CurrentUnitedHealthcarePolicy N/A

Prior authorization and advance notification requirements (UnitedHealthcare Colorado Rocky Mountain Health Plan Prime)

Governs prior authorization and advance notification requirements for providers when UnitedHealthcare Colorado Rocky Mountain Health Plan Prime is the primary payer; lists services and codes that require prior authorization and instructions for submitting requests.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization and advance notification requirements (UnitedHealthcare Colorado Rocky Mountain Health Plan Prime)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProviders must submit prior authorization requests and supporting documentation via UHCprovider.com/priorauth (select plan type) or follow eviCore submission instructions where indicated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~200+code listings

multipleservice categories

eviCoregenetic tests reference

800-792-8750prior auth vendor phone

Prior Authorization Coverage Criteria

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inv-01: Prior authorization requirements and exceptions

General prior authorization policy and submission pathways

Prior authorization is required for services listed in this document when UnitedHealthcare Colorado Rocky Mountain Health Plan Prime is the primary payer; services that are not a benefit of the member's Evidence of Coverage will not be authorized.

Providers must submit prior authorization requests and supporting documentation via UHCprovider.com/priorauth (select plan type); non‑participating providers may fax to 800-262-2567 or 970-255-5681.

Authorization routes

Use eviCore for certain services; submit online at www.evicore.com or call 800-792-8750.
Behavioral health prior authorization is via the behavioral health line at 888-282-8801.
Admitting facility notifications: phone 800-416-2157 (option 4) or 970-248-5197.

Prior authorization is not required for emergency or urgent care.

inv-02: Prior Authorization Requirement

Services and codes listed in these chunks require prior authorization before being provided.

Prior authorization is required for the listed CPT/HCPCS codes grouped by service type (diagnostic, therapeutic, digestive, DME) before the service is provided or billed.

Providers must request prior authorization using the codes shown in the policy and follow the 'How to Obtain Prior Authorization' instructions for each code entry.

Example service groups

Diagnostic and therapeutic services (examples: 91065, 91112, 91132, 91133, 92512, 93702, 96904, 96920-96922, 97610, 99183, S2080, S2411).
Digestive procedures (examples in the policy include CPTs such as 43289, 43497, 43647, 43648, 43659, 43881, 43882, 44238, 44979, 46707, 47379, 47579, 49329, 49659, 50549, 50949, 53855).

inv-03: Prior authorization required — code lists

Services and codes requiring prior authorization (partial list from document):

Enteral services and in‑home nutritional therapy (enteral or via gastrostomy tube) require prior authorization; specific B‑series HCPCS codes are listed (e.g., B4149–B4216, B5000-series, B9998).

Gender dysphoria treatment surgical codes require prior authorization when submitted with the specified diagnosis codes (examples: F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890) and associated CPTs listed in the policy (e.g., 15769, 15819–15839, 15847, etc.).

The policy lists numerous CPT/HCPCS procedure codes (examples shown in the policy such as 15820–15839, 15847) that require prior authorization per the code entries.

inv-04: Prior authorization code list guidance

Codes listed below require prior authorization as indicated in this document section. Some genetic tests note eviCore as the authorization path

Prior authorization is required for each listed CPT/HCPCS or genetic test code before the service is provided or billed; genetic/molecular codes are included in extensive lists.

Genetic/molecular code guidance

Numerous genetic test Category I/III/U codes (examples: 0001U, 0004M, 0005U, 0006M, 0016M, 0017M, 0018U, 0019U, 0021U, 0022U, etc.) include 'Prior authorization required' notes.
Large blocks of molecular/genomic CPT codes (examples in the 81162–81490 and 81471–81540 ranges) are enumerated with prior authorization instructions; some entries reference eviCore for authorization processing.

Providers should follow the 'How to Obtain Prior Authorization' instructions associated with each code entry in the full policy; some code entries show 'Additional Information' fields and eviCore continuation notes.

inv-05: Prior authorization requirement (partial list)

Codes listed in these chunks require prior authorization as indicated by entries.

Provider must obtain prior authorization for the listed CPT/HCPCS and temporary codes; some genetic tests explicitly state 'Prior authorization requird.' and certain entries reference eviCore for authorization processing.

inv-06: Prior authorization requirement — code and category listing

Listed CPT/HCPCS codes and service categories require prior authorization.

A broad set of CPT/HCPCS and temporary/T codes require prior authorization as listed (examples include many T‑codes, lab/test CPTs, and procedure codes enumerated across the policy).

Service categories explicitly flagged

Hearing/audio/vision services (examples: 92065, 92145, V‑series codes) require prior authorization.
Hyperbaric treatment (example: G0277) requires prior authorization.
Hysterectomy (example: 58578) requires prior authorization.
Infusion and injection services, injectable medications and medical/surgical supplies (numerous J‑ and Q‑codes listed) require prior authorization.

inv-07: Prior authorization requirements (partial)

Prior authorization requirements by service category and code (partial list):

Radiology/advanced outpatient imaging requires prior authorization for participating physicians ordering Procedures and Services Radiology; certain CT/MRI/MRA/PET scans and other advanced imaging are routed through eviCore.

Orthotics and prosthetics (HCPCS L‑codes) require prior authorization as listed in the policy.

Selected musculoskeletal procedures and nerve stimulator devices require prior authorization; specific CPTs are enumerated in the policy.

Obstetrical procedures and orthognathic surgery require prior authorization; examples and CPTs are listed in the document entries.

inv-08: Prior authorization requirements (categories and example codes)

Prior authorization/notification is required for the following categories and codes via evicore:

Care providers ordering an Advanced Outpatient Imaging Procedure are responsible for providing notification/requesting prior authorization before scheduling the procedure; submit requests online at www.evicore.com or call 800-792-8750.

Categories routed to eviCore

Advanced outpatient imaging (certain CT/MRI/MRA/PET and nuclear medicine procedures) — prior authorization and notification via eviCore.
Radiation therapy and many imaging/nuclear cardiology procedures — prior authorization via eviCore as listed (examples include codes in the 32701, 77373, 77435 ranges).
Respiratory procedures and other specified categories listed in the policy are routed to eviCore for authorization.

inv-09: Prior Authorization Criteria (listed items)

Prior authorization requirements and routing instructions for listed codes:

Transplant procedures require prior authorization; notification/prior authorization requests should be submitted online at www.evicore.com or by calling 800-792-8750 as indicated in the policy entries.

Effective 7/1/24, unclassified/unlisted drug and HCPCS codes J3490, J3590, and C9399 require prior authorization through Optum Transplant as specified in the policy.

Other listed procedure groups

Vein procedures (examples: CPT 36465–36522 series) require prior authorization as listed.
Many other specialty and surgical CPT/HCPCS codes throughout the document require prior authorization; providers must follow the routing instructions for each listed code.

Codes and Code Groups Requiring Authorization

Arthroplasty examplesCPTCovered

23472	Arthroplasty-related CPT code listed for prior authorization
27130	Total hip arthroplasty CPT code listed for prior authorization

Arthroscopy examplesCPTCovered

29805	Arthroscopy CPT code listed for prior authorization
29870	Arthroscopy CPT code listed for prior authorization

Continuous glucose monitoringHCPCSCovered

A4238	Continuous glucose monitor supplies
A4239	Continuous glucose monitor supplies
E0784	Continuous glucose monitor, transcutaneous
E2102	Continuous glucose monitor receiver/transmitter

Chemotherapy and related injectable drugsHCPCSCovered

J9000-J9999	Chemotherapy injectable drugs range requiring prior authorization
J0897	Bone modifying agent listed
J0640	Leucovorin

Sample diagnostic/therapeutic codesCPTCovered

91065	CPT/HCPCS code listed as prior auth required
91112	CPT/HCPCS code listed as prior auth required
91132	CPT/HCPCS code listed as prior auth required
91133	CPT/HCPCS code listed as prior auth required

Sample HCPCS DME (A-codes)HCPCSCovered

A0110	DME - prior authorization required
A9520	DME - prior authorization required
A9999	DME - prior authorization required

Sample HCPCS DME (E-codes)HCPCSCovered

E2207	DME E-code requiring prior authorization
E2215	DME E-code requiring prior authorization
E2225	DME E-code requiring prior authorization

Diagnosis codes associated with gender dysphoria surgical codesICD-10Covered

F64.0	Transsexualism
F64.1	Dual-role transvestism / Gender identity disorder of childhood (document lists F64.1)
F64.2	Gender identity disorder of adolescence and adulthood
F64.8	Other gender identity disorders
F64.9	Gender identity disorder, unspecified
Z87.890	Personal history of sex reassignment

Sample surgical CPT codes (gender dysphoria and other surgeries) listedCPT

15769	Tissue rearrangement (example surgical CPTs for gender dysphoria)
15771
15819
15820
15821
15822
15823
15824
15825
15826

1–10 of 40

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Listed CPT/HCPCS/genetic codes requiring prior authorizationCPT | HCPCS | mixedCovered

0001U-0399U (examples listed)	Category I/U/M genetic test CPT codes with prior authorization required as listed in document chunks
81162-81490 (examples listed)	Molecular pathology and genomic CPT codes requiring prior authorization

Genetic/lab CPT Category I/III and other U-codes (partial)mixedCovered

0207U	Genetic tests/lab service code listed for prior authorization
0210U	Genetic tests/lab service code listed for prior authorization
0219U	Genetic tests/lab service code listed for prior authorization
0221U	Genetic tests/lab service code listed for prior authorization

Category III / temporary and other procedure codes (partial)mixedCovered

0332T	Category III / Temp code listed
0333T	Category III / Temp code listed
0351U	Temporary code listed
95060	Listed CPT code

Examples of CPT/HCPCS codes requiring prior authorizationmixedCovered

G0277	Hyperbaric treatment
58578	Hysterectomy
92065	Hearing/vision related code listed

Injectable/J-code groups with mapping notesHCPCSCovered

J1554-J1556	Series mappings referenced in Additional Information
C9399*	Unspecified code with mapping note

Selected CPT codes (partial list)CPT

93895
95803
97537
97545
97546

Selected codes from radiology and injections (partial)mixed

64451
64461
70450	CT head/brain (example from radiology list)
70540	MRI brain (example from radiology list)

Selected HCPCS L-codes (orthotics/prosthetics)HCPCS

L1499	Orthotics (example L-code listed)
L3649
L4000

Sample imaging-related CPT codesCPTCovered

73206	Listed CPT/HCPCS code requiring authorization (example from list)
73700	Listed CPT/HCPCS code requiring authorization (example from list)
74150	Listed CPT/HCPCS code requiring authorization (example from list)

Spine/surgical/stimulator CPT codesCPTCovered

63012	Spine surgery CPT code requiring prior authorization
63650	Stimulator-related CPT code requiring prior authorization
64561	Neurostimulation/peripheral nerve CPT/HCPCS code requiring prior authorization

Unlisted surgery/procedure codesCPTCovered

15999	Unlisted surgery CPT code requiring prior authorization
29999	Unlisted surgery CPT code requiring prior authorization
95999	Unlisted procedure CPT code requiring prior authorization

Selected listed CPT/HCPCS codes (partial list from section)CPTCovered

95999
96999
36299
37799
38129
38589
38999
39499
39599
40799

1–10 of 14

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Unclassified drug/HCPCS codes with special prior auth routingHCPCSCovered

J3490	Unclassified drug code — requires Optum Transplant prior authorization effective 7/1/24
J3590	Unclassified drug code — requires Optum Transplant prior authorization effective 7/1/24
C9399	Unclassified HCPCS code — requires Optum Transplant prior authorization effective 7/1/24

Vein procedure CPT codesCPTCovered

36465	Vein procedures prior authorization required
36466
36468
36470
36471
36473
36474
36475
36476
36478

1–10 of 14

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How Providers Should Request Prior Authorization

Prior Authorization

How to request prior authorization

Submit prior authorization requests and supporting documentation via UHCprovider.com/priorauth (select the member's plan) or, when instructed below, to eviCore. Prior authorization is required for many diagnostic and therapeutic services, specified procedures, enteral nutrition services, genetic and laboratory tests, certain durable medical equipment (DME) and many unlisted surgery codes. Emergency and urgent care are excluded. Non-participating providers may fax requests and documentation to the numbers listed on the payer site.

How to request prior authorization: UHCprovider.com/priorauth (select plan)
eviCore submission for certain services: www.evicore.com or call 800-792-8750
Behavioral Health Services: call 888-282-8801
Notification by admitting facility: phone 800-416-2157, option 4 or 970-248-5197
Non-participating provider fax numbers: 800-262-2567 or 970-255-5681

Prior Authorization

Prior authorization required — diagnostic and therapeutic services

Prior authorization is required for many diagnostic and therapeutic procedures. Examples include the following CPT codes and HCPCS where indicated. Always submit requests via the appropriate channel (UHCprovider portal or eviCore when noted).

Selected diagnostic and therapeutic CPT codes requiring prior authorization: 91065, 91112, 91132, 91133
Selected therapeutic CPT codes requiring prior authorization: 92512, 93702, 96904, 96920–96922, 97610, 99183, S2080, S2411, 97610
How to obtain: Submit requests online at www.evicore.com or call 800-792-8750 when eviCore is specified

Prior Authorization

Prior authorization required — digestive procedures

Prior authorization is required for many digestive and gastrointestinal procedures. Examples include (but are not limited to) the CPT codes listed below. Submit requests through the payer portal or to eviCore when imaging or other eviCore-managed services are identified.

Digestive procedure examples: 41120, 41130, 41512, 41530, 41800, 41805, 41806, 41825–41827
Upper/lower GI and endoscopic procedure examples: 42140, 42145, 42160, 43206, 43210, 43252, 43257, 43284–43289
Additional digestive examples: 43497, 43647–43659, 43881–43882, 44238, 44979, 46707, 47379, 47579, 49329, 49659, 50549, 50949, 53855

Prior Authorization

Prior authorization required — additional procedures and DME

Prior authorization is required for additional specified procedures and durable medical equipment (DME). Numerous HCPCS E- and K-codes, L-codes and other DME codes require authorization before provision. Providers should verify the exact code group and submit via the payer portal or eviCore when directed.

Examples of DME/HCPCS codes requiring prior authorization: A0110, A9520, A9999
Examples of equipment and orthotics/prosthetics E-codes: E0170, E0194, E0196, E0250, E0255–E0373, E0445, E0457, E0459, E0465
Extended DME E-codes (cont.): E2207–E2225 and E2219–E2224 series; K0839–K0864; K0868–K0885 (see payer list for full enumeration)
Orthotics and prosthetics L-codes requiring prior authorization: L1499, L3649, L4000, L5010–L5595 and numerous L5xxx codes (see payer list)

Prior Authorization

Enteral services prior authorization

Enteral nutrition services and in‑home nutritional therapy (including gastrostomy tube feedings) require prior authorization. Submit prior authorization requests for enteral products and in‑home enteral nutritional therapy through the payer portal.

Enteral product HCPCS codes requiring authorization: B4149, B4150, B4152–B4159, B4160–B4164, B4168, B4172, B4176, B4178, B4180, B4185, B4187, B4189, B4193, B4197, B4199, B4216
In-home nutritional therapy/gastrostomy tube feeding HCPCS codes requiring authorization: B4159–B4162, B4164, B4168, B4172, B4176, B4178, B4180, B4185, B4187, B4189, B4193
How to obtain: Submit via UHCprovider.com/priorauth or as directed by the member's plan

Prior Authorization

Genetic test codes requiring prior authorization

Many genetic and molecular laboratory tests require prior authorization; a substantial list of CPT, proprietary and T/UNII/other codes are listed by the payer. Some genetic/molecular tests are managed through eviCore and must be submitted to eviCore.

Genetic test examples (partial list): 0001U, 0002U, 0003U, 0004M, 0005U, 0006M, 0007M, 0007U, 0008U, 0009U, 0010U, 0011M–0019U series
Molecular/genomic and related CPT ranges requiring authorization: 81201–81299, 81302–81363, 81400–81479, 81500–81540, 81162–81166, 81173–81190 and extensive 8xx–06x/07x T‑codes and 04xx–06xx T‑codes shown in payer list
eviCore-managed genetic tests: Specific codes in the genetic/lab lists are marked “eviCore” — submit those requests to www.evicore.com or call 800-792-8750

Prior Authorization

J‑code mappings / additional information

Certain miscellaneous procedure and supply codes, J‑code mappings, injectable medications and other items require prior authorization. Many J‑codes map to specific authorization requirements; review the payer’s J‑code mapping list prior to ordering.

Injectable medications and J‑codes: numerous J‑codes listed require authorization (see payer mapping). Examples include J1302, J1411, J1449, J1950 and many others noted in the J‑code mapping table
J‑code mapping note: payer lists equivalent mappings (e.g., J1554 = J1951, J1555 = J1559, etc.) — check the mapping table before submission
How to obtain: Follow instructions in the payer J‑code table; submit requests via UHCprovider portal or to eviCore when indicated

Prior Authorization

Unlisted surgery prior authorization

Many procedures billed with unlisted or miscellaneous surgery CPT codes require prior authorization. When using unlisted CPT codes (e.g., 1xxxx, 2xxxx, 3xxxx series ending in 99), obtain authorization prior to scheduling.

Unlisted surgery codes that require prior authorization include (examples): 15999, 17999, 19499, 20999, 21299, 21499, 22899, 22999, 24999, 25999, 27599, 28899, 29999, 30999, 33999, 84999, 95999, 96999 and many other 99‑ending unlisted surgical codes
How to obtain: Submit for prior authorization via UHCprovider.com/priorauth; for certain specialties or imaging related to unlisted procedures, eviCore may be the required submission channel

Definitions and Reference Terms

Prior authorization — definition entry

DefinitionPrior authorization is the process where health care providers seek approval before rendering a service as required by UnitedHealthcare policy.

When requiredPrior authorization is required for services listed in this document when UnitedHealthcare (Rocky Mountain Health Plans) is the primary payer; services not a benefit of the member's Evidence of Coverage will not be authorized.

ExceptionsPrior authorization is not required for emergency or urgent care.

Submission contextProviders must follow the 'How to Obtain Prior Authorization' instructions in the policy (online submission, vendor portals, or phone contacts).

Advance notification — definition entry

DefinitionAdvance notification is a requirement for care providers to give UnitedHealthcare timely communication of services so the plan can perform prospective, concurrent and retrospective care review.

When usedCare providers ordering Advanced Outpatient Imaging Procedures are responsible for providing notification/requesting prior authorization before scheduling the procedure.

PurposeEnables UnitedHealthcare to perform prospective, concurrent and retrospective reviews to determine authorization and coverage.

DME — Durable medical equipment definition

DefinitionDurable medical equipment (DME) refers to medical equipment (HCPCS A- and E-codes and K-/L-codes series) that may require prior authorization as listed in the policy.

ExamplesExamples include A0110, A9520, A9999 and E2207–E2225 (E-code series) listed in the document.

Authorization requirementDME codes listed in the policy require prior authorization prior to provision or billing.

Prior authorization — definition entry (alternate chunks)

DefinitionPrior authorization required: entries marked 'Prior authorization required' indicate the provider must obtain approval before the service is rendered.

ScopeUsed across multiple service categories such as enteral services, gender dysphoria treatment, surgical and diagnostic procedures listed in the document.

Provider responsibilityProviders must request authorization using the specific code entries and 'How to Obtain Prior Authorization' instructions associated with each entry.

EviCore — third-party authorization vendor and contact

DefinitioneviCore (also styled EviCore or evicore) is a third-party authorization vendor used by UnitedHealthcare to process prior authorization and advanced imaging notifications.

Websitewww.evicore.com

Phone800-792-8750

eviCore referenced for parts of the genetic test list

Reference within genetic listPortions of the genetic test and laboratory code lists include '(eviCore)' or '(eviCore cont.)' indicating eviCore is the authorization route for those entries.

Examples of codes referencing eviCoreExamples include entries in the 0001U–0317U ranges and 81518–81521 series noted as '(eviCore cont.)'.

ImplicationWhen a genetic test entry references eviCore, providers should submit authorization requests via the eviCore portal/phone per policy instructions.

Indicates that listed genetic tests/lab services require prior authorization

Requirement statementGenetic tests and laboratory services listed with 'Additional Information = Prior authorization required' require prior authorization before coverage.

Code rangesMultiple Category I/U/M and temporary U-codes (e.g., 0001U–0399U and various 80000-series molecular codes) are shown with prior authorization required notes.

Provider actionProviders must obtain prior authorization for the listed genetic/lab codes following the policy's 'How to Obtain Prior Authorization' instructions.

eviCore referenced as a prior authorization agent/process for subset of codes

eviCore as prior auth agentThe policy explicitly lists many genetic/lab CPT entries followed by '(eviCore cont.)' indicating eviCore is the designated authorization agent for those subsets.

ExamplesEntries such as 81471, 81479, 81518–81521 and multiple U-codes are annotated with eviCore continuation notes.

ActionSubmit authorization requests for those annotated genetic/lab codes via eviCore as instructed in the policy.

Genetic tests/lab prior authorization — explicit instruction present

Explicit instructionSome genetic tests/lab entries include the explicit text 'Prior authorization requird.' indicating authorization is required.

ScopeThis explicit instruction appears in the genetic/lab sections tied to specific U-codes and temporary codes (e.g., 0002U, 0003U, 0007U, etc.).

Follow-upProviders should verify the specific 'How to Obtain Prior Authorization' instructions for each coded entry in the full policy before ordering or billing.

Prior authorization required — definition entry

DefinitionPrior authorization required: the provider must obtain approval before the service is rendered in order for UnitedHealthcare to consider payment.

Applies toMany listed procedure, diagnostic, surgical, DME, genetic, imaging and drug administration codes across the document.

How to requestFollow the 'How to Obtain Prior Authorization' instructions (online portals, vendor contacts, phone numbers) provided in the policy.

eviCore (external imaging authorization vendor referenced for advanced outpatient imaging prior authorization)

RoleeviCore is the external imaging authorization vendor referenced for Advanced Outpatient Imaging prior authorization and notification.

Websitewww.evicore.com

Phone800-792-8750

Participating physicians — providers required to obtain prior authorization

DefinitionParticipating physicians ordering listed procedures (e.g., radiology/advanced outpatient imaging) are responsible for obtaining prior authorization or providing advance notification as required.

ResponsibilityParticipating physicians must request authorization/notification before scheduling the procedure per the policy instructions.

ExclusionsEmergency or urgent care do not require prior authorization.

Notification/prior authorization — definition entry for advanced outpatient imaging

DefinitionNotification/prior authorization for Advanced Outpatient Imaging means care providers must request authorization or notify UnitedHealthcare before scheduling such procedures.

ProcessCare providers should submit requests/notifications via the eviCore portal or phone as specified in the policy prior to scheduling.

PurposeEnsures review of advanced imaging (CT/MRI/MRA/PET and nuclear medicine) and determination of coverage eligibility.

evicore — portal and phone contact reference

Portal contacteviCore portal: www.evicore.com

Phone contacteviCore phone: 800-792-8750

ContextThe policy repeatedly instructs providers to submit notification/prior authorization requests online at eviCore or by phone for specified services and codes.

Unclassified codes (J3490/J3590/C9399) require prior authorization through Optum Transplant effective 7/1/24

RequirementUnclassified codes J3490, J3590 and C9399 require prior authorization through Optum Transplant effective 7/1/24.

Effective dateEffective 7/1/24 (as stated in policy).

RoutingPrior authorization for these unclassified codes must be obtained via Optum Transplant per the policy note.

Submit requests online at www.evicore.com or call 800-792-8750 — how to obtain prior authorization

Online submissionSubmit requests online at www.evicore.com

Phone submissionOr call eviCore at 800-792-8750 to obtain prior authorization or provide advance notification.

Alternate contactsPolicy also provides other contacts (UHCprovider portal, behavioral health line, fax numbers) for specific scenarios; follow the instructions associated with each code entry.