CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania

Lists services, CPT/HCPCS/ICD codes, and instructions for submitting prior authorization requests for participating UnitedHealthcare Community Plan of Pennsylvania providers. Affects providers delivering inpatient and outpatient services to members of the Community Plan of Pennsylvania.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania

Policy CodePolicy N/A

Change TypeAdministrative (no material change)

Effective DateNovember 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, or by phone (888-702-2202) or fax (866-968-7582).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Portalonline submission

888-702-2202phone

866-968-7582fax

someservices marked PA required

C43/C44 listdiagnoses exempt

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.

Coverage criteria and required authorizations

Excerpted coverage stance

Services and associated codes identified as requiring prior authorization in this portion of the document include:

ALL of the following

Examples
- Abortion procedures (CPT/HCPCS codes 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, 59866) require prior authorization.
- Bariatric surgery and specific obesity-related services (example CPT codes 43644, 43645, 43659, 43770, 43775, 43842, 43845, 43846, 43847, 43860) require prior authorization.
- Bone growth stimulators (e.g., 20975, 20979; device HCPCS E0747–E0760 noted elsewhere) require prior authorization.
- BRCA and selected genetic testing (examples: 81162, 81432) require prior authorization.
- Cancer supportive outpatient colony-stimulating factor and related injectable medications (multiple J- and Q-codes listed) require prior authorization; certain listed colony-stimulating factor codes also require PA for non-oncology diagnoses.
- Selected cardiovascular/interventional cardiac procedures (examples: 37220, 37221, 37224, 37225, 37231, 93580) require prior authorization as listed.

Providers should submit prior authorization requests using the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com) or by the contact methods listed in the policy.

Prior authorization coverage statements

Services explicitly noted as requiring prior authorization

Outpatient injectable chemotherapy (chemotherapy injectable drugs J9000–J9999 and specified related codes such as J0640, J0641, J0642, J1950 and Q-codes) — prior authorization required for administration in an outpatient setting for a cancer diagnosis; requests to be submitted via the Provider Portal Prior Authorization and Notification tool.

Cochlear and other auditory implant procedures and related device HCPCS (examples in other sections) — prior authorization required.

Continuous glucose monitor when billed with a Type 2 Diabetes diagnosis — prior authorization required.

EEG/cerebral seizure monitoring — some monitoring codes require prior authorization for inpatient services, while outpatient hospital or ambulatory EEG prior authorization is not required.

Prior authorization exemptions by diagnosis code

Exemptions by diagnosis code (when billed with the following diagnosis codes, prior authorization is not required):

Services billed with the extensive C43.x and C44.x series diagnosis codes listed in the policy (examples and crosswalks shown) are exempt from prior authorization per the document.

Prior authorization criteria (partial)

Prior authorization requirements and codes listed in these chunks indicate which services require authorization.

ALL of the following

Enteral services and related supply codes (examples: B4034, B4035, B4036, B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4155, B4158, B4159, B4160, B4161, B9002, B9998) — prior authorization required.
Durable Medical Equipment (DME) — prior authorization required only for DME codes listed with a retail purchase or cumulative rental cost that exceeds $500 (prosthetics excluded).
Threshold: $500 retail purchase or cumulative rental cost
Femoroacetabular impingement (FAI) surgery — CPT 29916 requires prior authorization.
Services designated as experimental or investigational in this section (examples include CPT/HCPCS codes 33477, 36514, 64722, 65765, 65767, 66180 and multiple A-/S-/E- codes) — prior authorization required.

Administrative coverage and prior authorization requirements

Stated coverage stance and administrative requirements in this excerpt:

Genetic and molecular testing (many CPT/HCPCS and U-codes listed, e.g., 81163, 81164, 81228, 81229, 81277, 81400–81408, 81410–81417, 81431, 81435, etc.) — prior authorization/notification required; ordering provider and laboratory notification required for certain tests.

Home health services (listed G-codes and S-codes such as G0156, G0162, G0299, G0300, G0493–G0496, S9122–S9124, S9474) — prior authorization required when provided in outpatient settings including the member's home.

Hospice services — prior authorization required for listed hospice code T2045.

Hysterectomy procedures — prior authorization required for the listed CPT codes (examples include 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58290–58292, 58542–58544, 58550, 58552, 58553, 58570–58573).

Human milk bank services — prior authorization required for code T2101.

Prior authorization/notification criteria (selected)

Selected services and codes require prior authorization or notification as noted.

ANY of the following

Inpatient admissions to specified post-acute facilities — prior authorization and notification of admission date required.
Joint replacement and orthognathic surgery — prior authorization required for listed CPT codes.
Orthotics and prosthetics — prior authorization required only for codes listed with a retail purchase or cumulative rental cost of more than $500 (examples: L0112, L0170, L0456, others).

Prior authorization criteria (partial)

Examples of services and codes requiring prior authorization or notification (partial):

Advanced outpatient imaging (certain CT, MRI, MRA, PET, nuclear medicine/nuclear cardiology) — health care professionals ordering these advanced outpatient imaging procedures are responsible for providing notification prior to scheduling; prior authorization/notification requests can be submitted via the Provider Portal or by calling 866-889-8054.

Proton beam therapy (CPT codes 77520, 77522, 77523, 77525) — prior authorization required.

Rhinoplasty, septoplasty and sinuplasty (examples: 30400–30465 series, 31295–31298) — prior authorization required for treatment of nasal functional impairment and septal deviation and for sinuplasty.

Private duty nursing (T1000, T1002, T1003) and pediatric day services (T1024) — prior authorization required.

Prostate procedures listed in the policy (examples: 37243, 53852, 52441, 55873, 52442, 55874, 53850) — prior authorization required.

Prior authorization code sets

Codes in this section with explicit prior authorization notes:

Sleep apnea procedures and surgeries (examples include 21685, 41599, 42145) — prior authorization required.

Spinal surgery codes enumerated in the policy (examples include 22100, 22101, 22102, 22110, 22112, 22114, 22206–22214, 22220, 22224, 22510–22515, 22532–22533, 22548, 22551, 22554, 22556, 22558, 22586, 22590, 22595, 22600–22612, 22630–22633, 22800–22812, 22818–22819, 22830, 22849–22856, 22861) — prior authorization required.

Prior authorization requirements (codes listed)

This section enumerates codes and notes which services require prior authorization or notification.

ALL of the following

Implantable stimulators and device implantation entries flagged with '*SOS also applies' (examples: bone growth stimulators and neurostimulator HCPCS E0747–E0760; implantable device HCPCS L8680–L8688) — prior authorization and site-of-service (SOS) rules apply.
Transplants — prior authorization required; Code 38232 will only require prior authorization for an oncology diagnosis; contact Transplant Case Management as instructed in the policy for notification/authorization.
Ventricular assist devices (VAD) — prior authorization required; follow the notification routing instructions (call the number on the member's ID and fax required form to Optum VAD Case Management Team).
Vein procedures (saphenous vein removal/ablation — examples: 36473, 36475, 36478, 37700) and wound VAC (E2402) — prior authorization required.

Code lists and coding notes

Cancer supportive injectable HCPCS/J-codes (require prior authorization)HCPCSCovered

J1442	Filgrastim (Neupogen)
J1447	Tbo-filgrastim (Granix)
J1448	Trilaciclib (Cosela)
J1453	Fosaprepitant, 1 mg (Emend for Injection)
J1454	Fosnetupitant 235 mg and palonosetron 0.25 mg
J1456	Fosaprepitant (Teva)
J0185	Aprepitant (Cinvanti)
J1449	Eflapegrastim-xnst (Rolvedon)
J2820	Sargramostim (Leukine)
J0885	Erythropoiesis-Stimulating Agent

1–10 of 12

1/2

Additional injectable Q-code biosimilars (require prior authorization)HCPCSCovered

Q5108	Pegfilgrastim-jmdb (Fulphila)
Q5110	Filgrastim-aafi (Nivestym)
Q5111	Pegfilgrastim-cbqv (UDENYCA)
Q5120	Pegfilgrastim-bmez (Ziextenzo)
Q5122	Pegfilgrastim-apgf (Nyvepria)
Q5125	Filgrastim-ayow (Releuko)
Q5101	(Listed in cancer supportive group)

Cardiovascular diagnosis ICD-10 codes requiring prior authorizationICD-10Covered

I70.*	Atherosclerosis and related I70 series (multiple specific I70 codes listed throughout document)
I70.221	Atherosclerosis of native arteries of the extremities with rest pain, right leg

Cardiovascular/CPT examplesCPT

37220	Endovascular revascularization, percutaneous, initial
93580	Electrocardiographic monitoring

Examples of CPT/HCPCS groups referencedmixedCovered

J9000-J9999	Chemotherapy injectable drugs range
Q-codes	Drugs with Q-codes requiring PA
Misc HCPCS (C9399,J3490,J3590)	Unclassified drug codes

Diagnosis codes exempt from prior authorization (selected skin cancer ICD-10 series)ICD-10Covered

C43.x	Melanoma in situ and invasive melanoma codes (C43.0 - C43.9 series as listed)
C44.x	Other malignant neoplasms of skin (C44.0 - C44.9 series as listed)

ICD-10 code crosswalk examplesICD-10

C43.0	Malignant melanoma of lip (example crosswalk entries present)
C44.01	Basal cell carcinoma of skin of external ear (example crosswalk)

Sample CPT/HCPCS codes requiring prior authorization (subset)CPTCovered

38232	Bone marrow transplantation (PA only for oncology diagnosis)
36473	Injection procedure for veins
36475	Ablation of saphenous veins
33927	Ventricular assist device implantation

Procedure codes excerpt (selected injectable and biologic J/Q-codes)HCPCSCovered

J2506	Pegfilgrastim (Neulasta)
J2507	Krystexxa
J1439	Injectafer
J0177	Eylea HD
J0178	Eylea

Orthotics and prosthetics HCPCS L-codes (PA if cost > $500)HCPCSCovered

L0112	Standard wheelchair component
L0456	Lumbar-sacral orthosis
L0638	Ankle-foot orthosis, plastic
L8680	Neurostimulator, implantable

Orthotics/Prosthetics and miscellaneous HCPCS codes (partial)HCPCSCovered

A0430	Ambulance service, basic life support, non-emergency
E2402	Wound VAC pump, each
A9276	CGM supplies (example)

Selected CPT procedure codes (partial)CPT

19364	Breast reconstruction
19367	Breast reconstruction, revision
19368	Breast reconstruction, other

Example procedures listed (partial)CPTCovered

43235	Esophagogastroduodenoscopy
52276	Cystourethroscopy
63064	Laminectomy with decompression

Spine-related CPT codes (partial list)CPTCovered

63050	Laminectomy, cervical
63055	Laminectomy, thoracic

Stimulators and implantable device HCPCS (require prior authorization)HCPCSCovered

L8686	Neurostimulator, rechargeable
L8687	Neurostimulator, non-rechargeable

Neuro/interventional CPT codes (partial)CPT

61863	Stereotactic radiosurgery
63650	Insertion or replacement of neurostimulator leads

Vein, VAD, wound VAC codes requiring prior authorizationmixedCovered

36478	Endovenous ablation, other areas
33927	Ventricular assist device, implantation
E2402	Wound VAC pump

Prior authorization required markermixed

*	Codes marked with * require prior authorization unless otherwise noted

DME prior authorization cost thresholdmixed

$500	Prior authorization required for retail purchase or cumulative rental cost over $500

Genetic testing prior authorizationCPT

81163	Genetic testing (example)
81400	Molecular pathology procedure

Orthotics/prosthetics PA threshold remindermixed

$500	Retail purchase or cumulative rental cost > $500 requires prior authorization

Site of service - outpatient hospitalCPT

various

Many codes annotated with 'Site of service - outpatient hospital' in document

38232 prior auth conditionCPT

38232

Will only require prior authorization for an oncology diagnosis

Provider submission instructions and required notifications

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID, or by phone at 888-702-2202, or by fax at 866-968-7582.

Online: Prior Authorization and Notification tool on UnitedHealthcare Provider Portal (UHCprovider.com) — sign in with One Healthcare ID.
Phone: 888-702-2202.
Fax: 866-968-7582 (use Prior Authorization Forms).

Prior Authorization

Service-specific submission instructions

For certain service areas (for example, cancer supportive care and cardiology), providers should submit prior authorization requests online using UHCprovider.com; specific phone numbers are provided for service-area requests.

Cardiology: submit via UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-889-8054.

Definitions and portal information

Online portal method for submitting PA requests via UHCprovider.com using One Healthcare ID

Online portal submissionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) using your One Healthcare ID.

Phone submissionPrior authorization requests may also be submitted by phone at 888-702-2202.

Fax submissionRequests may be faxed to 866-968-7582 using the Prior Authorization fax form.

Cancer supportive care

Cancer supportive care PACancer supportive care agents (including antiemetics, colony‑stimulating factors, erythropoiesis‑stimulating agents and bone‑modifying agents) require prior authorization when administered in an outpatient setting for a cancer diagnosis.

Examples of agents/codes

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania

Policy CodePolicy N/A

Change TypeAdministrative (no material change)

Effective DateNovember 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, or by phone (888-702-2202) or fax (866-968-7582).

SourceLink

On This Page

Providers must follow the code-specific prior authorization instructions shown in the policy for submitting requests.

Numerous injectable medications (many J- and Q-codes listed across the document) — prior authorization required as noted in the injectable medications lists.

Site of service note: some codes require prior authorization only when performed in an outpatient hospital site of service (examples referenced in the document include 64721, 66821, 45378).

Prior Authorization

Prior authorization for outpatient injectable chemotherapy

Prior authorization is required for injectable chemotherapy drugs administered in an outpatient setting (including intravenous, intravesical, and intrathecal) for a cancer diagnosis; requests should be submitted online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

Applies to chemotherapy injectable drugs (J9000-J9999), leucovorin (J0640, J0641, J0642), Lupron Depot (J1950), Q‑coded chemotherapy, and miscellaneous HCPCS-billed agents pending a code assignment.

Documentation Required

Cerebral seizure monitoring / EEG prior authorization guidance

Some cerebral seizure monitoring (CPT 95700–95718; 95720–95726) monitoring codes require prior authorization when performed inpatient; EEG codes for outpatient hospital or ambulatory settings do not require prior authorization.

Monitoring codes listed (e.g., 95700–95718) noted as required for inpatient prior authorization.
EEG codes (e.g., 95720–95726) — prior authorization not required for outpatient hospital or ambulatory.

Prior Authorization

Auditory implant prior authorization

Prior authorization is required for cochlear and other auditory implant procedures and devices (examples include CPT codes 69710, 69714, 69930 and HCPCS L8619, L8690).

Auditory implant entries are marked: 'Prior authorization required.'

Prior Authorization

Continuous glucose monitor prior authorization

Continuous glucose monitors require prior authorization when billed with a Type 2 Diabetes diagnosis.

Examples of related codes listed include A4226, A9277*, E2103 and similar CGM HCPCS entries.

Billing Rule

DME prior authorization rule

Prior authorization is required only for DME codes listed with a retail purchase or cumulative rental cost of more than $500; prosthetics are not considered DME and are excluded from this threshold.

Threshold: retail purchase or cumulative rental cost > $500 triggers prior authorization requirement.
Prosthetics are explicitly not DME for this rule.

Prior Authorization

Enteral services prior authorization

Enteral services and related supply HCPCS codes (examples: B4034, B4035, B4036, B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4155, B4158, B4159, B4160, B4161, B9002, B9998) require prior authorization.

Enteral services are listed with the note: 'Prior authorization required.'

Prior Authorization

FAI surgical prior authorization (CPT 29916)

Femoroacetabular impingement (FAI) surgical procedure CPT 29916 requires prior authorization.

FAI is specifically annotated: 'Prior authorization required.'

Prior Authorization

Experimental/investigational services prior authorization

Services designated as experimental or investigational are labeled as requiring prior authorization; examples include several CPT/HCPCS codes listed under that designation.

Document flags specific codes (e.g., 33477, 36514, 64722, 65765, 65767, 66180, A4638, A6000) as investigational and requiring prior authorization.

Documentation Required

Genetic/molecular testing prior authorization and ordering/lab notification

Prior authorization and/or notification is required for genetic and molecular testing codes and many U-codes; ordering health care professionals and laboratories may need to be notified per the document.

Examples include many 8xx, 81xxx, 814xx series and numerous proprietary U-codes listed with the note: 'Prior authorization is...'.

Prior Authorization

Home health prior authorization (outpatient/home settings)

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

Note: 'Prior authorization required... required only in outpatient settings, to include member's home.'

Prior Authorization

Hospice prior authorization (T2045)

Hospice services require prior authorization for listed hospice codes (example: T2045).

Hospice entry annotated: 'Prior authorization required.'

Prior Authorization

Hysterectomy prior authorization (listed CPT codes)

Hysterectomy procedures listed in the document require prior authorization for the CPT codes provided (examples include 58150, 58152, 58180, 58260, 58262–58263, 58267, 58270, 58290–58292, 58542, 58543–58544, 58550, 58552–58553, 58570–58573).

The hysterectomy section is noted: 'Prior authorization required.'

Prior Authorization

Human milk bank prior authorization (T2101)

Human milk bank services require prior authorization for HCPCS code T2101.

Human milk bank entry explicitly: 'Prior authorization required.'

Prior Authorization

Injectable medications prior authorization (J‑ and Q‑codes)

Many injectable medications (listed J- and Q-codes) are marked as requiring prior authorization; providers must obtain prior authorization for the specific injectable codes listed in the document.

Numerous examples are provided (e.g., J3262, J0801, J7192, J3111, J1305, J1428, and many others) with the document note: 'Prior authorization required*'.

Note

Prior authorization and notification rules (selected services)

Facilities providing post-acute inpatient services must provide prior authorization and notification of the admission date; joint replacement and orthognathic surgery require prior authorization, and orthotics/prosthetics require prior authorization only when retail purchase or cumulative rental cost exceeds $500.

Inpatient admissions: 'Notification required for admissions' and 'Prior authorization and notification of admission date required for these facilities providing post-acute inpatient services.'
Orthotics/prosthetics: prior authorization required only if retail purchase or cumulative rental cost > $500.

Prior Authorization

Prior authorization and submission method for selected services (imaging, proton beam, rhinoplasty/sinuplasty, etc.)

Prior authorization is required for specified services and codes such as advanced outpatient imaging (certain CT/MRI/MRA/PET and nuclear medicine/nuclear cardiology), proton beam therapy (77520, 77522, 77523, 77525), rhinoplasty/septoplasty, sinuplasty, private duty nursing (T1000/T1002/T1003), pediatric day services (T1024), and other listed procedures; request prior authorization online via the Provider Portal or by calling 866-889-8054.

Advanced outpatient imaging: providers must notify prior to scheduling; request prior authorization by calling 866-889-8054 or via the Prior Authorization and Notification tool on UHCprovider.com.
Proton beam therapy: prior authorization required (codes 77520, 77522, 77523, 77525).
Rhinoplasty/septoplasty and sinuplasty: prior authorization required (examples: 30400–30465; 31295–31298).

Prior Authorization

Prior authorization for sleep apnea procedures and spinal surgery codes

Prior authorization is required for specified sleep apnea procedures/surgeries and for the spinal surgery codes listed in the document; these entries are annotated as requiring prior authorization.

Sleep apnea procedures examples include codes 21685, 41599, 42145.
Spinal surgery codes listed (e.g., 22100–22102, 22110, 22112, 22114, 22206–22224, 22510–22515, 22532–22533, etc.) require prior authorization.

Prior Authorization

Transplant prior authorization and notification

Prior authorization is required for transplant services; contact the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or use the notification number on the member's ID card as directed.

Note: Code 38232 will only require prior authorization for an oncology diagnosis per the transplant section.

Prior Authorization

VAD prior authorization and routing instructions

Ventricular assist devices (VAD) require prior authorization; providers should call the notification number on the back of the member's ID card and then fax the form provided by the nurse to the Optum VAD Case Management Team as instructed.

VAD entry: 'Prior authorization required' and follow the notification/fax routing instructions on the member's ID card.

Prior Authorization

Vein procedures and wound VAC prior authorization

Vein procedures for removal/ablation of saphenous veins and wound VAC therapy are labeled 'Prior authorization required' and must have prior authorization.

Vein procedure examples include CPT codes 36473, 36475, 36478, 37700.
Wound VAC example HCPCS code E2402 is listed with 'Prior authorization required.'

Prior Authorization

Device implant prior authorization / Site-of-service (SOS) note

Multiple neurostimulator and bone growth stimulator devices are flagged with '*SOS also applies = Prior authorization' and require prior authorization; device HCPCS entries include E0747–E0760 and L8680–L8688 among others.

Stimulator/device implant entries carry '*SOS also applies' with the note that prior authorization is required.

Examples include colony‑stimulating factors and listed antiemetic J‑codes and Q‑codes (see injectable medication list for full entries).

Non‑oncology noteCertain CSF and biosimilar codes (e.g., J1442, Q5110, Q5125) also require prior authorization for non‑oncology diagnoses per the injectable medications section.

Prior authorization

Prior authorization definitionPrior authorization means approval is required before a specified service or code is provided; the document lists codes and services that require prior authorization or notification and directs providers to the Provider Portal, phone or specified numbers for requests.

Where defined in documentThe term and its application are used throughout sections on genetic testing, advanced imaging, transplant, device implants and other service areas.

How to obtainProviders should use the Prior Authorization and Notification tool on UHCprovider.com or call the applicable phone number listed in the relevant section (e.g., 866-889-8054 for imaging).

Continuous glucose monitor

CGM prior authorization conditionContinuous glucose monitors require prior authorization when billed with a Type 2 Diabetes diagnosis.

Example CGM codesReferenced HCPCS include A4226, A9277*, E2103 and related A4238/A9278* entries.

Action for providersFollow the prior authorization submission instructions in the document when billing CGM codes with Type 2 Diabetes diagnosis.

Durable medical equipment (DME)

DME PA applicabilityDME prior authorization requirement applies only to codes listed with a retail purchase or cumulative rental cost exceeding $500.

Prosthetics clarificationProsthetics are not considered DME under this rule and are handled separately.

Sample DME codesExamples in the DME list include A9279, A9280, A9900 and E‑series codes noted in the DME section.

Experimental/investigational services

Experimental/investigational servicesServices designated as experimental and investigational require prior authorization.

ExamplesDocument lists codes such as 33477, 36514, 64722, 65765, 65767 and 66180 in the investigational category.

Provider actionFollow the prior authorization instructions in the investigational services entries before providing or billing these services.

Prior authorization/notification

General PA/notification policyPrior authorization/notification is required for many specified services and codes across the document; providers must request authorization via the Provider Portal or the phone number listed for the service area.

Examples of areas requiring PA/notificationAdvanced outpatient imaging, proton beam therapy, injectable chemotherapy, joint replacement, inpatient admission notifications and others.

Submission methodsUse UHCprovider.com Prior Authorization and Notification tool or call the service‑specific number (e.g., 866‑889‑8054 for imaging; 888‑702‑2202 general PA line).

Prior authorization/notification — supplemental references

Advanced imaging and other examplesAdvanced outpatient imaging (certain CT/MRI/MRA/PET, nuclear medicine), proton beam therapy (77520/77522/77523/77525) and other listed services require prior authorization.

Transplant and VADsTransplants require prior authorization and notification (see transplant case management contact); ventricular assist devices (VAD) also require prior authorization with specific routing instructions.

Vein/wound VACsVein procedures (e.g., 36473–36478) and wound VACs (e.g., E2402) are labeled 'Prior authorization required.'

Prior authorization — advanced imaging notification references

SOS definition'*SOS also applies' indicates the Site of Service—outpatient hospital—annotation applies to those device and stimulator entries and carries prior authorization expectations.

Device examplesDevice and stimulator HCPCS such as E0747–E0760 and implantable device L8680–L8688 are flagged with '*SOS also applies'.

Action for providersWhen '*SOS also applies' appears, follow the outpatient hospital prior authorization process before scheduling the implant/service.

Prior authorization — note about sleep apnea and spinal surgery entries

Sleep apnea and spinal surgery noteSleep apnea procedures/surgeries and listed spinal surgery codes are explicitly flagged as requiring prior authorization.

How to requestProviders should request prior authorization via the Prior Authorization and Notification tool on UHCprovider.com or call the specified number for the service area.

Example codesSleep apnea example codes include 21685, 41599, 42145; spinal surgery codes listed in the spinal section require PA (see spinal code list).

SOS — note indicating '*SOS also applies'

'*SOS also applies' usageMany stimulator and implant entries are annotated '*SOS also applies', meaning site‑of‑service (outpatient hospital) requirements apply and prior authorization is expected.

ExamplesEntries include bone growth stimulator and neurostimulator codes and related HCPCS such as E0747–E0749, E0760 and various L868x device codes.

Provider instructionFollow the document's prior authorization and site‑of‑service instructions for these device implant codes prior to scheduling.

38232 prior auth condition

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

Location in documentThis condition is specified in the Transplants section of the prior authorization list.

Related codesThe transplant entry also references unclassified codes C9399, J3490 and J3590—follow transplant guidance for those codes.