CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for UnitedHealthcare Community Plan of Florida

Defines prior authorization requirements and submission methods for participating UnitedHealthcare Community Plan of Florida providers for inpatient and outpatient services; excludes emergency and urgent care and applies to out-of-network providers who must request prior authorization for non-emergent services.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Florida

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2025

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; if no ID visit UHCprovider.com/access.

SourceLink

Online portalprimary prior authorization submission method

Excludedemergency/urgent care

Many codesexamples listed

$500DME threshold

OptumHealth 800-873-4575therapy contact

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.

Prior Authorization — Coverage Criteria

Summary of prior authorization requirements (partial)

Services and specific codes listed require prior authorization; behavioral health services often require referral to a designated behavioral health network and prior authorization is obtained by calling the number on the member's health plan ID card.

ALL of the following

Acupuncture (CPT 97810, 97811, 97813, 97814) requires prior authorization.
Bariatric surgery (e.g., CPT 43644, 43645, 43659, 43770) requires prior authorization.
Bone growth stimulator (CPT 20975, 20979) requires prior authorization.
Electric breast pump (HCPCS E0604) requires prior authorization.
Cancer supportive care: colony-stimulating factor and bone‑modifying agents administered outpatient for cancer diagnosis require prior authorization (see J- and Q-codes listed).
Behavioral health services: prior authorization required through a designated behavioral health network; call the number on the member's health plan ID card for specific codes.

ALL of the following

Submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID; if no ID, visit UHCprovider.com/access.
Prior authorization is not required for emergency or urgent care (exclusion).
Out-of-network providers must request prior authorization for all procedures and services excluding emergent or urgent care.

ALL of the following

Where specific J-, Q- or HCPCS codes are listed in this document, those services require prior authorization as indicated (see code lists in coding module).

Explicit prior authorization criteria present

Specific coverage/prior authorization requirements called out in the listed sections:

ALL of the following

Injectable chemotherapy drugs administered in an outpatient setting for a cancer diagnosis require prior authorization; submit requests via the UnitedHealthcare Provider Portal or call 888-397-8129.

ALL of the following

Inpatient video electroencephalogram (EEG) requires prior authorization (CPT examples include 95716, 95718); prior authorization is not required for outpatient hospital or ambulatory surgical center settings.

ALL of the following

Chiropractic services (CPT 98940–98943) require prior authorization.

ALL of the following

Prior authorization/notification requirements by service category

Prior authorization/notification is required for the following service categories and codes:

ALL of the following

Enteral and in‑home nutritional services and related supplies (examples: HCPCS B4034–B4036, B4100–B4161, B9998) require prior authorization.

ALL of the following

Experimental and investigational services and linked services (examples: CPT 33477, 36514, 64722, 65765–66180, selected S-codes) require prior authorization.

ALL of the following

Functional endoscopic sinus surgery (FESS) CPT codes (e.g., 31240, 31253–31259, 31267, 31276, 31287–31288) require prior authorization.

ALL of the following

Genetic/molecular testing authorization/notification

Genetic and molecular testing

ALL of the following

UnitedHealthcare requires prior authorization or notification for a broad set of genetic and molecular CPT/HCPCS codes (examples include 0060U, 0087U, 0088U, 0097U, 0111U, 0129U, 0154U–0168U and many CPT molecular panels listed).
Laboratory will notify UnitedHealthcare for certain tests; ordering providers must notify the laboratory when required and include the laboratory and test name during notification.

Operational: Providers should follow the notification/authorization instructions in the molecular testing listing and include lab/test identifiers when submitting.

Home health prior authorization

Home health care

ALL of the following

Prior authorization is required for home health services when provided in outpatient settings, including the member's home (example HCPCS/S codes: S9122, T1030, S9123, T1031, S9124, T1021).

Hysterectomy prior authorization

Surgical procedures

ALL of the following

Hysterectomy procedures listed (examples include CPT 58150, 58152, 58180, 58260–58292, 58542–58573) require prior authorization.

Injectable medications prior authorization

Injectable medications

ALL of the following

Numerous injectable medications identified by J-, Q- and other HCPCS codes require prior authorization (examples: J3262 Actemra, J0801 Acthar, J0791 Adakveo, J0172 Aduhelm, J1426 Amondys 45, J0225 Amvuttra, J0739 Apretude; see extended injectable medication lists in document).
Intravenous immunoglobulin (IVIG) products and other specialty injectables (examples: J1459, J1555, J1556, J1458, J1439) require prior authorization.
Some sodium hyaluronate and related codes (e.g., J7320, J7322, J7325, J7331) are listed with prior authorization indicators.

Operational: For new-to-market medications, consult the 'Review at Launch' policy and consider pre-determination as recommended.

Prior authorization code listings

Code-level prior authorization entries (placeholders)

ALL of the following

Listed HCPCS/J codes flagged in the document include J7320, J7322, J1930, J1747, J2326, J3358 and HCPCS S0013 (Spravato); prior authorization indicated or additional information fields present for these entries.

Operational: Providers should refer to the coding module and the Prior Authorization and Notification tool for submission instructions for listed codes.

Prior authorization criteria (enumerated items)

Services and codes requiring prior authorization (partial list in this document fragment):

ALL of the following

Joint replacement — total hip and total knee arthroplasty procedures (examples: CPT 27130, 27134, 27137, 27138, 27486, 27487, 29866–29868) require prior authorization.

ALL of the following

Orthognathic surgery/treatment of maxillofacial/jaw functional impairment (extensive CPT list including 21121–21299 series) requires prior authorization.

ALL of the following

Non-emergent air ambulance transport (HCPCS A0430, A0431, A0435, A0436) requires prior authorization.

ALL of the following

Prior authorization coverage criteria (code lists)

Codes listed below require prior authorization per payer rules; where noted, prior authorization is explicitly required.

ALL of the following

Orthognathic surgery CPT codes listed (examples: 21193–21199, 21206–21215, 21240–21255, 21296–21299) — prior authorization required as indicated.

ALL of the following

Extensive orthotics and prosthetics HCPCS L‑code listings require prior authorization only when retail purchase or cumulative rental cost exceeds $500 (examples include L0170, L0456, L0462, L0464, L0480, etc.).

Operational: Providers should verify cost threshold applicability when submitting PA requests for orthotics/prosthetics.

Radiation therapy criteria

Radiation therapy prior authorization conditions

ALL of the following

Radiation therapy modalities (IGRT, IMRT, proton beam, SRS/SBRT and other focused radiation; examples: CPT/HCPCS 77014, 77385–77387, 77520–77525, 77371–77373) require prior authorization.

ALL of the following

Certain radiation CPT/HCPCS require prior authorization only when billed with diagnosis codes in specified ranges (e.g., C34.00–C34.92, C50.011–C50.929, C61, C79.51–C79.52, C84.7A).

Advanced imaging criteria

Advanced imaging prior authorization/notification

ALL of the following

Prior authorization (or notification) is required for certain advanced outpatient imaging procedures (specific CT, MRI, MRA, PET scans, nuclear medicine and nuclear cardiology procedures).
Care providers ordering advanced outpatient imaging are responsible for notifying prior to scheduling and must submit requests via the Prior Authorization and Notification tool on UHCprovider.com or call 866-889-8054.

Operational: Submit requests online via the UnitedHealthcare Provider Portal or call the phone number provided for assistance.

Therapy and procedural criteria

Outpatient therapy and selected procedures

ALL of the following

Outpatient therapy evaluation and re-evaluation codes (examples mapped: S9152, 92507, 92508, 97161–97168, etc.) require prior authorization; providers may call OptumHealth Physical Health at 800-873-4575 or use the notification number on the member's ID card for these requests.

ALL of the following

Selected surgical/procedural services (shoulder arthroscopy, sinuplasty, rhinoplasty, nasal functional procedures; examples CPT 29805–29807, 31295–31298, 30400–30435 series) are flagged as requiring prior authorization when indicated.

Operational: Some therapy and ancillary codes have place-of-service exceptions (no PA required when performed in member's home or specified bill types).

Prior authorization criteria — procedural listing

Prior authorization is required for the following procedure categories and device implantations where indicated.

ALL of the following

Sleep apnea procedures and surgeries: Maxillomandibular advancement and related sleep apnea procedures require prior authorization.
Spinal surgery procedures require prior authorization.
Stimulator implantation: Implantation of stimulators (bone growth stimulator, neurostimulator) and related device codes (examples: E0747–E0749, E0760, 0164T, L8680–L8688) require prior authorization.

Prior authorization criteria (listed items)

Services and devices explicitly noted as requiring prior authorization and the relevant contact/fax process.

ALL of the following

Transplant and CAR T‑cell therapy services require prior authorization; providers must call the Optum transplant team at 888-936-7246 or use the notification number on the back of the member's health plan ID card.

ALL of the following

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

ALL of the following

Vein procedures — removal and ablation of saphenous trunks and named branches for venous disease/varicose veins — require prior authorization.

Codes and Mappings

Selected CPT/HCPCS codes requiring prior authorization (partial list)CPT | HCPCSCovered

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

Selected HCPCS/J/Q codes for outpatient oncology supportive care (partial list)HCPCSCovered

20975	Bone growth stimulator
20979	Bone growth stimulator
E0604	Electric breast pump
J1442	Filgrastim (Neupogen) injectable
Q5110	Filgrastim-aafi (Nivestym)
Q5101	Filgrastim-sndz (Zarxio)
J2506	Pegfilgrastim (Neulasta)

Listed ICD-10 codes (examples)ICD-10

M86.10	Osteomyelitis code listed in cardiovascular section
M86.151	Osteomyelitis code
M86.152	Osteomyelitis code
M86.159	Osteomyelitis code
M86.161	Osteomyelitis code
M86.162	Osteomyelitis code
M86.169	Osteomyelitis code

Cosmetic/reconstructive CPT examplesCPT

11960	Cosmetic/reconstructive surgery CPT examples
14060	Cosmetic/reconstructive surgery CPT examples
15821	Cosmetic/reconstructive surgery CPT examples
21139	Cosmetic/reconstructive surgery CPT examples

Example DME codes requiring prior authorizationHCPCSCovered

E0445

Enteral pump (example code found in DME list)

Selected genetic/molecular testing CPT codesmixedCovered

81352	CPT/HCPCS code listed
81353	CPT/HCPCS code listed
81357	CPT/HCPCS code listed
81360	CPT/HCPCS code listed
81400	CPT/HCPCS code listed
81401	CPT/HCPCS code listed

Selected injectable medication codesHCPCSCovered

J1555	IVIG or injectable medication J-code
J1459	IVIG or injectable medication J-code
J1556	IVIG or injectable medication J-code

Stelara codesHCPCS

J3358

Stelara (multiple mentions)

Spravato/Spinraza codesHCPCS

J2326	Spravato / Spinraza references
S0013	Spravato HCPCS entry

Misc medication codesHCPCS

J7320	Sodium hyaluronate referenced
J1930	Unspecified drug entry
J1747	Spevigo

Enumerated injectable and procedure codesHCPCS | CPTCovered

J9226	Supprelin LA
J2781	Syfovre
90378	Synagis
J3241	Tepezza
J2356	Tezspire
J1322	Vyepti
J3032	Vyjuvek
27130	Total hip replacement
27486	Total knee replacement
J7330	Implantable hip/knee device code (example)

Orthognathic surgery CPT examplesCPTCovered

21193	Treatment of maxillofacial/jaw functional impairment
21194	Orthognathic surgery
21195	Orthognathic surgery

Orthotics/prosthetics HCPCS examplesHCPCSCovered

L0170	Orthotic/prosthetic HCPCS example
L0456	Orthotic/prosthetic HCPCS example

Therapy and audiology code mappingsCPT

70371	Mapped to multiple hearing/audiology codes in mapping block
92521	Audiology code (example mapping shown)
92522	Audiology code
92523	Audiology code
92524	Speech therapy/related code
97161	PT/OT evaluation codes mapped to higher complexity codes 97162-97164

Selected procedural codesCPT

30400	Rhinoplasty
31295	Sinuplasty
45380	Colonoscopy

Selected HCPCS/T-code/device codes with PA requirementmixed

0164T	Stimulator implantation (category III)
E0747	Bone growth stimulator
E0748	Bone growth stimulator
E0749	Bone growth stimulator
E0760	Electrical impulse device
L8680	Implantable neurostimulator component
L8682	Implantable neurostimulator component

Code mappings for transplant/CAR-T and related itemsmixed

J9999 -> Q2041/Q2042/Q2053	Mapping of J9999 to Q-codes as shown in the list
50370 -> 50547/J3392/J3393	Example CPT/J-code mappings from list

VAD CPT/HCPCS codesmixedCovered

33983	VAD-related CPT code listed
Q0507/Q0509	VAD-related HCPCS/Q-codes listed

Neurosurgery and neurostimulation codesCPT

61864/61867/61868/61885/61886	Neurosurgical or spine-related CPT codes listed
63650/63655/63685/64553/64555/64568/64570/64590	Neurostimulation or neurosurgery CPT codes listed

inv-35: DME cost threshold

ThresholdPrior authorization required for DME items when retail purchase or cumulative rental cost is more than $500

ScopeApplies to the DME codes listed in the policy (select HCPCS/E-codes shown in the DME list)

ExceptionProsthetics are not classified as DME for these rules (separate orthotics/prosthetics rules apply)

What Providers Must Do

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID; if you do not have a One Healthcare ID, visit UHCprovider.com/access. Prior authorization is not required for emergency or urgent care. Out-of-network providers must request prior authorization for all procedures and services excluding emergent or urgent care.

Prior Authorization

Examples of services requiring prior authorization

Examples of services and codes that require prior authorization include acupuncture (CPT 97810–97814), bariatric surgery (e.g., 43644, 43645, 43659, 43770), bone growth stimulator (20975, 20979), electric breast pump (E0604), and specified colony-stimulating factor and bone-modifying agents listed by HCPCS/J/Q codes. Behavioral health services require authorization through the designated behavioral health network—call the number on the member's ID card for specific codes.

Acupuncture: 97810, 97811, 97813, 97814
Bariatric surgery: 43644, 43645, 43659, 43770
Bone growth stimulator: 20975, 20979

Key Definitions and Scope

inv-74: Prior authorization required

DefinitionPrior authorization: Provider must obtain approval before performing services or supplying items listed as requiring prior authorization

Submission methodSubmit requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (One Healthcare ID)

ExclusionPrior authorization is not required for emergency or urgent care

inv-75: Emergency/urgent care

DefinitionEmergency or urgent care services are excluded from prior authorization requirements

ApplicabilityApplies to participating UnitedHealthcare Community Plan of Florida providers; out-of-network providers still must request prior authorization for non-emergent services

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Florida

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2025

Next Review DateN/A

SourceLink

On This Page

Circumcision (CPT 54161) requires prior authorization for patients ages 12 weeks and older.

ALL of the following

Continuous glucose monitor codes (HCPCS A9276–A9278) require prior authorization when used for type 2 diabetes.

ALL of the following

Cochlear implants and related auditory implant codes (CPT/HCPCS listed) require prior authorization.

Genetic and molecular testing CPT codes (broad list including 81162–81168, 81191–81194, 81228–81279, 81338–81360, 81400–81465) require prior authorization or notification; include laboratory and test name during notification.

ALL of the following

Home health care services require prior authorization when provided in outpatient settings including the member's home (example codes S9122, T1030, S9123, T1031, S9124, T1021).

Massage therapy and related therapeutic procedure codes (e.g., 97010, 97112, 97124, 97140) require prior authorization.

ALL of the following

Note: Multiple injectable medications and radiopharmaceuticals are listed; providers should check Review at Launch for new medications and consider pre-determination.

inv-36: Orthotics/prosthetics prior authorization cost threshold

ThresholdPrior authorization required only for orthotics and prosthetic codes with a retail purchase or cumulative rental cost of more than $500

CodesApplies to the extensive list of HCPCS L-codes enumerated under Orthotics and Prosthetics (examples include L0170, L0456, L0462, etc.)

NoteRequests for orthotics/prosthetics meeting the threshold must follow the same prior authorization submission processes as other items (Provider Portal)

Electric breast pump: E0604

Colony-stimulating factor drugs and related J/Q codes (see list)

Prior Authorization

Chemotherapy prior authorization

Prior authorization is required for injectable chemotherapy drugs administered in an outpatient setting for a cancer diagnosis. Submit requests online via the UnitedHealthcare Provider Portal or call 888-397-8129.

Includes chemotherapy injectable drugs billed J9000–J9999, leucovorin (J0640), levoleucovorin (J0641, J0642), Lupron Depot (J1950), Q-code chemotherapy products, and miscellaneous HCPCS-billed agents.

Prior Authorization

Inpatient video EEG

Inpatient video electroencephalogram (EEG) requires prior authorization (CPT 95700, 95711–95713, 95716, 95718); prior authorization is not required when performed in an outpatient hospital or ambulatory surgical center.

Inpatient video EEG CPTs: 95700, 95711, 95712, 95713, 95716, 95718
Outpatient hospital/ASC setting: prior authorization not required

Prior Authorization

Chiropractic prior authorization

Chiropractic services require prior authorization for the listed CPT codes (e.g., 98940–98943).

Chiropractic CPTs: 98940, 98941, 98942, 98943

Prior Authorization

CGM prior authorization

Continuous glucose monitors require prior authorization when used for members with a type 2 diabetes diagnosis; the listed HCPCS codes include A9276–A9278.

CGM HCPCS: A9276, A9277, A9278

Prior Authorization

Cochlear implant prior authorization

Cochlear implants and other auditory implants require prior authorization; listed CPT/HCPCS include 69710, 69714, 69930 and L8614, L8619, L8690, L8691, L8692.

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

Prior Authorization

Circumcision prior authorization

Circumcision requires prior authorization for patients aged 12 weeks and older (CPT 54161).

Circumcision CPT: 54161

Prior Authorization

Cosmetic and reconstructive surgeries prior authorization

Cosmetic and reconstructive surgeries listed by ICD/CPT/HCPCS codes require prior authorization as shown in the code lists.

Examples include CPT/ICD entries such as 11960 and ICD-10 codes C44.500–C44.599 (see coding section)

Prior Authorization

DME prior authorization list and thresholds

Durable medical equipment (DME) codes listed in the document require prior authorization; certain items are subject to a retail purchase or cumulative rental cost threshold (prior authorization required when cost is more than $500). Prosthetics are not classified as DME for these rules.

Examples include HCPCS: A9279, E0445 and many E-/K-/L-codes listed in the DME sections
Prior authorization threshold: retail purchase or cumulative rental cost > $500

Prior Authorization

Enteral/in-home nutrition prior authorization

Enteral and in‑home nutritional services and related supplies require prior authorization; listed HCPCS include B4034–B4036, B4100–B4161 and related B‑codes.

Enteral HCPCS examples: B4034, B4035, B4036, B4100, B4102, B4103, B4104, B4149, B4150, B4152–B4161, B9998

Prior Authorization

Experimental/investigational services authorization

Services designated as experimental and investigational (and linked services) require prior authorization as listed by CPT/HCPCS codes (examples include 33477, 36514, 64722, 65765, 66180 and specified S-codes).

Examples of investigational codes: 33477, 36514, 64722, 65765, 65767, 66180, 0191T, A4638, A6000

Prior Authorization

Functional endoscopic sinus prior authorization

Functional endoscopic sinus surgery (FESS) CPT codes require prior authorization; listed CPTs include 31240, 31253–31259, 31267, 31276, 31287–31288 and related codes.

FESS CPTs: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288

Prior Authorization

Genetic and molecular testing prior authorization/notification

Genetic and molecular testing CPT codes require prior authorization or notification; providers must include the laboratory and test name during notification. A broad list of molecular testing CPTs (e.g., 81162–81168, 81191–81194, 81228–81279, 81338–81360, 81400–81465) is subject to authorization/notification.

Genetic/molecular CPT examples: 81162, 81163, 81164, 81168, 81191–81194, 81228, 81229, 81279, 81338–81360, 81400–81465
Notification must include laboratory and test name; laboratories will notify UnitedHealthcare for certain tests

Documentation Required

Genetic/molecular testing notification and authorization

Certain genetic/molecular tests are such that the laboratory will notify UnitedHealthcare; ordering providers may need to notify the laboratory per test-specific instructions.

Laboratory notification applies to specific U‑codes and other molecular test entries (e.g., 0060U, 0087U, 0088U, 0097U, 0111U, 0129U, etc.)

Prior Authorization

Home health care prior authorization

Home health care requires prior authorization when provided in outpatient settings, including the member's home; listed HCPCS include S9122, S9123, S9124, T1030, T1031 and T1021.

Home health HCPCS examples: S9122, T1030, S9123, T1031, S9124, T1021

Prior Authorization

Hysterectomy prior authorization

Hysterectomy procedures listed in the document require prior authorization; multiple hysterectomy CPTs are enumerated (e.g., 58150, 58152, 58180, 58260–58275, 58290–58292, 58542–58573).

Hysterectomy CPT examples: 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58275, 58290, 58291, 58292, 58542–58573

Prior Authorization

Injectable medications prior authorization

Numerous injectable medications require prior authorization; the policy lists many J- and Q-codes (examples include J3262, J0801, J0791, J0172, J1426, J0225, J0739, Q5121, J0490, J1414 and others).

Examples: Actemra J3262, Acthar J0801, Adakveo J0791, Aduhelm J0172, Ilumya J3245, Tezepel J2356, and many additional J/Q codes listed throughout the injectable medications sections

Note

Code entries (example: J7320/J7322)

The document includes HCPCS code entries such as J7320 and J7322 with notes indicating these HCPCS codes are listed and may require prior authorization.

Examples: J7320, J7322

Note

Drug code listings (examples)

Drug code listings in the document include examples such as J1930, J1747 (Spevigo), and J2326 (Spinraza/Spravato) that are presented with prior authorization placeholders or instructions.

Examples: J1930, J1747 (Spevigo), J2326 (Spinraza/Spravato)

Note

Spravato — S0013 references

The HCPCS S0013 code is repeatedly referenced in association with Spravato entries; the listing indicates S0013 is the HCPCS code tied to Spravato in multiple entries.

Spravato HCPCS: S0013 (repeated references)

Prior Authorization

Prior authorization required (services and codes)

Prior authorization is required for the listed services and codes including numerous injectable medications, joint replacement procedures (total hip and knee such as 27130 and 27486), non‑emergent air ambulance transports (A0430–A0436), massage therapy (97010, 97112, 97124, 97140), and orthognathic surgery codes.

Joint replacement examples: 27130 (total hip arthroplasty), 27486 (total knee arthroplasty)
Non‑emergent air ambulance HCPCS: A0430, A0431, A0435, A0436
Massage therapy CPTs: 97010, 97112, 97124, 97140
Orthognathic surgery CPT ranges listed (see orthognathic block)

Prior Authorization

Outpatient therapy prior authorization process

Prior authorization is required for outpatient therapy evaluation and re‑evaluation codes; authorization requests must be submitted by a primary care provider and submitted online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

Requests for outpatient therapy evaluation/re-evaluation must be submitted by a primary care provider
Submit online using the Prior Authorization and Notification tool on UHCprovider.com

Prior Authorization

Orthognathic surgery codes requiring prior authorization

Orthognathic surgery CPT codes listed require prior authorization; examples include 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21208, 21209, 21210, 21215, 21240, 21242–21255, 21296, 21299 and related codes.

Orthognathic CPT examples: 21193–21199, 21206, 21208–21215, 21240–21255, 21296, 21299

Prior Authorization

Orthotics and prosthetics codes requiring prior authorization (threshold $500)

Orthotics and prosthetics HCPCS L‑codes listed require prior authorization only when the retail purchase or cumulative rental cost is more than $500; extensive L‑code listings are provided in the policy.

Orthotics/prosthetics L‑code examples: L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631, etc.
Prior authorization threshold: retail purchase or cumulative rental cost > $500

Prior Authorization

Outpatient therapy CPT codes requiring prior authorization

Outpatient therapy CPT codes requiring prior authorization include multiple hearing/audiology and PT/OT evaluation codes mapped in the document (examples: 70371 mapping to 92521–92523, 97161 mapping to 97162–97164, and listed codes such as 92507, 92508, 92597).

Examples: 70371 -> 92521/92522/92523; 97161 -> 97162/97163/97164; specific codes: 92507, 92508, 92597

Documentation Required

Alternate contact for outpatient therapy prior authorization

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

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

Prior Authorization

Outpatient therapy prior authorization

Outpatient therapy prior authorization for listed codes (e.g., S9152, 92507, 92508) requires prior authorization; follow the outpatient therapy submission process and contact OptumHealth Physical Health as needed.

Examples: S9152, 92507, 92508

Prior Authorization

Advanced outpatient imaging prior authorization/notification

Advanced outpatient imaging (certain CT, MRI, MRA, PET scans, nuclear medicine and nuclear cardiology) requires prior authorization/notification; submit requests online via the UnitedHealthcare Provider Portal or call 866-889-8054.

Care providers must provide notification prior to scheduling
Submission methods: Prior Authorization and Notification tool on UHCprovider.com or phone 866-889-8054

Prior Authorization

Radiation therapy prior authorization

Radiation therapy services (including IGRT, IMRT, proton beam therapy, SRS/SBRT and other focused radiation) require prior authorization; some radiation CPT/HCPCS require authorization only when billed with specific cancer diagnosis ranges.

Radiation CPT examples: 77014, 77385, 77386, 77520, 77522–77525, and associated IMRT/IGRT codes
Some authorizations apply only with diagnosis code ranges (e.g., C34.xx, C50.xx, C61, C79.51–C79.52, C84.7A)

Prior Authorization

Selected procedures prior authorization

Selected surgical and procedural services (shoulder arthroscopy, sinuplasty, rhinoplasty, nasal functional procedures) are flagged as prior authorization required and are listed by CPT codes in the document.

Examples: Shoulder surgery CPTs 29805–29807, 29819; Sinuplasty CPTs 31295–31298; Rhinoplasty CPTs 30410–30430; nasal functional CPTs 30435–30465

Documentation Required

Therapy and ancillary codes — place of service exception

Certain therapy and ancillary CPT/HCPCS codes have a place‑of‑service exception: prior authorization is not required when the place of service is the member's home (place of service 12) or bill type 3XX for specified codes.

Place-of-service exception applies to listed therapy/ancillary codes when delivered in member's home (POS 12) or bill type 3XX

Prior Authorization

Prior authorization requirement — selected procedures/devices

Prior authorization is required for selected procedures and device implantations such as sleep apnea surgeries (e.g., maxillomandibular advancement), spinal surgery, and implantation of stimulators (bone growth stimulator, neurostimulator) and related device codes.

Sleep apnea and maxillomandibular advancement procedures: prior authorization required
Stimulator/neurostimulator device examples: 0164T, E0747–E0749, L8680–L8688

Prior Authorization

Transplant and CAR T-cell therapy prior authorization

Transplant and CAR T‑cell therapy services require prior authorization; providers must call the Optum transplant team at 888-936-7246 or use the notification number on the back of the member's health plan ID card.

Contact Optum transplant team: 888-936-7246
Applies to listed CAR T products (Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta, etc.)

Prior Authorization

VAD prior authorization and notification process

For ventricular assist devices (VAD) prior authorization/notification, call the notification number on the back of the member's ID card and fax the nurse-provided form to the Optum VAD Case Management team at 855-282-8929.

Fax Optum VAD Case Management at 855-282-8929 after calling the notification number on the member's ID card
VAD CPT/HCPCS examples include 33927, 33928, 33975–33983, Q0507, Q0509

Prior Authorization

Vein procedures prior authorization

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

Vein procedure examples and mappings are provided in the policy (see vein procedures section)

Documentation Required

General CPT/HCPCS code listings and mappings

The document provides multiple CPT and HCPCS code listings and code mappings that reference services or devices which may require prior authorization; providers should consult the listed code sections for specifics.

See coding sections for extensive CPT/HCPCS mappings (e.g., transplant mappings, device codes, neurostimulation codes)

Provider guidanceIf unsure whether a service is emergent/urgent, follow clinical judgment and document rationale

inv-76: Cochlear implant

DefinitionCochlear implant: a medical device within the inner ear with an external portion to help persons with profound sensorineural deafness achieve conversational (speech) perception

Prior authorizationCochlear implants and other auditory implants require prior authorization (listed CPT/HCPCS codes such as L8619, L8690, L8691, L8692)

Codes examplesExamples of related CPT/HCPCS codes are provided in the policy's cochlear implant entries

inv-77: Durable medical equipment (DME)

DefinitionDurable medical equipment (DME): items listed in the DME section that may require prior authorization

Prior authorization ruleDME codes listed require prior authorization; some items are subject to a retail purchase or cumulative rental cost threshold (see $500 threshold)

Prosthetics noteProsthetics are not classified as DME for these rules (see orthotics/prosthetics section)

inv-78: Prior authorization/notification requirement

RequirementProviders must obtain prior authorization or submit notification for the CPT/HCPCS codes listed in the policy

Molecular testingFor molecular/genetic testing, providers must include the laboratory and test name during notification

ProcessFollow the Prior Authorization and Notification tool on UHCprovider.com or contact numbers provided for specific services

inv-79: Laboratory will notify UnitedHealthcare

ProcessLaboratory will notify UnitedHealthcare for certain genetic and molecular tests; ordering provider may be required to notify the laboratory in some cases

ScopeApplies to the molecular/genetic CPT/HCPCS codes enumerated in the policy (BRCA and many molecular testing codes)

Provider actionWhen submitting notification include laboratory name and specific test identifier per policy instructions

inv-80: Home health care prior authorization scope

ScopeHome health care prior authorization required only in outpatient settings, including the member's home

CodesApplies to listed home health CPT/HCPCS entries such as S9122, T1030, S9123, T1031, S9124

SubmissionSubmit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal

inv-81: Spravato

DefinitionSpravato: the policy references Spravato and associated HCPCS S0013 entries repeatedly

CodingSpravato is referenced alongside HCPCS S0013 and other drug code placeholders in the injectable medications/drug listings

Provider noteProviders should follow the policy's drug code listing and prior authorization instructions where indicated

inv-82: Review at Launch for New to Market Medications

DefinitionReview at Launch for New to Market Medications: check the payer's Review at Launch policy for newly approved FDA drugs

Provider actionPre-determination is highly recommended for new-to-market injectable medications listed in the policy (see Review at Launch list)

ExamplesPolicy lists numerous J-codes (e.g., J1322 Vyepti, J3032 Vyjuvek, J9202 Zolgensma) and advises checking Review at Launch for updates

inv-83: Outpatient therapy prior authorization

RequirementPrior authorization is required for outpatient therapy evaluation and re-evaluation codes listed in the policy

SubmissionRequests must be submitted by a primary care provider and submitted online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal

Alternate contactFor outpatient therapy prior authorization, providers may call OptumHealth Physical Health at 800-873-4575 as noted in the policy

inv-84: Prior authorization required when retail purchase or cumulative rental cost exceeds $500

ThresholdPrior authorization required when retail purchase or cumulative rental cost exceeds $500 for listed DME items

Applies toDME codes enumerated in the policy where a retail purchase or cumulative rental cost is specified

Related ruleOrthotics and prosthetics also reference the $500 retail/cumulative rental threshold under their section

inv-85: place of service including member's home/12/bill type 3XX

Place of service exceptionPrior authorization is not required for certain therapy and ancillary codes when the place of service is the member's home (place of service 12) or bill type 3XX

ApplicabilityApplies to specific therapy and ancillary CPT/HCPCS codes listed in the outpatient therapy section

Provider guidanceConfirm place of service billing code to determine if prior authorization is required

inv-86: Certain CT, MRI, MRA, PET scans, nuclear medicine and nuclear cardiology procedures

ScopeCertain advanced outpatient imaging procedures (selected CT, MRI, MRA, PET scans, nuclear medicine and nuclear cardiology) require prior authorization or notification

ProcessCare providers ordering advanced outpatient imaging must notify prior to scheduling and submit requests via the Prior Authorization and Notification tool on UHCprovider.com or call 866-889-8054

ExamplesPolicy lists example CPT/HCPCS entries for advanced imaging and instructs providers to follow the portal or phone process

inv-87: Stimulators / Neurostimulator

DefinitionStimulators / Neurostimulator: implantation of a device that sends electrical impulses (includes bone growth stimulator and neurostimulator codes)

Prior authorizationPrior authorization is required for implantation of stimulators and related device codes listed in the policy (e.g., E0747, E0748, E0749, 0164T, L8680 series)

ExamplesBone growth stimulator and implantable neurostimulator CPT/HCPCS codes are enumerated; follow submission procedures in the policy

inv-88: Ventricular assist device (VAD)

DefinitionVentricular assist device (VAD): a mechanical pump that takes over the function of the damaged ventricle

Prior authorization processProviders must call the notification number on the back of the member's health plan ID card and fax the nurse-provided form to the Optum VAD Case Management team at 855-282-8929

CodesPolicy lists VAD-related CPT/HCPCS codes (examples include 33927, 33928, 33975, 33976, 33979, 33982) which require prior authorization