirement

Failure to obtain prior authorization when required may result in claim denial or reduced reimbursement. Providers should verify benefit eligibility and prior authorization requirements before performing services. Authorization is required for services listed throughout this policy and for codes that are unlisted or temporary when the policy specifies authorization is needed.

Prior authorization is required for services and codes enumerated in this policy (including advanced imaging, select genetic tests, enteral nutrition, DME, orthotics/prosthetics, surgical procedures, and others).
Unlisted/temporary codes (e.g., C9399, J3490, J3590, Q5123) require authorization for specified drugs/supplies — check policy details for which products are covered.
If authorization is not obtained, the claim is at risk for denial or nonpayment.

StatementOperational clarification in the listing: 'Prosthetics are not DME.'

ContextProsthetics are listed separately from durable medical equipment (DME) in the HCPCS/E‑code sections.

Authorization noteOrthotics and prosthetics codes (L‑codes) are listed with instructions to obtain prior authorization where applicable.

EviCore routing

EviCore routing — codesCodes C9762, C9763 and S8080 require authorization through eviCore; submit requests online prior to service.

Advanced imagingAdvanced outpatient imaging (certain CT/MRI/MRA/PET and related codes) requires notification/prior authorization via eviCore (www.evicore.com, 800-792-8750).

How to submitFor notification/prior authorization of eviCore‑routed services, submit requests online or call 800-792-8750.

Gender dysphoria DX codes

Listed diagnosis codesF64.0, F64.1, F64.2, F64.8, F64.9 and 287.890 are the diagnosis codes shown for gender dysphoria surgical authorization.

UsageThese DX codes must accompany the specified surgical CPT codes for prior authorization of gender dysphoria treatment.

ReferenceSee gender dysphoria surgical CPT code section for the CPT codes that require authorization when billed with these DX codes.

eviCore (genetic tests)

eviCore for genetic testsMany listed genetic/molecular test codes reference eviCore for prior authorization (examples include 0013M, 0013U and multiple U‑series/OO/U codes).

Prior authorization statusGenetic tests/lab services are marked as 'Prior authorization required' across multiple code lists.

Code examplesExamples of genetic test codes in the list include OO01U, OO04M, 0013M, 0013U and numerous 0242U–0271U and 81415–81439 series codes.

Genetic tests/lab services

Coverage stanceGenetic tests and laboratory services listed are subject to prior authorization (document marks 'Prior authorization required').

Code rangesDocument lists many genetic/molecular codes (U‑series, OO/00xU, 814xx series and others) that require authorization.

Submission instructionFor notification/prior authorization of genetic tests, the document directs providers to submit requests online; some items routed to eviCore.

Unclassified/temporary codes

Unclassified/temporary codes listedUnclassified and temporary codes include C9399, J3490, J3590 and Q5123 and are referenced in the document.

Authorization limitationAuthorization for these unclassified/temporary codes is required only for a specified list of drugs (e.g., Amvuttra, Fylnetra, Nulibry, Riabni, Skyrizi, Syfovre, Veopoz, Purified Cortrophine Gel).

Mapping noteThe document provides mappings and special instructions for how certain J‑codes and unclassified codes map to authorization entries (see Additional Information).

Temp code C9160

C9160 for DaxxifyTemporary code C9160 is the code indicated for Daxxify effective January 1, 2024 and maps to multiple Q‑codes in the Q41xx–Q41xx series as noted.

Effective dateEffective January 1, 2024 Daxxify should only use temp code C9160 per the document instructions.

Mapped Q‑codesDocument lists Q4118, Q4132–Q4139, Q4140–Q4149, Q4145–Q4149 and additional Q‑codes as mappings from C9160 for Daxxify supplies.

Daxxify / temporary HCPCS mapping

Daxxify temporary mappingEffective Jan 1, 2024, Daxxify should use temporary HCPCS code C9160 which maps to multiple Q‑codes (examples: Q4118, Q4132–Q4149).

Supplies classificationThe mapping and usage are listed under medical and surgical supplies with prior authorization required.

Prior authorizationMedical/surgical supplies related to Daxxify are subject to prior authorization as noted in the supplies section.

eviCore

eviCore vendoreviCore healthcare is the external prior authorization manager referenced for certain services; website www.evicore.com and phone 800-792-8750.

Services routedeviCore is referenced for authorization of specific codes (e.g., C9762, C9763, S8080) and advanced outpatient imaging procedures.

Submission instructionProviders ordering advanced outpatient imaging procedures must provide notification/request prior authorization via eviCore before scheduling.

Psych testing prior authorization

Psychological testing codesPsych testing codes 96112 and 96113 are listed and noted as requiring prior authorization.

ContextPsych testing entries appear in the same section that requires prior authorization for several interventional procedures and imaging codes.

Provider actionProviders should obtain prior authorization for psych testing codes prior to scheduling as indicated in the list.

Prior authorization (notification/prior auth)

Prior authorization vs notificationThe document uses both 'notification' and 'prior authorization'—providers must submit a notification/prior authorization request for listed services via the specified channels.

How to requestSubmit requests online via UHCprovider prior auth resources or, for eviCore‑routed services, via www.evicore.com or call 800-792-8750.

Fax optionNon‑participating providers may fax requests to 800-262-2567 or 970-255-5681.

Prior authorization required

Requirement statementPrior authorization is required for the services and code ranges listed in the document; providers must obtain authorization prior to scheduling except in emergency/urgent care.

Where not requiredEmergency and urgent care are explicitly exempt from prior authorization requirements.

Vendor contactFor many services (e.g., advanced imaging) authorization/notification is handled via eviCore (www.evicore.com, 800-792-8750).

evicore contact

evicore websiteSubmit prior authorization or notification to eviCore at www.evicore.com.

evicore phoneCall eviCore at 800-792-8750 for prior authorization or notification support.

When to contactContact eviCore for advanced outpatient imaging and other eviCore‑routed services before scheduling the procedure.