CurrentUnitedHealthcarePolicy N/A

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

Lists services, CPT/HCPCS and some ICD-10 codes that require prior authorization for participating providers in the UnitedHealthcare Community Plan Apple Health Expansion in Washington; includes submission methods and contact numbers.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone at 877-542-9231.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

manyCPT/HCPCS & ICD-10 codes included

online, phoneAuthorized submission methods

877-542-9231Primary phone

2025-06-01Effective date

20+Procedure codes listed (sample)

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.

Services and Prior Authorization Criteria

Prior authorization required services (partial list in this section)

Listed services and codes require prior authorization unless otherwise noted (for example, some diagnosis codes for post‑mastectomy reconstruction may be exempt).

Prior authorization is required for the services and CPT/HCPCS codes listed in this section unless an exception is specifically indicated in the policy.

Examples of service categories

Bariatric and obesity-related surgeries (e.g., CPT 43644, 43645, 43659, 43770, 43775, 43842, 43845, 43846, 43847, 43848, 43860)
Breast reconstruction and related procedures (e.g., CPT 19316, 19318, 19325, 19328, 19368, 19369, 19370, 19371, 19380, 19396, 11971)
Cancer supportive care injectable drugs and colony-stimulating factors (codes include J2506, Q5122, Q5120, J1447, J2820, J0885 and others)
Cardiology outpatient/office-based diagnostic catheterizations, echocardiograms and implants (see Cardiology prior authorization resource)

Coverage stance for listed services

Stated coverage/authorization stances for selected services and code groups in these excerpts.

Injectable chemotherapy administered in an outpatient setting requires prior authorization (includes J9000–J9999 and listed J-codes).

Cochlear implants and other auditory implants require prior authorization (examples: CPT 69710, 69714, 69930; device HCPCS L8614).

Continuous glucose monitors require prior authorization when billed with Type 2 diabetes diagnosis codes; relevant HCPCS examples include A4226, A9278, A4238, A4239, E0787, A9276, E2103, A9277, E2102.

Cerebral seizure monitoring requires prior authorization for CPTs such as 95700, 95712, 95713; inpatient video EEG codes (e.g., 95720, 95722) are noted as not requiring prior authorization in some inpatient/outpatient hospital contexts.

Prior authorization criteria (general, code-driven)

Prior authorization is required for the listed devices/procedures unless a specific exception is documented (for example, certain CPTs billed with specified oncology diagnosis codes).

Continuous glucose monitor prior authorization is required when billed with Type 2 or gestational diabetes diagnosis codes; obtain authorization using the CGM HCPCS codes listed (e.g., A4238, A4239, A9276, A9277, E0787, E2102/E2103).

Cosmetic and reconstructive procedures listed require prior authorization. Effective 2023, codes 14020, 14021 and 14061 do NOT require prior authorization when billed with specified ICD-10 diagnosis codes (examples: multiple C43.*, C44.* codes listed).

Other general rules

Most device, DME and implant codes shown elsewhere in the policy require prior authorization as enumerated.
When an asterisked code appears, refer to the exception rule that may waive prior authorization if billed with listed diagnosis codes.

Prior authorization code criteria (excerpt)

Prior authorization requirements and additional notes for specific code groups shown in these excerpts.

Durable medical equipment (DME) — prior authorization is required only for the specific DME codes listed (examples include A9279, A9280, E0118, E0194, E0265, E0266); orthotics and prosthetics have a cost threshold for authorization requirements.

Experimental/investigational services listed (examples: CPTs 36514, 64722, 65765, 66180 and various S-codes) require prior authorization.

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

Genetic and molecular testing (multiple CPTs in the 81400–815xx range and others) are listed as requiring prior authorization; BRCA and related breast cancer molecular tests are included in that group.

Prior authorization exception rule (partial)

Operational notes on exceptions and billing rules related to prior authorization.

Codes marked with an asterisk (*) do NOT require prior authorization when billed with the diagnosis codes listed in the policy (effective June 1, 2023).

The policy contains diagnostic code lists (ICD-10) specifying the diagnoses that, when present on the claim, permit certain asterisked CPT/HCPCS codes to be billed without prior authorization—refer to the diagnostic lists in the policy for the exact ICD-10 codes.

Molecular/genetic testing notes

Notes on molecular and genetic testing as referenced across oncology and related diagnosis code entries.

Molecular and genetic testing—including BRCA and other breast cancer related tests—is referenced throughout the oncology diagnosis sections; these tests require prior authorization and are mapped to the corresponding diagnosis entries in the policy.

Diagnosis-to-authorization mapping (partial)

Partial mapping of ICD-10 diagnosis codes to prior authorization instructions (placeholders present where CPT/HCPCS fields are indicated).

The policy lists many ICD-10 diagnosis codes (for example C69.*, C71.*, C95.* and numerous C7A/C82–C92 series codes) followed by fields indicating associated CPT/HCPCS codes and/or how to obtain prior authorization; some entries act as placeholders directing the provider to the CPT/HCPCS listings or prior authorization instructions elsewhere in the policy.

Mapping of codes to prior authorization references

Entries indicate referral to CPT/HCPCS prior authorization listings for the ICD-10 codes shown; clinical criteria are not detailed in these rows.

For the listed ICD-10 codes in the C82–C92 and C84 ranges the policy indicates genetic/molecular testing and references CPT/HCPCS prior authorization steps; providers should refer to the CPT/HCPCS code lists and prior authorization instructions associated with those diagnosis entries.

Prior authorization criteria and submission

Prior authorization requirements plus submission/process guidance for specific services.

Prior authorization is required for listed injectable medications; for injectable drugs follow the submission instructions in the policy (submit online via the UnitedHealthcare Provider Portal or by calling the phone number listed).

Home health care prior authorization is required only when services are provided in outpatient settings, which includes a member's home (see home health care entries and CPTs such as 99504, G0299, G0300).

Submission options

Submit prior authorization requests online using UHCprovider.com (Provider Portal).
Alternatively, submit by phone using the numbers provided in the policy for the specific service line (examples include 888‑397‑8129 and 866‑889‑8054).

Prior authorization code references (partial)

Partial listing of CPT/HCPCS codes that require prior authorization (excerpted).

Representative injectable and HCPCS codes

Examples include J0802, C9157, Q5152, J1745, J9311, J2327 and multiple J73xx series hyaluronate codes (see full policy for complete list).
The policy lists many additional injectable product and biologic HCPCS codes that require prior authorization; providers should consult the complete CPT/HCPCS list in the policy for specifics.

Prior authorization codes for sodium hyaluronate

Prior authorization requirement for sodium hyaluronate injectable products (codes shown).

Prior authorization is required for sodium hyaluronate injectable products billed under HCPCS/CPT codes J2327 and J7320–J7324 (and related J73xx entries listed).N/A

Clinical medical necessity criteria for these products are not shown in this excerpt; consult the full policy for medical necessity requirements.

Selected coverage/prior authorization criteria

Selected coverage and prior authorization criteria highlighted in these excerpts.

Prior authorization is required for many listed injectable medications and certain therapeutic radiopharmaceuticals (examples shown in the policy include J1558, J2357, J9202, J2327 and others); some drugs may be subject to Review at Launch and pre-determination is recommended for newly marketed products.

Orthotics and prosthetics require prior authorization only when the retail purchase or cumulative rental cost exceeds $500 (examples: L0112, L0456, L0462 and numerous L-codes listed).

Prior authorization criteria (partial)

Site-of-service rules and other conditional prior authorization requirements (partial).

Radiation therapy procedures require prior authorization; specific CPT/HCPCS codes (e.g., IGRT 77014, 77385, 77386, 77387 and related G-codes) are listed as requiring authorization.

Health care professionals ordering advanced outpatient imaging (certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology) are responsible for providing notification/prior authorization prior to scheduling; submission via the Provider Portal is indicated.

Site-of-service guidance: procedures performed at a participating ambulatory surgery center (ASC) may not require prior authorization, while the same procedures performed in an outpatient hospital setting may require prior authorization—refer to the site-of-service entries in the policy.

Outpatient therapy visits require prior authorization after the 12th visit for members aged 21 and older.

Prior authorization requirements (excerpt)

Prior authorization requirements and notes for procedure groups and select CPTs in this excerpt.

Sleep apnea procedures: Prior authorization required for listed sleep apnea procedure codes (examples: 21685, 41599, 42145).

CPT 22865 age restriction: Effective Oct 1, 2024: CPT 22865 requires prior authorization for members age 21 and older.

Stimulators: Prior authorization is required for stimulator device codes (examples: E0747, E0748, E0749, E0760 and related neurostimulator entries).

Site of service outpatient examples: The policy lists numerous outpatient site-of-service procedure codes with instructions on how to obtain prior authorization for outpatient hospital settings (examples include 11770, 13121, 15100, 15120, 15240, 19020, 19120, 19125, 47000, 54840).

Prior authorization criteria and instructions (Part 15)

Additional prior authorization instructions and special-case contact pathways from the policy (partial).

Code 38232: prior authorization is required only when billed with an oncology diagnosis (policy notes this oncology-only restriction).

Ventricular assist devices (VADs) require prior authorization; providers should call the notification number on the member's ID card and fax the required form to the Optum VAD Case Management team at 855‑282‑8929.

Transplant and CAR T-cell therapy (including Carvykti) require prior authorization; providers should contact the Optum Transplant Case Management team at 888‑936‑7246 or follow the notification instructions on the member's ID card.

Wound VAC devices (e.g., E2402) require prior authorization as listed in the policy.

CPT/HCPCS and ICD-10 Code Lists

Orthotics & Prosthetics HCPCS/L-codesHCPCSCovered

L0112	Orthotic code listed in policy
L0456	Orthotic code listed in policy
L0462	Orthotic code listed in policy
L0464	Orthotic code listed in policy
L0480	Orthotic code listed in policy
L0482	Orthotic code listed in policy
L0484	Orthotic code listed in policy
L0486	Orthotic code listed in policy
L0624	Orthotic code listed in policy
L0629	Orthotic code listed in policy

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Orthotics & Prosthetics (cont.)HCPCSCovered

L5826	Orthotic/prosthetic code listed in policy
L5828	Orthotic/prosthetic code listed in policy
L5830	Orthotic/prosthetic code listed in policy
L5845	Orthotic/prosthetic code listed in policy
L5848	Orthotic/prosthetic code listed in policy
L5857	Orthotic/prosthetic code listed in policy
L5858	Orthotic/prosthetic code listed in policy
L5930	Orthotic/prosthetic code listed in policy
L5950	Orthotic/prosthetic code listed in policy
L5960	Orthotic/prosthetic code listed in policy

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Orthotics & Prosthetics L-code RemainderHCPCSCovered

L5973	Orthotic/prosthetic code listed in policy
L5976	Orthotic/prosthetic code listed in policy
L5979	Orthotic/prosthetic code listed in policy
L5980	Orthotic/prosthetic code listed in policy
L5981	Orthotic/prosthetic code listed in policy
L5982	Orthotic/prosthetic code listed in policy
L5984	Orthotic/prosthetic code listed in policy
L5986	Orthotic/prosthetic code listed in policy
L5987	Orthotic/prosthetic code listed in policy
L5988	Orthotic/prosthetic code listed in policy

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Orthotics & Prosthetics — High-cost threshold notemixed

Prior authorization is required only for orthotic and prosthetic items with a retail purchase or cumulative rental cost greater than $500.

Additional L-codes referencedHCPCSCovered

L6000	Orthotic/prosthetic code listed in policy placeholder
L6010	Orthotic/prosthetic code listed in policy placeholder
L6020	Orthotic/prosthetic code listed in policy placeholder
L6050	Orthotic/prosthetic code listed in policy placeholder
L6055	Orthotic/prosthetic code listed in policy placeholder

Radiation therapy CPT/G-codesCPTCovered

77014	Image guidance for radiation therapy (IGRT)
77385	Special radiotherapy procedure
77386	Special radiotherapy procedure
77387	Radiation treatment management
77402	Radiation therapy planning
77407	Radiation therapy planning
77412	Radiation therapy planning
77371	SRS/SBRT
77372	SRS/SBRT
77373	SRS/SBRT

Sodium Hyaluronate / Viscosupplementation HCPCS/J-codesHCPCSCovered

J7320	Hyaluronic acid injection
J7321	Hyaluronic acid injection
J7322	Hyaluronic acid injection
J7324	Hyaluronic acid injection
J2327	Sodium hyaluronate (viscosupplement)

Selected Surgical CPT codes (examples)CPTCovered

43644	Bariatric surgery (example)
43645	Bariatric surgery (example)
43659	Bariatric surgery (example)
43770	Bariatric surgery (example)
43775	Bariatric surgery (example)
43842	Bariatric surgery (example)
43845	Bariatric surgery (example)
43846	Bariatric surgery (example)
43847	Bariatric surgery (example)
43848	Bariatric surgery (example)

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Durable Medical Equipment HCPCSHCPCSCovered

A9279	DME code listed in policy
A9280	DME code listed in policy
E0118	DME code listed in policy
E0194	DME code listed in policy
E0265	DME code listed in policy
E0266	DME code listed in policy
E0270	DME code listed in policy
E0277	DME code listed in policy
E0300	DME code listed in policy
E0328	DME code listed in policy

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Genetic / Molecular Testing CPT/HCPCSCPTCovered

81400	Molecular pathology (example range)
81401	Molecular pathology (example range)
81402	Molecular pathology
81403	Molecular pathology
81404	Molecular pathology
81405	Molecular pathology
81406	Molecular pathology
81407	Molecular pathology
81408	Molecular pathology
81410	Molecular pathology

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Continuous Glucose Monitor HCPCS and relatedHCPCSCovered

A4226	Sensor, glucose monitor
A9278	CGM component
A4238	CGM transmitter
A4239	CGM receiver
E0787	Meter or device
E2103	CGM supply
A9276	CGM component
A9277	CGM component
E2102	CGM supply

Cancer Supportive Care Injectable & CSF HCPCS/J-codesHCPCSCovered

J2506	Pegfilgrastim (Neulasta)
Q5122	Pegfilgrastim biosimilar (Nyvepria)
Q5120	Pegfilgrastim biosimilar (Ziextenzo)
Q5108	Pegfilgrastim-jmdb (Fulphila)
Q5111	Pegfilgrastim-cbqv (UDENYCA)
J1442	Filgrastim product
Q5110	Filgrastim biosimilar (Nivestym)
J2820	Sargramostim (Leukine)
J1447	Tbo-filgrastim (Granix)
J0897	Trilaciclib or related

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How to Request Prior Authorization and Operational Guidance

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) using One Healthcare ID and password, or by phone at 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

Service-specific submission guidance

Some service lines have specific submission channels: cardiology and cancer supportive care requests may be submitted via the Provider Portal or the service-specific phone numbers referenced in the policy; cardiology details and required CPTs are available in the separate Cardiology Prior Authorization and Notification resource.

Prior Authorization

Prior authorization for injectable chemotherapy (outpatient)

Injectable chemotherapy drugs administered in an outpatient setting require prior authorization; submit requests via the UnitedHealthcare Provider Portal.

Definitions and Reference Notes

inv-92: prior authorization

DefinitionPrior authorization: The insurer's process to approve certain services or supplies before they are provided to determine coverage eligibility.

How to requestOnline via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID, or by phone at 877-542-9231.

ExceptionsPrior authorization is not required for emergency or urgent care; out-of-network requests must be made by a network care provider.

inv-93: Cochlear implant

DefinitionCochlear implant: An implantable device with an internal component in the inner ear and an external portion that helps those with profound sensorineural deafness achieve improved hearing.

Codes listed

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone at 877-542-9231.

SourceLink

On This Page

Applies to chemotherapy injectable drug codes (J9000–J9999) and listed J-codes such as J0640, J0641, J0642, J1950, J1952, J1932.

Prior Authorization

EEG and seizure monitoring authorization

Prior authorization is required for cerebral seizure monitoring (EEG) procedures (e.g., CPT 95700, 95712, 95713). Inpatient video EEG (CPT 95720, 95722) does not require prior authorization when performed as described.

Obtain prior authorization for cerebral seizure monitoring CPTs 95700, 95712, 95713.
Inpatient video EEG CPTs 95720 and 95722 are noted as not requiring prior authorization in the inpatient/outpatient hospital setting.

Prior Authorization

Continuous glucose monitor prior authorization for Type 2 diabetes

Continuous glucose monitors require prior authorization when billed with Type 2 diabetes diagnosis codes; specific CGM HCPCS listed include A4226, A9278, A4238, A4239, E0787, A9276, E2103, A9277 and E2102.

Prior authorization is required when CGM codes are billed with Type 2 or specified gestational diabetes diagnosis codes.
Examples of CGM HCPCS: A4238, A4239, A9276, A9277, A9278, A4226, E0787, E2102, E2103.

Prior Authorization

Cochlear implant prior authorization

Cochlear implants and other auditory implants require prior authorization (examples include CPT 69710, 69714, 69930 and HCPCS L8614).

Submit prior authorization for device and procedure codes associated with cochlear implants (69710, 69714, 69930, L8614).

Prior Authorization

Continuous glucose monitor prior auth

Prior authorization is required for continuous glucose monitor HCPCS codes when billed with Type 2 diabetes diagnosis codes; see the listed CGM HCPCS codes for submission.

CGM HCPCS examples: A4226, A9278, A4238, A4239, E0787, A9276, E2103, A9277, E2102.

Prior Authorization

Cosmetic and reconstructive procedures prior auth

Cosmetic and reconstructive procedures listed require prior authorization, except certain codes (e.g., 14020, 14021, 14061) marked effective 1/2023 do not require prior auth when billed with the specified diagnosis codes.

Obtain prior authorization for the cosmetic/reconstructive CPTs listed in the policy unless the code is noted with an exception.
Codes 14020, 14021 and 14061 are specified as NOT requiring prior authorization when billed with the listed diagnosis codes (effective 1/2023).

Prior Authorization

Prior authorization required — equipment, enteral, in-home nutrition

Prior authorization is required only for the specific DME, enteral, and in-home nutrition codes listed in the policy; these codes are identified in the equipment and enteral sections.

Examples of listed DME codes requiring prior authorization include A9279, A9280, E0118, E0194, E0265, E0266, E0270, E0277, E0300, E0328, E0329, E0445.

Prior Authorization

Prior authorization required — experimental/investigational services

Experimental and investigational services listed in the policy require prior authorization; the section enumerates CPT/HCPCS codes that must be authorized before service.

Examples include procedure codes such as 36514, 64722, 65765, 65767, 66180 and HCPCS like A4638 and A9274.

Prior Authorization

Prior authorization required — FAI procedures (age-restricted)

Prior authorization is required for femoroacetabular impingement (FAI) procedures for members age 21 and older (e.g., CPTs 29914, 29915, 29916).

Age restriction: prior authorization applies to members 21 years and older.

Prior Authorization

Prior authorization required — ENT procedures and genetic/molecular testing

Prior authorization is required for listed endoscopic sinus/functional (ENT) procedures and for a broad set of genetic and molecular testing codes (including BRCA-related CPTs); the policy lists the applicable CPT/HCPCS codes.

ENT/FESS examples: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288.
Genetic/molecular testing examples: CPTs 81400–81408, 81410–81416, 81431–81436, 81439–81440, 81445, 81448, 81460, 81465, 81479 and others listed.

Prior Authorization

Genetic and molecular testing prior auth codes

The policy lists CPT and HCPCS codes for genetic and molecular testing (including BRCA and cancer-related tests) that require prior authorization; some codes are noted with an asterisk indicating exceptions when billed with specified diagnoses.

Examples include 81415, 81416, 81431–81436, 81439, 81440, 81445, 81448, 81460, 81465, 81479, 81518–81521, 81522, 87505–87507, and proprietary codes such as 0111U.
Effective June 1, 2023: codes marked with an asterisk do NOT require prior authorization when billed with the DX codes listed in the policy.

Prior Authorization

Diagnosis codes mapped to prior authorization instructions (partial)

The policy maps many ICD-10 diagnosis codes to prior authorization instructions indicating associated CPT/HCPCS codes and how to obtain prior authorization; providers should follow the listed guidance for each diagnosis.

Examples in the document include extensive oncology/neoplasm ICD-10 blocks (e.g., C69.*, C82–C92 series) with associated prior authorization references.

Note

Diagnosis codes with prior authorization placeholder

Certain diagnosis code sections include a placeholder field stating 'CPT or HCPCS codes and/or how to obtain prior authorization,' indicating providers should refer to the CPT/HCPCS listings in the policy for submission instructions.

Note

Genetic and molecular testing - prior authorization placeholder

Entries referencing genetic and molecular testing include placeholder instructions to obtain prior authorization for molecular testing (including breast/BRCA-related tests); providers should use the CPT/HCPCS code lists in the policy to submit requests.

Prior Authorization

C82-series prior authorization references

For C82-series diagnosis codes the policy provides entries indicating CPT/HCPCS code references and how to obtain prior authorization; providers should follow the listed instructions for those C82 subcodes.

Examples of C82 subcodes shown: C82.48, C82.49, C82.5, C82.50–C82.65.

Prior Authorization

C82-series genetic/molecular testing

C82-series entries specifically reference genetic and molecular testing and associated prior authorization steps (including BRCA mentions); follow the policy's CPT/HCPCS references for submission.

Prior Authorization

C84-series prior authorization references

The policy lists C84-series diagnosis codes with entries that reference genetic/molecular testing and prior authorization steps (including breast/BRCA-related testing); providers should obtain authorization per the listed instructions.

Prior Authorization

C83–C92 prior authorization map

The policy provides a broad prior authorization mapping across many C83–C92 diagnosis codes, enumerating CPT/HCPCS codes and instructions for obtaining prior authorization for those oncology-related diagnoses.

Providers should reference the C83–C92 entries in the policy for specific CPT/HCPCS code requirements and submission instructions.

Prior Authorization

How to obtain prior authorization for injectable medications

Submit prior authorization requests for injectable medications online via the UnitedHealthcare Provider Portal (UHCprovider.com) or by calling the provider-directed phone number referenced in the injectable medications section (e.g., 888-397-8129 for some injectable submissions).

The injectable medication listings include numerous J-/Q- codes; follow the portal or phone submission guidance listed with the drug entries.

Prior Authorization

Home health care prior authorization note

Home health care prior authorization is required only in outpatient settings, including when services are provided in the member's home.

Documentation Required

CPT/HCPCS codes referenced for prior authorization

The policy lists many CPT/HCPCS codes and corresponding drug/product names that require prior authorization; providers should use the code lists in the policy when preparing authorization requests.

Examples shown include J0802, J1745, J2327, J9311, Q5152, and many other J-/Q-/C- codes tied to injectable or specialty products.

Billing Rule

HCPCS/CPT codes requiring prior authorization

Prior authorization is required for sodium hyaluronate injectable products; the HCPCS/J-codes listed include J2327 and the J7320–J7324 series.

Examples: J2327, J7320, J7321, J7322, J7324.

Prior Authorization

Prior authorization requirements and submission instructions

Prior authorization is required for the listed injectable medications and certain therapeutic radiopharmaceuticals; requests should be submitted online via the UnitedHealthcare Provider Portal or by calling the phone number provided in the injectable medication entries.

Examples in the injectable list include J1930 (Somatuline Depot), J1747 (Spevigo), J3358 (Stelara), and 90378 (Synagis).
Use UHCprovider.com or the phone numbers shown in the policy for submission.

Billing Rule

Orthotics & prosthetics prior authorization threshold

Orthotics and prosthetics require prior authorization when the retail purchase price or cumulative rental cost exceeds $500; providers should obtain authorization for listed L-codes when the threshold is met.

Threshold: retail purchase or cumulative rental cost greater than $500 triggers prior authorization requirement.
Example L-codes are listed in the orthotics & prosthetics sections of the policy.

Prior Authorization

Submission instructions for prior authorization

Submit prior authorization requests online using the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-889-8054 as directed in sections covering advanced imaging and radiation therapy submissions.

Advanced outpatient imaging and radiation therapy entries reference the portal and phone number 866-889-8054 for submissions.

Prior Authorization

Radiation therapy prior authorization

Radiation therapy services require prior authorization; specific CPT/HCPCS codes such as IGRT 77014, 77385, 77386 and related G/775-series codes are listed and must be authorized as indicated.

Standard radiation therapy (2D/3D) requires prior authorization only when obtained with diagnosis codes in specified cancer ranges (e.g., C34.00–C34.92, C50.011–C50.929, C61).
Examples of codes: 77014 (IGRT), 77385, 77386, 77371 (SRS/SBRT), 77523.

Billing Rule

Outpatient therapy visit prior authorization threshold

Prior authorization is required after the 12th outpatient therapy visit for members aged 21 years and older.

Prior Authorization

Advanced outpatient imaging notification requirement

Health care professionals ordering advanced outpatient imaging (certain CT, MRI, MRA, PET, nuclear medicine, nuclear cardiology) must provide notification prior to scheduling and obtain prior authorization per the policy.

Providers are responsible for notification/prior authorization before scheduling advanced outpatient imaging procedures.

Prior Authorization

Site of service prior authorization guidance

Site-of-service rules: prior authorization may be required when services are performed in an outpatient hospital setting; procedures performed at a participating ambulatory surgery center (ASC) generally do not require prior authorization per the listed entries.

If a procedure is performed at a participating ASC, prior authorization may not be required; verify the listed CPTs and site-of-service guidance in the policy.

Prior Authorization

Sleep apnea procedures prior authorization

Sleep apnea procedures listed in the policy require prior authorization (examples include CPTs 21685, 41599, 42145).

Obtain prior authorization for the sleep apnea procedures enumerated in the policy prior to scheduling.

Prior Authorization

Prior authorization for CPT 22865 (age restriction)

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

Age-restricted requirement applies beginning Oct 1, 2024.

Prior Authorization

Stimulators prior authorization

Stimulators (including bone-growth and neurostimulator devices) require prior authorization; listed HCPCS/CPT examples include E0747, E0748, E0749 and E0760.

Neurostimulator and bone-growth stimulator codes are listed under the stimulators section and require prior authorization.

Prior Authorization

Site of service — outpatient prior auth codes

The policy lists many outpatient site-of-service procedure codes with 'how to obtain prior authorization' instructions; providers should follow the portal/phone submission guidance associated with those outpatient procedure codes.

Examples include CPTs 11770, 13121, 15100, 15120, 15240, 19020, 19120, 19125, 47000, 54840.

Prior Authorization

Transplant and CAR T-cell therapy prior authorization contact

For transplant and CAR T-cell therapy services (including Carvykti), contact the Optum Transplant Case Management team at 888-936-7246 or use the notification number on the back of the member's health plan ID card to obtain prior authorization.

Use the Optum Transplant Case Management contact (888-936-7246) for submission and prior authorization instructions for transplant and CAR T-cell therapies.

Prior Authorization

VAD prior authorization contact and fax instructions

For ventricular assist devices (VAD) call the notification number on the back of the member's health plan ID card, then fax the form provided by the nurse to the Optum VAD Case Management team at 855-282-8929 to obtain prior authorization.

Fax instructions: send the completed form to Optum VAD Case Management at 855-282-8929 after calling the notification number on the member's ID card.

Prior Authorization

38232 oncology-only prior authorization

Code 38232 requires prior authorization only when billed for an oncology diagnosis.

Verify oncology diagnosis coding before submitting prior authorization for CPT 38232.

Prior Authorization

Device and implant prior authorization examples

The policy enumerates many device and implant codes that require prior authorization or have specific contact/submission instructions (examples include wound vac E2402, VAD HCPCS Q0507–Q0509, and various L-codes for prosthetics/implants).

Examples: wound vac E2402, implantable device L8680, VAD codes Q0507–Q0509 and numerous L‑series prosthetic codes.
Follow the listed contact or portal submission instructions for these devices.

Examples in the policy: 69710, 69714, 69930, and device HCPCS L8614 (prior authorization required).

Provider actionObtain prior authorization for cochlear implant procedures and associated device billing prior to service delivery.

inv-94: continuous glucose monitor

DefinitionContinuous glucose monitor (CGM): Ambulatory glucose monitoring device and supplies billed under HCPCS codes (examples listed).

Codes listedExamples in the policy: A4226, A9278, A4238, A4239, E0787, A9276, E2103, A9277, E2102 (prior authorization required when billed with Type 2 diabetes Dx).

Condition for prior authPrior authorization is required when CGM codes are billed with Type 2 or gestational diabetes diagnosis codes (numerous E11.* and related codes listed).

inv-95: cochlear implant

DefinitionCochlear implant (summary): Implantable inner-ear device with external portion used for profound sensorineural deafness; prior authorization required for procedures and device codes.

Associated codesProcedure and device examples: 69710, 69714, 69930, L8614 (listed in prior authorization requirements).

Provider actionSubmit prior authorization requests for cochlear implant procedures and devices before scheduling the service.

inv-96: DME prior authorization

DefinitionDME prior authorization: Prior authorization is required only for the specific DME codes listed in the policy; not all DME requires authorization.

ExamplesSample DME codes listed include A9279, A9280, E0118, E0194, E0265, E0266, E0270, E0277 and many others (see DME section).

Provider actionCheck the listed DME codes in the policy and obtain prior authorization only for those codes annotated as requiring it.

inv-97: Experimental/investigational

DefinitionExperimental/investigational: Services and procedures identified as experimental or investigational in the policy require prior authorization.

ExamplesExamples of codes listed as experimental/investigational include 36514, 64722, 65765, 65767, 66180 and related HCPCS/CPT entries.

Provider actionObtain prior authorization for services flagged as experimental/investigational before providing the service.

inv-98: FAI age restriction

DefinitionFAI age restriction: Prior authorization for femoroacetabular impingement (FAI) procedures is required for members aged 21 and older.

Codes listedProcedure examples: 29914, 29915, 29916 are listed under FAI requiring prior authorization for members 21+.

Effective handlingObtain prior authorization for listed FAI procedures when the patient is age 21 or older prior to service.

inv-99: Codes with '*'

NotationCodes displayed with an asterisk (*) in the policy indicate the special rule described in the exceptions: when billed with specified diagnosis codes, those asterisked codes do not require prior authorization.

Example markerThe asterisk is shown adjacent to listed CPT/HCPCS codes in the genetic/molecular testing/code tables (see code listings with *).

inv-100: General information entries

Entry formatGeneral information entries map ICD-10 diagnosis codes to a field titled 'CPT or HCPCS codes and/or how to obtain prior authorization' or provide 'Additional information'.

PurposeThese entries indicate which CPT/HCPCS codes are linked to specific diagnoses and provide the instruction for obtaining prior authorization where applicable.

Provider actionRefer to the diagnosis-to-authorization mapping lines to identify associated CPT/HCPCS codes and submission instructions for prior authorization.

inv-101: Genetic and molecular testing (BRCA)

DefinitionGenetic and molecular testing (BRCA): Molecular/genetic tests including BRCA-related testing are referenced in the policy and require prior authorization as indicated.

Codes referencedThe policy lists many CPT codes associated with molecular/genetic testing (examples in other sections include 81415–81416, 81431–81436, 81439–81440 and BRCA-related entries).

Provider actionObtain prior authorization for genetic and molecular testing codes where the policy indicates prior authorization is required; consult the diagnosis mappings for exceptions.

inv-102: Genetic and molecular testing

DefinitionGenetic and molecular testing: Broad set of molecular/genetic CPT/HCPCS codes are included in the policy and many require prior authorization; some codes have exception rules when billed with qualifying Dx codes.

Representative codesPolicy lists many test codes (partial examples: 81400, 81415–81416, 81431–81436, 81439–81440, 81445, 81448, 81460, 81465, 81479, 81518–81521).

Provider actionCheck both the test CPT/HCPCS code and associated diagnosis code to determine whether prior authorization is required or an exception applies.

inv-103: Genetic and molecular testing (BRCA)

BRCA testing noteGenetic and molecular testing to include breast cancer (BRCA) gene testing is specifically referenced; prior authorization instructions and code placeholders appear alongside relevant diagnosis codes.

ICD-10 linkageThe policy includes ICD-10 code groupings tied to molecular testing entries (many C7x–C9x series entries reference molecular testing fields).

Provider actionFollow the mapping lines and the genetic/molecular testing code lists to determine prior authorization requirements for BRCA-related tests.

inv-104: CPT/HCPCS codes and prior authorization list (partial)

Partial list noteThe policy includes numerous CPT/HCPCS codes tied to prior authorization; the section presents a partial list of codes and drug names that require prior authorization.

Sodium hyaluronate exampleSodium hyaluronate codes shown in the list include J2327 and the J73xx series (e.g., J7320, J7321, J7322, J7324).

Provider actionUse the CPT/HCPCS lists in the policy when preparing prior authorization requests for injectable medications or drug-administered services.

inv-105: Sodium Hyaluronate

ProductSodium Hyaluronate (viscosupplement/viscoelastic injectable products billed under listed HCPCS/CPT codes).

Codes listedPolicy lists J2327 and J73xx series (examples: J7320, J7321, J7322, J7324) as sodium hyaluronate codes requiring prior authorization.

Provider actionObtain prior authorization for sodium hyaluronate products billed under the listed J-codes prior to administration.

inv-106: Review at Launch for New to Market Medications

Review at LaunchReview at Launch for New to Market Medications: Newly approved drugs are included on the Review at Launch Medication List and pre-determination is highly recommended for those drugs.

Provider actionCheck the Review at Launch policy and medication list for newly approved FDA drugs and consider pre-determination prior to providing these medications.

Contact/Submission guidancePrior authorization requests for injectable medications should be submitted via the UnitedHealthcare Provider Portal or the phone numbers listed in the policy.

inv-107: Prior notification (for Cimzia and Synagis)

Prior notification requirementPlease obtain prior notification for Cimzia and Synagis through Optum Rx prior notification services at 800-310-6826 (policy note).

ExamplesSynagis is shown in the injectable medications list (code 90378) with an asterisk and prior notification instruction.

Provider actionUse Optum Rx prior notification services for Cimzia and Synagis as indicated before dispensing/administration.

inv-108: UHCprovider.com and phone number 866-889-8054 for prior authorization submission

PortalUHCprovider.com: Submit prior authorization requests online via the UnitedHealthcare Provider Portal (Prior Authorization and Notification tool).

Phone numberPrimary phone contacts shown for prior authorization submission: 877-542-9231 and the document also lists 866-889-8054 and 888-397-8129 for some services.

Provider actionSign in to UHCprovider.com using One Healthcare ID for online submissions or call the listed phone number for assistance or to submit by phone.

inv-109: SOS Outpatient

DefinitionSOS Outpatient: Site-of-service entries identify outpatient hospital procedures that may require prior authorization; participating ASCs may be exempt for certain procedures.

ExamplesOutpatient site-of-service CPT examples include 11770, 13121, 15100, 15120, 15240, 19020, 19120, 19125 and others listed in the SOS Outpatient section.

Provider actionProvide notification/prior authorization prior to scheduling advanced outpatient imaging or other SOS Outpatient procedures as instructed.

inv-110: Prior authorization

SummaryPrior authorization is required for the services and codes listed in this policy unless an explicit exception or asterisk rule applies.

How to submitSubmit prior authorization requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID, or by phone (primary number 877-542-9231; additional numbers appear for specific service lines).

ExceptionsEmergency/urgent care does not require prior authorization; some code/diagnosis combinations and site-of-service rules provide exceptions noted in the policy.

inv-111: Age-restricted prior authorization

Age-restricted rule22865 — Effective Oct 1, 2024: Prior authorization required for CPT 22865 for members aged 21 and older.

Other age notesFemoroacetabular impingement procedures (e.g., 29914–29916) require prior authorization for members 21 and older as noted elsewhere in the policy.

Provider actionVerify patient's age when requesting authorization for age-restricted codes and obtain prior authorization when the member meets the age threshold.

inv-112: Ventricular assist device (VAD)

DefinitionVentricular assist device (VAD): A mechanical pump that takes over the function of the damaged ventricle of the heart and restores normal blood flow; VAD services require prior authorization.

Contact instructionsCall the notification number on the back of the member's health plan ID card, then fax the form provided by the nurse to the Optum VAD Case Management team at 855-282-8929.

Codes listedVAD-related codes referenced include 33927, 33928, 33929, 33975, 33976, 33979, 33981, 33982, 33983 and HCPCS Q0507–Q0509.