ModifiedUnitedHealthcarePolicy N/A

Prior authorization requirements (Colorado Rocky Mountain Health Plan)

This document lists services that require prior authorization from UnitedHealthcare Colorado Rocky Mountain Health Plan (CHP) and explains how providers should request authorization; it applies to participating and non-participating providers when UnitedHealthcare CHP is the primary payer.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements (Colorado Rocky Mountain Health Plan)

Policy CodePolicy N/A

Change TypeMultiple code additions and prior authorization flags

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests and supporting documentation online at UHCprovider.com/priorauth or via eviCore (www.evicore.com, 800-792-8750); non-participating providers may fax requests to 800-262-2567 or 970-255-5681.

SourceLink

POLICY UPDATE CHANGES

Effective Oct 1, 2024: Prior authorization required for Q5133 and many related HCPCS mappings (multiple Q-codes to C-/Q- codes).

Effective January 1, 2024 - Izervay only use temp codes of J3490, J3590.

Effective Oct 1, 2024: code C9172, prior authorization is only required for Beqvez.

Effective Aug 1, 2023 Prior authorization required for J0174.

Effective Oct 1, 2024: Prior authorization required for Q5133 and multiple listed HCPCS/CPT codes (examples include S1030, S3650, 90587, 90626, 97597, 99174, 20957, 59897, many L-codes).

Q5133Newly flagged code

No PAEmergency rule

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PA submission channels

~120+Representative code volume

Coverage and Prior Authorization Criteria

Prior authorization general rules

Covered when ALL of the following are met:

Services not included in the Member's Evidence of Coverage will not be authorized.

Prior authorization is required for the listed services except for emergency or urgent care.

Participating providers should submit prior authorization requests and supporting documentation via UHCprovider.com/priorauth (Advance Notification and Plan Requirement Resources).

For certain clinical areas (for example, cardiology and oncology) and many specified codes, notifications/prior authorizations should be submitted to eviCore (www.evicore.com, 800-792-8750).

Non-participating providers may fax requests to 800-262-2567 or 970-255-5681.

Oncology drug prior authorization

Covered when ALL of the following are met:

Injectable chemotherapy drugs administered in an outpatient setting (including intravenous, intravesical, intrathecal) for a cancer diagnosis require prior authorization.

Specific J- and Q-code ranges and individual chemotherapy/oncology agents listed (for example J9000-J9999 and multiple Q-codes) require authorization.

Bone modifying agents and colony stimulating factors identified by listed J- and Q-codes require prior authorization.

Oncology-related prior authorization requests should be submitted via eviCore as instructed in the document.

Prior authorization and classification notes

Notes on authorization classification and applicability:

Submit notification/prior authorization requests online at www.evicore.com or by phone at 800-792-8750 for codes and services routed to eviCore.

Certain listed items and durable medical equipment (DME) explicitly require prior authorization as noted in the list.

Prosthetics are not classified as DME in this document; see the Orthotics and prosthetics section for prosthetic L-code requirements.

Prior Authorization Requirement

Covered when ALL of the following are met:

Prior authorization is required for the listed DME and enteral service HCPCS/CPT/K codes shown in the document.

Requests for the listed DME and enteral services should be submitted via the eviCore notification/prior authorization channels (www.evicore.com or 800-792-8750) as indicated.

PA-required services (partial)

Covered when ANY of the following apply:

Enteral services and in‑home nutritional therapy codes (examples: B4149, B4150, B4152, B4153, B4154, B4155, etc.) are listed as requiring prior authorization.

Procedures identified as experimental or investigational in the list (specific CPT codes enumerated) require prior authorization.

Genetic tests and laboratory services identified by the enumerated CPT/PLA/U codes require prior authorization; some genetic/molecular codes are routed to eviCore as noted.

Prior authorization

Covered when ALL of the following are met:

Prior authorization is required for genetic tests and laboratory services identified by the listed CPT/HCPCS/U codes within this section.

Prior authorization requirements (excerpt)

Covered when ANY of the following service‑specific criteria are met:

Genetic tests and laboratory services shown with 'How to Obtain Prior Authorization' instructions require prior authorization.

Hearing, audio and vision services listed in the document (codes shown) require prior authorization.

Home healthcare services identified by listed home health codes require prior authorization.

Hyperbaric oxygen treatment (code G0277) requires prior authorization.

Prior authorization coverage criteria (summary)

Prior authorization is required for the following categories and specific codes (examples):

Home healthcare services: prior authorization required for the listed home health codes (for example G0176, G0248, G0249, G0250, S9340‑S9343, S9355, S9364‑S9368).

Hyperbaric oxygen treatment: prior authorization required for code G0277.

Injectable medications: numerous J‑codes and mapped codes listed throughout the document require prior authorization; unclassified/temporary codes (J3490, J3590, C9399) require prior authorization only for specified drugs as noted.

Q5133 and many mapped HCPCS/C‑/Q‑codes are subject to a new prior authorization requirement effective Oct 1, 2024 as enumerated in the document.

Prior Authorization — Code-specific

Covered when ALL of the following are met:

Effective Oct 1, 2024: prior authorization is required for Q5133 and the numerous HCPCS/CPT/S/L codes mapped and listed in this segment.

This requirement applies to injectable medications, medicine services, procedures, musculoskeletal, obstetrical, and prosthetics codes as enumerated; providers must obtain prior authorization prior to billing.

Prior authorization code lists (radiology, pain management, orthotics/prosthetics)

The following service categories and code groups require prior authorization as listed (select examples):

Radiology examples: Advanced outpatient imaging codes (examples include 70450, 70460, 70540, 71250, 71550, 72125, etc.) require prior authorization; eviCore is the referenced prior authorization vendor for advanced imaging.

Pain management examples: Select pain management procedure codes (for example 64451‑64495 series) require prior authorization.

Orthotics/prosthetics examples: Multiple L‑codes for orthotics and prosthetics (examples include L6883‑L6885, L6900, L6905, etc.) require prior authorization as listed.

Authorization requirement for listed procedures

Providers must obtain prior authorization before scheduling in these categories:

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

For notification/prior authorization of advanced outpatient imaging and many listed procedures, submit requests online at www.evicore.com or call 800‑792‑8750.

Prior Authorization Requirements (section)

Covered when ANY of the following procedure‑category conditions are met:

Transplant procedures listed in the document require prior authorization.

Urinary system procedures identified in the list require prior authorization.

Vein procedures, including removal and ablation of the main trunks and named branches of the saphenous veins for treating venous disease and varicose veins, require prior authorization.

Codes and Coding Rules

Bariatric surgery (CPT)CPTCovered

43644	Bariatric surgery - gastric bypass (Roux-en-Y)
43645	Bariatric surgery - revision or conversion of prior bariatric procedure
43770	Laparoscopy, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (with small intestine reconstruction)
43771	Laparoscopy, gastric restrictive procedure; with gastric bypass and small intestine reconstruction
43772	Laparoscopy, gastric restrictive procedure; other
43773	Laparoscopy, gastric restrictive procedure; other (open)
43774	Laparoscopy gastric restrictive; adjustable gastric band
43775	Laparoscopic adjustable gastric band removal
43842	Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass
43843	Laparoscopy, gastric restrictive procedure; with revision

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1/2

Bariatric surgery (HCPCS)HCPCSCovered

S2083

Bariatric surgery device or supply (HCPCS S-code)

Chemotherapy / Oncology drugs (J-codes and related)HCPCSCovered

J9000-J9999	Chemotherapy injectable drugs range (specific agents billed within this series require prior auth)
J0640	Leucovorin, for injection
J0641	Levoleucovorin, for injection
J0642	Levoleucovorin, per mg
J1950	Leuprolide acetate (Lupron Depot)
J0885	Injection, pertuzumab (example), antineoplastic
J1449	Injection, example colony stimulating factor (HCPCS placeholder)
J1932	Injection, trastuzumab (example)
J1954	Injection, example antineoplastic
A9607	Lutetium Lu 177 injection (theranostic agent)

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Chemotherapy - related Q/C codes and miscmixed

Q5108-Q5122

Range of Q-codes for colony stimulating factors and related oncology injectables

Injectable / Medical supplies (sample mapping & temp codes)HCPCS

Q5133	Temporary/novel injectable code - see mapping and prior authorization exceptions
Q5135	Temporary code mapping example
C9399	Unclassified drug code (miscellaneous) - prior auth required for specific drugs
J3490	Unclassified drug code - prior auth required for select agents
J3590	Unclassified drug code - prior auth required for select agents (effective temp code uses)
C9172	Specific product code requiring PA only for named product (Beqvez)
Q5101	Sample Q-code listed in injections section

Notable injectable/temp code rulesmixed

Effective Jan 1, 2024	Izervay use J3490, J3590 temporary codes
Effective Oct 1, 2024	Prior authorization required for Q5133 and many mapped C-/Q- codes as listed
Note	For unclassified and temporary codes C9399, J3490, J3590 prior authorization is required only for specified agents (list in policy).

Durable Medical Equipment (sample HCPCS)HCPCSCovered

A9999	Unclassified DME HCPCS - prior auth required for specific items
E0250	External power wheelchair component (example)
E0260	Power wheelchair component (example)
K0898	DME K-code example
S1030	Sample supply HCPCS referenced in injectable mappings
S2083	Bariatric-related HCPCS S-code (also listed under bariatric)

DME / HCPCS additional examplesHCPCS

E2219	DME example
E2220	DME example
K0014	DME K-code example
K0015	DME K-code example

Partial - Prior authorization conditionality for unclassified codesmixed

C9399 / J3490 / J3590

PA required only for a specified list of high-cost agents; see policy notes for effective dates and product lists.

How Providers Request Authorization and Required Actions

Prior Authorization

Prior authorization required for selected enteral, in‑home nutritional, and experimental services

Prior authorization is required for selected enteral services, in-home nutritional therapy (enteral or otherwise), and certain services considered experimental or investigational. Providers must request prior authorization before providing these services to ensure coverage decisions and to avoid claim denials.

Enteral services (examples listed in policy): B4149, B4150, B4152, B4153
In‑home nutritional therapy codes requiring authorization: B4154, B4155
Certain enteral/DME HCPCS codes (e.g., E2298, K0868–K0885 series)

Prior Authorization

PA requirement for experimental/investigational and ENT CPT codes

Experimental and investigational services and selected ENT procedures require prior authorization. When submitting requests, include clinical rationale and supporting documentation for investigational claims.

Experimental/investigational examples include listed procedure and supply codes (see full genetic/experimental code lists)

Definitions and Key Terms

prior authorization

DefinitionPrior authorization is the process where providers seek approval before rendering a service; required under UnitedHealthcare policy.

How to requestParticipating providers: submit requests and supporting documentation online at UHCprovider.com/priorauth > Advance Notification and Plan Requirement Resources.

Non-participating providersMay fax requests and documentation to 800-262-2567 or 970-255-5681.

ExceptionsPrior authorization is not required for emergency or urgent care.

advance notification

DefinitionAdvance notification: provider communication to UnitedHealthcare so prospective, concurrent and retrospective care review can be performed.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements (Colorado Rocky Mountain Health Plan)

Policy CodePolicy N/A

Change TypeMultiple code additions and prior authorization flags

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

ENT-specific CPT/HCPCS examples requiring authorization: 68816, 69705–69706, 69719, 69726–69730, 69727–69728, 69730

Prior Authorization

Prior authorization for genetic/molecular lab test codes

Prior authorization is required for many genetic and molecular laboratory tests. Submit requests to eviCore when indicated and include pertinent clinical documentation, test indication, and results of prior relevant testing.

Representative genetic/molecular test codes that require PA include (but are not limited to): 0001U, 0002U, 0003U, 0004M, 0005U, 0006M, 0007M, 0009U, 0010U, 0011M, 0013M, 0016M, 0338T, 0342U, 0344U, 0345T
Many additional U-, T-, and multi‑segment CPT codes in the 80000–03000 ranges shown in the policy require prior authorization — verify the member’s plan and use eviCore as instructed

Prior Authorization

Temporary/unclassified code prior authorization notes

Temporary, unclassified, and miscellaneous codes (for example J3490, J3590, J1748, C9399, J0174 and other J‑codes/C‑codes noted) may require prior authorization depending on the drug or supply billed with the code. Authorization may be limited to specific products mapped to those temporary codes.

Unclassified/temporary codes requiring PA only when used for specific products (examples): C9399, J3490, J3590 — PA required only for select drugs (Amvuttra, Fylnetra, Lupaneta Pack, Nulibry, Recovi, Riabni, Rivfloza, Skyrizi, white blood cell colony stimulating factors, Veopoz, Beqvez)
Effective Jan 1, 2024: Izervay uses J3490/J3590 temporary codes
Effective Oct 1, 2024 and other noted effective dates: check policy for code‑to‑product mappings

Prior Authorization

Prior Authorization — Prosthetics (L‑codes)

Prior authorization is required for prosthetics and many orthotics/prosthetics L‑codes. Providers must obtain authorization prior to dispensing or scheduling services.

Examples of prosthetics/orthotics L‑codes requiring prior authorization: L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5400, L5420, L5460
Additional hospital/obstetrical prosthetic mappings from S2409/S2411 to L‑codes are listed in the policy — verify specific code pairs before submission

How to submitSubmit notification/prior authorization via UHCprovider.com/priorauth or eviCore (www.evicore.com, 800-792-8750).

Admitting facility notificationPhone: 800-416-2157, option 4 or 970-248-5197.

Prosthetics vs DME

ClarificationProsthetics are not classified as Durable Medical Equipment (DME); see Orthotics and prosthetics section for L-code treatment.

DME mapping examplesSeveral E- and K-codes listed in DME sections are separate from prosthetics (examples: E0170, E0250, K0898).

Provider actionSubmit prior authorization requests for prosthetics per Orthotics and prosthetics guidance via the listed channels (eviCore/UHCprovider).

Prior authorization

ApplicabilityCertain listed items and DME require prior authorization as explicitly noted in the document.

Submission channelsFor notification/prior authorization submit requests online at www.evicore.com or call 800-792-8750.

Coverage noteServices not a benefit of the member's Evidence of Coverage will not be authorized.

Prior Authorization Requirement

Enteral and in-home nutritional therapyPrior authorization required for listed enteral HCPCS codes (examples include B4149, B4150, B4152, B4153) and associated in‑home nutrition codes.

DME examplesMultiple K- and E-codes (e.g., K0868, K0869, E0652, E0655) listed with prior authorization instructions.

How to obtainHow to Obtain Prior Authorization entries reference specific K/E codes and require submission via the indicated channels (eviCore/UHCprovider).

Genetic tests/lab services

Genetic/molecular tests requiring PANumerous molecular/genetic CPT/PLA/U codes require prior authorization (many routed to eviCore as indicated, e.g., 0013M, 0414U, 81221).

How to obtainWhere noted, 'How to Obtain Prior Authorization' directs providers to eviCore (www.evicore.com, 800-792-8750) or specified submission instructions.

PA statementThe document explicitly states: 'Prior authorization required' for genetic tests/lab services in listed entries.

Genetic tests/lab services

Code groupsSpecific genetic test codes (examples: 0338T, 0348U, 0351T) are listed with 'How to Obtain Prior Authorization' instructions.

PA requirementGenetic tests/lab services entries include the note 'Prior authorization required.'

Vendor routingSome genetic test codes are marked '(eviCore)' indicating routing to eviCore for authorization.

Home healthcare

DefinitionHome healthcare: services delivered in the home setting; listed home health codes require prior authorization.

Example codesHome health codes listed include G0176, G0248, G0249, G0250 and multiple S- codes (e.g., S9340–S9343).

How to obtainHow to Obtain Prior Authorization entries indicate submission via the listed channels (eviCore/UHCprovider) for these codes.

Hyperbaric oxygen treatment

ServiceHyperbaric oxygen treatment

PA requirementPrior authorization required for hyperbaric oxygen treatment as noted in the document.

Example codeG0277 is listed with 'Prior authorization required.'

J3490, J3590, C9399

Temporary/unclassified codesJ3490; J3590; C9399 are treated as temporary/unclassified drug codes in this list.

PA conditionalityPrior authorization for J3490/J3590/C9399 is required only for specified drugs (examples enumerated in the policy).

Code mapping examplesThe document maps some specific injectable drug codes to these unclassified codes for authorization handling (see detailed entries).

Effective Oct 1, 2024 change applying prior authorization to Q5133 and mapped codes

Effective dateEffective Oct 1, 2024: Prior authorization required for Q5133 and numerous mapped HCPCS/C codes as listed.

ScopeThe change applies to Q5133 and many C-/Q-/M-/P- mapped codes and supply codes enumerated across the entries.

Provider actionProviders must obtain prior authorization for Q5133 and mapped codes beginning Oct 1, 2024 before billing or scheduling services.

Prior authorization

General rulePrior authorization is required for listed services except emergency or urgent care.

How to requestSubmit requests via UHCprovider.com/priorauth or eviCore (www.evicore.com, 800-792-8750); non-participating providers may fax to 800-262-2567 or 970-255-5681.

Coverage noteServices not a benefit in the Member's Evidence of Coverage will not be authorized.

L-codes

DefinitionL-codes: HCPCS codes that refer to prosthetics and related supplies.

PA requirementMultiple L-codes for orthotics/prosthetics are included in the prior authorization list and require authorization as documented.

Obstetrical mappingsSeveral S-codes map to L-codes for prosthetics and are noted as subject to prior authorization (examples: S2411 = L3649, L4000).

eviCore

VendoreviCore is referenced as the prior authorization/notification vendor for advanced outpatient imaging procedures.

Provider responsibilityCare providers ordering Advanced Outpatient Imaging must provide notification/request prior authorization before scheduling the procedure.

ContactSubmit requests online at www.evicore.com or call 800-792-8750.

Prior authorization (authorization required for participating physicians for listed CPT/HCPCS codes)

RequirementParticipating physicians requesting the listed CPT/HCPCS medicine and imaging codes must obtain prior authorization as indicated.

How to obtainFor advanced outpatient imaging, submit notification/prior authorization via eviCore (www.evicore.com, 800-792-8750).

ExamplesSample listed CPT/HCPCS codes requiring authorization include CT/MRI codes (e.g., 70450, 70553) and other advanced imaging CPT codes listed in radiology section.

Prior authorization

Musculoskeletal and therapy codesMusculoskeletal procedure and therapy CPT codes (examples: 97597, 97598, 99174) are listed as requiring prior authorization effective Oct 1, 2024.

Medicine/procedure examplesMedicine service codes requiring authorization include 90587 and 90626 as listed in the document.

Provider instructionObtain prior authorization prior to scheduling or billing for these codes as per the Oct 1, 2024 effective entries.

Transplants

ScopeTransplant procedures are explicitly listed as requiring prior authorization.

ExamplesTransplant-related CPT codes referenced include 32850–32856 and 33930 series among others.

How to obtainSubmit notification/prior authorization via www.evicore.com or call 800-792-8750 as indicated in transplant entries.

Urinary system

ScopeUrinary system procedures listed in the document require prior authorization.

Provider actionProviders must request prior authorization via www.evicore.com or call 800-792-8750 as shown in the urinary system section.

Coverage noteSpecific CPT/HCPCS codes for urinary procedures are enumerated in the section; authorization required before scheduling/billing.

Vein procedures / saphenous vein ablation

ScopeVein procedures, including removal and ablation of the main trunks and named branches of the saphenous veins for venous disease/varicose veins, require prior authorization.

How to obtainProviders should submit authorization requests via www.evicore.com or call 800-792-8750 as directed in the vein procedures entries.

Clinical detailThe entries specifically describe removal and ablation of saphenous vein trunks/branches as subject to prior authorization.