UnitedHealthcare Prior Auth Requirements Update

Coverage criteria and authorization stance

Prior authorization coverage stance

The following services and CPT/HCPCS codes require prior authorization as indicated in the policy excerpt:

ALL of the following

Acupuncture
- CPT 97810 requires prior authorization
- CPT 97811 requires prior authorization
- CPT 97813 requires prior authorization
- CPT 97814 requires prior authorization
Bariatric surgery
- CPT 43644 requires prior authorization
- CPT 43775 requires prior authorization
- CPT 43645 requires prior authorization
- CPT 43842 requires prior authorization
- CPT 43659 requires prior authorization
- CPT 43845 requires prior authorization
- CPT 43770 requires prior authorization
Cancer supportive care (outpatient colony‑stimulating factors)
- HCPCS J1442 (Filgrastim) requires prior authorization when used in an outpatient setting for a cancer diagnosis
- HCPCS Q5110 (Filgrastim‑aafi) requires prior authorization when used in an outpatient setting for a cancer diagnosis
- HCPCS Q5101 (Filgrastim‑sndz) requires prior authorization when used in an outpatient setting for a cancer diagnosis
- HCPCS J2506 (Pegfilgrastim) requires prior authorization when used in an outpatient setting for a cancer diagnosis
Cardiovascular procedure example
- CPT 93580 (right heart catheterization) requires prior authorization
Inpatient video EEG monitoring
- CPTs 95700–95718 (inpatient continuous video EEG monitoring codes such as 95700, 95711, 95712, 95713, 95714, 95715, 95716, 95718) require prior authorization for inpatient services
Chemotherapy injectables (outpatient)
- Chemotherapy injectable drugs in the J9000–J9999 range require prior authorization when administered in an outpatient setting (includes examples such as J0640, J0641, J0642)
Chiropractic
- CPTs 98940, 98941, 98942, 98943 require prior authorization
How to submit requests
- Submit prior authorization requests via the UnitedHealthcare Provider Portal or call 888‑397‑8129

Prior authorization is required for the services above except as otherwise noted in other sections of the policy (see exemptions and code lists).

Prior authorization requirements (partial)

Partial list of CPT/HCPCS codes and notes indicating prior authorization requirements or status (examples from the excerpt):

Chemotherapy injectables

HCPCS J9000–J9999: chemotherapy injectable drugs — prior authorization required for outpatient administration (examples: J0640, J0641, J0642)

Continuous glucose monitors

HCPCS A9276, A9277, A9278: continuous glucose monitor devices — prior authorization process referenced (contact Provider Portal or 888‑397‑8129)

Cosmetic / reconstructive procedure examples (exemptions noted elsewhere)

CPT 11960 is referenced in the cosmetic and reconstructive surgeries section (see exemption lists)

Prior authorization exceptions and noted requirements (partial)

The excerpt enumerates codes and diagnosis groups that do NOT require prior authorization and notes exceptions where prior authorization is required:

Cosmetic and reconstructive surgeries (diagnosis codes)

Multiple ICD‑10 diagnosis codes in the C43 and C44 series (e.g., C43.0, C43.10, and numerous C44.xx codes) are listed as not requiring prior authorization for reconstructive/cosmetic surgeries

DME and enteral supplies

Numerous HCPCS DME codes (examples: A9279, E0270) and enteral/ in‑home nutrition codes (examples: B4034, B4100) are listed with prior‑authorization not required; some DME items may still require authorization depending on purchase/rental thresholds

Experimental/investigational procedures

Certain CPT codes flagged as experimental/investigational (examples: 33477, 36514) require prior authorization

Prior authorization stance (partial)

Partial stance and operational notes from the excerpt:

Genetic and molecular testing (U‑codes and 814xx series) — many tests in outpatient settings do not require prior authorization but laboratories must notify UnitedHealthcare and may need to register tests (examples listed in the excerpt).

Home health care codes (S9122, S9123, S9124, T1021) — prior authorization required only in outpatient settings including the member's home.

Injectable medications — the excerpt contains long enumerated lists: some injectable J‑ and Q‑codes require prior authorization (see separate lists), while others are listed as not requiring prior authorization; special rules and Optum Rx routing apply for specific products.

Prior authorization exemptions (partial list)

Examples of items explicitly listed as exempt from prior authorization in this excerpt:

Hysterectomy and related CPT codes (examples: 58180, 58260, 58542, 58550) — listed as not requiring prior authorization in this section.

Numerous injectable medications identified by J‑ and Q‑codes (partial examples in the excerpt: J3262, J1426, J0177, J1306, J0221) are listed as not requiring prior authorization in this section.

Certain product examples (Leqvio J1306, Lumizyme J0221) appear repeatedly across chunks indicating repeated listings as not requiring prior authorization in this excerpt.

Prior authorization exceptions / injectable medications (continued)

Continuation of injectable medication lists and diagnosis/code exemptions from prior authorization:

Leqvio (J1306) and Lumizyme (J0221) are shown in the excerpt as examples of injectable products listed as not requiring prior authorization in this section.

Continued injectable medication examples

Examples from the continuation include J0221 (Lupron Depot), J1950 and a large list of specialty injectables such as J9217 (Eligard), J3398 (Luxturna), J2350 (Ocrevus), J3399 (Zolgensma) — many are listed in the continued enumerations.

Prior authorization coverage criteria (partial)

Partial coverage criteria and examples of services with prior authorization requirements (and notes on exceptions):

Injectable medications (examples)

J1558 (Xembify), J0218 (Xenpozyme), J2357 (Xolair) and J3399 (Zolgensma) are listed in the excerpt; many injectables are noted as not requiring prior authorization while others or specific circumstances require prior authorization (see Optum Rx routing and Review at Launch notes).

Joint replacement

Total hip and knee replacement procedures (examples: CPTs 27130, 27486 and others listed) require prior authorization

Massage therapy

CPTs 97010, 97112, 97124, 97140 (massage/therapy codes) require prior authorization

Non‑emergent air ambulance

Excerpted authorization and coverage rules

Operational rules and contacts captured in this excerpt:

Numerous orthotics/prosthetics HCPCS L‑codes are designated as not requiring prior authorization in these chunks (sample L‑codes listed).

Outpatient therapy evaluation and reevaluation codes (examples: 97161–97163, 97165–97167 and related mapping entries) require prior authorization; the request must be submitted by a primary care provider via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool.

For many outpatient therapy codes, prior authorization/notification is handled by OptumHealth Physical Health; contact phone: 800‑873‑4575 or use the notification number on the back of the member ID card.

Summary of authorization stance

Summary notes on authorization/notification requirements by service type and site of service:

Place of service rule: prior authorization is not required when services are performed in the member's home (place of service 12 / bill type 3XX); prior authorization is required when requesting certain outpatient hospital services.

Advanced outpatient imaging

Certain CT, MRI, MRA, PET scans and selected nuclear medicine procedures require prior authorization or notification prior to scheduling; submit requests via the Provider Portal or call 866‑889‑8054.

Sinuplasty and select surgical procedures

Sinuplasty CPTs 31295–31298 require prior authorization; select arthroscopic shoulder CPTs (e.g., 29819, 29824, 29828) are referenced with prior‑auth requirements depending on site of service.

Prior authorization exemptions and requirements (partial)

Additional enumerated exemptions and required prior authorization items (partial):

Procedures listed as not requiring prior authorization

A large set of CPTs for procedures such as tonsillectomy/adenoidectomy, GI endoscopy, urologic procedures and numerous spine and neurosurgery CPTs are listed as not requiring prior authorization in this section (see chunks for full lists).

Transplant / CAR T‑cell services

Transplant and CAR T‑cell therapy services require prior authorization via the Optum transplant team (call 888‑936‑7246)

Ventricular assist devices (VAD)

VADs require prior authorization; contact the notification number on the back of the member's ID card and fax the nurse‑provided form to Optum VAD Case Management at 855‑282‑8929; related CPT/HCPCS include codes such as 33927–33929, 33975–33976, 33979, 33981–33983, Q0507–Q0509

Prior authorization requirements and exemptions

Codes and VAD-specific instructions captured in this excerpt:

Codes referenced / VADs

CPT/HCPCS codes referenced in connection with VADs include 37780, 33927, 33928, 33929, 33975, 33976, 33979, 33981, 33982, 33983 and HCPCS Q0507–Q0509
Operational instruction: Ventricular assist devices require prior authorization — call the notification number on the member's ID card and fax the nurse‑provided form to Optum VAD Case Management at 855‑282‑8929.

CPT, HCPCS and ICD-10 code lists

Acupuncture codes requiring prior authorizationCPTCovered

97810	Acupuncture, initial 15 minutes
97811	Acupuncture, each additional 15 minutes
97813	Acupuncture with electrostimulation, initial 15 minutes
97814	Acupuncture with electrostimulation, each additional 15 minutes

Colony-stimulating factor drugs requiring prior authorizationHCPCSCovered

J1442	Filgrastim
Q5110	Filgrastim-aafi
Q5101	Filgrastim-sndz
J2506	Pegfilgrastim

Example cardiovascular code requiring prior authorizationCPTCovered

93580

Right heart catheterization

Inpatient EEG monitoring codesCPTCovered

95700

Electroencephalogram monitoring, continuous

Injectable chemotherapy drugsHCPCSCovered

J9000-J9999	Chemotherapy injectable drugs range
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin (alternate)

Selected device/monitor codesCPT | HCPCSCovered

69710	Cochlear implant related code
69714	Cochlear implant related code
69930	Cochlear implant related code
A9276	Continuous glucose monitor
A9277	Continuous glucose monitor
A9278	Continuous glucose monitor

Ear/physiologic function and related codesCPT | HCPCS | mixedCovered

67950	Procedures to improve or restore physiologic function (ear/adjacent)
67961	Procedures to improve or restore physiologic function
67966	Procedures to improve or restore physiologic function
Q2026	Drug/biologic code noted in context

Cosmetic and reconstructive surgery codesCPTCovered

11960	Cosmetic and reconstructive code
14020	Cosmetic and reconstructive code (asterisked)
14021	Cosmetic and reconstructive code (asterisked)
14301	Cosmetic and reconstructive code

ICD-10 diagnosis codes (partial)ICD-10Covered

C43.0	Malignant melanoma of skin (example listed under cosmetic and reconstructive surgeries section)
C43.10	Specified malignant melanoma codes (partial list)

HCPCS codes for DME and enteral supplies (partial)HCPCSCovered

A9279	DME HCPCS code listed (example)
E0270	DME HCPCS code listed (example)
B4034	Enteral services HCPCS code listed
B4100	In-home nutritional therapy HCPCS code listed

CPT/Procedure codes flagged as experimental/investigational (partial)CPTExperimental

33477	Procedure code listed under Experimental and investigational (prior authorization required)
36514	Procedure code listed under Experimental and investigational (prior authorization required)

Genetic/molecular testing codes (U-codes and 814xx series)CPT | HCPCS | mixedCovered

0244U	genetic/molecular testing code listed as not requiring prior authorization (partial)
0250U	genetic/molecular testing code listed as not requiring prior authorization (partial)
0271U	genetic/molecular testing code listed as not requiring prior authorization (partial)
0299U	genetic/molecular testing code listed as not requiring prior authorization (partial)
81425	molecular testing code listed
81426	molecular testing code listed
81427	molecular testing code listed

Home health and hysterectomy codesCPT | HCPCS | mixedCovered

S9122	home health care HCPCS code (prior auth required only in outpatient/home settings)
S9123	home health care HCPCS code
S9124	home health care HCPCS code
T1021	home health care HCPCS code
58150	hysterectomy CPT code (listed with prior authorization notes)
58152	hysterectomy CPT code

Representative CPT/HCPCS codesmixedCovered

58180	Hysterectomy (example listed)
58550	Laparoscopic hysterectomy or related procedure (example listed)
J1306	Leqvio (alirocumab or inclisiran-related code listed repeatedly)
J0221	Lumizyme (alglucosidase alfa) referenced

Examples of HCPCS codes referenced as not requiring prior authorizationHCPCS

J1306	Listed in section as not requiring prior authorization (context incomplete)
J0221	Listed in section as not requiring prior authorization (context incomplete)
J1950	Listed in section as not requiring prior authorization (context incomplete)

Injectable medication HCPCS codes listed (continued)HCPCS

J9217	Eligard
J1954	Lutrate Depot
J3398	Luxturna
J3397	Mepsevii
J1437	Monoferric
J1458	Naglazyme
J0219	Nexviazyme
J9038	Niktimvo
J2802	Nplate
J2182	Nucala

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Injectable medications (partial list)HCPCSCovered

J0221	Lupron Depot
J1558	Xembify
J0218	Xenpozyme
J2357	Xolair
J3399	Zolgensma

Transport servicesHCPCSCovered

A0430

Non-emergent air ambulance transport

Maxillofacial / orthognathic codesCPTCovered

21121

Orthognathic surgery code (example)

Sample orthotics/prosthetics L-codes not requiring prior authorizationHCPCSCovered

L2010	HCPCS L-code listed as not requiring prior authorization
L2020	HCPCS L-code listed as not requiring prior authorization
L2030	HCPCS L-code listed as not requiring prior authorization
L2034	HCPCS L-code listed as not requiring prior authorization
L2036	HCPCS L-code listed as not requiring prior authorization
L2037	HCPCS L-code listed as not requiring prior authorization
L2038	HCPCS L-code listed as not requiring prior authorization
L2060	HCPCS L-code listed as not requiring prior authorization
L2106	HCPCS L-code listed as not requiring prior authorization

Outpatient therapy evaluation and common therapy CPT/HCPCS codesCPT | HCPCSCovered

97161	Physical therapy evaluation (low complexity) — listed among eval/reeval codes requiring prior authorization
97162	Physical therapy evaluation (moderate) — mapped in list
97163	Physical therapy evaluation (high) — mapped in list
97165	Occupational therapy evaluation series referenced
97166	OT eval (moderate) — referenced
97167	OT eval (high) — referenced
97110	Therapeutic exercise — appears in outpatient therapy list

Radiation therapy / PBT and treatment delivery codesCPTCovered

77387	Proton Beam Therapy (PBT)
77520	Radiation Treatment Delivery
77402	Radiation treatment delivery (example listed)

Shoulder surgery CPT examplesCPTCovered

29805	Shoulder arthroscopy (example)
29806	Shoulder procedure (example)
29807	Shoulder procedure (example)

Sinuplasty CPT examplesCPTCovered

31295	Sinuplasty CPT example
31296	Sinuplasty CPT example
31297	Sinuplasty CPT example
31298	Sinuplasty CPT example

Rhinoplasty / septoplasty CPT examplesCPTCovered

30400	Rhinoplasty / septoplasty example
30410	Rhinoplasty / septoplasty example
30420	Rhinoplasty / septoplasty example

Examples of CPT/diagnosis codes listed as not requiring prior authorizationCPTCovered

42820	Tonsillectomy and adenoidectomy (listed as not requiring prior authorization)
43235	Upper and lower gastrointestinal endoscopy (listed)
52000	Urologic procedures (listed)

Stimulator HCPCS referenced (some require prior auth)HCPCS

E0747	Bone growth stimulator (HCPCS) referenced
E0748	Bone growth stimulator (HCPCS) referenced
E0749	Bone growth stimulator (HCPCS) referenced
E0760	Referenced (HCPCS) in stimulators list

Transplant/CAR T-cell and J/Q code mappingsmixed

38232	Transplant-related code (listed in mapping rows)
J9999	Drug/procedure mapping entries (listed)
Q2054	Code mapping entries

Referenced CPT/HCPCS codesmixed

37780	Referenced for saphenous vein procedures
33927	VAD-related procedure code
33928	VAD-related procedure code
33929	VAD-related procedure code
33975	VAD-related procedure code
33976	VAD-related procedure code
33979	VAD-related procedure code
33981	VAD-related procedure code
33982	VAD-related procedure code
33983	VAD-related procedure code

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DME rental/purchase threshold

DME rental/purchase threshold$500 (retail purchase or cumulative rental cost threshold referenced)

How providers obtain prior authorization and operational contacts

Prior Authorization

How to submit prior authorization

Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com — sign in with One Healthcare ID). If you don't have a One Healthcare ID, go to UHCprovider.com/access to register. You may also call 888-397-8129 for prior authorization requests. 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: UnitedHealthcare Provider Portal — Prior Authorization and Notification tool (UHCprovider.com).
Phone: 888-397-8129.

Prior Authorization

Acupuncture — prior authorization required

Acupuncture services (CPT 97810, 97811, 97813, 97814) require prior authorization. Submit requests using the UnitedHealthcare Provider Portal or call the number on the member’s ID card.

CPT: 97810, 97811, 97813, 97814

Definitions and terms used

Definition of prior authorization

DefinitionPrior authorization is the process by which providers submit requests (online via the Provider Portal or by phone) to obtain approval before performing certain procedures or services

Submission methodsOnline via the Prior Authorization and Notification tool on UHCprovider.com or by phone (contact details in policy)

Emergency/urgent carePrior authorization is not required for emergency or urgent care

Cancer diagnoses

Term referenceCancer diagnoses referenced in sections listing codes and exceptions (policy notes cancer diagnoses in context of intrathecal and supportive care)

ContextCancer diagnoses appear across code lists as conditions affecting prior authorization requirements (see injectable and supportive care sections)

OpenPayer

Prior authorization requirements for UnitedHealthcare Community Plan of Florida providers

Coverage criteria and authorization stance

CPT, HCPCS and ICD-10 code lists

How providers obtain prior authorization and operational contacts

Definitions and terms used