CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP

Defines services, codes, and submission methods that require prior authorization for participating UnitedHealthcare Community Plan of Pennsylvania CHIP providers; applies to inpatient and outpatient services for the CHIP plan.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by phone at 800-600-9007, or by fax at 877-310-3826.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

online/phone/faxsubmission methods for prior authorization requests

exemptemergency/urgent care

20+distinct service categories

$500DME prior auth threshold

sleep apnea/spine/stimselected services requiring PA

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Services and Coverage Authorization Requirements

inv-01: Services requiring prior authorization (sample)

Listed services require prior authorization when performed for plan members unless otherwise noted (e.g., emergency/urgent care). Specific CPT/HCPCS codes are provided for many categories.

Prior authorization is required for the services and codes listed in this document when performed for plan members, except for emergency or urgent care which are exempt.

Examples include

Abortion procedures (e.g., CPT 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, 59866) require prior authorization.
Bariatric surgery and specific obesity-related services (e.g., CPT 43644, 43645, 43659, 43770, 43775, 43842, 43845, 43846, 43847, 43848, 43860) require prior authorization.
Bone growth stimulators (e.g., CPT 20975, 20979) require prior authorization.
BRCA genetic testing and selected genetic tests require prior authorization; specific molecular/genetic test CPT/HCPCS codes are listed.
Cancer supportive care injectable agents (colony-stimulating factors and bone-modifying agents) administered outpatient for cancer diagnosis require prior authorization.

inv-02: Extracted coverage/authorization statements

Explicit coverage and authorization statements extracted from the segment:

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

Cochlear implants and other auditory implants: Prior authorization is required; obtain authorization via the Provider Portal Authorization and Notification tab or by calling the number provided (see policy).

Codes: 69710, 69714, 69930, L8619, L8690, L8691

Continuous glucose monitor (CGM): Prior authorization required when used for Type 2 diabetes; listed HCPCS codes apply (examples: A4226, A9278, A4239, E0787).

Inpatient cerebral seizure monitoring (video): Prior authorization required for inpatient services (CPT examples: 95700, 95711–95713).

Cosmetic vs reconstructive note

inv-03: Antiemetics - excerpt

Antiemetics excerpt: CPT/HCPCS entries and prior authorization references provided in the antiemetics section.

Several injectable antiemetic and supportive-care agents are listed with HCPCS/J-codes (examples: J1453, J1454, J1627).

Injectable colony-stimulating factor drugs and related supportive agents listed in this section require prior authorization (examples: J1449, J1442, Q5110, Q5125, J2506, Q5122, Q5120, Q5111, Q5108, J1447, J2820, J1448).

Multiple CPT/HCPCS procedure codes are referenced with 'how to obtain prior authorization' placeholders in this section (examples: 21230, 21280, 21282, 21295, 21740).

The excerpt contains repeated 'how to obtain prior authorization' template lines; specific clinical criteria are not provided in the fragment.

inv-04: Prior authorization criteria (fragment)

Prior authorization requirements and notable exceptions shown in the fragment:

Durable medical equipment (DME): prior authorization is required only for codes listed with a retail purchase or cumulative rental cost of more than $500 (threshold applies to listed DME/orthotic/prosthetic codes).retail purchase or cumulative rental > $500

Prosthetics are not classified as DME for prior authorization purposes; see orthotics and prosthetics guidance for applicable codes and thresholds.

The fragment lists numerous CPT/HCPCS and ICD-10 codes with 'how to obtain prior authorization' labels, though some additional information fields in the fragment are empty; presence in the list indicates these codes require prior authorization or notification as noted elsewhere in the policy.

inv-05: Genetic/molecular testing — authorization criteria (partial)

Genetic and molecular testing: partial authorization/notification requirements.

Genetic and molecular tests performed in an outpatient setting require prior authorization/notification; authorization requests must include the ordering laboratory and test name as part of the process.

BRCA testing specifically requires notification/prior authorization before DNA sequencing is performed; the ordering provider must notify the laboratory and the laboratory will notify UnitedHealthcare prior to sequencing.

inv-06: DME and Enteral services

Durable medical equipment (DME) and enteral/in-home nutrition service authorization rules:

DME items listed (examples: V52xx series and E0xxx examples shown) require prior authorization when specified in the list.

Orthotics and prosthetics: prior authorization is required only for codes listed with a retail purchase or cumulative rental cost exceeding $500.

Enteral services and in‑home nutritional therapy (B40xx/B41xx series and related B4xxx codes) require prior authorization; specific HCPCS codes are enumerated in the list (examples: B4034, B4035, B4036, B4100, B4102–B4161, B9002).

inv-07: Home health, hospice, surgical procedures

Home health, hospice, and selected surgical procedures authorization rules:

Home health services (examples: G0156, G0162, G0299, G0300, G0493–G0496, S9122–S9124, S9474) require prior authorization when provided in outpatient settings or in the member's home.

Hospice services require prior authorization (example code: T2045).

Selected surgical procedures requiring prior authorization

Functional endoscopic sinus surgery (FESS) procedures (examples: CPT 31240, 31253–31259, 31267, 31276, 31287–31288) require prior authorization.
Femoroacetabular impingement procedures (example: CPT 29916) require prior authorization.

inv-08: Gender dysphoria services — authorization requirement

Gender dysphoria services and related surgical treatment authorization rule:

Gender dysphoria treatments and related surgical procedures require prior authorization; listed diagnosis codes include F64.0, F64.1, F64.2, F64.8, F64.9 and Z87.890 and associated surgical CPT codes are identified in the policy.

inv-09: Authorization and code listing criteria

Authorization/notification requirements and code listings in this section:

BRCA and certain genetic/molecular tests require notification/prior authorization before DNA sequencing; ordering provider and laboratory notification steps are specified.

Home health and hospice services require prior authorization when provided in outpatient settings or in the member's home; specific G‑ and S‑codes are listed.

Numerous injectable medications (J/Q codes and others) listed in the policy require prior authorization; the document provides J/Q/A code examples and indicates authorization instructions accompany many entries (examples include J3262, J7207, J0881, J1426, J2550).

The policy is a fragment of a larger listing; providers should consult the full policy for complete authorization submission instructions and any codes not fully shown in this excerpt.

inv-10: Authorization criteria and process (partial)

Coverage stance and authorization process notes (partial):

Notification is required for inpatient admissions to acute care, inpatient rehabilitation, critical access hospitals, LTAC and skilled nursing facilities; predetermination is highly recommended for certain new-to-market medications.

Joint total hip and knee replacement procedures require prior authorization for the listed CPT codes.

Non‑emergent air ambulance transport and specified transport/procedure codes require prior authorization (examples: A0430, A0431, A0435, A0436, related S‑codes).

Unclassified/temporary codes (e.g., C9159, C9172, C9399, J3490, J3590) require prior authorization only for specific drugs identified (e.g., Nulibry, Rivfloza, Revcovi); code J0897 requires prior authorization for non‑oncology indications.

How to submit prior authorization requests: submit via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call the specified phone number (policy lists portal and contact information).

inv-11: Prior authorization criteria and process

Prior authorization requirements, request methods, and site-of-service notes:

Specific services explicitly marked 'Prior authorization required' include pediatric day services (PDHC), private duty nursing, potentially unproven services, prostate procedures, proton beam therapy, and other listed items.

Advanced outpatient imaging (certain CT, MRI, MRA, PET scans and select nuclear medicine/nuclear cardiology procedures) requires prior authorization. Providers must notify prior to scheduling and may request prior authorization by phone (866-889-8054) or online via the UHC Provider Portal Prior Authorization and Notification tool.

Site‑of‑service rule: for some procedures prior authorization is required only when the service is requested in an outpatient hospital setting; prior authorization may not be required if performed at a participating ambulatory surgery center (ASC).

inv-12: Authorization criteria summary

Authorization summary and radiology procedural determination guidance:

Providers must refer to the Radiology Prior Authorization and Notification policy for specific prior authorization requirements for each CPT/HCPCS code listed in the radiology sections.

Some radiology procedures note that prior authorization is not required if performed at a participating ASC; other entries specify outpatient hospital as the site of service where prior authorization applies.

Numerous CPT codes across multiple body systems are enumerated; inclusion in the radiology lists implies a need to check the referenced Radiology Prior Authorization and Notification resource for code‑level authorization requirements.

inv-13: Prior authorization requirements (selected categories)

Selected categories and devices requiring prior authorization:

Sleep apnea procedures and surgeries identified in the radiology/procedures list require prior authorization (examples: CPT 21685, 41599, 42145).

Spinal surgery procedures listed require prior authorization (examples: CPT 22100, 22101, 22102, 22206, 22207, 22210 and related spinal CPTs).

Stimulators and implantable device procedures (including bone growth stimulators and neurostimulators) require prior authorization for the listed CPT/HCPCS codes (examples: 63286, 63300–63308, E0747–E0760, 63650, 63655).

inv-14: Prior authorization and notification rules (excerpts)

Prior authorization and special notification rules (excerpts):

Stimulators and implantation devices (including bone growth stimulators) require prior authorization as indicated in the implant/procedure listings; multiple CPT/HCPCS codes are provided for these entries.

Transplant and CAR T‑cell therapy services require case management contact/notification; providers should call the UnitedHealthcare Transplant Case Management Team at the number provided (888-936-7246) or use the notification number on the member ID card.

VADs and vein procedures

Ventricular assist devices (VAD) require prior authorization and Optum VAD Case Management Team notification/faxing of required materials (fax 855-282-8929).
Vein procedures (removal/ablation of saphenous veins; examples: CPT 36468, 36473, 36475, 36478) require prior authorization; code 38232 requires prior authorization only when used for an oncology diagnosis.

CPT / HCPCS / ICD-10 Code Listings

Abortion-related CPT codesCPTCovered

59840	Abortion procedure code listed as requiring prior authorization
59841	Abortion procedure code listed as requiring prior authorization
59850	Abortion procedure code listed as requiring prior authorization
59851	Abortion procedure code listed as requiring prior authorization
59852	Abortion procedure code listed as requiring prior authorization
59855	Abortion procedure code listed as requiring prior authorization
59856	Abortion procedure code listed as requiring prior authorization
59857	Abortion procedure code listed as requiring prior authorization
59866	Abortion procedure code listed as requiring prior authorization

Bariatric surgery CPT codesCPTCovered

43644	Bariatric surgery code requiring prior authorization
43645	Bariatric surgery code requiring prior authorization
43659	Bariatric surgery code requiring prior authorization
43770	Bariatric surgery code requiring prior authorization
43775	Bariatric surgery code requiring prior authorization
43842	Bariatric surgery code requiring prior authorization
43845	Bariatric surgery code requiring prior authorization
43846	Bariatric surgery code requiring prior authorization
43847	Bariatric surgery code requiring prior authorization
43848	Bariatric surgery code requiring prior authorization

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Injectable colony-stimulating and related agentsHCPCSCovered

J1449	Eflapegrastim-xnst (Rolvedon) - injectable CSF requiring prior authorization
J1442	Filgrastim (Neupogen) - injectable CSF flagged for prior authorization (also noted for non-oncology prior auth)
Q5110	Filgrastim-aafi (Nivestym) - biosimilar injectable requiring prior authorization
Q5125	Filgrastim-ayow (Releuko) - biosimilar injectable requiring prior authorization
Q5101	Filgrastim-sndz (Zarxio) - biosimilar injectable requiring prior authorization
J2506	Pegfilgrastim (Neulasta) - injectable requiring prior authorization
Q5122	Pegfilgrastim-apgf (Nyvepria) - biosimilar requiring prior authorization
Q5120	Pegfilgrastim-bmez (Ziextenzo) - biosimilar requiring prior authorization
Q5111	Pegfilgrastim-cbqv (UDENYCA) - biosimilar requiring prior authorization
Q5108	Pegfilgrastim-jmdb (Fulphila) - biosimilar requiring prior authorization

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Genetic testing and breast reconstruction/mastectomy codesmixedCovered

81162	BRCA genetic testing code requiring prior authorization
81212	BRCA genetic testing code requiring prior authorization
81216	BRCA genetic testing code requiring prior authorization
81432	BRCA genetic testing code requiring prior authorization
11971	Breast reconstruction-related code requiring prior authorization
19316	Breast reconstruction-related code requiring prior authorization
19318	Breast reconstruction-related code requiring prior authorization
19325	Breast reconstruction-related code requiring prior authorization
19328	Breast reconstruction-related code requiring prior authorization
19330	Breast reconstruction-related code requiring prior authorization

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Cochlear implant CPT/HCPCSCPTCovered

69714	Cochlear implant procedure code
69930	Cochlear implant procedure code
L8614	Cochlear implant HCPCS
L8619	Cochlear implant external sound processor
L8690	Cochlear implant component

Continuous glucose monitor HCPCSHCPCSCovered

A4226	Continuous glucose monitor supplies
A9278	Continuous glucose monitor supply
A4239	Continuous glucose monitor sensor
E0787	External glucose monitor

Cosmetic and reconstructive CPT examplesCPT

11960	Cosmetic procedure code listed
15820	Cosmetic procedure code listed
15830	Cosmetic procedure code listed
21172	Function-related procedure code listed
21230	Reconstructive procedure code listed

CPT/HCPCS references in antiemetics sectionCPT

21230	Referenced as a 'how to obtain prior authorization' code in antiemetics section
21280	Referenced repeatedly as 'how to obtain prior authorization' in antiemetics section
21282	Listed alongside other CPT/HCPCS codes
21295	Listed alongside other CPT/HCPCS codes
21740	Listed alongside other CPT/HCPCS codes
21256	Listed alongside other CPT/HCPCS codes

Antiemetics - listed CPT/HCPCSCPT | HCPCS

21280
21282
21295
21740

Selected CPT/HCPCS codes in fragmentmixed

21742	CPT/HCPCS code listed with prior authorization note
21743	CPT/HCPCS code listed with prior authorization note
30620	CPT/HCPCS code listed
67900	CPT/HCPCS code listed
Q2026	HCPCS code listed

ICD-10 codes and mappingsICD-10

C43.0	ICD-10 mappings and continuations present
C44.01	ICD-10 mappings and continuations present
C4A.112	ICD-10/alpha-numeric codes listed under cosmetic/reconstructive
D04.111	ICD-10 codes listed under cosmetic/reconstructive

Sample HCPCS E-codes listedHCPCS

E0471
E0483
E0486
E0620
E0636

Sample HCPCS K-codes listedHCPCS

K0830
K0848
K0850
K0868

Sample CPT surgical codes listedCPT

17380
19303
21083
21120

sample injectable medication J/Q/A codes listedHCPCS

J7207	Adynovate
J7171	Adzynma
J7210	Afstyla
J1931	Aldurazyme
J7193	AlphaNine SD, Mononine
J7201	Alprolix
J7214	Altuviio
J1426	Amondys 45
J0225	Amvuttra
J0739	Apretude

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home health service codesCPT

G0156	Home health services
G0162	Home health services
G0299	Home health services
G0300	Home health services
G0493	Home health services
G0494	Home health services

Injectable medications (partial list shown)HCPCS

J9226	Supprelin LA
J2779	Susvimo
J2781	Syfovre
90378	Synagis
S0189	Testopel
J3121	Testosterone Enanthate

Procedures and transports requiring prior authorization (examples)CPT | HCPCSCovered

A0430	Non-emergent air ambulance transport
A0431	Non-emergent air ambulance transport
21121	Treatment of maxillofacial/jaw functional impairment
27120	Hip replacement (example)
27447	Knee procedure (example)

Examples of CPT/HCPCS codes called out in this sectionmixed

T1024	Pediatric day health care (PDHC) - listed as requiring prior authorization
T1000	Private duty nursing - listed as requiring prior authorization
T1002	Private duty nursing - listed
T1003	Private duty nursing - listed
77520	Proton beam therapy - listed
77522	Proton beam therapy - listed
77523	Proton beam therapy - listed
77525	Proton beam therapy - listed
33289	Example potentially unproven service code listed
37243	Prostate procedure code listed

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Sample CPT codes listed in excerptCPT

45378	Colonoscopy
66982	Cataract surgery (complex)
66984	Cataract surgery (routine)
67010	Retinal procedure
29807	Arthroscopy, knee

Integumentary and biopsy codesCPT

10121	Incision and removal of foreign body
11440	Excision benign lesion
47000	Liver biopsy

Selected procedure codes (examples)mixed

31536	Endoscopic/bronchial related code referenced under Respiratory System
43235	Upper GI endoscopy
52276	Urologic procedure

Spinal surgery codesCPT

22515	Spinal fusion/related
22810	Spinal instrumentation

Selected procedural codes shownmixed

63286	Cranial procedure code listed for prior auth
0098T	Technology/procedure code listed
E0747	Implantation device HCPCS
61863	Spine/neuro surgery CPT
63650	Spinal neurostimulator lead placement

Unclassified drug/procedure codesmixed

C9399	Unclassified code — certain biologic/gene therapies require prior authorization
J3490	Unclassified drug code — specific gene therapies listed
J3590	Unclassified drug code

DME prior authorization cost threshold

DME prior authorization thresholdRetail purchase or cumulative rental cost greater than $500 requires prior authorization

Applies to listed DME codesOnly codes listed with retail purchase or cumulative rental cost > $500 require prior authorization (e.g., A9279, E0194 referenced)

How to Obtain Authorization and Provider Responsibilities

Prior Authorization

Submission methods and general authorization rules

Submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com → Sign In → Prior Authorization and Notification tab). If you do not have a One Healthcare ID, visit UHCprovider.com/access. Phone: 800-600-9007 (general) or 888-397-8129 (clinical/prior auth). Fax: 877-310-3826. Prior authorization is not required for emergency or urgent care. Out-of-network clinicians and facilities must request prior authorization for all procedures and services.

Online: Prior Authorization and Notification tool on UHCprovider.com
Phone (general): 800-600-9007
Phone (prior authorization/clinical): 888-397-8129 or 866-889-8054 (radiology/cardiology imaging)
Fax: 877-310-3826

Prior Authorization

Service categories requiring prior authorization

Certain service categories require prior authorization. This section highlights categories and examples — consult the full list and code-level tables for specifics and any site-of-service rules. When an item or procedure is listed below, obtain prior authorization before scheduling or performing the service except for emergency or urgent care.

Key Terms and Thresholds

Prior authorization — definition reference

DefinitionPrior authorization is the process by which providers obtain approval from UnitedHealthcare before delivering specified services or supplies

How to submit requestsSubmit requests via the Prior Authorization and Notification tool on UHCprovider.com, by phone, or by fax as specified in the policy

ScopeApplies to participating UnitedHealthcare Community Plan of Pennsylvania CHIP providers for listed inpatient and outpatient services

Emergency/urgent care — PA exemption

Emergency/urgent care exemptionEmergency or urgent care does not require prior authorization

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

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by phone at 800-600-9007, or by fax at 877-310-3826.

SourceLink

On This Page

Cosmetic procedures that change appearance are distinguished from reconstructive procedures that restore function; multiple CPT codes are listed.

Some reconstructive/cosmetic procedures are included with prior authorization instructions (see listed CPT examples).

Emergency care exemptionPrior authorization is not required for emergency or urgent care

Orthotics/prosthetics prior authorization cost threshold

Orthotics/prosthetics PA thresholdPrior authorization required only when retail purchase or cumulative rental cost exceeds $500

Many L-codes listedNumerous orthotics/prosthetic L‑codes are enumerated and subject to the $500 threshold (examples: L0632, L0634, L0636)

Prosthetics distinctionProsthetics are noted separately and are not treated as DME for PA purposes (see orthotics and prosthetics entries)

Advanced outpatient imaging (CT/MRI/MRA/PET and select nuclear medicine/nuclear cardiology) — call 866-889-8054 or use the Provider Portal.
Cardiology outpatient/office-based diagnostics, diagnostic catheterizations, electrophysiology implants and stress echocardiography — prior authorization required; see Cardiology Prior Authorization and Notification.
Orthotics and prosthetics — prior authorization required only when retail purchase or cumulative rental cost > $500 (many L-codes listed).
Durable medical equipment (DME) — prior authorization required only for listed codes with retail purchase or cumulative rental cost > $500.
Home health and hospice — prior authorization required for home health and hospice services.
Joint replacements, select maxillofacial and spinal surgeries, cochlear and auditory implants, stimulators/neurostimulator implantation, VADs, transplant and CAR T-cell therapy — prior authorization required.
Non-emergent air ambulance and certain transport services — prior authorization required.
Enteral/in-home nutrition and gastrostomy-related supplies — prior authorization required.
Potentially unproven, experimental/investigational services and listed surgical procedures — prior authorization required.
Private duty nursing, pediatric day health care (PDHC), proton beam therapy, sleep apnea surgeries, vein procedures — prior authorization required for listed codes.

Prior Authorization

Cardiology prior authorization note

Cardiology outpatient and office-based diagnostic procedures (including diagnostic catheterizations), electrophysiology implants, and stress echocardiography require prior authorization for participating physicians. For details and the full CPT/HCPCS list, submit requests via the Prior Authorization and Notification tool on the Provider Portal or call the Cardiology prior authorization number.

Cardiology prior authorization phone: 866-889-8054
Cardiology prior authorization phone (alternate): 888-397-8129
Reference: Cardiology Prior Authorization and Notification (see Provider Portal for code list)

Prior Authorization

Outpatient injectable chemotherapy prior authorization

Outpatient injectable chemotherapy and other injectable oncology drugs (including IV, intravesical, intrathecal administration) require prior authorization when administered in an outpatient setting for a cancer diagnosis. This includes outpatient administration of colony-stimulating factors and bone-modifying agents given for oncology indications.

Injectable chemotherapy (outpatient) — prior authorization required for cancer diagnosis
Cancer supportive care (outpatient) — colony-stimulating factors and bone-modifying agents require prior authorization (see specific J/Q codes listed in injectable medications section)

Prior Authorization

Continuous glucose monitor prior authorization

Continuous glucose monitors (CGMs) require prior authorization. Applicable HCPCS/HCPCS‑like codes include A4239, E0787, A9276, E2102, A9277, E2103, A4226 and A9278 (device and supply codes). Verify member eligibility and submit prior authorization via the Provider Portal.

Examples of CGM codes: A4239, E0787, A9276, E2102, A9277, E2103, A4226, A9278
Prior authorization method: Provider Portal or phone

Prior Authorization

Inpatient video seizure monitoring prior authorization

Inpatient video EEG/seizure monitoring requires prior authorization for inpatient services. Obtain authorization prior to admission when possible.

Inpatient video seizure monitoring CPT codes: 95700, 95711, 95712, 95713
Prior authorization required for inpatient services

Note

Antiemetics CPT/HCPCS cross-reference

Several reconstructive and cosmetic-related CPT/HCPCS codes commonly require prior authorization; the policy reiterates repeated PA code references used for authorization routing. Use the Prior Authorization and Notification tool to submit supporting documentation and code details.

Common CPT/HCPCS cross-reference codes used for prior authorization routing: 21230, 21280, 21282, 21295, 21740
When these codes appear in the policy text, submit requests via the Provider Portal or by phone

Prior Authorization

Prior authorization — listed codes

Many specific procedure and device codes are listed in the policy and require prior authorization. Examples include joint replacement series, spinal surgery codes, neurostimulator/CPT device implantation codes, and numerous HCPCS L-/E-/A- codes for orthotics, prosthetics, DME and implants. Always consult the code tables or the Provider Portal for the full, up-to-date list.

Examples of procedure codes requiring prior authorization: multiple joint replacement CPTs (see policy listing), spinal surgery CPTs (22100, 22101, 22102, 22110, 22112, 22114, etc.), neurostimulator CPTs (61863, 61864, 61867, 61868, 61885, 61886, 63650, 63655, 63685, 64553, 64555, 64568, 64570, 64590)
Examples of device/implant HCPCS codes: L8680, L8682, L8685, L8686, L8687, L8688 and many L-codes for orthotics/prosthetics
For full code lists, use Radiology/Cardiology/Provider Portal resources

Prior Authorization

Home health and hospice prior authorization

Home health services and hospice require prior authorization. For outpatient home health services, prior authorization is required for listed G- and S- codes when services are provided in the member's home. Hospice services also require prior authorization.

Home health example codes: G0156, G0162, G0299, G0300, G0493–G0496, S9122–S9124, S9474
Hospice example code: T2045
Prior authorization required for outpatient home health and hospice

Prior Authorization

Surgical procedures prior authorization

Many surgical procedures require prior authorization. Notable categories include joint replacement, hysterectomy, maxillofacial/jaw functional‑impairment procedures, spinal surgery, selected cosmetic/reconstructive procedures, and gender dysphoria surgical treatments. Confirm required diagnosis codes and submit supporting clinical documentation.

Joint replacement, hysterectomy and select spinal surgery CPTs listed in the policy require prior authorization
Gender dysphoria surgical codes require prior authorization and must include applicable DX codes (e.g., F64.x; see policy)
For reconstructive vs cosmetic determinations, submit clinical rationale and documentation

Prior Authorization

Authorization/notification for molecular/genetic testing

Authorization/notification is required for many types of molecular and genetic testing. BRCA testing specifically requires notification/prior authorization before DNA sequencing is performed; the ordering provider must notify the laboratory performing the test and the laboratory will notify UnitedHealthcare. A broad series of molecular/genetic CPT codes (e.g., 81162, 81212, 81216, 81432, 81163–81164, 81228–81229, 81277, 81400–81417, 81431, 81435, 81437, 81439–81440, 81445, 81448, 81460, 81465, 81479, 81518–81522, 81546, 81595, 81599, 87505–87507, S3870, etc.) are listed and require notification or prior authorization as specified.

BRCA testing: notification/prior authorization required before DNA sequencing; ordering provider must notify laboratory and laboratory will notify UnitedHealthcare
Large panels and single‑gene tests (CPT ranges in the 81xxx and 814xx series) require prior authorization/notification — include lab name and test name when submitting
Submit molecular/genetic test requests via Provider Portal and include test methodology and laboratory information

Prior Authorization

Special rules for unclassified/temporary codes

Special rules apply to unclassified and temporary codes. Prior authorization is only required for select products billed with unclassified/temporary or miscellaneous codes (for example C9159, C9172, C9399, J3490, J3590) when they represent specific drugs identified by policy (e.g., Nulibry™, Rivfloza, Revcovi, Amtagvi, Lantidra, Lenmeldy, Skysona, Tecelra). For J0897, prior authorization is required for non-oncology indications only. Always verify the drug/product when an unclassified or J3490/J3590 line item is submitted.

Unclassified/temporary codes: C9159, C9172, C9399, J3490, J3590 — PA only for specified drugs (e.g., Nulibry™, Rivfloza, Revcovi, Amtagvi, Lantidra, Lenmeldy, Skysona, Tecelra)
J0897 requires prior authorization when used for non‑oncology indications
Check Review at Launch and the Provider Portal for newly approved medications and PA requirements

Billing Rule

Orthotics and prosthetics prior authorization threshold

Orthotics and prosthetics require prior authorization only when the retail purchase or cumulative rental cost exceeds $500. A long list of L‑codes in the policy denotes items subject to this threshold — confirm pricing and obtain authorization when the threshold is met.

Orthotics/prosthetics examples (subject to $500 threshold): L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631, L0632, L0634, L0636, L0637, L0638, L0640, L0700, L0710, L0810, L0820, L0830, L0859, L1000, L1005, L1200, L1300, L1310, L1680, L1685, L1700, L1710, L1720, L1730, L8044–L8659 series as mapped in the policy
Obtain prior authorization when retail purchase or cumulative rental cost > $500

Prior Authorization

Site of service prior authorization notes

Site-of-service rules (SOS) can affect prior authorization requirements. Some services require prior authorization only when performed in an outpatient hospital setting; the same CPT performed in another setting (e.g., ASC or office) may not require prior authorization. Always verify the SOS requirement in the Radiology Prior Authorization and Notification document or the specific service table.

SOS example: certain radiology procedures require PA only when performed in an outpatient hospital setting — see Radiology Prior Authorization and Notification
When scheduling, confirm the site of service and obtain PA if the policy indicates SOS-dependent authorization

Prior Authorization

Radiology prior authorization reference and SOS notes

For advanced outpatient imaging (CT/MRI/PET, nuclear medicine/nuclear cardiology), refer to the Radiology Prior Authorization and Notification document for the complete list of CPT codes and site‑of‑service rules. Health care professionals ordering advanced outpatient imaging are responsible for notification prior to scheduling. Use the Provider Portal or call 866-889-8054 to request authorization.

Advanced outpatient imaging PA phone: 866-889-8054
Authorization via Provider Portal: Prior Authorization and Notification tool on UHCprovider.com
See Radiology Prior Authorization and Notification for full CPT code lists and SOS guidance

Documentation Required

Prior authorization procedural reference

Consult the procedural sections and the Radiology/Cardiology Prior Authorization references for step‑by‑step prior authorization procedures. Submit requests online via the Provider Portal or by calling the applicable prior authorization phone numbers. Include supporting clinical documentation, diagnosis codes, attending provider information, and, for genetic/molecular tests, the lab name and test description.

Online: Provider Portal → Prior Authorization and Notification
Include clinical documentation, DX codes, and test/lab names for genetic testing
If in doubt, call the listed prior authorization phone numbers for the service category

Prior Authorization

Cranial/neurostimulator procedures and stimulators

Cranial and neurostimulator procedures and implantation of stimulators require prior authorization. The policy lists numerous CPT and HCPCS codes for neurostimulator implantation and related device codes — obtain authorization and provide device model/implant details when submitting.

Neurostimulator CPT examples: 61863, 61864, 61867, 61868, 61885, 61886, 63650, 63655, 63685
Neurostimulator/implant HCPCS examples: L8680, L8682, L8685, L8686, L8687, L8688
Provide device/implant model and clinical indication with the PA request

Prior Authorization

Implantable devices and select surgeries; transplants/CAR T

Implantable devices, select surgeries, transplants and CAR T-cell therapies require prior authorization or direct case management notification. For transplant and CAR T services, contact the UnitedHealthcare Community and State Transplant Case Management Team.

Transplant and CAR T-cell therapy notification/authorization: call UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or use the notification number on the member's ID card
Implantable devices and select surgeries (e.g., VADs, cochlear implants, certain spinal implants) require PA and documentation of device details
For VADs, follow additional Optum VAD Case Management Team instructions when directed

Prior Authorization

Transplant and CAR T-cell therapy notification

For transplant and CAR T-cell therapy services (including Abecma, Breyanzi, Kymriah, Tecartus, Yescarta and others), providers must call the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or follow the notification number on the member's health plan ID card. Preauthorization and case management are required before scheduling.

Transplant/CAR T phone: 888-936-7246
Include indication, prior therapies, cell product name, and planned treatment dates in the notification

Prior Authorization

Vein procedures, unclassified drug codes, VADs

Vein procedures, certain unclassified drug codes, and ventricular assist devices (VADs) require prior authorization. Specific notes: code 38232 requires authorization only for oncology diagnosis; unclassified codes C9399, J3490 and J3590 may require PA for named products (Amtagvi, Lantidra, Lenmeldy, Skysona, Tecelra); VADs require prior authorization and specific notification/fax routing may apply.

Vein procedure examples (ablation/removal of saphenous veins): CPTs listed in policy (e.g., 36468, 36473, 36475, 36478) — prior authorization required
Code 38232: prior authorization required only for an oncology diagnosis
Unclassified codes C9399, J3490, J3590: PA required for specific drugs identified in policy (Amtagvi, Lantidra, Lenmeldy, Skysona, Tecelra)
VADs: prior authorization required; follow Optum VAD Case Management Team instructions and fax routing when requested (855-282-8929)

Provider submission methodsProviders should still use standard submission methods (portal, phone, fax) for non-emergent requests

Prior authorization — definition with examples of services that require PA

Definition and purposePrior authorization is required for certain services and supplies listed in this document to confirm medical necessity before delivery

Examples of services requiring PAExamples include outpatient injectable chemotherapy for cancer, cochlear implants, continuous glucose monitors, home health, hospice, select surgeries and many CPT/HCPCS‑listed procedures

Reference to Radiology PAFor many imaging procedures, providers must refer to the Radiology Prior Authorization and Notification policy for specific PA requirements

How to obtain prior authorization — numeric reference codes used in document

Numeric authorization referencesThe document uses numeric 'how to obtain prior authorization' reference codes (examples shown: 21230, 21280, 21282, 21295, 21740) adjacent to listed CPT/HCPCS entries

Repeated template structureMany lines follow the pattern 'CPT/HCPCS codes and how to obtain prior authorization = <numeric code>' indicating an internal cross‑reference method

Codes appear with entriesThese numeric references are shown repeatedly alongside procedure and drug listings in the policy fragment

Antiemetics prior authorization fragment — template and repetitive structure noted

Antiemetics PA templateSection repeats lines: 'how to obtain prior authorization = <code>' and lists CPT/HCPCS codes with additional information fields (often empty)

Repeated PA codes in sectionCommon numeric references in this fragment include 21280 and 21230; CPT/HCPCS such as 21282, 21295, 21740 are listed repeatedly

Structure noteMany entries include 'Additional information' fields that are blank in the excerpt, reflecting a templated listing format

Prosthetics / DME distinction

Prosthetics vs DMEProsthetics are not considered durable medical equipment (DME) for prior authorization purposes; orthotics and prosthetics have separate PA rules

Orthotics PA thresholdOrthotics and prosthetic codes require prior authorization only when retail purchase or cumulative rental cost exceeds $500

Separate code listingsThe policy lists many L‑ and E‑series codes under orthotics/prosthetics distinct from DME listings

Genetic/molecular testing — definition and PA/notification requirement

DefinitionGenetic and molecular testing performed in an outpatient setting requires prior authorization or notification

BRCA notification requirementBRCA testing requires notification/prior authorization before DNA sequencing; the ordering provider must notify the laboratory and the laboratory will notify UnitedHealthcare

Requesting laboratory infoAuthorization requests must include the requesting laboratory and test name as part of the process (per listed U codes)

Enteral/in-home nutritional therapy — definition and PA requirement

Enteral/in-home nutrition PAEnteral services and in‑home nutritional therapy require prior authorization

Relevant HCPCS/B codesExamples of codes listed include B4034, B4035, B4036 and B4100‑B4161 series for enteral and in‑home nutrition services

DME vs enteral distinctionEnteral services are listed separately from DME and have explicit PA requirements in the policy fragment

Notification/prior authorization — provider must notify lab or obtain authorization before certain tests (e.g., BRCA)

Provider notification requirement for genetic testsFor certain tests (e.g., BRCA), the ordering care provider must notify the laboratory before DNA sequencing; the laboratory will notify UnitedHealthcare

Authorization before testingNotification or prior authorization is required before performing specified genetic/molecular tests listed by U/C codes

Lab and test detailsRequests should include the requesting laboratory and the specific test code(s) as part of the authorization/notification process

Home health/hospice prior authorization — definition note about PA requirement

Home health/hospice PA requirementHome health services provided in outpatient settings and in the member's home require prior authorization; hospice services require prior authorization

Relevant codesHome health codes cited include G0156, G0162, G0299, G0300 and G0493‑G0496; hospice listed as T2045

ScopePA applies when services are outpatient or in‑home per the policy text

Predetermination — recommended review for Review at Launch Medication List

Predetermination recommendationPredetermination is highly recommended for drugs on the Review at Launch Medication List to confirm coverage before administration

ContextPredetermination is advised especially for new‑to‑market medications referenced in the policy

How to request predeterminationUse the standard prior authorization submission channels (Provider Portal or phone) as specified for PA requests

Prior Authorization submission methods — online via portal or phone

Submission channelsSubmit prior authorization requests online via the Prior Authorization and Notification tool on UHCprovider.com, by phone (numbers shown in policy), or by fax where specified

Portal instructionsTo use the portal, sign in at UHCprovider.com and select the Prior Authorization and Notification tab on the dashboard

Phone numbersPhone contacts in the document include 800‑600‑9007, 888‑397‑8129 and 866‑889‑8054 for specific services

Advanced outpatient imaging — definition of advanced imaging types that may require PA

Advanced outpatient imaging definitionCertain CT, MRI, MRA, PET scans and nuclear medicine/nuclear cardiology procedures are classified as advanced outpatient imaging that may require prior authorization

Provider responsibilityProviders ordering advanced outpatient imaging are responsible for notifying UnitedHealthcare prior to scheduling the procedure

How to request PAAuthorization for advanced outpatient imaging may be requested via the Provider Portal or by calling 866‑889‑8054 per the policy

Prior authorization request methods — phone number and portal reference for submitting PA requests

Submission phone and portalTo request prior authorization, submit online via UHCprovider.com Prior Authorization and Notification tool or call the phone number specified for the service (examples: 888‑397‑8129 or 866‑889‑8054)

Portal access stepsSign in at UHCprovider.com with One Healthcare ID and select the Prior Authorization and Notification tab to submit requests

Fax optionSome sections list fax as an available submission method (example general contact: fax 877‑310‑3826)

Radiology PA document reference — many entries refer to Radiology Prior Authorization and Notification

Radiology PA document referenceMany entries reference the Radiology Prior Authorization and Notification policy for specific CPT/HCPCS PA requirements and for 'how to obtain prior authorization' instructions

Site-of-service notesRadiology entries note that prior authorization may be required only for outpatient hospital settings and not when performed at a participating ASC for some codes

Cross-reference guidanceProviders must consult the Radiology Prior Authorization and Notification resource for the complete list of CPT codes and PA procedures

SOS - outpatient hospital — site of service definition reference

Site of service (SOS) — outpatient hospital'Site of service (SOS) - outpatient hospital' is used in the policy to indicate when prior authorization is required for services delivered in an outpatient hospital setting

SOS effect on PAFor some procedures, PA is required only when the service is requested in an outpatient hospital; PA may not be required if performed at a participating ASC

Radiology cross-referenceSOS notes frequently direct providers to the Radiology Prior Authorization and Notification policy for details

Stimulators / Implantation — definition note about stimulator/implant devices and HCPCS mapping

Stimulator/implantation devicesStimulators and implantable device procedures (e.g., bone growth stimulators, neurostimulators) require prior authorization as listed; related HCPCS/CPT codes are enumerated

HCPCS/CPT mapping noteThe policy lists specific HCPCS (e.g., E0747, E0748, E0749, E0760) and CPT codes (e.g., 63650, 63655) associated with stimulators/implantation procedures

SOS also appliesSome stimulator/implantation entries include a site‑of‑service (SOS) condition noting outpatient hospital applicability

38232 — code-specific PA rule (oncology exception)

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

Unclassified code exceptionsCertain unclassified/temporary codes (e.g., C9399, J3490, J3590) require PA only for specific gene/biologic therapies listed in the policy

Contextual listing38232 appears within vein/procedure listings and is explicitly noted as oncology‑only for PA

Transplant/CAR T notification — case management contact guidance

Transplant/CAR T notificationFor transplant and CAR T‑cell therapy services (listed products), providers must call the UnitedHealthcare Community and State Transplant Case Management Team at 888‑936‑7246 or use the notification number on the member ID card

Case management requirementThese services require case management contact prior to scheduling per the policy text

Examples listedNamed CAR T products include Abecma, Breyanzi, Kymriah, Tecartus and Yescarta in the policy guidance

VAD case management — VAD notification and fax process to Optum VAD Case Management Team

VAD notification and PAVentricular assist devices (VADs) require prior authorization and notification; providers should call the notification number on the member's ID card and then fax the nurse‑provided form to the Optum VAD Case Management Team at 855‑282‑8929

Contact stepsCall the member ID notification number first, then fax the required form to Optum VAD Case Management Team at 855‑282‑8929

Policy placementVAD instructions are included in the vein/procedures and device implantation sections alongside PA requirements for related CPT/HCPCS codes