CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania

This document lists services, procedures and drugs that require prior authorization for participating UnitedHealthcare Community Plan of Pennsylvania providers and explains how to submit requests. It applies to in-network and out-of-network providers serving plan members in Pennsylvania.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr. 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on UHCprovider.com, by phone at 800-366-7304, or by fax at 800-600-9007.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PApolicy scope

multiplerequires prior auth

online/phone/faxsubmission methods

J9000-J9999chemo injectables

>$500DME cost threshold

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.

part 5/10document part

Services and Items Requiring Prior Authorization

Excerpt coverage criteria

Examples of coverage items requiring prior authorization in this excerpt include cancer supportive care drugs, colony-stimulating factors and certain injectable supportive agents administered in an outpatient setting.

ALL of the following

ONE of
- Colony-stimulating factor or bone-modifying agent is administered in an outpatient setting for a cancer diagnosis.
- Requested drug is listed among the colony-stimulating factor or bone-modifying agent HCPCS/CPT codes requiring prior authorization (examples: J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125).

Prior authorization is also required for the listed colony-stimulating factor agents even when used for non-oncology diagnoses when the code is one of the specified codes (see Injectable medications section).

Prior authorization requirements (extract)

Prior authorization is required for specific diagnostic monitoring, chemotherapy injectable drugs and related outpatient services as described below.

ALL of the following

Inpatient video EEG/cerebral seizure monitoring CPT codes (e.g., 95712–95718, 95720–95726) require prior authorization when performed as inpatient video services.
Prior authorization is NOT required for outpatient hospital or ambulatory surgical center EEG services.

ALL of the following

Prior authorization required for injectable chemotherapy drugs administered in an outpatient setting for a cancer diagnosis.
Examples include

Cochlear implants and continuous glucose monitors

Device-specific prior authorization requirements for cochlear and other auditory implants and related device codes.

ALL of the following

Prior authorization required for cochlear implant and auditory implant CPT/HCPCS codes (examples: 69710, 69714, 69930, L8614, L8619, L8690).
These codes represent medical devices within the inner ear with external portions to assist persons with profound sensorineural deafness; prior authorization must be obtained per the listed process.

Continuous glucose monitors and related device codes may be listed with prior authorization requirements in the device/procedure section (see full injectable/device lists).

Authorization rules excerpt

Authorization and billing rules and notes for listed CPT/HCPCS codes, including DME thresholds, enteral services and gender dysphoria coding notes.

ALL of the following

Prior authorization is required only for the DME/HCPCS codes listed with a retail purchase or cumulative rental cost of more than $500.
Examples of DME codes subject to this threshold include A9279, A9280, A9900, E0194, E0445 and many E-series codes listed.

ALL of the following

Prior authorization required for listed enteral service HCPCS codes (examples: B4034, B4035, B4036, B4100, B4102, B4103, B4104).

ALL of the following

Certain CPT/HCPCS codes (e.g., 67966; Q2026) include a Gender Dysphoria flag; prior authorization exceptions may apply when billed with specified diagnosis codes.

Prior Authorization Requirements (partial)

Items and services in these sections require prior authorization as indicated below.

ONE of

Enteral/in‑home nutritional services — Prior authorization required for listed B40xx codes (B4034, B4035, B4036, B4100, B4102–B4104).
Experimental and investigational procedures — Prior authorization required for listed procedure codes marked investigational (examples in list include codes such as 65767, 66180 and others flagged investigational).
Home health services — Prior authorization required for listed home health G‑series and S‑series codes when provided in outpatient settings (examples: G0156, G0162, G0299, G0300, G0493–G0496, S9122–S9124).
Injectable medications — Prior authorization required for injectable medications listed in the injectable medications section; list begins with Actemra (J3262) and continues through numerous J/Q codes identified in the document.

Prior authorization — injectable medications (excerpt)

Selected injectable medications are listed with HCPCS/J-codes; prior authorization is required as indicated but detailed clinical criteria are provided elsewhere.

ALL of the following

ANY of the following
- Actemra — J3262
- Acthar — J0801
- Adakveo — J0791
- Aduhelm — J0172
- Advate/other clotting factors — J7192, J7207

Observed coverage-related entries (partial)

Observed product‑code pairings and prior authorization mentions for biologic products (partial list).

Product-code examples

Wilate — J7183
Xembify — J1558
Zinplava — J7185 and J0565 (repeated entries noted).
Xolair — (multiple mentions paired with prior authorization notes).

Note: This excerpt lists product-to-code pairings and references to how to obtain prior authorization; explicit clinical coverage criteria are not present in these chunks.

Authorization criteria (partial)

Coverage-related authorization requirements present in this excerpt include high-cost injectables, joint replacement and orthotics/prosthetics rules.

ALL of the following

Notification required for admissions and prior authorization and notification of admission date required for post-acute inpatient facilities (acute care hospitals, acute inpatient rehabilitation, critical access hospitals).

Joint replacement procedures — Prior authorization required for listed CPT/HCPCS codes for total hip and knee replacement (multiple CPT codes listed in the joint replacement section).

Orthognathic surgery — Prior authorization required for listed CPT codes for treatment of maxillofacial/jaw functional impairment.

Air ambulance — Non-emergent air ambulance HCPCS codes (A0430, A0431, A0435, A0436) require prior authorization.

Prior authorization requirements (excerpt)

Provider must obtain prior authorization for the listed services/codes or follow the notification process via phone or the provider portal.

ALL of the following

Health care professionals should request prior authorization via the Prior Authorization and Notification tool on UHCprovider.com (sign in and select the tab) or by calling the designated phone number (examples: 888 397 8129 for general PA requests; 866-889-8054 for advanced outpatient imaging).

Examples of services requiring prior authorization

Orthotics/prosthetics L‑codes when cost threshold exceeded (see orthotics rule).
Radiology/advanced outpatient imaging procedures (certain CT, MRI, MRA, PET and nuclear medicine) — prior authorization required; request via UHCprovider.com or call 866-889-8054.
Rhinoplasty/septoplasty and sinuplasty CPT codes (e.g., 30400–30462, 31295–31298) — prior authorization required as listed.

Prior authorization criteria (code-based and site-of-service)

Prior authorization requirements, code-based listings and site-of-service notes for advanced imaging and various surgical categories.

ALL of the following

Prior authorization required for participating physicians ordering these advanced outpatient imaging procedures.
Providers must notify prior to scheduling and may request prior authorization via the Prior Authorization and Notification tool on UHCprovider.com or by calling 866-889-8054.

Procedures and surgical categories listed

ENT, sinus and nasal procedures (examples: rhinoplasty/septoplasty 30400–30462; sinuplasty 31295–31298) — prior authorization required as listed.
Ophthalmologic procedures (examples include cataract surgery codes 66821, 66982, 66984) — listed with prior authorization notes.

Prior authorization criteria (documented flags)

Prior authorization flags and contact instructions for specialized procedure categories.

ALL of the following

Prior authorization required for stimulators and related implantation device codes (examples include E0747, E0748, E0749, E0760 and L8680–L8688 series where listed).

ALL of the following

Prior authorization required for transplant and CAR T-cell therapy services; select unclassified drug and procedure codes (C9301, C9399, J3490, J3590) and specified gene therapies require prior authorization through Optum Transplant; code 38232 requires prior authorization only for an oncology diagnosis.

ALL of the following

Prior authorization required for listed vein procedure CPT codes (examples: 36473, 36475, 36478, 37700) and for wound VAC therapy (example: E2402).

ALL of the following

Relevant CPT / HCPCS / ICD-10 Codes

Covered HCPCS (L0xxx series)HCPCSCovered

L0112	Custom fitted wheelchair accessory or component
L0170	Foot/ankle orthosis, molded to patient model
L0456	Lower extremity prosthesis, socket, transfemoral, preparatory
L0462	Prosthetic component, knee, single axis, for transfemoral prosthesis
L0464	Prosthetic component, knee, polycentric
L0480	Prosthetic socket, transtibial, preparatory
L0482	Prosthetic device, ankle/foot, dynamic
L0484	Prosthetic device, foot, energy storing
L0486	Prosthetic component, pylon/shank
L0624	Orthotic device, lumbar-sacral orthosis, prefabricated

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How to Request Authorization and Provider Responsibilities

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) by signing in with a One Healthcare ID and selecting Prior Authorization and Notification on your dashboard; or call 800-366-7304; or fax to 800-600-9007. Prior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all procedures and services.

Prior Authorization

Diagnostic and procedure prior authorization note

Participating physicians must obtain prior authorization before performing outpatient and office-based diagnostic catheterizations, electrophysiology implants and stress echocardiograms.

Prior Authorization

Cancer supportive care prior authorization

Prior authorization is required for colony-stimulating factor drugs and bone‑modifying agents administered in an outpatient setting for a cancer diagnosis.

Key Terms and Notes

Definition: Prior authorization

DefinitionPrior authorization is the requirement to obtain approval from UnitedHealthcare before performing certain services or providing certain medications; not required for emergency or urgent care.

Submission methodsRequests may be submitted online via the Prior Authorization and Notification tool on UHCprovider.com, by phone or by fax (see provider contact details in document)

Out-of-network providersOut-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services

Behavioral health carve-out

Carve-outBehavioral health services are carved out and are managed by the Behavioral Health Managed Care Organization (MCO) that covers the member's county of residence.

Action

Policy Revision Notes

Apr. 1, 2025effective_dateLatest

Document effective date as stated in header: Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania become effective Apr. 1, 2025.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr. 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on UHCprovider.com, by phone at 800-366-7304, or by fax at 800-600-9007.

SourceLink

On This Page

Chemotherapy injectable drugs billed in the J9000–J9999 range.

Leucovorin (J0640) or levoleucovorin (J0641, J0642).

Lupron Depot (J1950) and Q-coded chemotherapy injectables or miscellaneous HCPCS-billed oncology injectables.

ALL of the following

Submit prior authorization requests online using the Prior Authorization and Notification tool on UHCprovider.com after signing in and selecting Prior Authorization and Notification on the dashboard, OR call 888 397 8129.

Femoroacetabular impingement syndrome (FAI) — Prior authorization required for associated procedure codes (example: 29916).

Operational note: Prior authorization instructions and submission methods for these injectable medications are referenced in the document (use the Prior Authorization and Notification tool on UHCprovider.com or the phone numbers provided).

Orthotics and prosthetics — Prior authorization required only for listed L‑codes when the retail purchase or cumulative rental cost exceeds $500 (examples include L0112, L0170, L0456, L0462, L0464, L0480, etc.).

Integumentary, hemic and hernia procedures (examples: 10121, 11440, 38500, 49505) — listed with prior authorization notes.

Musculoskeletal and nervous system procedures (examples include arthroscopy and neurostimulation codes) — listed with prior authorization notes and possible site-of-service restrictions.

ALL of the following

Prior authorization may be required when services are performed in an outpatient hospital setting; the same procedures may not require prior authorization if performed at a participating ASC for specified codes.

For transplant and CAR T-cell therapy services call the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or use the notification number on the back of the member's health plan ID card; for VADs and other specialized device workflows follow the notification/fax instructions provided in the document.

Codes listed include J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125 (also require PA for non‑oncology diagnoses).

Prior Authorization

How to obtain prior authorization

To obtain prior authorization submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) after signing in and selecting Prior Authorization and Notification on your dashboard; or call 888 397 8129.

Prior Authorization

Chemotherapy injectable drugs prior authorization

Prior authorization is required for injectable chemotherapy drugs administered in an outpatient setting for a cancer diagnosis.

Includes chemotherapy injectable drugs in the J9000–J9999 range, Leucovorin (J0640), Levoleucovorin (J0641, J0642), Lupron Depot (J1950), Q‑coded chemotherapy injectables, and injectable drugs billed under miscellaneous HCPCS codes.

Prior Authorization

Selected device/procedure prior authorization examples

Prior authorization is required for listed cochlear implant and auditory implant CPT/HCPCS codes and for specified continuous glucose monitor codes where indicated.

Cochlear implant codes include 69710, 69714, 69930, L8614 (and related L-codes).
Continuous glucose monitor codes (e.g., A9276, A9277, A9278, A4238, A4239) require prior authorization as noted (CGM prior authorization required with Type 2 Diabetes diagnosis where specified).

Prior Authorization

EEG / cerebral seizure monitoring prior auth rules

EEG and inpatient video cerebral seizure monitoring CPT codes require authorization for inpatient video EEG; outpatient hospital or ambulatory surgical center EEG does not require prior authorization.

Inpatient video EEG codes: 95711–95718 (examples listed: 95712–95716, 95718).
Outpatient EEG prior authorization is not required for outpatient hospital or ambulatory surgical center settings.

Billing Rule

DME prior authorization threshold

Prior authorization is required for the listed DME codes only when the retail purchase price or cumulative rental cost is more than $500.

Examples of DME HCPCS in this list include A9279, A9280, A9900, E0194, E0265, E0465, E0470, E0445, etc.

Prior Authorization

Enteral services prior authorization

Enteral services and in‑home nutritional services listed (B4034, B4035, B4036, B4100, B4102, B4103, B4104) require prior authorization.

Documentation Required

Select procedure coding notes

Certain CPT/HCPCS procedure codes carry coding notes; Gender Dysphoria may apply to some codes and prior authorization exceptions are noted when billed with specified diagnosis codes.

Examples shown include CPT 67966 and Q2026 with a Gender Dysphoria flag; prior authorization may not be required when billed with the specified diagnosis.

Prior Authorization

Enteral and In-home Nutritional Services

Enteral and in‑home nutritional services listed in the enteral services section require prior authorization as noted in the code list.

Codes include B4034, B4035, B4036, B4100, B4102, B4103, B4104.

Prior Authorization

Experimental and Investigational Procedures

Procedures and services identified as experimental and investigational in the list require prior authorization.

Examples of codes marked investigational include 65767, 66180, A4638, A6000 and others as listed.

Prior Authorization

Home Health Services

Home health services require prior authorization only when provided in outpatient settings.

Home health codes cited include G0156, G0162, G0299, G0300, G0493–G0496 and certain S- and T-series codes.

Prior Authorization

Hospice and Hysterectomy

Hospice services and hysterectomy procedures listed in this section require prior authorization.

Hymenectomy/hysterectomy codes include 58150, 58152, 58180, 58260 and related CPTs; hospice code example T2045.

Prior Authorization

Injectable Medications

Prior authorization is required for injectable medications listed in the injectable medications section; the injectable list begins with Actemra (J3262) and includes many specific J-/Q-codes.

Examples include J3262 (Actemra), J0801 (Acthar), J0791 (Adakveo), J0172 (Aduhelm) and many others shown in the injectable medications list.

Documentation Required

Injectable medications — selected codes

Selected injectable medication HCPCS/J-/Q- codes and product pairs are listed with prior authorization instructions elsewhere in the document.

Examples in the extract include Wilate (J7183), Xembify (J1558), Zinplava (J7185) and repeated entries indicating PA is required; follow the listed PA instructions for each product.

Documentation Required

Prior authorization codes and products (partial list)

This partial list pairs CPT/HCPCS codes with prior authorization requirements for multiple biologic products; follow the product‑specific PA instructions in the document.

Examples include Wilate (J7183) and Xembify (J1558) which are listed with PA instructions.

Prior Authorization

Zinplava prior authorization codes

Zinplava is listed with HCPCS J7185 (and related mentions of J0565) and requires prior authorization as shown in repeated entries.

Follow the prior authorization instructions provided in the injectable medications/product sections for Zinplava (J7185).

Prior Authorization

Zolgensma / post-acute inpatient notification

J9202 (Zolgensma) requires notification 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).

Prior Authorization

Joint replacement prior authorization

Joint replacement procedures (total hip and knee and related CPT/HCPCS codes) require prior authorization for the listed codes.

The document lists numerous CPTs (e.g., 23470–23474, 27120–27138, 27412, 27446–27487, 29866–29868, J7330, S2112) that require prior authorization.

Prior Authorization

Orthognathic surgery prior authorization

Orthognathic surgery (treatment of maxillofacial/jaw functional impairment) requires prior authorization for the listed CPT codes.

Examples include CPTs 21121, 21123, 21125, 21127, 21141–21147, 21150–21155, 21188–21210, 21215, 21246–21249 and others listed.

Billing Rule

Orthotics and prosthetics prior authorization threshold

Orthotics and prosthetics listed require prior authorization only when the retail purchase price or cumulative rental cost exceeds $500.

Listed L‑codes include L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631–L0638 and many others.

Prior Authorization

Air ambulance prior authorization

Non‑emergent air ambulance transport requires prior authorization for the listed HCPCS codes (A0430, A0431, A0435, A0436).

Prior Authorization

Orthotics and prosthetics prior authorization

Prior authorization is required for the extensive list of orthotics and prosthetic L‑codes shown when the retail purchase or cumulative rental cost exceeds $500; those listed L‑codes require PA as noted.

See the L‑code list in the document for all specific orthotics/prosthetics codes subject to the $500 threshold.

Prior Authorization

Radiology and proton beam therapy prior authorization

Prior authorization is required for proton beam therapy and for specified advanced outpatient imaging procedures (certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology); providers must notify prior to scheduling and may request authorization via the portal or by calling 866‑889‑8054.

Proton beam therapy CPTs include 77520, 77522, 77523, 77525.
To request PA call 866‑889‑8054 or submit via the Prior Authorization and Notification tool on UHCprovider.com.

Prior Authorization

Other services requiring prior authorization

Selected other services shown (pediatric day services, private duty nursing, potentially unproven services, prostate procedures, rhinoplasty/septoplasty, sinuplasty) require prior authorization as noted in the list.

Examples include prostate procedure CPTs 37243, 52441, 52442, 53850–53852, 55873–55874; rhinoplasty/septoplasty CPTs 30400–30430; sinuplasty CPTs 31295–31298; select T‑codes for pediatric day/private duty nursing.

Prior Authorization

How to obtain prior authorization for advanced outpatient imaging

Health care professionals ordering advanced outpatient imaging must provide notification prior to scheduling and obtain prior authorization by calling 866‑889‑8054 or submitting requests online using the Prior Authorization and Notification tool on UHCprovider.com.

Prior Authorization

Site-of-service prior authorization notes

Prior authorization is required for certain procedures when performed in an outpatient hospital setting; some of those same codes may not require prior authorization if performed at a participating ambulatory surgical center — check the site‑of‑service notes for each code.

Site‑of‑service (SOS) notes indicate PA is required for outpatient hospital but not required if performed at a participating ASC for specified codes.

Prior Authorization

Prior authorization contact instructions

For transplant and CAR T‑cell therapy services call the UnitedHealthcare Community and State Transplant Case Management Team at 888‑936‑7246 or the notification number on the back of the member's health plan ID card for prior authorization and coordination.

Includes CAR T and transplant therapies such as Abecma, Breyanzi, Kymriah, Tecartus and Yescarta.

Prior Authorization

Prior authorization requirement flags

Multiple categories in the document are explicitly flagged as 'Prior authorization required' (for example: stimulators, transplants, vein procedures, ventricular assist devices, wound vac), so obtain prior authorization for the listed codes in those categories.

Stimulators and implantable device codes (e.g., E0747–E0760, L8680–L8688) require PA.
Vein procedure CPTs (e.g., 36473, 36475, 36478, 37700) require PA.
VADs and wound vac (e.g., 33927–33983, E2402) require PA and specified notification/fax procedures.

For more information, contact the Member Services number on the back of the member's ID card (per the document)

ImplicationBehavioral health prior authorization and management follow the Behavioral Health MCO’s processes, not this document's processes

Chemotherapy injectable drugs prior authorization

Covered codes/rangeChemotherapy injectable drugs requiring prior authorization include the J9000–J9999 range and specified agents (examples: Leucovorin J0640; Levoleucovorin J0641/J0642; Lupron Depot J1950)

SettingPA applies to injectable chemotherapy drugs administered in an outpatient setting for a cancer diagnosis

How to requestSubmit prior authorization requests online via UHCprovider.com or call 888‑397‑8129 (per the chemotherapy section)

EEG prior authorization

Outpatient EEGPrior authorization is not required for EEG performed in an outpatient hospital or ambulatory surgical center

Inpatient video EEGInpatient video electroencephalogram monitoring (listed inpatient video CPTs) does require prior authorization

Relevant CPTsExamples of inpatient video EEG CPT codes listed: 95712, 95713, 95714, 95715, 95716, 95718

Cosmetic procedures

DefinitionCosmetic procedures are those that change or improve physical appearance without significantly improving or restoring physiological function

ContrastReconstructive procedures treat a medical condition or improve/restore physiological function and are distinguished from cosmetic procedures

PA implicationCertain cosmetic and reconstructive CPT codes are listed in the document and may require prior authorization as noted

Reconstructive procedures

DefinitionReconstructive procedures treat a medical condition or improve or restore physiological function

ExamplesThe document lists multiple reconstructive CPT codes (e.g., 21172–21184, 21230, 21235, 21256, 21275, 21280, 21282, 21295)

PA implicationReconstructive procedure codes are included in the prior authorization listings; follow the code-specific notes

Prior authorization (general note)

General rulePrior authorization is required where indicated in the document for listed services, procedures and medications

Emergency carePrior authorization is not required for emergency or urgent care

Provider responsibilityProviders must follow the submission methods and contact instructions in the document when PA is required

Experimental and investigational

ScopeItems or procedures identified as investigational/experimental in the document require prior authorization

ExamplesThe investigational list includes certain CPT/HCPCS codes (examples in section: 65767, 66180, A4638, A6000, A9274, E0231, E1831, S0810, S1030, S1031, S2102, S9988, S9990, S9991)

ImplicationProviders should obtain PA for procedures flagged investigational before scheduling or performing them

Injectable medications (cont.)

ContentThe injectable medications section lists numerous products with HCPCS/J‑codes (examples: Actemra J3262, Acthar J0801, Adakveo J0791, Aduhelm J0172)

PA requirementPrior authorization is required for the injectable medications listed in this section (per section header)

Continuation noteThe list continues across multiple pages/chunks; consult the full injectable medications section for complete code list and PA instructions

CPT/HCPCS prior authorization entries

Coding pairsThe document lists product names paired with HCPCS codes (examples: Wilate J7183; Xembify J1558; Zinplava J7185/J0565) and indicates PA process references

Repetition noteSome product entries (e.g., Zinplava) appear repeatedly in the excerpt with PA references but without additional threshold detail

ActionFollow the code-specific PA instructions in the document for these products

Notification required for admissions / prior authorization and admission date notification

Notification requirementNotification (and prior authorization where indicated) is required for admissions and certain services; advanced outpatient imaging requires notification prior to scheduling

Contacts for imagingTo request PA for advanced outpatient imaging call 866‑889‑8054 or submit online via UHCprovider.com Prior Authorization and Notification tool

Zolgensma noteJ9202 (Zolgensma) requires prior authorization and notification of admission date for post‑acute inpatient facilities

Orthotics/prosthetics prior auth threshold

Orthotics/prosthetics threshold summaryPrior authorization required only for orthotics and prosthetic codes listed when retail purchase or cumulative rental cost exceeds $500

ExamplesListed L‑codes include L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, etc.

Cross-referenceSee DME section for related $500 threshold language; prosthetics are noted as not DME

Site of service (SOS)

Site‑of‑service notePrior authorization may be required for procedures when performed in an outpatient hospital setting; some codes may not require PA if performed at a participating ASC

ExamplesSinuplasty CPTs (31295–31298) and various auditory/cataract procedures include site‑of‑service PA notes in the document

Action for ordering cliniciansProviders ordering advanced outpatient imaging must notify prior to scheduling and obtain PA per instructions

Transplant/CAR T authorization contact

Transplant/CAR T contactFor transplant and CAR T‑cell therapy services call the UnitedHealthcare Community and State Transplant Case Management Team at 888‑936‑7246 or the notification number on the back of the member's ID card

VAD/Ventricular Assist DeviceFor VADs, notify the number on the back of the member's ID card and fax required form to the Optum VAD Case team as instructed

Optum TransplantSome unclassified codes and gene therapies require PA through Optum Transplant (see transplant section notes)