CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for UnitedHealthcare Community Plan of Florida

List of services, CPT/HCPCS/ICD-10 codes, and instructions for submitting prior authorization requests for participating UnitedHealthcare Community Plan of Florida providers. Applies to inpatient and outpatient services and out-of-network providers (excluding emergency/urgent care).

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Florida

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2024-09-01policy effective date stated

Portalsubmission method described

Exemptemergency/urgent care

$500DME cost threshold

Manycode listings present

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 Requiring Prior Authorization

Partial prior authorization criteria by service

Services and codes that require prior authorization (partial list from document).

Acupuncture: prior authorization required for CPT/HCPCS codes 97810, 97811, 97813, 97814.

Bariatric surgery and specific obesity-related services: prior authorization required for CPT codes 43644, 43645, 43659, 43770.

Breast reconstruction (non-mastectomy): prior authorization required for CPT/HCPCS codes 19371, 19380, 19396 and HCPCS L8600.

Cancer supportive care (colony-stimulating factor drugs and bone-modifying agents) administered in an outpatient setting for a cancer diagnosis require prior authorization; example injectable drug Filgrastim J1442 listed.

Cardiovascular services: prior authorization required; specific referenced CPT codes include ranges such as 37220–37230 (see listing).

Prior authorization requirements (partial list)

Selected coverage/prior authorization positions from the document section:

Inpatient video electroencephalogram (EEG): prior authorization required for inpatient video EEG (CPT codes 95700, 95711–95713, 95716, 95718).

Outpatient EEG: prior authorization not required for EEGs performed in an outpatient hospital or ambulatory surgical center.

Injectable chemotherapy (outpatient): prior authorization required for chemotherapy injectable drugs billed J9000–J9999, leucovorin J0640, levoleucovorin J0641/J0642, Lupron Depot J1950, Q‑coded chemotherapy injectables, and miscellaneous HCPCS for unassigned injectables; submit requests online via the UnitedHealthcare Provider Portal or call 888-397-8129.

Cochlear implants and other auditory implants: prior authorization required (examples: CPT 69710, 69714, 69930; HCPCS L8614, L8619, L8690–L8692).

Continuous glucose monitors: prior authorization required when diagnosis is type 2 diabetes (HCPCS A9276, A9277, A9278).

Prior authorization requirements by service/category

Selected service categories and specific codes require prior authorization or notification as listed.

Durable medical equipment (DME): prior authorization required only for the DME codes listed (examples include A9279, A9280, A9900, E0265, E0270, E0300); DME items with a retail purchase or cumulative rental cost of more than $500 require prior authorization.

Enteral and in-home nutritional services: prior authorization required for listed B-codes (examples: B4034, B4035, B4036, B4100, B4102).

Functional endoscopic sinus procedures: prior authorization required for listed CPT codes (examples: 31240, 31253–31259, 31267, 31276, 31287, 31288).

Genetic and molecular testing: prior authorization or notification required for multiple CPT codes (examples: 81162, 81163, 81164 and an extensive list of 81415–81443 and U‑codes); some codes require that the ordering provider or laboratory be specified as part of the notification process.

Prior authorization and notification items

Codes and items in this section are subject to prior authorization or notification as indicated:

Home health care: HCPCS codes such as S3870, S9122, S9123, S9124, T1031, T1021 require prior authorization when provided in outpatient settings including the member's home.

Hysterectomy: prior authorization required for listed hysterectomy CPT codes (examples: 58150, 58152, 58180, 58260, 58262–58263, 58267, 58270, 58275, 58290–58292, 58542–58543).

Injectable medications: numerous J‑ and Q‑codes require prior authorization; document lists many specialty drug HCPCS codes and mapped brand names (examples across the listing include J0172, J1413, J2508, J2326, J9226, J9202, J3399, among others).

Genetic/molecular test notification: genetic and molecular testing CPT and U‑codes have notes indicating either authorization required or that the laboratory will notify UnitedHealthcare; specific U‑codes (e.g., 0285U–0299U range examples) appear in the listing.

Specific specialty drugs and biologics (examples: Spinraza J2326, Spravato S0013, Stelara listings) are included in injectable medication lists and carry prior authorization requirements.

PA requirements (enumerated)

Prior authorization requirements and submission instructions for listed drugs, procedures, and durable medical equipment:

How to obtain prior authorization: submit prior authorization requests using the UnitedHealthcare Provider Portal or call 888-397-8129; for select biologics (Cimzia, Synagis, Xolair) obtain prior authorization through Optum Rx at 800-310-6826.

Joint total hip and knee replacement procedures: prior authorization required for listed joint replacement CPT codes as enumerated in the document.

Massage therapy: prior authorization required for codes 97010, 97112, 97124, 97140.

Non-emergent air ambulance transport: prior authorization required for A0430, A0431, A0435, A0436.

Orthotics and prosthetics: prior authorization required only for the orthotics and prosthetic codes listed when retail purchase or cumulative rental cost exceeds $500 (see L‑code listing).

Prior authorization/notification criteria and code listings

Prior authorization and notification requirements for specified services and codes:

Outpatient therapy evaluation and re-evaluation codes: prior authorization required; requests must be submitted by a primary care provider and submitted online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (examples include evaluation codes 97161–97168).

Outpatient therapy (selected CPT codes): for prior authorization/notification contact OptumHealth Physical Health at 800-873-4575 or use the number on the member's ID card (therapy code examples listed in the document).

Advanced outpatient imaging: care providers ordering certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures must provide notification prior to scheduling and submit requests online via the Prior Authorization and Notification tool or call 866-889-8054; radiology T‑codes cited include 0697T, 0698T, 0710T, 0711T.

Orthotics/prosthetics L‑codes: numerous L‑codes listed in the document require prior authorization (see L8040–L8612 and other L‑code groupings in the listing).

Prior authorization criteria (code & site rules)

Prior authorization required for the following categories and conditions:

Radiology and advanced imaging: certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures require prior authorization; specific T‑codes cited include 0697T, 0698T, 0710T, 0711T.

Site‑of‑service rule: prior authorization is required when requesting services in an outpatient hospital setting; prior authorization is not required if the same service is performed at a participating ambulatory surgery center (ASC).

Transplant and CAR T‑cell therapy: prior authorization/notification required for transplant and CAR T‑cell services; providers must call the Optum transplant team at 888-936-7246 or use the notification number on the member's ID card (branded CAR‑T products listed in the document).

Surgical and procedure categories: specified surgical categories (rhinoplasty/septoplasty, shoulder surgery, sinuplasty, sleep apnea procedures, spinal surgery, implantable stimulators and select transplants) have associated CPT codes enumerated that require prior authorization as listed in the section; code 38232 requires prior authorization only when associated with an oncology diagnosis.

Prior authorization requirements (segment)

Prior authorization required for the following procedure groups and codes as listed in this segment:

Vein procedures (removal and ablation of saphenous vein trunks and named branches): prior authorization required for CPT codes 36473, 36475, 36478, 37700, 37718, 37780, 37722, 37765, 37766.

Ventricular assist devices (VAD): prior authorization required; providers should call the notification number on the back of the member's health plan ID card and fax required forms to the Optum VAD Case Management team at 855-282-8929 (related CPT/HCPCS examples include 33927–33929 and Q0507–Q0509).

CPT, HCPCS and ICD-10 Codes

Highlighted CPT/HCPCS groupsmixed

19371	Breast reconstruction (partial list)
19380	Breast reconstruction (partial list)
19396	Breast reconstruction (partial list)
L8600	Breast prosthesis
J1442	Filgrastim (Neupogen)
J0256	Aralast NP
J9202	Zolgensma
J3399	Unclassified (see policy)

Cardiovascular-related ICD-10 codesICD-10Covered

E08.52	Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy
E09.52	Drug or chemical induced diabetes with peripheral angiopathy
E10.52	Type 1 diabetes with peripheral angiopathy
E11.52	Type 2 diabetes with peripheral angiopathy
E13.52	Other specified diabetes with peripheral angiopathy
I70.221	Atherosclerosis of native arteries of right leg with rest pain
I70.222	... left leg
I70.223	... bilateral legs
I70.228	Other extremity involvement
I70.229	Unspecified extremity

Osteomyelitis ICD-10 examplesICD-10Covered

M86.261	Acute hematogenous osteomyelitis, right shoulder
M86.262	... left shoulder
M86.269	... unspecified shoulder
M86.271	Chronic osteomyelitis, right shoulder
M86.272	... left shoulder
M86.279	... unspecified shoulder

Cosmetic & Reconstructive CPT examplesCPT

14060	Adjacent tissue transfer or rearrangement
15821	Secondary reconstruction
15847	Scar revision
17108	Destruction benign lesion(s)
21139	Reconstruction of skull

Sample DME codes requiring prior authorizationHCPCS

A9279	Durable medical equipment - misc
A9280	DME - misc
A9900	DME - misc
E0265	Electric lift chair
E0270	Misc DME
E0300	Hospital bed
E0328	Patient lift
E0329	Patient lift
E0445	Nebulizer
E0470	Oxygen concentrator

Enteral nutrition HCPCS codesHCPCSCovered

B4034	Enteral nutrient, bacterial formula
B4035	Enteral nutrient
B4036	Enteral nutrient
B4100	Enteral supply
B4102	Enteral supply

Listed CPT/HCPCS code groups (therapy, genetic testing, radiation)mixed

92521	Audiology/therapy codes (example mapping)
97161	PT evaluation level 1
81415	Genetic testing - exome
81416	Genetic testing
77014	Radiology prior authorization (example)
77385	IMRT planning

Selected injectable / HCPCS codes (partial list)HCPCS

J0172	Aduhelm
J0739	Apretude
J0585	Botulinum toxin
J1413	Injectable (example)
J1554	Additional injectable
J9376	Veopoz

Named drugs in this sectionmixed

Filgrastim - J1442	Colony-stimulating factor (requires prior auth for oncology outpatient)
Neupogen - J1442	Filgrastim product
Nivestym - J1442	Filgrastim-aafi
Zolgensma - J9202	Gene therapy

Orthotics / Prosthetics examples (partial list)HCPCS

L0170	Knee orthosis
L0456	Foot orthosis
L0462	Shank advance
L0480	Lower extremity prosthesis
L0710	Prosthetic accessory

Orthotics/prosthetics L-codes (selection)HCPCS

L3649	Custom foot orthotic
L3671	Ankle/foot orthosis
L3720	Prosthetic component
L3976	Prosthetic device
L6580	Custom prosthetic

Outpatient therapy evaluation / re-eval CPT codesCPTCovered

97161	PT eval, low complexity
97162	PT eval, moderate
97163	PT eval, high
97164	PT re-eval

Radiation therapy and advanced radiology codesCPTCovered

77014	Radiology prior auth example
77385	IMRT treatment planning
77386	IMRT delivery
77520	Proton beam therapy
77331	Special/associated services

Radiology T-codes (selected)CPT

0697T	Advanced imaging code
0698T	Advanced imaging code
0710T	Advanced imaging code
0711T	Advanced imaging code

Spinal surgery and instrumentation CPT examplesCPT

22533	Anterior cervical discectomy
22612	Spinal fusion
22830	Posterior instrumentation
63030	Laminectomy
63685	Implant neurostimulator

Cardiovascular ICD-10 codes requiring prior authorizationICD-10Covered

E08.52	Diabetes with peripheral angiopathy
E09.52	Diabetes with peripheral angiopathy
E10.52	Diabetes with peripheral angiopathy
E11.52	Diabetes with peripheral angiopathy
E13.52	Other specified diabetes with peripheral angiopathy
I70.221	Atherosclerosis of native arteries, right leg with rest pain
I70.222	... left leg
I70.223	... bilateral legs
I70.228	... other extremity
I70.229	... unspecified extremity

Osteomyelitis ICD-10 codes (sample)ICD-10Covered

M86.261	Acute hematogenous osteomyelitis, right shoulder
M86.262	... left shoulder
M86.269	... unspecified shoulder
M86.271	Chronic osteomyelitis, right shoulder
M86.272	... left shoulder
M86.279	... unspecified shoulder
M86.30	Acute osteomyelitis, pelvis
M86.351	Chronic osteomyelitis, right lower leg

Cosmetic and reconstructive surgery CPT codes (examples)CPT

14020	Adjacent tissue transfer (example)
14060	Adjacent tissue transfer
15821	Secondary reconstruction
15847	Scar revision
17106	Destruction of benign lesions
21137	Reconstruction of facial bones
21139	Craniofacial reconstruction
21172	Maxillofacial reconstruction

Sample DME codes requiring prior authorizationHCPCS

A9279	DME - miscellaneous
A9280	DME - miscellaneous
A9900	DME - miscellaneous
E0265	Patient lift
E0270	Standing frame
E0300	Hospital bed
E0328	Patient lift component
E0329	Patient lift component
E0445	Nebulizer
E0457	Room air or oxygen equipment

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Enteral nutrition / in-home nutritional HCPCS codesHCPCSCovered

B4034	Enteral nutrient, complete formula
B4035	Enteral nutrient, modular
B4036	Enteral nutrient
B4100	Enteral supply, pump
B4102	Enteral supply

Listed CPT/HCPCS code groupsmixed

81162	Genetic/molecular testing
81415	Targeted genomic sequence analysis
81416	Genetic testing
81431	Certain gene panels
0018U	Genetic test (temporary U-code)
0022U	Genetic test (temporary U-code)
0023U	Genetic test (temporary U-code)
0055U	Genetic test (temporary U-code)
0060U	Genetic test (temporary U-code)
0087U	Genetic test (temporary U-code)

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Selected injectable / HCPCS codes (partial list)HCPCS

J7325	Injectable (example)
J7326	Injectable (example)
J7327	Injectable (example)
J7331	Injectable (example)
J1413	Injectable medication
J1554	Additional injectable
J2329	Briumvi
J0225	Amvuttra
J1426	Amondys 45
J0172	Aduhelm

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Drugs named in this sectionmixed

Aralast - J0256	Alpha-1 proteinase inhibitor
Zolgensma - J9202	Onasemnogene abeparvovec
J3399	Unclassified drug code (see policy)
Filgrastim - J1442	Colony-stimulating factor
Neupogen - J1442	Filgrastim
Nivestym - J1442	Filgrastim-aafi

Orthotics and Prosthetics codes (partial)HCPCS

L0170	Knee orthosis
L0456	Foot orthosis
L0462	Shank/heel orthosis
L0480	Lower extremity prosthesis
L0624	Transtibial socket
L0710	Prosthetic accessory
L1300	Shoulder/humeral prosthesis
L1680	Prosthetic component
L3649	Custom foot orthosis
L3976	Prosthetic device

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Outpatient therapy evaluation / re-evaluation CPT codesCPTCovered

92507	Speech therapy evaluation
92508	Speech therapy (related)
92521	Audiology
97161	PT eval level 1
97162	PT eval level 2
97163	PT eval level 3
97164	PT re-evaluation

Radiation therapy and advanced radiology codesCPTCovered

77014	Advanced radiology prior auth example
77385	IMRT planning
77386	IMRT delivery
77387	IMRT additional services
77520	Proton beam therapy
77522	Proton beam
77523	Proton beam
77331	Special/associated services
77370	Physics consult
77399	Unlisted therapeutic radiology procedure

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Spinal surgery and instrumentation codesCPT

22533	Anterior cervical discectomy with fusion
22548	Cervical fusion
22610	Lumbar fusion
22800	Posterior instrumentation
22849	Insertion interbody device
63030	Laminectomy
63650	Insertion neurostimulator pulse generator
64553	Percutaneous implantation neurostimulator
L8680	Prosthetic implant code
L8686	Prosthetic implant code

Transplant and CAR T-cell therapy codesmixedCovered

CAR T-cell therapy	Multiple specific CAR T services require case management contact (Optum transplant team 888-936-7246)
0537T	CAR T related temporary code
0538T	CAR T related temporary code
0539T	CAR T related temporary code
0540T	CAR T related temporary code
J9999	Unclassified drug code (see policy)
Q2041	CAR T related HCPCS
Q2042	CAR T related HCPCS

Unclassified and special-case codesmixed

C9399	Unclassified HCPCS - requires review
J3490	Unclassified drug code - requires review
J3590	Unclassified drug code - requires review
C9090	Temporary code (see exceptions)
C9094	Temporary code (see exceptions)
C9151	Temporary code
C9157	Temporary code
C9166	Temporary code
C9167	Temporary code
C9168	Temporary code

Procedure groups (examples)CPT

36473	Endovenous ablation, percutaneous
36475	Ablation of varicose veins
36478	Sclerotherapy
33927	Ventricular assist device procedure
33928	VAD procedure
33929	VAD procedure
33975	Heart assist device
33976	Heart assist device
33979	Heart assist device

What Providers Must Do

Prior Authorization

How to submit prior authorization requests and scope

Submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) using your One Healthcare ID and password; see the Contact us page for additional information. Prior authorization is not required for emergency or urgent care. Out-of-network providers must request prior authorization for all procedures and services except emergent or urgent care.

Online: Prior Authorization and Notification tab on UHCprovider.com (sign in with One Healthcare ID)
Contact info available on the Contact us page
Emergency/urgent care exempt
Out-of-network providers must request prior authorization (except emergent/urgent care)

Prior Authorization

Example CPT/HCPCS codes requiring prior authorization

Examples of CPT/HCPCS services that require prior authorization (partial list) include acupuncture (97810, 97811, 97813, 97814) and bariatric surgery codes (43644, 43645, 43659, 43770).

Key Definitions and Terms

inv-58: Prior authorization

DefinitionPrior authorization: a required approval process before certain services, procedures, drugs or equipment are provided; submit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call the published phone numbers.

ExemptionsPrior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for non-emergent services.

How to submitOnline via UHCprovider.com (One Healthcare ID) or contact the Provider Contact/phone numbers in the policy (e.g., 888-397-8129 for general PA).

inv-59: Inpatient video EEG

DefinitionInpatient video EEG: continuous cerebral seizure monitoring performed in the inpatient setting; prior authorization required for inpatient video EEG (CPT examples: 95700, 95711, 95712, 95713, 95716, 95718).

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Florida

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID.

SourceLink

On This Page

Chiropractic services (CPT 98940–98943): prior authorization required.

Circumcision: prior authorization required for patients age 12 weeks and older (CPT 54161 referenced).

Acupuncture: 97810, 97811, 97813, 97814
Bariatric surgery: 43644, 43645, 43659, 43770

Prior Authorization

Chemotherapy prior authorization

Injectable chemotherapy drugs administered in an outpatient setting require prior authorization; examples include chemotherapy J-codes (J9000-J9999), leucovorin (J0640) and levoleucovorin (J0641, J0642), and Lupron Depot (J1950). Submit requests online via the UnitedHealthcare Provider Portal or call 888-397-8129.

Chemotherapy injectable drugs: J9000-J9999
Leucovorin: J0640; Levoleucovorin: J0641, J0642
Lupron Depot: J1950
Submission: UHCprovider.com Prior Authorization tool or 888-397-8129

Prior Authorization

Inpatient video EEG prior authorization

Inpatient video electroencephalogram (continuous cerebral seizure monitoring) requires prior authorization; prior authorization is not required for outpatient hospital or ambulatory surgical center EEGs.

Inpatient video EEG CPT codes: 95700, 95711, 95712, 95713, 95716, 95718
Outpatient hospital or ambulatory surgical center EEGs do not require prior authorization

Prior Authorization

Cochlear implant prior authorization

Cochlear implants and other auditory implants require prior authorization; listed codes include 69710, 69714, 69930 and device L-codes such as L8614, L8619, L8690, L8691, L8692.

Cochlear implant CPT codes: 69710, 69714, 69930
Auditory implant HCPCS/L-codes: L8614, L8619, L8690, L8691, L8692

Prior Authorization

Continuous glucose monitor prior authorization

Continuous glucose monitors require prior authorization when the diagnosis is type 2 diabetes; listed HCPCS codes include A9276, A9277 and A9278.

CGM HCPCS codes: A9276, A9277, A9278
Prior authorization required when diagnosis = type 2 diabetes

Prior Authorization

Chiropractic prior authorization

Chiropractic services require prior authorization; listed CPT codes include 98940, 98941, 98942 and 98943.

Chiropractic CPT codes: 98940, 98941, 98942, 98943

Prior Authorization

Circumcision prior authorization

Circumcision requires prior authorization for patients ages 12 weeks and older; example CPT code listed is 54161.

Circumcision CPT code example: 54161
Prior authorization required for patients age ≥ 12 weeks

Prior Authorization

Durable Medical Equipment (DME) prior authorization

Prior authorization is required only for the DME codes listed; DME items with a retail purchase or cumulative rental cost of more than $500 require prior authorization.

Sample DME HCPCS listed: A9279, A9280, A9900, E0265, E0270, E0300, E0328, E0329, E0445, E0457, E0465, E0466, E0470
Authorization threshold: retail purchase or cumulative rental cost > $500

Prior Authorization

Enteral/In-home nutritional services prior authorization

Enteral and in-home nutritional services require prior authorization for listed B-codes such as B4034, B4035, B4036 and B4100; submit requests per the general prior authorization process.

Enteral/in-home nutrition HCPCS: B4034, B4035, B4036, B4100, B4102
Prior authorization required for listed codes

Prior Authorization

Functional endoscopic sinus prior authorization

Functional endoscopic sinus procedures require prior authorization for the listed CPT codes; examples include 31240, 31253–31259, 31267, 31276, 31287 and 31288.

FESS CPT examples: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288
Prior authorization required for the listed CPT codes

Documentation Required

Genetic and molecular testing prior authorization/notification

Genetic and molecular testing codes require prior authorization or notification; the notification process may require indicating the laboratory and test name and some tests require laboratory registration.

Examples of genetic/molecular CPT codes: 81162–81168, 81191–81194, 81228–81279, 81338–81360, 81400–81443, 81479, 81507, 81518–81523, 81546, 81554, 81595, 81599
Notification/prior authorization process may require ordering provider and laboratory/test name; some tests require laboratory registration

Prior Authorization

Experimental/Investigational services prior authorization

Experimental and investigational services listed require prior authorization; examples include CPT/HCPCS such as 36514, 64722, 65765, 66180, 0191T and various A-, E- and S-codes.

Example codes: 36514, 64722, 65765, 65767, 66180, 0191T, A4638, A6000, A9274, E0231, E1831, S0810, S1030, S1031, S9988, S9990, S9991
Prior authorization required for listed experimental/investigational codes

Prior Authorization

Home health care and hysterectomy prior authorization

Home health care HCPCS codes require prior authorization when provided in outpatient settings including the member's home; hysterectomy CPT codes also require prior authorization.

Home health HCPCS examples: S3870, S9122, S9123, S9124, T1031
Prior authorization required only in outpatient settings (including member's home)
Hysterectomy CPT codes listed in the policy require prior authorization

Prior Authorization

Injectable medications prior authorization

Numerous injectable medications billed with J- and Q-codes require prior authorization; the policy lists many specific J-/Q-codes and mapped brand names requiring authorization.

Examples of J-/Q-codes listed: J0256, J1413, J2508, J1554, J1555, J1561, J1572, J2782, J1290, J2840, J0225, J0739, Q5121, J0490, J0597, J0585, J0567, J2329, J0741, J0717, J2786, J0598, J0802, J3247, J0584, J1412, J1556, J1566, J1557, J1568, J1559, J1569 (partial list)
Prior authorization required for the injectable medications listed

Documentation Required

Genetic and molecular testing and miscellaneous CPT/HCPCS prior authorization/notification

Extensive lists of genetic/molecular test CPT, U-codes and other procedure codes are included with notes that laboratories may notify UnitedHealthcare and that some tests require authorization or notification.

Large lists include codes such as 81415–81443, multiple U-codes (e.g., 0007M, 0012U, 0013U…0191U…0299U) and other CPT/HPCS codes
Additional information: laboratories will notify UnitedHealthcare for some tests; some tests require authorization/registration

Prior Authorization

How to obtain prior authorization

Submit prior authorization requests using the UnitedHealthcare Provider Portal or call 888-397-8129. For Cimzia, Synagis and Xolair obtain prior authorization through the Optum Rx Prior Authorization Line at 800-310-6826.

UHCprovider.com portal or phone: 888-397-8129
Optum Rx Prior Authorization Line for Cimzia, Synagis, Xolair: 800-310-6826

Prior Authorization

Procedures requiring prior authorization

Prior authorization is required for numerous procedures and services listed (partial examples include total hip/knee joint replacement, massage therapy, musculoskeletal surgeries, non-emergent air ambulance and orthognathic surgery).

Joint replacement examples: multiple CPT entries listed under joint total hip/knee replacement
Massage therapy CPT codes: 97010, 97112, 97124, 97140
Non-emergent air ambulance CPT/HCPCS: A0430, A0431, A0435, A0436
Orthognathic surgery examples: 21121, 21123, 21125, 21127, 21141–21160 (partial list)

Billing Rule

Orthotics and prosthetics prior authorization threshold

Prior authorization is required only for orthotics and prosthetic codes listed whose retail purchase or cumulative rental cost exceeds $500; numerous L-codes are enumerated in the policy.

Orthotics/prosthetics examples: L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631, L0700, L0710, L0810, L0820, L0830, L1300, L1310, L1499, L1680, L1685, L1700, L1710, L1720, L1730, L1755, L1820 (partial)
PA threshold: retail purchase or cumulative rental cost > $500

Prior Authorization

Outpatient therapy prior authorization — submission requirements

Outpatient therapy evaluation and re-evaluation codes require prior authorization; the request must be submitted by a primary care provider and submitted online via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool.

Request must be submitted by a primary care provider
Submit online using the Prior Authorization and Notification tool on UHCprovider.com

Note

Outpatient therapy prior authorization — contact

For prior authorization/notification of the listed outpatient therapy codes, call OptumHealth Physical Health at 800-873-4575 or use the notification number on the member's health plan ID card.

OptumHealth Physical Health phone: 800-873-4575
Alternatively use the notification number on the member's ID card

Prior Authorization

Advanced outpatient imaging prior authorization/notification

Care providers ordering advanced outpatient imaging (certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures) must notify prior to scheduling and submit requests online via the UnitedHealthcare Provider Portal or call 866-889-8054; specific T-codes (0697T, 0698T, 0710T, 0711T) are included.

Notification prior to scheduling required for advanced outpatient imaging
Submit via UHCprovider.com Prior Authorization and Notification tool or call 866-889-8054
Radiology T-codes called out: 0697T, 0698T, 0710T, 0711T

Prior Authorization

Imaging prior authorization and notification

Care providers ordering advanced outpatient imaging must provide notification prior to scheduling and submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-889-8054.

Notification prior to scheduling required
Submit via UHCprovider.com or call 866-889-8054

Prior Authorization

Transplant and CAR T-cell authorization

For transplant and CAR T-cell therapy services (branded CAR-T products listed), providers must call the Optum transplant team at 888-936-7246 or use the notification number on the member's health plan ID card.

Optum transplant team phone: 888-936-7246
Use notification number on member's ID card for submission

Prior Authorization

Site-of-service prior authorization rule

Site-of-service prior authorization is required when requesting services in an outpatient hospital; prior authorization is not required if the service is performed at a participating ambulatory surgery center (ASC).

SOS rule: PA required for outpatient hospital setting
No PA required if service performed at participating ASC

Prior Authorization

VAD prior authorization and notification

Ventricular assist devices (VAD) require prior authorization; providers should call the notification number on the back of the member's health plan ID card and then fax the form provided by the nurse to the Optum VAD Case Management team at 855-282-8929.

Call notification number on member's ID card
Fax nurse-provided form to Optum VAD Case Management at 855-282-8929
VAD related CPT/HCPCS examples referenced (e.g., 33927)

Prior Authorization

Vein procedure prior authorization

Vein procedures for removal and ablation of saphenous veins and named branches require prior authorization; listed CPT examples include 36473, 36475, 36478, 37700, 37718, 37780, 37722, 37765 and 37766.

Vein procedure CPT examples: 36473, 36475, 36478, 37700, 37718, 37780, 37722, 37765, 37766
Prior authorization required for the listed vein procedures

Prior Authorization

Miscellaneous CPT/HCPCS prior authorization entries

A large set of miscellaneous CPT/HCPCS and unclassified codes are listed as requiring prior authorization; note that code 38232 requires prior authorization only when associated with an oncology diagnosis and unclassified codes (e.g., C9399, J3490, J3590) are included.

Examples include 47147, 48551–48554, 50300–50370, 50547, J3393, J3394, S2060, S2061, S2152, 0537T–0540T, J9999, Q2041–Q2056, 38232 (PA only if oncology diagnosis), unclassified codes C9399, J3490, J3590
Many entries note additional information or conditions for authorization

ExceptionPrior authorization is not required for outpatient hospital or ambulatory surgical center EEGs.

SubmissionSubmit requests online via the UnitedHealthcare Provider Portal or call 888-397-8129 as directed in the policy.

inv-60: Injectable chemotherapy drugs

RequirementInjectable chemotherapy drugs administered in an outpatient setting require prior authorization (includes J9000-J9999, leucovorin J0640, levoleucovorin J0641/J0642, Lupron Depot J1950, Q-coded chemotherapy injectables, and miscellaneous HCPCS when unassigned).

Codes/examplesChemotherapy injectable drug range: J9000-J9999; specific supportive codes noted (J0640, J0641, J0642, J1950).

How to obtainSubmit prior authorization requests online via the UnitedHealthcare Provider Portal or call 888-397-8129 per policy instructions.

inv-61: Durable medical equipment (DME)

DefinitionDurable medical equipment (DME): items listed in the DME section that require prior authorization (prosthetics are noted as not considered DME for some rules).

Examples of listed DME codesExamples include A9279, A9280, A9900, E0265, E0270, E0300, E0328, E0329, E0445, E0457, E0465, E0466, E0470.

Cost ruleA retail purchase or cumulative rental cost greater than $500 triggers prior authorization for applicable DME codes.

inv-62: Genetic and molecular testing

DefinitionGenetic and molecular testing: genetic/molecular CPT and U-codes for which prior authorization or notification is required; some tests require laboratory notification and ordering provider/lab identification.

Examples of CPT codesExamples include 81162–81168, 81191–81194, 81228–81279, 81338–81351 and related codes listed in the policy.

U-code examplesMultiple U-codes are listed that may require notification or prior authorization (examples in policy: 0018U, 0022U, 0023U, 0026U, 0055U, 0060U, 0087U, 0088U, etc.).

inv-63: genetic/molecular test unique CPT/HCPCS codes (examples: 0018U, 0022U, etc.)

DefinitionU-codes: unique CPT/HCPCS molecular test codes (examples in the policy include 0018U, 0022U, 0023U, 0026U, 0055U, 0060U, etc.) that are listed for authorization/notification.

Examples listedSpecific U-codes called out in the policy include 0018U, 0022U, 0023U, 0026U, 0055U, 0060U, 0087U, 0088U, 0097U, 0111U, 0129U, 0154U, 0155U, and many more through the 02xx and 03xx ranges.

Process notePolicy notes laboratories will notify UnitedHealthcare for many of these tests and some require prior authorization or registration as part of the notification process.

inv-64: Home health care codes (e.g., S3870) require prior authorization when provided in outpatient settings including the member's home

RequirementHome health care HCPCS codes (examples: S3870, S9122, S9123, S9124, T1031) require prior authorization when provided in outpatient settings, including the member's home.

ScopeApplies only when services are in outpatient settings (including in‑home), not necessarily for inpatient/homebound coverage rules outside this segment.

ActionSubmit prior authorization per the policy instructions (Provider Portal or contact numbers).

inv-65: Review at Launch

DefinitionReview at Launch: the policy references the Review at Launch Medication List for newly approved drugs; pre-determination is highly recommended for drugs on that list.

ActionCheck the Review at Launch list and obtain pre-determination for new-to-market medications as recommended in the policy.

Contact detailGeneral prior authorization submissions use the UnitedHealthcare Provider Portal or phone 888-397-8129; select biologics use Optum Rx prior authorization line per policy guidance.

inv-66: Optum Rx Prior Authorization Line

DefinitionOptum Rx Prior Authorization Line: phone line to obtain prior authorization for select biologics (policy example: Cimzia, Synagis, Xolair) via 800-310-6826.

When to useUse Optum Rx Prior Authorization Line for specified biologics identified in the policy; other drugs use the UnitedHealthcare Provider Portal or general PA phone number.

Portal alternativeProvider Portal submission remains the primary route for most prior authorization requests as noted in the policy.

inv-67: Advanced outpatient imaging procedures (certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures)

DefinitionAdvanced outpatient imaging procedures: certain outpatient CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures that require prior authorization or notification.

Procedure examplesPolicy references radiology T-codes (0697T, 0698T, 0710T, 0711T) and other CPT codes listed in the Radiology Prior Authorization and Notification Program.

Notification & submissionCare providers ordering advanced outpatient imaging must provide notification prior to scheduling and submit prior authorization requests via the UnitedHealthcare Provider Portal or call 866-889-8054.

inv-68: advanced outpatient imaging procedure

DefinitionAdvanced outpatient imaging procedure: a designated set of outpatient imaging services that require prior notification and often prior authorization (see Radiology Prior Authorization and Notification Program).

Key T-codesExamples cited in policy: 0697T, 0698T, 0710T, 0711T — these are included on the Radiology Prior Authorization and Notification Program list.

ContactSubmit requests online via UHCprovider.com Prior Authorization tool or call 866-889-8054 per policy instructions.

inv-69: Optum transplant notification

RequirementOptum transplant notification: providers must call the Optum transplant team for transplant and CAR T-cell therapy services (phone: 888-936-7246) or use the notification number on the member's ID card.

ScopeApplies to listed transplant services and CAR T-cell therapies (policy lists branded CAR-T products such as Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta, etc.).

ActionContact Optum transplant team prior to scheduling as specified in the policy for authorization/notification requirements.

inv-70: Ventricular assist devices (VAD)

DefinitionVentricular assist devices (VAD): mechanical pumps that take over heart function; prior authorization is required for VADs.

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

Example codesPolicy references related procedure codes such as 33927, 33928, 33929 and others for VAD services.

inv-71: CAR T-cell therapy

DefinitionCAR T-cell therapy: cellular immunotherapy services listed in the policy that require prior authorization/notification (policy lists related T-codes, Q- and HCPCS codes and branded products).

Codes/examplesExamples in policy include CAR T-related T-codes 0537T–0540T and HCPCS/Q-codes such as J9999, Q2041, Q2042, Q2053–Q2056; branded CAR-T products are listed (Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta, etc.).

How to obtainProviders must call the Optum transplant team at 888-936-7246 or use the notification number on the member's ID card per policy instructions.