UnitedHealthcare Prior Auth Requirements

Prior Authorization and Coverage Criteria

Prior authorization criteria summary

Prior authorization requirements and notable exceptions

Prior authorization is required for the CPT/HCPCS codes and service categories listed in this document unless an exception is noted (see routing and exclusions).

Notable exceptions

Emergency or urgent care — prior authorization is not required.
Breast reconstruction codes (listed) — prior authorization is NOT required when billed with breast reconstruction diagnosis codes; PA required for other diagnoses.
Incontinence supplies provided by Tenderheart Health Outcomes — follow Tenderheart routing; if not provided by Tenderheart, prior authorization required via the service coordinator.

Out-of-network prior authorization requests must be submitted by a network care provider.

Many DME/prosthetics items require prior authorization regardless of billed amount; specific HCPCS mappings and effective dates are listed in the DME/prosthetics sections.

Prior authorization criteria (partial)

Specific codes and categories require prior authorization as noted; some entries include effective dates or limits.

Numerous HCPCS/CPT codes enumerated in the document require prior authorization regardless of billed amount (see DME/prosthetics and other sections for code-level entries and effective dates).

Durable Medical Equipment (DME) items with cumulative rental cost of more than $1,000 require prior authorization.

Certain medications and specialty drugs listed (examples: Panzyga J1576; Hemgenix/Spevigo J1411/J1747; Cutaquig J1551; others) require prior authorization effective on the dates shown in the medication list entries.

Prosthetics and orthotics code groups include multiple entries with PA required regardless of billed amount or subject to retail purchase/cumulative rental cost thresholds; specific effective dates are shown with code groupings.

Therapy authorization criteria (partial)

Therapy services authorization rules (partial):

Prior authorization is required for all re-evaluations and for the other listed therapy codes in the therapy section.

Initial therapy evaluations do not require prior authorization.

Submit therapy prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

Orthotics/Prosthetics criteria (partial)

Orthotics/prosthetics authorization rules (partial):

Prior authorization is required for orthotics/prosthetics codes listed with a retail purchase or cumulative rental cost of more than $1,000.

Many prosthetic codes are listed with PA required regardless of billed amount; specific L-code groupings and effective dates appear in the prosthetics sections.

Post-acute admissions criteria (partial)

Post-acute inpatient services and notification requirements (partial):

Prior authorization and notification of admission date is required for post-acute inpatient facilities including acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long-term acute care hospitals and skilled nursing facilities.

Submit prior authorization requests for Continued Care through naviHealth (Phone: 855-851-1127; Fax: 844-244-9482).

UnitedHealthcare Assisted Living Plans (HMO SNP/HMO-POS SNP/PPO SNP) and UnitedHealthcare Nursing Home plans are excluded from the SNF prior authorization requirement noted in this section.

Radiology notification criteria (partial)

Radiology advanced outpatient imaging:

Care providers ordering advanced outpatient imaging procedures are responsible for providing notification prior to scheduling the procedure.

Radiology code groups in the document include multiple nuclear medicine, PET/CT and related CPT codes with listed prior authorization effective dates where applicable.

Enumerated prior authorization entries (partial)

Selected service categories and their prior authorization notes from the document fragment:

Psychological testing: prior authorization effective Oct. 1, 2019; PA not required for dates of service on or after Mar. 1, 2022.

Spinal surgery: multiple CPT/T codes enumerated in the spinal surgery sections require prior authorization (see code lists).

Transplants and CAR T‑Cell therapy: specific product and temporary/unclassified codes listed; certain CAR T and transplant products have PA effective dates (examples include Apr. 1, 2024; Jan. 1, 2022; Oct. 1, 2021; May 1, 2021). Providers must contact the UnitedHealthcare Community and State Transplant Case Management team for these services.

Prior authorization code listings and instructions (excerpt)

Codes listed here are identified as requiring prior authorization or notification; where present, effective dates and contact instructions are provided.

Extensive code lists for transplant, abdominal, vascular, venous, Vagus/cranial nerve stimulation, saphenous vein ablation/removal, and Ventricular Assist Device (VAD) procedures are included; diagnosis codes are largely absent in this excerpt — use the full code listings for submission details.

Vagus nerve stimulation/cranial nerve implantation: vagus nerve prior authorization effective Jan. 1, 2015; cranial nerves effective July 1, 2021; device codes (C1767, C1778, L8681, 61888, 64569) are listed.

Ventricular Assist Device (VAD) services: VAD-related codes are listed (examples: 33927-33929, 33975-33983); for VAD services call the notification number on the member ID card and fax the nurse-provided form to the Optum VAD Case Management team at 855-282-8929.

Code Lists and Coding Notes

Examples of codes in behavioral health / bone growth stimulator / BRCA testingCPT | HCPCS

20974-20979	Bone growth stimulator CPT codes listed
81163-81164	BRCA genetic testing CPT codes listed

Cardiovascular and DME examplesCPT | HCPCS

37230-37231	Cardiovascular codes
E0616	Durable medical equipment example

Cosmetic & Reconstructive surgery codesCPT

14020-14060	Cosmetic & Reconstructive procedure codes
11951-11954	Reconstructive procedure codes

Durable Medical Equipment examplesHCPCSCovered

E0328	DME code listed
E0635	DME code listed
E0639	DME code listed

Selected Technology/Category III codesCPT

0054T	T-code listed
0101T	T-code listed
0175T	T-code listed

Procedure codes (examples)CPT

29914	Femoroacetabular impingement (FAI) procedure code listed
29915	FAI procedure code listed
55970	Gender dysphoria treatment code listed

Selected specialty medication HCPCS codes (partial)HCPCS

J1576	Panzyga (example entry from medication list)
J1411	Hemgenix/Spevigo (example entries)
J1551	Cutaquig

Orthotics/Prosthetics L-code group (partial)Modifier

L3020	Orthotics/prosthetic code listed
L5818	Prosthetics code listed

Radiology advanced imaging codes (partial)CPT

78430	Nuclear medicine / cardiology imaging code (example)
78830	PET/CT code (example)

Miscellaneous HCPCS L-codesHCPCS

L6880-L6884, L6905, L6910

Series of L-codes listed in fragment

Transplants and CAR T‑Cell therapymixedCovered

C9399, J3590, J3490, Q2053-Q2055, 0537T-0539T, Q2041-Q2042

Transplant and CAR T‑Cell therapy codes and temporary/unclassified codes

Procedures requiring prior authorization (excerpt)mixed

33945	cardiac transplant-related code (listed)
38210	bone marrow/explant/harvest related (listed)
36473	removal/ablation saphenous veins (listed)
33975	VAD-related code (listed)
61888	vagus nerve procedure (listed)

DME cumulative rental cost threshold

Threshold amount$1,000 cumulative rental cost

Applies toDurable Medical Equipment (DME) cumulative rentals

Action triggeredPrior authorization required when cumulative rental cost exceeds threshold

How stated in policy"cumulative rental cost of more than $1,000."

Provider Actions and Submission Instructions

Prior Authorization

Vagus / Cranial Nerve Stimulation Prior Authorization Required

Prior authorization is required for vagus nerve stimulation and cranial nerve stimulation procedures. Submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by chat via the Contact us page, or by fax to 877-940-1972. Prior authorization is not required for emergency or urgent care. Out-of-network requests must be made by a network care provider.

Vagus nerve stimulation codes: 61888, 64569 (effective Jan. 1, 2015).
Implantation device/stimulation codes: C1767, C1778.
Cranial nerve stimulation code: L8681 (effective July 1, 2021).
Submission channels: Provider Portal Prior Authorization and Notification tool, 24/7 chat via Contact us page, or fax 877-940-1972.

Key Terms and Definitions

Prior authorization — definition

DefinitionPrior authorization: review requirement to obtain approval before certain services are provided as specified in this policy; not required for emergency or urgent care.

Submission methodsOnline via Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, chat 24/7 via Contact us page, or fax to 877-940-1972.

Out-of-network requestsMust be made by a network care provider.

DME rental threshold

TriggerDurable Medical Equipment cumulative rental cost greater than $1,000

ScopeApplies to DME codes listed in the DME section (examples include E0328, E0635, E0639 and many others).

Policy Revision History

2024-11-01policy_effective_dateLatest

This prior authorization list for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas became effective.

OpenPayer

Prior authorization requirements — UnitedHealthcare Connected (Medicare‑Medicaid Plan) Texas

Prior Authorization and Coverage Criteria

Code Lists and Coding Notes

Provider Actions and Submission Instructions

Key Terms and Definitions

Policy Revision History