CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for UnitedHealthcare West Non-Capitated Supplement

Lists inpatient and outpatient services that require prior authorization for participating care providers under specified UnitedHealthcare commercial benefit plans and explains how to request authorization. Applies to network and out-of-network providers except in emergency/urgent care.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare West Non-Capitated Supplement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call 877-842-3210.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

phone & onlinesubmission methods

excludedemergency/urgent

multiple CPT/HCPCS listscode lists

$1,000DME/orthotics threshold

95805-11sleep study codes

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.

Prior Authorization Coverage Criteria

COVERAGE CRITERIA — Prior authorization coverage criteria (document excerpts)

Services listed in the document require prior authorization as noted; some services have additional requirements or routing instructions.

Prior authorization is required for the services and procedures listed in this document except in cases of emergency or urgent care (no prior authorization required).

Requests must be submitted online using the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by phone at the numbers listed in this document (see provider contact nodes).

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

Examples (ONE or more) of service categories requiring prior authorization

Arthroplasty procedures (multiple CPT codes listed) require prior authorization.
Cardiology services including diagnostic catheterizations, echocardiograms, electrophysiology implants and stress echoes require prior authorization prior to performance.
Bariatric surgery and specified obesity-related services require prior authorization.
BRCA genetic testing requires prior authorization before DNA sequencing; ordering provider must notify the laboratory and genetic counseling is required prior to testing.

For cardiology prior authorization submission and contact, submit via the Prior Authorization and Notification tool on the Provider Portal or call 866-889-8054.

COVERAGE CRITERIA — Prior authorization coverage statements (partial)

Service-level prior authorization stance as listed in this section:

Cartilage implants require prior authorization (example codes include 27412, 29867, 27415, 29868, 27416, J7330, 29866).

Clinical trials (investigational clinical studies) require prior authorization (example codes S9988, S9990, S9991).

Cochlear and other auditory implants require prior authorization (example codes 69710, 69714, 69930, L8614, L8619, L8690–L8692).

Continuous glucose monitor devices require prior authorization when billed for Type 2 or gestational diabetes diagnoses; Type 1 diabetes may be exempt per document notes (example HCPCS A4226, A9277, A4238, A9278, A4239, E0787, E2102).

Cosmetic and reconstructive procedures require prior authorization; reconstructive procedures that treat medical conditions or improve function are listed with multiple CPT codes (e.g., 11960, 15572, 15879, 17106).

COVERAGE CRITERIA — Authorization and exceptions (partial)

Prior authorization requirements and exceptions for listed cardiovascular codes and DME.

Prior authorization is required for the cosmetic/reconstructive and other listed procedures in the cardiovascular section (see specific CPT/HCPCS lists).

Durable medical equipment (DME) items listed require notification or prior authorization; for some items a retail purchase or cumulative rental threshold of $1,000 applies.

Exceptions noted

Certain entries state 'Prior authorization not required when billed with the [unspecified item]' (context incomplete in document segment).

COVERAGE CRITERIA — Partial criteria set (segment)

Selected prior authorization/notification requirements captured in this segment:

Functional endoscopic sinus surgery (FESS) requires prior authorization (example CPTs 31240, 31253–31259, 31267).

Gender dysphoria treatments require notification or prior authorization for specified procedure codes (e.g., 55970, 55980) and for listed procedures when submitted with diagnosis codes F64.x or Z87.890.

Home health private duty nursing (T1002, T1003) requires notification/prior authorization in outpatient/home settings; inpatient vaginal hysterectomies require prior authorization.

Injectable medications (IV/SC/IM) require prior authorization; drug-specific requirements referenced at UHCprovider.com/priorauth Clinical Pharmacy and Specialty Drugs Prior Authorization.

COVERAGE CRITERIA — Prior authorization criteria (selected)

Prior authorization requirements and conditions

Prior authorization and notification of admission date are required for post-acute inpatient facilities including acute care hospitals, critical access hospitals, and acute inpatient rehabilitation facilities.

MR-guided focused ultrasound (MRgFUS) to treat uterine fibroid is covered for certain plans but requires prior authorization; additional conditions include contracted facility, physician/facility experience, written member consent acknowledging limited published evidence and lack of out-of-network benefits.

Orthotics listed require prior authorization when retail purchase or cumulative rental cost exceeds $1,000 (multiple L-codes listed).

Pain management and injection procedures (multiple CPTs such as 62320–62361 and 64451, 64484, 64520, 64620, 64640) require prior authorization.

Potentially unproven, experimental, or investigational services require prior authorization when insufficient peer-reviewed clinical evidence exists.

COVERAGE CRITERIA — Proton beam therapy

Proton beam therapy coverage prerequisites

Prior authorization is required for proton beam therapy; providers must indicate whether the therapy is being performed as part of a clinical trial.

Relevant CPT/HCPCS codes include 77520, 77522, 77523, 77525 and multiple related L-codes listed in the document.

COVERAGE CRITERIA — Advanced outpatient imaging

Advanced outpatient imaging coverage prerequisites

Prior authorization is required for selected advanced outpatient imaging procedures (advanced CT/MRI/MRA/PET and related studies).

Care providers ordering an Advanced Outpatient Imaging Procedure are responsible for providing notification or requesting prior authorization before scheduling the procedure.

COVERAGE CRITERIA — Prosthetics

Prosthetics prior authorization rule

Prior authorization is required only for prosthetic codes with a retail purchase or cumulative rental cost of more than $1,000.

Example prosthetic HCPCS (ONE or more)

L5010
L5105
L5150
L5060

COVERAGE CRITERIA — Selected ENT and sleep apnea surgeries

Surgical procedures requiring prior authorization

Rhinoplasty, sinuplasty, and specified surgical procedures for sleep apnea require prior authorization; submit requests via the Provider Portal or call 866-889-8054.

Example CPT groups (ONE or more)

Rhinoplasty example CPTs: 30400–30465 (selected examples 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462).
Sinuplasty example CPTs: 31295–31298 (31295, 31296, 31297, 31298).
Sleep apnea surgery example CPTs: 21685 and other listed CPTs (e.g., 21685, 41599, 42145).

COVERAGE CRITERIA — Sleep studies

Sleep studies (facility-based) prior authorization

Laboratory-assisted sleep studies (polysomnography) performed in facility settings require prior authorization; home sleep studies are excluded from this facility-based requirement.

Relevant CPT examples (ONE or more)

95805
95807
95808
95810
95811

COVERAGE CRITERIA — Spinal cord stimulators

Spinal cord stimulator prior authorization

Spinal cord stimulators implanted for pain management require prior authorization.

Example codes (ONE or more)

64570
L8683
L8679
L8685

Submit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call 866-889-8054.

COVERAGE CRITERIA — Prior authorization requirements

Prior authorization is required for the listed inpatient procedures and codes. Specific contact and submission channels are provided. Some codes have conditional requirements.

Providers must submit prior authorization requests using the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call 866-889-8054.

For transplant and CAR T-Cell therapy services, contact 888-936-7246 (or the notification number on the member's ID card) for prior authorization and coordination.

Conditional requirement: CPT code 38232 requires prior authorization only when billed for an oncology diagnosis.

Multiple inpatient procedure, vein procedure and VAD codes listed require prior authorization (see inpatient code lists in document).

COVERAGE CRITERIA — Inpatient prior authorization requirements (partial)

Prior authorization required for the listed inpatient procedure codes (partial extract).

The following inpatient procedure codes require prior authorization (partial list): 38232, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 37243, 37700, 37718, 37722, 37780, 33927, 33928, 33929, 33975, 33976, 33979, 33981, 33982, 33983.

Condition on specific code: Code 38232 requires prior authorization only when the diagnosis is oncology.

Relevant CPT / HCPCS / ICD-10 Codes

Sample arthroplasty CPT codes requiring prior authorizationCPTCovered

23470	Arthroplasty — listed as prior auth required
24360	Arthroplasty — listed as prior auth required
25441	Arthroplasty — listed as prior auth required
27120	Arthroplasty — listed as prior auth required

Sample bariatric surgery CPT codes requiring prior authorizationCPTCovered

43644	Bariatric surgery CPT code requiring prior authorization
43770	Bariatric surgery CPT code requiring prior authorization
43842	Bariatric surgery CPT code requiring prior authorization
43860	Bariatric surgery CPT code noted with * (notification/PA required)

BRCA genetic testing CPT/HCPCSCPTCovered

81162	BRCA genetic testing code requiring prior authorization
81433	BRCA genetic testing code requiring prior authorization

Sample cardiology CPT codes requiring prior authorizationCPTCovered

37225	Vascular/cardiology code (prior authorization required)
93653	Electrophysiology code referenced for prior authorization

Cardiovascular code list (partial)mixed

170.644	Listed CPT/HCPCS code or internal code reference
170.645	Listed CPT/HCPCS code or internal code reference
170.648	Listed CPT/HCPCS code or internal code reference

Cardiovascular/related diagnosis codes (partial)mixed

T82.818A	ICD-10 code referenced in cardiovascular list
T82.868A	ICD-10 code referenced in cardiovascular list
S81.801A	ICD-10 code referenced in cardiovascular list

Type 2 and gestational diabetes diagnosis codes (CGM prior auth applicability)ICD-10Covered

E11.00	Type 2 diabetes mellitus diagnosis codes (examples listed)
E11.01	Type 2 diabetes mellitus diagnosis codes (examples listed)
E11.10	Type 2 diabetes mellitus diagnosis codes (examples listed)

Sample DME/Codes from sectionHCPCS | mixedCovered

E2511	DME / cardiovascular related code as listed
K0012	DME code listed; different prior authorization
K0812	DME code listed
K0850	DME code listed
K0862	K0862 - K0869 group

FESS procedure codesCPTCovered

31240	Functional endoscopic sinus surgery (FESS)
31253	FESS
31254	FESS
31255	FESS
31256	FESS
31257	FESS
31259	FESS
31267	FESS

Gender dysphoria, hysterectomy and infertility codesCPT | HCPCS | mixedCovered

55970	Gender dysphoria related procedure (notification/prior auth required)
55980	Gender dysphoria related procedure (notification/prior auth required)
S4011	Vaginal hysterectomy / infertility related S-codes
S4013	Vaginal hysterectomy / infertility related S-codes

Sample ICD‑10 diagnosis codes referencedICD-10

N46.01	DX code listed in infertility section
N97.0	DX code listed in infertility section

Sample J‑codes (injectables/immune globulin/etc.)HCPCS | NDC | mixedCovered

J1786	Injectable/infusion drug J-code listed
J7180	J-code listed
J1459	Immune globulin / injectable J-code listed
J0129	Inflammatory J-code listed

Selected listed T-codes and other procedure codesCPTCovered

0075T	MRgFUS or related code listed in segment
0234T
0235T
0236T
0237T
0238T
0347T
0348T

Additional listed T-codes requiring authorizationCPTCovered

0601T
0613T
0622T
0632T
0643T
0660T
0682T
0699T

Inpatient admission CPT/HCPCS codes (selected examples)CPT

0643T	Listed inpatient admission related code
0682T	Listed inpatient admission related code
0737T	Listed inpatient admission related code

Procedure-specific codesmixedCovered

52441	Prostate procedure
77520	Proton beam therapy
L7186	Proton beam therapy related HCPCS

Sleep study CPT codes requiring prior authorizationCPTCovered

95805	Polysomnography, sleep study
95811	Polysomnography, sleep study
95810	Polysomnography, sleep study

Sleep study codes requiring prior authorizationCPTCovered

95805	Polysomnography (sleep study)
95807	Split-night sleep study / polysomnography
95808	Polysomnography with initiation of CPAP
95810	Polysomnography with video

Bone marrow / stem cell collectionCPTCovered

38232

Collection of hematopoietic progenitor cells

Inpatient prior auth codes (partial)CPT | HCPCSCovered

38232	Requires prior authorization only for an oncology diagnosis
36470	Vein procedure
36471	Vein procedure
36473	Vein procedure
36474	Vein procedure
36475	Removal/ablation of main trunks/named branches
36476	Removal/ablation
36478	Removal/ablation
36479	Removal/ablation
37243	Trunks and named branches procedure

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DME retail purchase cumulative rental threshold

DME retail purchase / cumulative rental thresholdPrior authorization/notification required when retail purchase or cumulative rental cost exceeds $1,000 for listed DME items

Examples of affected HCPCS codesE0297, E0300, E0302, E0304, E0328, E0329 (see DME list)

Exception note

How Providers Should Request Authorization

Prior Authorization

How to request prior authorization

To request prior authorization, submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 877-842-3210. Prior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all procedures and services excluding emergent or urgent care.

Online: Prior Authorization and Notification tile on UnitedHealthcare Provider Portal (UHCprovider.com).
Phone: 877-842-3210.

Prior Authorization

Cardiology prior authorization contact and scope

Cardiology prior authorization requests must be submitted via the Prior Authorization and Notification tool on the Provider Portal or by calling 866-889-8054. Prior authorization is required for diagnostic catheterizations, echocardiograms, electrophysiology implants, and stress echoes prior to performance; special rules apply for vascular codes and patients age 18 and older.

Submit online: Provider Portal Prior Authorization and Notification tool.

Key Terms and Definitions

Prior authorization definition

DefinitionPrior authorization is the review and approval process required before certain inpatient and outpatient services are performed for members in the listed UnitedHealthcare commercial benefit plans (excluding emergency or urgent care)

Who must requestParticipating and out-of-network providers must request prior authorization for applicable services (except emergent/urgent care)

How to requestRequests may be submitted online via the Provider Portal Prior Authorization and Notification tool or by phone (877-842-3210)

Clinical trials definition

DefinitionClinical trials: A rigorously controlled study of a new drug, medical device, or other treatment on eligible human subjects that is subject to oversight by an Institutional Review Board

Authorization stance

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare West Non-Capitated Supplement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call 877-842-3210.

SourceLink

On This Page

Non-emergency air transport (air ambulance) requires prior authorization (example codes A0430, A0431, A0435, A0436).

Out-of-network services require prior authorization.

Some home health care services may qualify under DME but are not subject to the $1,000 retail purchase threshold

Orthotics purchase/rental cost threshold

Orthotics purchase / cumulative rental thresholdPrior authorization required when retail purchase or cumulative rental cost exceeds $1,000

Examples of orthotic HCPCS codesL1685, L1710, L1720, L1755, L1844, L1846, L2020, L2034

Repeated guidanceThreshold statement appears multiple times emphasizing $1,000 retail/cumulative rental limit

prosthetic prior authorization threshold

Prosthetic prior authorization thresholdPrior authorization is required only for prosthetic codes with a retail purchase or cumulative rental cost of more than $1,000

Example prosthetic HCPCS codesL5010, L5105, L5150, L5060

Relation to DMEProsthetics are noted as distinct from DME; threshold applies to listed prosthetic codes

Phone: 866-889-8054.

Prior authorization required for listed cardiology procedures; see UHCprovider.com/priorauth for codes and details.

Prior Authorization

BRCA testing prior authorization and counseling requirement

BRCA genetic testing requires prior authorization before DNA sequencing is performed; the ordering provider must notify the laboratory and the laboratory will notify UnitedHealthcare. Genetic counseling by a qualified provider is required prior to testing.

Codes: 81162, 81433 (and related BRCA sequencing codes).
Lab must notify UnitedHealthcare after provider notification.
Genetic counseling required before testing; supportive documentation available at UHCprovider.com/priorauth.

Prior Authorization

Behavioral health authorization routing

Behavioral health services require prior authorization; providers should call the number on the member's health plan ID card to refer for mental health and substance use services.

Follow referral instructions on member's ID card for behavioral health prior authorization.

Prior Authorization

Cartilage implants prior authorization

Cartilage implant procedures require prior authorization.

Example codes: 27412, 29867, 27415, 29868, 27416, J7330, 29866.

Prior Authorization

Clinical trials prior authorization

Clinical trials require prior authorization.

Example codes: S9988, S9990, S9991.

Prior Authorization

Cochlear implants prior authorization

Cochlear and other auditory implants require prior authorization.

Example codes: 69710, 69714, 69930, L8614, L8619, L8690–L8692.

Prior Authorization

Continuous glucose monitor prior authorization

Continuous glucose monitors require prior authorization when billed with Type 2 or gestational diabetes diagnosis codes; prior authorization is not required for some Type 1 diabetes scenarios per the document.

Example HCPCS/Codes: A4226, A9277, E2103, A4238, A9278, A4239, E0787, E2102.
Prior authorization required for specified Type 2 and gestational diabetes DX codes (see list in document).

Prior Authorization

Cosmetic/Reconstructive prior authorization

Cosmetic and reconstructive procedures require prior authorization; reconstructive procedures that treat a medical condition or improve function are listed and require authorization.

Example CPTs include 11960, 11970, 14021, 15570, 15879, 17106 and others listed in the cosmetic/reconstructive section.
Submit prior authorization before performing listed procedures.

Prior Authorization

Prior authorization requirement (general)

Prior authorization is required for the listed services and codes throughout this document.

Providers should consult the document code lists and obtain authorization before performing listed services.

Billing Rule

DME prior authorization and thresholds

Durable medical equipment (DME) items listed require notification or prior authorization; for items with a retail purchase or cumulative rental cost over $1,000 prior authorization is required.

Example DME codes listed include A7025, A7026, E0194, E0265, E0297, E0328, K0862–K0869 and many others.
Threshold: retail purchase or cumulative rental cost more than $1,000 triggers prior authorization.

Note

Exceptions where prior authorization not required

The document lists limited exceptions where prior authorization is not required for certain items when billed with another item; the segment repeats 'Prior authorization not required when billed with the' without specifying the companion item in this extract.

Review the full policy for complete exception details where companion billing exempts prior authorization.

Prior Authorization

Procedure prior authorization examples

Examples of procedures that require prior authorization include Functional Endoscopic Sinus Surgery (FESS) and gender dysphoria treatments; notification or prior authorization is required for the listed codes.

FESS example codes: 31240, 31253–31259, 31267.
Gender dysphoria example codes requiring notification or prior authorization: 55970, 55980 and multiple procedure codes when submitted with F64.x or Z87.890.

Prior Authorization

Home health and hysterectomy notification/prior auth

Notification or prior authorization is required for home health care private duty nursing (T1002, T1003) in outpatient settings (including the patient's home). Prior authorization/notification is also required for inpatient vaginal hysterectomies and notification/prior authorization applies for outpatient vaginal hysterectomies as noted.

Home health private duty nursing codes: T1002, T1003 (outpatient/home settings require notification/prior authorization).
Hysterectomy and related S‑codes listed; follow notification/prior authorization guidance.

Prior Authorization

Injectable medications prior authorization

Injectable medications (IV, SC, IM) require prior authorization; drug-specific authorization requirements are referenced at UHCprovider.com/priorauth (Clinical Pharmacy and Specialty Drugs Prior Authorization).

Review drug-specific prior authorization rules at UHCprovider.com/priorauth.
Example injectable J‑codes are listed in the policy (e.g., J1786, J7180).

Prior Authorization

DME prior authorization

Durable medical equipment (DME) K‑series codes listed are included in the policy and may have different prior authorization requirements depending on the member's benefit plan.

Example K‑series codes: K0862–K0869 and K0863 K0870 groupings; check benefit plan for specific requirements.

Prior Authorization

Post-acute inpatient services authorization

Prior authorization and notification of the admission date are required for facilities providing post‑acute inpatient services, including acute care hospitals, critical access hospitals, and acute inpatient rehabilitation.

Notify or obtain authorization prior to admission for post‑acute inpatient services in the listed facility types.

Prior Authorization

MRgFUS authorization and consent

MR‑guided focused ultrasound (MRgFUS) to treat uterine fibroid is covered for certain plans but requires prior authorization; the member must provide written consent acknowledging limited published evidence, the facility must be contracted with UnitedHealthcare, and the provider/facility must demonstrate experience as determined by UnitedHealthcare.

Example MRgFUS codes: 0071T, 0072T.
Member written consent and contracted facility required; no out‑of‑network benefits for MRgFUS.

Prior Authorization

Non-emergency air transport

Non‑emergency air transport (non‑urgent ambulance by air) requires prior authorization.

Example codes: A0430, A0431, A0435, A0436.

Billing Rule

Orthotics prior authorization and cost threshold

Orthotics listed require prior authorization when the retail purchase or cumulative rental cost exceeds $1,000.

Examples of orthotics codes: L1685, L1710, L1720, L1755, L1844, L2020, L2034, L3251, L3485, L3766, L3900, L3961, L3971, L3975, L3976, L3977, etc.
Threshold: retail purchase or cumulative rental cost of more than $1,000.

Prior Authorization

Pain management prior authorization

Pain management and injection procedures require prior authorization.

Example CPTs: 62320, 62322, 62324, 62325, 64451, 64484, 64520, 64620, 64640 and related E‑codes.

Prior Authorization

Potentially unproven/experimental services

Services determined to be potentially unproven, experimental, or investigational require prior authorization when there is insufficient peer‑reviewed clinical evidence.

Examples of potentially unproven codes listed include 26340, 33289, 33361–33366 and multiple T‑codes (0746T–0782T).
Prior authorization is required for these services prior to performance.

Prior Authorization

Out-of-network prior authorization

Out‑of‑network services require prior authorization.

Out‑of‑network physicians, facilities and other providers must request prior authorization for all procedures and services excluding emergent or urgent care.

Prior Authorization

How to obtain prior authorization (portal or phone)

Prior authorization requests can be submitted online via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by phone at 866-889-8054 for many services.

Online: Prior Authorization and Notification tile on UHCprovider.com Provider Portal.
Phone: 866-889-8054 (for prior authorization submissions).

Prior Authorization

Proton beam therapy prior authorization

Proton beam therapy requires prior authorization; providers must indicate whether treatment is performed as part of a clinical trial.

Example codes: 77520, 77522, 77523, 77525, V2629 and related L‑codes.
Indicate if proton beam therapy is part of a clinical trial when requesting authorization.

Prior Authorization

Advanced outpatient imaging prior authorization

Advanced outpatient imaging procedures require prior authorization; care providers ordering these procedures are responsible for providing notification or requesting prior authorization before scheduling.

Examples of advanced imaging HCPCS/L‑codes listed (e.g., L6310, L6370, L6930, L6950, L6970).
Obtain authorization prior to scheduling the imaging procedure.

Billing Rule

Prosthetics prior authorization threshold

Prosthetic devices require prior authorization only when the retail purchase or cumulative rental cost exceeds $1,000.

Example prosthetic HCPCS: L5010, L5105, L5150, L5060.
Threshold: retail purchase or cumulative rental cost of more than $1,000.

Prior Authorization

Spinal cord stimulator prior authorization

Spinal cord stimulators implanted for pain management require prior authorization.

Example codes: 64570, L8683, L8679, L8685, L8680, L8686, 64553, L8682, L8687.

Prior Authorization

Sleep studies prior authorization

Laboratory‑assisted sleep studies (polysomnography) performed in facility settings require prior authorization; submit requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call 866-889-8054.

Relevant CPTs: 95805, 95807, 95808, 95810, 95811.
Home sleep studies are excluded from this facility-based authorization requirement.

Prior Authorization

Spine, stimulators, and other inpatient surgery prior authorization

Spinal cord stimulators, spinal surgeries, various neurosurgical and other inpatient procedures require prior authorization; submit requests via the Provider Portal or call 866-889-8054.

Extensive lists of CPT codes for spine and neurosurgical procedures are provided; obtain authorization prior to admission or scheduling.
Use Provider Portal or phone 866-889-8054 to submit requests.

Prior Authorization

Transplant and CAR T-Cell therapy prior authorization

Transplant and CAR T‑Cell therapy services require prior authorization; for CAR T‑Cell and transplant services call 888-936-7246 or the notification number on the member's ID card.

Prior authorization required for transplant evaluation, bone marrow harvest, organ transplants and CAR T‑Cell therapies.
Contact for CAR T‑Cell/transplant authorization: 888-936-7246 or the number on the member's ID card.

Prior Authorization

CAR T-Cell and related code prior authorization

CAR T‑Cell therapy codes and related miscellaneous codes require prior authorization; CPT code 38232 requires prior authorization only when billed for an oncology diagnosis.

Example CAR T codes: 0537T–0540T, C9098, C9399, J3490, J3590, Q2042, Q2053–Q2055.
Code 38232: prior authorization required only for oncology diagnoses.

Prior Authorization

Vein procedures prior authorization

Vein procedures and related removal/ablation procedures require prior authorization.

Example CPTs: 36470, 36471, 36473, 36474, 36475–36479, 37243, 37700, 37718, 37722, 37780.

Prior Authorization

VAD prior authorization

Ventricular assist device (VAD) procedures require prior authorization.

Example codes: 33927, 33928, 33929, 33975, 33976, 33979, 33981–33983.

Prior Authorization

Inpatient procedure prior authorization (partial list)

Various inpatient CPT/HCPCS codes listed in the document require prior authorization; note that code 38232 requires prior authorization only for an oncology diagnosis.

Providers must obtain prior authorization for the inpatient procedures listed before performing services.
Use Provider Portal or call the applicable prior authorization phone numbers.

Prior Authorization

Inpatient procedure prior authorization (continued)

Additional inpatient CPT/HCPCS codes for venous disease/varicose procedures and ventricular assist devices require prior authorization as listed in the policy.

Examples include 37722, 37780 and multiple VAD codes (33927–33983).
Obtain prior authorization prior to scheduling inpatient procedures.

Clinical trials require prior authorization

Related codesExample codes: S9990, S9991 (clinical trial designations)

Cochlear and other auditory implants definition

DefinitionCochlear and other auditory implants: A medical device within the inner ear with an external portion that helps persons with profound sensorineural deafness achieve improved hearing

Authorization stancePrior authorization is required for cochlear and other auditory implants

Example CPT/HCPCS codes69710, 69714, 69930, L8614, L8619

Durable medical equipment (DME) prior authorization guidance

Guidance summaryDurable medical equipment (DME) items listed require notification or prior authorization; some items trigger prior authorization when retail purchase or cumulative rental cost exceeds $1,000

Examples of DME HCPCSA7025, A7026, E0194, E0265, E0266, E0277, E0296, E0297

Home health noteSome home health care services may qualify under DME but are not subject to the $1,000 retail purchase threshold

Injectable medications definition

DefinitionInjectable medications: Drugs administered intravenously, by infusion, subcutaneously, or intramuscularly

Authorization noteInjectable medications require prior authorization; drug-specific requirements referenced at UHCprovider.com/priorauth Clinical Pharmacy and Specialty Drugs Prior Authorization

Example J-codesJ1786, J7180, J7178, J7181 (examples listed)

Potentially unproven services definition

DefinitionPotentially unproven services: Services (including medications) determined to be ineffective or lacking sufficient evidence to demonstrate benefit based on prevailing peer-reviewed literature

Authorization stancePotentially unproven/experimental services require prior authorization when insufficient clinical evidence exists

Examples / codesExamples include listed T-codes (e.g., 0746T, 0750T, 0776T) and other procedures flagged as investigational

MRgFUS definition and consent note

DefinitionMRgFUS (MR-guided focused ultrasound): a procedure to treat uterine fibroid using focused ultrasound under MRI guidance

Consent and coverage conditionsCovered for certain plans but prior authorization is required; member must provide written consent acknowledging limited published evidence and facility must be contracted with UnitedHealthcare; members have no out-of-network benefits

Facility/physician requirementsPhysician and facility must confirm coverage and demonstrate experience and expertise as determined by UnitedHealthcare

Proton beam therapy definition

DefinitionProton beam therapy: focused radiation therapy using beams of protons

Authorization requirementPrior authorization is required; providers must indicate whether treatment is part of a clinical trial

Relevant CPT/HCPCS codes77520, 77522, 77523, 77525, V2629 (examples listed)

Advanced Outpatient Imaging Procedure definition

DefinitionAdvanced Outpatient Imaging Procedure: select advanced CT/MRI/MRA/PET and related imaging procedures that require prior authorization before scheduling

Provider responsibilityCare providers ordering an Advanced Outpatient Imaging Procedure are responsible for notifying/requesting prior authorization before scheduling

Authorization stancePrior authorization is required for participating physicians who request these procedures

How to Obtain Prior Authorization (definition/summary)

How to obtain prior authorizationSubmit requests online via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call 866-889-8054 (portal preferred)

Specialty contactsFor certain services (e.g., transplant/CAR T-Cell therapy) use specialty contact numbers as listed in the document

Portal navigationGo to UHCprovider.com and select the Prior Authorization and Notification tile on the Provider Portal dashboard to submit requests

Ventricular assist device (VAD) definition

DefinitionVentricular assist device (VAD): a mechanical pump that takes over the function of the damaged ventricle of the heart and restores function

Authorization stanceProcedures involving VADs require prior authorization (example CPTs: 33927, 33928, 33929, 33975, 33976, 33979, 33981, 33982, 33983)

Context noteVAD procedures are listed among inpatient services that require prior authorization