CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for UnitedHealthcare Community Plan Apple Health Expansion of Washington

Lists prior authorization requirements and submission instructions for participating providers under UnitedHealthcare Community Plan Apple Health Expansion in Washington, and enumerates services and CPT/HCPCS codes that require prior authorization.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan Apple Health Expansion of Washington

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) or call the provider phone number.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-02-01effective date shown on document

Provider portal / phonesubmission methods

multipleservice categories listed

after 12th visitoutpatient therapy threshold

$500orthotics/prosthetics 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.

Optumtransplant/CAR T contact

Services and Coverage Criteria Requiring Prior Authorization

Listed prior authorization-required services — selected services and codes explicitly listed as requiring prior authorization in this document segment

The following services, procedures, CPT/HCPCS codes, and administrative requirements are listed in this section as requiring prior authorization or notification. This consolidated index includes coding references and coverage stance notes where provided in the source excerpt. This is an administrative/coding index — specific medical necessity criteria are not included in this excerpt.

Bariatric surgery — Prior authorization is required. Codes listed: 43644, 43645, 43659, 43770, 43775, 43847, 43842, 43848, 43845, 43860, 43846, 97802.

Behavioral health services — For specific codes requiring authorization, contact the number on the member's health plan ID card prior to referral for mental health and substance use services.

Bone growth stimulator — Prior authorization is required. Codes listed: 20975, 20979.

Breast reconstruction (non-mastectomy) and reconstruction of the breast other than following mastectomy — Prior authorization is required. Codes listed: 19316, 19330, 19318, 19325, 19371, 19380, 19396, 11971.

Cancer supportive care — Prior authorization is required for colony-stimulating factor drugs and bone-modifying agents administered in an outpatient setting. Example biotherapy listed: biosimilar (Zarxio).

Cardiovascular procedures — Prior authorization is required for multiple endovascular codes (examples listed): 37220*, 37221, 37224*, 37225*, 37226*, 37227*, 37228*, 37229*, 37230*, 37231. Asterisked codes note prior authorization is required (see excerpt for DX exceptions).

Cerebral seizure monitoring — Prior authorization is required, including for inpatient services. Codes listed: 95700, 95714, 95711, 95715, 95712, 95716, 95713, 95718.

Chemotherapy (injectable) — Prior authorization is required for injectable chemotherapy drugs administered in an outpatient setting for a cancer diagnosis. Includes J9000-J9999 range and select J-codes; miscellaneous HCPCS-coded injectables should be submitted via the UnitedHealthcare Provider Portal or by calling the listed prior authorization number.

Cochlear implants and auditory implants — Prior authorization is required. Example codes listed: 69710 L8690, 69714 L8691, 69930 L8692, L8614, L8680, L8682, L8685, L8686, L8687, L8688.

Continuous glucose monitor (CGM) and related supplies — Prior authorization references present; listed HCPCS examples: A4239, E0787, A9276, E2103, A9277, E2102.

Cosmetic and reconstructive procedures — Prior authorization is required. Example procedure codes: 11960, 14061, 14020*, 15820.

Durable medical equipment (DME) — Prior authorization is required. Example HCPCS codes: A9279, A9280; various V52xx codes and E2298 also referenced.

Enteral services and in-home nutritional therapy — Prior authorization is required for enteral services. Codes listed: B4034, B4035, B4036, B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4155, B4158, B4159, B4160.

Femoroacetabular impingement syndrome (FAI) — Prior authorization required for members 21 and older. Codes listed: 29914, 29915, 29916.

Functional procedures — Prior authorization is required for certain endoscopic functional codes: 31240, 31253, 31254.

Genetic and molecular testing — Multiple CPT-level codes listed as requiring prior authorization (examples include 81432*, 81433*, 81435*, 81436*, 81439, 81440, 81443, 81445*, 81448, 81460, 81465, 81479*, 81507, 81518*, 81519*, 81520, 81521, 81522*, 81546, 81595, 81599, 87505, 87506, 87507, 0018U, 0111U, 0129U, S3870). Asterisked codes may have DX-based exceptions effective June 1, 2023 (see source).

Orthotics and prosthetics — Prior authorization required only for items with a retail purchase or cumulative rental cost > $500. Numerous L-codes listed (sample: L0112, L0464, L0486, L0170, L0480, L0624, L0634, L0640, L0456, L0482, L0629, L0636, L0830, L1200, L0484, L0631, L0638, L0810, L1310, L0820, L1680, L1685, L1710, L1720, L1730, L1755, L1820, L1832, L1834, L1300, L1200).

Outpatient therapy — Prior authorization is required after the 12th visit for members 21 and older.

Physician supervision / chronic care management — Prior authorization is required for certain physician supervision services. Codes referenced: 99424, 99425, 99437, 99491.

Potentially unproven services — Prior authorization is required. Example codes: 33289, C2624.

Radiation therapy — Prior authorization required for radiation therapy when obtained with diagnosis codes in certain cancer ranges (example DX ranges: C34.00-C34.92, C50.011-C50.929, C61). Example CPT/HCPCS codes listed: 77401, 77402, 77407, 77412, G6003, G6004, G6005, G6006.

Site of service (SOS) outpatient hospital — Prior authorization is required only when requesting service in an outpatient hospital setting for specified systems/procedures (examples: CPT 36590, 36832). Prior authorization not required if performed at a participating ambulatory surgery center for certain procedures (example: carpal tunnel surgery 64721).

Sleep apnea procedures and surgeries — Prior authorization is required. Example codes listed: 21685, 41599, 42145.

Saphenous vein removal/ablation — Codes listed: 37700, 37718, 37722, 37765, 37766.

Transplants and CAR T-cell therapy — Prior authorization is required. For transplant and CAR T-cell services (including Carvykti), contact Optum Transplant Case Management at 888-936-7246 or the notification number on the member's ID card.

Ventricular assist devices (VAD) — Prior authorization is required. Call the notification number on the member's ID card and fax required form to Optum VAD Case Management at 855-282-8929. Example CPT codes: 33927, 33928, 33929, 33975, 33983, 33981; example Q-codes: Q0507, Q0508, Q0509.

Wound VAC — Prior authorization is required. Example HCPCS: E2402.

ICD-10 to CPT/HCPCS mapping entries — Numerous ICD-10 codes (C00–C83 ranges, C43.x, C44.x, etc.) are listed in the excerpt as diagnosis code groups tied to prior authorization requirements for certain procedures (see source excerpt). This section functions as a coding index; clinical coverage criteria are not present in the excerpt.

Administrative submission instructions and contacts — Prior authorization requests should be submitted online using the UnitedHealthcare Provider Portal at UHCprovider.com or by calling the numbers listed in the source (example: 888-397-8129). Specific programs require different contacts: Optum Transplant Case Management 888-936-7246; Optum VAD Case Management fax 855-282-8929; Optum Rx prior notification for Cimzia and Synagis at 800-310-6826.

Special notes on drug and miscellaneous codes — Prior authorization for unclassified/temporary J-codes (e.g., C9399, J3490, J3590) is limited to select products (Ryplazim, Xenpozyme, Altuviiio, Cablivi, Veopoz). Effective dates and drug-specific prior authorization requirements noted in excerpt (examples: J0897 effective Jan 1, 2023 for non-oncology DX; Q5133, Q5135, J1748 effective Oct 1, 2024 require prior authorization).

Coding index only — This excerpt contains many coding references and administrative rules but does not include full medical necessity or clinical criteria. For coverage determination, refer to the complete policy or contact UnitedHealthcare as directed in the provider portal or the member ID card.

Prior authorization and submission instructions (partial) — stated coverage-related requirements in this partial section

Prior authorization submission instructions and program-specific contacts referenced in the excerpt. Consolidated operational notes for submitting requests and required notifications.

Submit prior authorization requests online using the UnitedHealthcare Provider Portal at UHCprovider.com (sign in required).

If online submission is not available, contact the telephone numbers listed in the source excerpt for prior authorization (examples: 888-397-8129 and other program-specific lines).

Transplant and CAR T-cell therapy (including Carvykti): call Optum Transplant Case Management at 888-936-7246 or use the notification number on the member's health plan ID card.

Ventricular assist devices (VAD): call the notification number on the member's health plan ID card and fax the form provided by the nurse to Optum VAD Case Management at 855-282-8929.

Cimzia and Synagis prior notification: use Optum Rx prior notification services at 800-310-6826 for notification only (per excerpt).

Administrative prior authorization criteria — administrative criteria and requirements for submitting prior authorization requests and codes that require prior authorization.

Administrative prior authorization criteria and coding-index entries extracted from the source excerpt. This block lists administrative rules, cost thresholds, visit limits, and examples of codes that require prior authorization or notification.

Orthotics and prosthetics — Prior authorization required only for items with a retail purchase or cumulative rental cost greater than $500.

Outpatient therapy — Prior authorization is required after the 12th visit for members age 21 and older.

Site of service (SOS) outpatient hospital — Prior authorization required only when requesting services in an outpatient hospital setting for specified procedures; prior authorization not required if performed at a participating ambulatory surgery center for certain procedures (example: carpal tunnel surgery 64721).

Physician supervision / chronic care management services — Prior authorization required for listed codes (99424, 99425, 99437, 99491).

Partial coverage criteria and notes — coverage stance and specific criteria indicated in this excerpt (partial)

Coverage stance and coding index notes — the excerpted material is an administrative/coding index and does not include explicit clinical coverage criteria or medical necessity decision rules. The following consolidates that stance and highlights that the section contains numerous coding references without full policy criteria.

Coverage stance: None of the excerpted chunks provide full clinical coverage criteria or medical necessity thresholds — the content is primarily an index of services, codes, and administrative prior authorization/notification requirements.

Coding index: The excerpt contains extensive ICD-10 code ranges (for oncology and other diagnoses) and CPT/HCPCS code lists; these function as a coding crosswalk to indicate when prior authorization is required but are not standalone coverage determinations.

Action required: Providers must follow the administrative instructions (portal submission or program-specific contacts) and check the complete policy for medical necessity criteria before scheduling services.

Reference: For definitive coverage determinations and clinical criteria, consult the full UnitedHealthcare policy documentation or contact UnitedHealthcare provider services as listed on the member ID or UHCprovider.com.

Prior authorization requirements (partial) — prior authorization requirements and contacts for select services in this section

Prior authorization requirements summary and coding-index references (operational). Consolidated list of key program contacts and code groups that require prior authorization or notification as indicated in the excerpt.

Key contacts for program-specific prior authorization/notification as referenced: UnitedHealthcare Provider Portal (UHCprovider.com) for online submissions; phone examples from excerpt include 888-397-8129 (general PA line), Optum Transplant Case Management 888-936-7246, Optum VAD Case Management fax 855-282-8929, Optum Rx prior notification 800-310-6826.

Drug/J-code special handling: Temporary and miscellaneous J-codes (C9399, J3490, J3590) require PA only for specified products (Ryplazim, Xenpozyme, Altuviiio, Cablivi, Veopoz).

Effective-date notes from excerpt: J0897 PA required for non-oncology DX effective Jan 1, 2023; Q5133, Q5135, J1748 PA required effective Oct 1, 2024.

Operational reminder: When codes are billed under miscellaneous HCPCS, submit PA requests via the Provider Portal and include supporting clinical documentation to identify the drug or service.

CPT, HCPCS, ICD-10 and Other Code Lists

Covered CPT codes - Cardiovascular (prior auth required where marked with *)CPTCovered

37220	Revascularization, endovascular, open or percutaneous (see CPT)
37221	Transcatheter therapy (adjacent vascular)
37224
37225
37226
37227
37228
37229
37230
37231

Covered CPT codes - Dermatology / Lesion excision and related procedure codesCPTCovered

170.221	Destruction of benign lesions, trunk/arms/legs - code series
170.221-170.745	Range of CPT/HCPCS codes for lesion destruction and related excisions (multiple specific codes listed in source)
172.3	Malignant melanoma in situ (code group referenced)
172.4	Melanoma localized, other specified subsites
172.8	Melanoma, unspecified
172.9	Malignant melanoma, unspecified site
174.3	Malignant neoplasm of upper-outer quadrant of female breast
174.4	Malignant neoplasm of lower-outer quadrant of female breast
174.5	Malignant neoplasm of upper-inner quadrant of female breast
174.8	Malignant neoplasm of overlapping sites of female breast

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HCPCS codes - DME and related (sample)HCPCS

A9276	Adjunctive wound care dressing, specified
A9277	Adjunctive wound care dressing, specified
A9278	Adjunctive wound care dressing, specified
E0118	Crutches, underarm, other than wood
L8690	Implantable hearing device, cochlear; internal component
L8691	Implantable hearing device, cochlear; external component
L8692	Implantable hearing device, cochlear; replacement or add-on component

HCPCS codes - Cochlear and implantable hearing device L-codesHCPCSCovered

L8690	Cochlear implant internal device
L8691	Cochlear implant external processor
L8692	Cochlear implant replacement components

HCPCS codes - DME / Wound care sample A-codesHCPCS

A9276	Wound dressing, unspecified (sample listing)
A9277	Wound dressing, unspecified (sample listing)
A9278	Wound dressing, unspecified (sample listing)

Covered CPT codes - Ophthalmic / OculoplasticCPTCovered

67901	Repair of conjunctival defect; full thickness (example range included up to 67961)
67902	Repair of eyelid/canalicular laceration (examples through series to 67961)
67961	Excision, lesion of eyelid or periorbital area (series includes 67901-67961)

How to Request Prior Authorization and Operational Contacts

Prior Authorization

How to request prior authorization

To request prior authorization submit online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 877-542-9231. Prior authorization is not required for emergency or urgent care; out-of-network requests must be made by a network care provider.

Prior Authorization

Drug prior authorization submission note

For certain injectable supportive-care and specialty drugs (e.g., colony-stimulating factors, pegfilgrastim biosimilars, denosumab, antiemetics), submit prior authorization requests online using the UnitedHealthcare Provider Portal or call the specified phone numbers listed per service.

Prior Authorization

Prior authorization required for listed services

Prior authorization is required for the listed services (examples include cerebral seizure monitoring CPTs 95700–95718, outpatient injectable chemotherapy J‑codes, cochlear implants HCPCS, continuous glucose monitor A‑codes, and multiple surgical CPTs). Submit requests online via the UnitedHealthcare Provider Portal or call the provider phone number shown.

Key Terms and Definitions

Policy Revision History

2025-02-01effective_dateLatest

Document effective date: Prior authorization requirements effective Feb. 1, 2025.

2024-10-01policy_change

Effective Oct. 1, 2024: prior authorization required for Q5133, Q5135, J1748 and for CPT 22865 for members age 21 and older.

2023-01-01policy_change

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan Apple Health Expansion of Washington

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) or call the provider phone number.

SourceLink

On This Page

Chemotherapy injectable drugs billed under miscellaneous HCPCS codes: submit requests online via the UnitedHealthcare Provider Portal or call the listed prior authorization number.

For unclassified/temporary J-codes requiring prior authorization only for specified products (Ryplazim, Xenpozyme, Altuviiio, Cablivi, Veopoz), follow drug-specific prior authorization pathways as noted in the excerpt.

Durable medical equipment (DME) — Prior authorization is required for select codes (examples A9279, A9280) and certain V52xx codes referenced in excerpt.

Transplants / CAR T-cell therapy — Prior authorization required; use Optum Transplant Case Management contact (888-936-7246).

Drug-specific PA exceptions and effective dates — Examples: J0897 required PA for non-oncology DX effective Jan 1, 2023; Q5133, Q5135, J1748 required PA effective Oct 1, 2024. Unclassified J-codes C9399, J3490, J3590 require PA only for named products.

Submission portals and phone numbers — UnitedHealthcare Provider Portal (UHCprovider.com) is primary; supplemental phone numbers provided in source for specific programs.

Coding index note — Many entries list ICD-10 diagnosis ranges (C00–C83, C43.x, C44.x, etc.) that map to PA requirements for procedures in the excerpt; this section serves as an administrative mapping rather than clinical guidance.

Coding groups highlighted: select L-codes for orthotics/prosthetics, B-codes for enteral nutrition, A- and E-codes for DME and CGM supplies, 3xxxx and 7xxxx series CPTs for surgical and vascular procedures, and ranges of CPT/HCPCS/ICD-10 oncology codes listed across the excerpt.

Prior Authorization

Submission instructions for prior authorization

Please submit prior authorization requests online using the UnitedHealthcare Provider Portal (UHCprovider.com). For chemotherapy injectable drugs or items billed under a miscellaneous HCPCS code, you may also call the telephone number provided in the document (888‑397‑xxxx).

Prior Authorization

DME prior authorization requirement

Durable medical equipment (DME) codes listed in the policy require prior authorization; some DME entries include additional notes and a retail purchase or cumulative rental cost threshold (e.g., more than $500) that trigger prior authorization.

Prior Authorization

Enteral and in‑home nutrition prior authorization

Prior authorization is required for enteral services and in‑home nutritional therapy codes (examples include B4034–B4036, B4102–B4161, B9998).

Prior Authorization

Genetic/molecular testing prior authorization and exceptions

Genetic and molecular testing codes listed require prior authorization; codes marked with a red asterisk do NOT require prior authorization when billed with the specific diagnosis codes listed (effective June 1, 2023).

Prior Authorization

FAI procedures prior authorization (age 21+)

Femoroacetabular impingement (FAI) procedures (CPT 29914–29916) require prior authorization for members age 21 and older.

Prior Authorization

Experimental/investigational prior authorization

Experimental and investigational services and listed linked procedures require prior authorization.

Documentation Required

Prior authorization cross‑references (C15–C17)

The policy lists prior authorization cross‑reference identifiers for ICD‑10 codes in the C15–C17 range to map authorization requirements and related CPT/HCPCS entries.

Documentation Required

Authorization mapping for ICD‑10 C22

Authorization mapping continues for C22 entries and surrounding ICD‑10 codes, indicating where prior authorization references and CPT/HCPCS links are recorded.

Documentation Required

Genetic/molecular testing authorization references

The document includes multiple authorization references tied to genetic and molecular testing ICD‑10 entries (e.g., BRCA‑related identifiers) to indicate prior authorization linkage.

Documentation Required

Authorization cross‑references (C34–C44)

The policy contains extensive authorization cross‑references for ICD‑10 codes in the C34–C44 ranges showing associated prior authorization identifiers.

Documentation Required

Authorization cross‑references (C45–C47)

Authorization cross‑references continue through ICD‑10 entries C45–C47 with associated prior authorization identifiers where provided.

Documentation Required

Prior authorization references for ICD‑10 codes

Many ICD‑10 code lines include fields that reference CPT or HCPCS codes and/or how to obtain prior authorization; these references are listed alongside ICD‑10 codes throughout the section.

Documentation Required

Prior authorization mapping fields (ICD‑10 C69–C83)

ICD‑10 entries in the C69–C83 excerpt include placeholder fields for CPT/HCPCS codes and instructions on how to obtain prior authorization; many fields are empty or contain placeholders in this excerpt.

Documentation Required

Prior authorization placeholders for C‑codes

Placeholders in the C‑code sections indicate where CPT/HCPCS codes and prior authorization instructions are to be recorded for listed C‑codes.

Prior Authorization

How to obtain prior authorization (portal or phone)

Submit prior authorization requests online using the UnitedHealthcare Provider Portal (UHCprovider.com) or call 888‑397‑8129 as indicated in the policy excerpt.

Prior Authorization

Home health prior authorization note

Prior authorization is required for home health care only when provided in outpatient settings, including a member's home.

Prior Authorization

Prior authorization timing and submission for select codes

Effective Oct 1, 2024: prior authorization is required for Q5133, Q5135, and J1748. Effective Jan 1, 2023: prior authorization is required for J0897 when billed for non‑oncology diagnoses. Submit requests via the Provider Portal or call 888‑397‑8129.

Prior Authorization

Unclassified/temporary codes prior‑auth guidance

For unclassified or miscellaneous drug/biologic codes (C9399, J3490, J3590), prior authorization is required only for specific named products (e.g., Ryplazim, Xenpozyme, Altuviiio, Cablivi, Veopoz).

Prior Authorization

Physician supervision and chronic care management prior authorization

Physician supervision and chronic care management services require prior authorization as indicated (e.g., chronic care management CPTs listed).

Prior Authorization

Orthotics and prosthetics PA requirements (>$500)

Orthotics and prosthetics require prior authorization only when the retail purchase or cumulative rental cost exceeds $500; numerous L‑codes are listed in the policy.

Prior Authorization

Potentially unproven services — prior authorization required

Potentially unproven services listed in the policy require prior authorization (examples include CPT 33289 and code C2624).

Prior Authorization

Prior authorization submission instructions for imaging

Submit advanced outpatient imaging prior authorization requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866‑889‑8054 for prior authorization/notification of advanced imaging procedures.

Prior Authorization

Outpatient therapy prior authorization threshold

Outpatient therapy requires prior authorization after the 12th visit for members age 21 and older.

Prior Authorization

Radiation therapy prior authorization by diagnosis

Radiation therapy requires prior authorization when obtained with diagnosis codes in the ranges C34.00–C34.92, C50.011–C50.929, and C61 only.

Prior Authorization

Site‑of‑service prior authorization rule (SOS outpatient hospital)

Site‑of‑service rule: prior authorization is required only when requesting service in an outpatient hospital setting; some services may not require prior authorization if performed at a participating ambulatory surgery center.

Prior Authorization

Sleep apnea procedures prior authorization

Prior authorization is required for sleep apnea procedures and surgeries listed in the policy.

Prior Authorization

Spinal surgery prior authorization

Prior authorization is required for the spinal surgery CPT codes listed throughout the policy (multiple codes provided).

Prior Authorization

Sterilization and other procedures prior authorization

Sterilization procedures and many other listed procedure codes require prior authorization.

Prior Authorization

Transplant / CAR T prior authorization contact

For transplant and CAR T‑cell therapy services (including Carvykti), call the Optum Transplant Case Management team at 888‑936‑7246 or use the notification number on the member's ID card.

Prior Authorization

VAD prior authorization contact and fax

For Ventricular Assist Devices (VAD), call the notification number on the back of the member's health plan ID card and fax the form provided by the nurse to Optum VAD Case Management at 855‑282‑8929.

Prior Authorization

Saphenous vein procedures — prior authorization referenced

Removal and ablation procedures of the saphenous veins (CPT 37700, 37718, 37722, 37765, 37766) are listed with prior authorization referenced.

Prior Authorization

VAD / mechanical circulatory support prior authorization

Ventricular assist devices (VAD) and mechanical circulatory support devices (CPT 33927–33929, 33975, 33981, 33983; HCPCS Q0507–Q0509) require prior authorization/notification; providers should call the notification number on the member ID and fax the nurse‑provided form to Optum VAD Case Management at 855‑282‑8929.

Prior Authorization

Wound VAC prior authorization (E2402)

Wound VAC therapy requires prior authorization; HCPCS E2402 is listed.

Effective Jan. 1, 2023: prior authorization required for J0897 for non-oncology diagnoses.

2023-06-01policy_change

Effective June 1, 2023: specified genetic/molecular test codes marked with a red asterisk do NOT require prior authorization when billed with listed DX codes.