CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements — UnitedHealthcare Individual Exchange plans

Defines prior authorization requirements and portal submission instructions for UnitedHealthcare Individual & Family (ACA Marketplace) plans and participating providers for listed states; governs pre-service authorization for many surgical and device CPT/HCPCS codes and some diagnosis-based notifications.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements — UnitedHealthcare Individual Exchange plans

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2024

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+States where this list applies

09/01/2024Effective date

NumerousProcedure codes flagged

Cancer drugsOutpatient drugs PA

Required (all states)Pain injections

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Coverage and Authorization Criteria

inv-01: Prior authorization coverage criteria — Coverage stance for listed procedures and programs

Coverage stance for listed procedures and programs

Prior authorization is required for the surgical procedures and program-based services listed (examples include arthroplasty, arthroscopy, bariatric surgery, body lengthening, bone growth stimulation, bone marrow/stem cell procedures, and selected breast reconstruction procedures).

See code lists in the policy for specific CPT/HCPCS codes (e.g., arthroplasty codes 23470 series, arthroscopy codes 29826/29843/29871, bariatric codes 43644/43843 and others).

EXCEPT: Prior authorization is not required for emergency or urgent care.

Site-of-service review may apply to many listed codes; Texas and Wisconsin still require prior authorization for listed codes but are excluded from site-of-service review.

Bariatric services: prior authorization is required and coverage includes a Center of Excellence requirement; some state-specific exclusions apply (examples: certain authorizations not required in South Carolina and Wisconsin for listed bariatric codes; some notification/authorization diagnosis-based conditions and other state exceptions noted).

Notification/prior authorization is required for specified diagnosis codes related to bariatric procedures (examples include E66.x and Z68.x ranges).

How to obtain authorization: submit prior authorization and notification requests online using the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (sign in with One Healthcare ID).

inv-02: Prior authorization requirements (partial) — Outpatient oncology supportive care and selected medications require prior authorization.

Outpatient oncology supportive care and selected medications require prior authorization.

Prior authorization is required for colony-stimulating factors and bone-modifying agents administered in an outpatient setting for a cancer diagnosis (example codes include J0897, J1442 and others).

Prior authorization is required for specified anti-emetic products (examples listed: Akynzeo J1454; Cinvanti J0185; Emend J1453; Sustol J1627).

Note: Some listed oncology-supportive codes may also require prior authorization when used for non-oncology diagnoses (see injectable medications section).

Submit prior authorization/notification requests using the UnitedHealthcare Provider Portal Prior Authorization and Notification tool.

inv-03: Partial coverage criteria — chemotherapy and anti-emetics

Coverage/authorization stance for chemotherapy and related services (partial):

Prior authorization is required for inpatient chemotherapy services.

Prior authorization is required for the chemotherapy J-codes and other listed chemotherapy-related codes in the extract (selected examples shown in the policy).

Site-of-service note: Site-of-service review may also apply for many chemotherapy items; Texas and Wisconsin require prior authorization for all listed codes but are excluded from site-of-service review.

Anti-emetics — diagnosis linkage: Anti-emetics that require prior authorization are associated with multiple ICD-10 diagnosis codes (examples include vascular and musculoskeletal ranges cited in the extract).

inv-04: Cochlear implants — Device coverage condition

Device coverage condition

Prior authorization is required for cochlear implants and other auditory implants listed by CPT/HCPCS codes (examples include CPT 69710/69714/69930 and HCPCS L8615–L8628).

inv-05: Continuous glucose monitoring — Coverage condition

Continuous glucose monitoring coverage condition

Prior authorization is required for continuous glucose monitoring (CGM) devices and related codes when used with type 2 diabetes or gestational diabetes.

Example CGM codes: Representative device/supply codes include A4238, A4239, A9276–A9278 and E0787/E2102–E2103 as listed in the policy extract.

inv-06: Cosmetic and reconstructive procedures — Procedures coverage condition

Procedures coverage condition

Prior authorization is required for cosmetic and reconstructive procedures listed; the policy distinguishes cosmetic procedures (performed to change or improve appearance) from reconstructive procedures (treat or restore physiologic function).

Operational note: Reconstructive procedures that restore physiologic function are treated separately but many entries still require prior authorization per the extract.

inv-07: Durable medical equipment (DME) — Coverage condition

Durable medical equipment coverage condition

Prior authorization is required for the Durable Medical Equipment (DME) items listed in the policy (examples include multiple HCPCS E- and K- series codes and specific E-codes such as E0147, E0266, E0193, E0277, etc.).

Prosthetics note: Prosthetics are not considered DME in this document; prosthetics are addressed under orthotics/prosthetics/HCPCS L-code listings that require prior authorization.

inv-08: Excerpted coverage notes — Coverage stance and criteria excerpts from these chunks

Coverage stance and criteria excerpts from these chunks:

State exceptions: Multiple entries include state-specific exclusions or exceptions (examples: New Mexico, South Carolina, Wisconsin and others are excluded for certain codes or programs; flap repair CPTs exempted in FL/IL/MD/MI/VA/WA).

Experimental/Other: Experimental, investigational and linked services require prior authorization per the extract; foot surgery and FESS also require prior authorization with possible site-of-service review exceptions.

inv-09: Genetic/molecular testing and related services coverage criteria

Coverage/authorization conditions for genetic/molecular testing and related services as specified:

Notification or prior authorization is required for listed genetic and molecular testing CPT/HCPCS codes under the Molecular Testing Prior Authorization/Notification Program; the ordering provider must indicate the laboratory and test name and the laboratory will notify UnitedHealthcare.

State exclusions and plan notes: Many codes are excluded in South Carolina and Wisconsin; prior authorization requirement was removed for Washington Individual Exchange Plans for certain codes as noted; other state-specific exclusions are described in the policy extract.

BRCA testing: BRCA genetic testing requires notification/prior authorization before DNA sequencing is performed as described in the extract.

Benefit reference: For some services (e.g., home health), reference to the member-specific benefit plan document is required to determine coverage and prior authorization requirements.

inv-10: Coverage criteria excerpt — Coverage and authorization stance for listed services and codes in this excerpt

Coverage and authorization stance for listed services and codes in this excerpt:

Home health services: prior authorization required when coverage applies; reference the member-specific benefit plan document to determine available coverage and specific prior authorization requirements (example codes: G0155 and others).

Hospice services: prior authorization required for listed hospice CPT/HCPCS codes (examples include G0299, G0300 and others).

Hysterectomy procedures: prior authorization required for the listed CPT hysterectomy codes in the extract.

Infertility services: diagnostic and treatment services require prior authorization when the listed diagnosis codes are present; some S-code exclusions by state are noted.

Injectable medications administered IV/SC/IM: prior authorization required for numerous HCPCS/J-codes; an extensive injectable code list is provided across the policy extract.

inv-11: Authorization requirement for listed injectable and vaccine codes

Codes listed below require prior authorization or predetermination/notification as indicated in this section.

A large listing of injectable HCPCS/J-codes and related codes require prior authorization or predetermination as shown in the policy extract (see the multi-chunk injectable lists).

Unclassified codes (J3490, J3590, C9151, C9167, C9168) require notification/prior authorization only when used for specific named products (Fylnetra, Nulibry, Revcovi, Rivfloza); submit requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool.

inv-12: Codes requiring prior authorization / predetermination

This segment provides enumerated HCPCS (J-) and selected CPT codes that require prior authorization or predetermination.

Sections labeled 'Injectable medications' and 'Predetermination' enumerate numerous HCPCS J-codes requiring prior authorization or predetermination (examples include J0741–J0744, J0750, J0770, J0780, J0795 and many additional J-codes listed across the policy).

Process note: Providers must obtain prior authorization for the listed injectable and predetermination codes; consult the full listing in the policy extract for specific codes and any asterisked notes.

inv-13: Prior authorization required — listed codes

Codes/procedures listed require prior authorization:

Injection arthrogram (CPT 27096): prior authorization required for all states; site-of-service will be reviewed as part of the prior authorization process except in Texas.

Various medical/surgical supplies and listed procedure codes (including mastectomy-related entries and supply codes) require prior authorization as enumerated in the extract; some mastectomy-related authorizations have state-specific exclusions noted.

inv-14: Prior authorization by category — Prior authorization requirements by service category

Prior authorization requirements by service category

Orthognathic surgery: prior authorization required for the listed maxillofacial functional CPT codes (examples include 21010, 21121, 21142, etc.).

Orthotics and prosthetics: prior authorization required for the numerous HCPCS L-codes listed in the policy extract (examples include L0112, L0220, L0452 and many others).

Pain injections and pain management procedures: prior authorization required for all states for listed injection and pain management CPT/HCPCS codes (example pain injection code G0260 and multiple CPT injection/block codes are listed). Site-of-service review may also apply except in Texas and Wisconsin.

inv-15: Authorization and site-of-service coverage criteria

Coverage stance and authorization triggers for listed codes

Pain injections and pain management codes require prior authorization for all states (examples include G0260 and multiple injection CPT codes).

Site-of-service review: may apply for many codes; Texas and Wisconsin require prior authorization for all listed codes but are excluded from site-of-service review per the extract.

Flap repair exemption: Flap repair CPT codes 14020, 14021, 14061 do not require prior authorization in specified states (Florida, Illinois, Maryland, Michigan, Virginia and Washington) as noted in the policy extract.

Diagnostic mapping note: Various ICD-10 diagnosis codes (C43*, C44*, D03*, etc.) are associated with potentially cosmetic procedures and appear alongside CPT/HCPCS entries to guide authorization decisions.

inv-16: Prior authorization criteria for radiation therapy

Prior authorization requirements for radiation therapy depend on the procedure code and associated diagnosis code ranges.

When standard radiation therapy (2D/3D) CPT codes listed (e.g., 77401, 77402, 77407, 77412 and related codes) are billed with diagnosis codes in specified ranges (examples: C34.00–C34.92; C50.011–C50.929; C61; C79.51–C79.52; C84.7A), prior authorization is required.

SRS/SBRT (stereotactic radiosurgery/stereotactic body radiation therapy) and associated CPT/HCPCS codes (examples include 77331, 77370, 77371, 77372, G0339, G0340) require prior authorization when performed for diagnoses in the specified ranges.

Proton beam therapy requires authorization; providers should indicate whether the therapy is part of a clinical trial when submitting authorization requests.

Universal codes note: Certain standard radiation therapy codes (e.g., 77401, 77402, 77407, 77412) are noted as requiring prior authorization for all states in the extract.

inv-17: Authorization criteria for radiation therapy codes — Applies when billed with specific diagnosis ranges

Prior authorization coverage criteria for listed procedure codes when billed with specific diagnosis ranges:

Standard radiation therapy (2D/3D) CPT codes listed require prior authorization when billed with diagnosis codes within specified oncology-related ranges (examples: C34.00–C34.92; C50.011–C50.929; C61; C79.51–C79.52; C84.7A).

SRS/SBRT HCPCS and CPT codes (for example G0339, G0340, 77371, 77372, 77370, 77399, 77373) are identified as special/associated services and require prior authorization when associated diagnoses are present.

Related imaging/procedures note: Additional imaging and related procedures (e.g., CT, PET, nuclear scans) are referenced across the section and may be considered as part of authorization review when accompanying radiation therapy codes.

Representative CPT/HCPCS/ICD Codes

Example CPT/HCPCS codes requiring prior authorizationCPTCovered

23470	Arthroplasty example code listed
29826	Arthroscopy example code listed
43644	Bariatric surgery example code listed (asterisked in source)
20974	Bone growth stimulator / electrical stimulation
38204	Bone marrow/stem cell collection/transplant example
19316	Breast reconstruction example code listed

Breast cancer ICD-10 codes (examples)ICD-10

C50.011	Malignant neoplasm of nipple and areola of unspecified breast (example from list)
C50.111	Malignant neoplasm of central portion of breast (example from list)
C50.119	Malignant neoplasm of unspecified site of breast (example from list)

Select HCPCS/J-codes for oncology supportive care and anti-emeticsHCPCSCovered

J0897	Denosumab
J1442	Filgrastim
J1454	Akynzeo (palonosetron/fosnetupitant)
J0185	Cinvanti (aprepitant)
J1453	Emend (fosaprepitant)
J1627	Sustol (granisetron extended release)

ICD-10 codes cited in anti-emetics prior authorization list (partial)ICD-10

I70.533
I70.534
I70.535
I70.538
I70.539
I70.541
I70.542

Representative chemotherapy J-codes listed (partial)HCPCS

J9015
J9021
J9033
J9057
J9061
J9070

Selected chemotherapy and related codesHCPCS

J9271	Chemotherapy drug (listed)
J9272	Chemotherapy drug (listed)
J9330	Chemotherapy drug (listed)
J9999	Chemotherapy/other injectable (listed)
Q2017	Drug administration / vaccine (listed)
G0276	Clinical trial related code (listed)

CGM and diabetes diagnosis codesmixed

A4238	CGM supplies (listed)
E2102	CGM component / DME (listed)
E11.9	Type 2 diabetes mellitus (example ICD-10 listed among codes)

Selected DME/HCPCS codesHCPCS

E0147	DME code listed
E0266	DME code listed
E0193	DME code listed
E0277	DME code listed
E2623	DME code listed
K0005	DME/orthotics code listed
K0820	K-series equipment codes with state exclusions noted

Selected CPT surgical codesCPTCovered

31240	Functional endoscopic sinus surgery (FESS)
31256	Endoscopic sinus surgery code listed
28285	Foot surgery code listed
28299	Foot surgery code listed

Selected gender dysphoria and related CPT codesCPTCovered

11980	Gender dysphoria related procedure
15734	Gender dysphoria related procedure
54520	Genitourinary procedure listed
54690	Genitourinary procedure listed

Genetic and Molecular Testing CPT codesCPTCovered

81162	BRCA genetic testing (example listed)
81433	Molecular genetics code listed
81228	Genetic testing code listed
81406	Molecular testing code listed
81471	Molecular testing / prior auth program registered code
81541	Molecular testing code listed

Selected molecular/genetic CPT/HCPCS codes listedCPT | HCPCS | mixed

0022U	Molecular/genetic test (example)
0037U	Molecular/genetic test (example)
0213U	Molecular/genetic test (example)
0419U	Molecular/genetic test (example)
81449	Molecular pathology or sequencing related code
81542	Molecular test code

Hearing and home health codesCPT | HCPCS | mixed

G0155	Home health or ancillary service
V5095	Hearing device related code

IMRTCPTCovered

77385	Intensity-modulated radiation therapy planning/management
77386	IMRT special dosimetry
G6015	IMRT related HCPCS
G6016	IMRT related HCPCS

HysterectomyCPTCovered

58150

Hysterectomy codes (example)

Injectables (sample)HCPCSExperimental

C9067	Injectable medication HCPCS
A9607	Injectable product HCPCS

Injectables (sample - authorization required)HCPCS

C9067	Injectable medication HCPCS
A9607	Injectable product HCPCS

Injectables (sample) - alternateHCPCS

C9067	Injectable medication HCPCS
A9607	Injectable product HCPCS

HCPCS J-codes for injectablesHCPCS

No codes listed

Unclassified HCPCS/C codes with special authorization requirementsHCPCSCovered

J3490	Unclassified drugs — notification/prior authorization required for specified products
J3590	Unclassified drugs — notification/prior authorization required for specified products
C9151	Unclassified drug code — notification/prior authorization required for specified products
C9167	Unclassified drug code — notification/prior authorization required for specified products
C9168	Unclassified drug code — notification/prior authorization required for specified products

Selected J- and other HCPCS codes from listHCPCSCovered

J7303	Example injectable HCPCS code listed
J9333	Injectable/infusion product listed
L8605	Prosthetic/biologic related code listed among injectables

Selected CPT codesCPTCovered

91315	CPT/HCPCS code listed for prior authorization
91316	CPT/HCPCS code listed for prior authorization
91317	CPT/HCPCS code listed for prior authorization

Highlighted HCPCS J-codesHCPCSCovered

J0741	HCPCS injectable medication code (asterisked in list)
J1746	HCPCS injectable medication code (asterisked in list)
J1961	HCPCS injectable medication code (asterisked in list)

Sample injectable HCPCS codes (many more listed in chunks)HCPCSCovered

J2430	HCPCS code listed in injectable medications section
J2440	HCPCS code listed in injectable medications section

Orthognathic CPT codesCPTCovered

21010	Orthognathic surgery-related CPT — listed for prior authorization
21121	Orthognathic surgery-related CPT — listed for prior authorization
21240	Orthognathic/craniofacial CPT — listed (some codes excluded from SC noted)

Orthotics/prosthetics HCPCS L-codesHCPCSCovered

L0112	Orthotics/prosthetics HCPCS L-code requiring prior authorization
L8699	Orthotics/prosthetics HCPCS L-code requiring prior authorization

Pain injection codesHCPCSCovered

G0260

Pain injection HCPCS code requiring prior authorization

Representative HCPCS/CPT codesmixed

L7191	Orthotics/prosthetics HCPCS code listed
G0260	Pain injection related HCPCS code listed
62320	Epidural/injection CPT code listed
64416	Nerve block injection CPT code listed

Cosmetic/surgical codesCPT

14020	Flap repair (not requiring PA in specified states)
11960	Potentially cosmetic injection/excision code

Sample ICD-10 codesICD-10

C43.70	ICD-10 diagnosis code listed in document
C44.300	ICD-10 diagnosis code listed in document
C79.2	ICD-10 diagnosis code listed in document

Radiation therapy CPT/HCPCSmixed

77331	Stereotactic radiosurgery / SBRT
77370	SRS/SBRT related code
77401	Radiation therapy delivery
G0340	SRS/SBRT HCPCS

Radiation therapy and SRS/SBRT codesCPT | HCPCSCovered

77407	Radiation therapy code listed as requiring prior authorization
77412	Radiation therapy code listed as requiring prior authorization
77401	Radiation therapy code listed (multiple mappings across chunks)
77402	Radiation therapy code listed
77331	Special/associated service
77370	SRS/SBRT associated code
77371	SRS/SBRT associated code
77372	SRS/SBRT associated code
77399	SRS/SBRT associated code
77373	SRS/SBRT associated code

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Site-of-service review applicability

ApplicabilitySite-of-service review may apply for codes in this list for all states except Texas and Wisconsin (TX and WI still require prior authorization for listed codes but are excluded from site-of-service review).

Submission, Notification, and Billing Actions

Prior Authorization

Provider submission and general rules

Submit prior authorization requests online using the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com > Sign In > Prior Authorization and Notification). Prior authorization is not required for emergency or urgent care. Site-of-service review may apply for certain codes; Texas and Wisconsin are commonly excluded from site-of-service review for some services — check individual entries.

Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.
Prior authorization is not required for emergency or urgent care.
Site-of-service review may apply; Texas and Wisconsin often excluded for site-of-service review on listed codes.

Prior Authorization

Anti-emetics prior authorization

Certain anti-emetic medications require prior authorization. When requesting authorization, include the cancer diagnosis when applicable. Examples of HCPCS/J-codes for anti-emetics requiring prior authorization include: J1454 (Akynzeo - palonosetron/fosnetupitant), J0185 (Cinvanti - aprepitant), J1453 (Emend - fosaprepitant), and J1627 (Sustol - granisetron extended release). Some diagnosis code ranges are associated with prior authorization for anti-emetics; ensure diagnosis codes are provided.

Terms and Definitions

Individual Exchange plans

DefinitionUnitedHealthcare Individual & Family (ACA Marketplace) plans — referred to as Individual Exchange plans covered by this prior authorization list.

Geographic scopeApplies to members receiving care in the states listed in the document (e.g., AL, AZ, FL, GA, IL, KS, LA, MD, MI, MS, MO, NJ, NM, NC, OH, OK, SC, TN, TX, VA, WA, WI).

Plan actionWhen deciding coverage, reference the member-specific benefit plan document for applicable benefits and exclusions.

One Healthcare ID / Provider portal

One Healthcare IDCredential used to sign in to the UnitedHealthcare Provider Portal to submit prior authorization requests via the Prior Authorization and Notification tool.

Portal accessGo to UHCprovider.com and click Sign In (top-right) to log in with your One Healthcare ID; select the Prior Authorization and Notification tab on the dashboard.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements — UnitedHealthcare Individual Exchange plans

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2024

Next Review DateN/A

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

SourceLink

On This Page

Hearing services: prior authorization required for members ages 21 and older for listed hearing codes with specific state exclusions identified in the policy extract.

Excluded states from site-of-service reviewTexas and Wisconsin — these states still require prior authorization but are not subject to the site-of-service review provision.

ScopeSite-of-service review described applies across the listed surgical and procedural codes (arthroplasty, arthroscopy and other listed services).

Prior authorization requirement

RequirementPrior authorization is required for pain injections and pain management services for all states listed in this document.

Representative codesPain injection example: G0260; pain management examples include CPT codes 11981, 62320–62327 and various nerve block codes (e.g., 64416).

Site-of-service noteSite-of-service review may also apply to these services except in Texas and Wisconsin, where site-of-service review is excluded though prior authorization is still required.

Akynzeo (palonosetron/fosnetupitant) — J1454
Cinvanti (aprepitant) — J0185
Emend (fosaprepitant) — J1453
Sustol (granisetron extended release) — J1627
Provide associated diagnosis codes when applicable

Prior Authorization

Chemotherapy and cancer supportive care prior authorization

Cancer supportive care drugs (including many injectable colony-stimulating factors, anti-emetics, and bone-modifying agents) and a broad list of chemotherapy drugs require prior authorization. Prior authorization applies for outpatient-administered supportive agents and for many chemotherapy drugs and associated J-codes. Site-of-service review may apply for chemotherapy and related services (site-of-service may be reviewed for all states except Texas and Wisconsin; Texas and Wisconsin still require PA for listed codes).

Colony-stimulating factors and bone-modifying agents require prior authorization for cancer diagnoses (see injectable list).
Site-of-service review may apply for chemotherapy services (except TX and WI exclusions noted).
Submit requests including diagnosis and regimen details where applicable.

Prior Authorization

Selected chemotherapy/CPT/HCPCS/J-code examples

Selected chemotherapy and related procedure codes (CPT/HCPCS/J-codes) that require prior authorization include (partial list): J0640, J0641, J0642, J1932, J9000, J9015, J9017, J9019, J9020, J9021, J9022, J9023, J9025, J9027, J9029, J9030, J9032, J9033, J9034, J9035, J9036, J9039, J9040, J9041, J9042, J9043, J9045, J9046, J9048, J9049, J9050, J9051, J9052, J9055, J9056, J9057, J9058, J9059, J9060, J9061, J9063, J9064, J9065, J9060, J9070, J9071, J9072, J9073, J9074, J9075, J9098, J9100, J9118, J9119, J9120, J9130, J9144, J9145, J9150, J9151, J9153, J9155, J9158, J9160, J9165, J9171, J9172, J9173, J9175.

Partial list of chemotherapy J-codes requiring PA: J0640, J0641, J0642, J1932, J9000, J9015, J9017, J9019, J9020, J9021, J9022, J9023, J9025, J9027, J9029, J9030, J9032, J9033, J9034, J9035, J9036, J9039, J9040, J9041, J9042, J9043, J9045, J9046, J9048, J9049, J9050, J9051, J9052, J9055, J9056, J9057, J9058, J9059, J9060, J9061, J9063, J9064, J9065, J9070, J9071, J9072, J9073, J9074, J9075, J9098, J9100, J9118, J9119, J9120, J9130, J9144, J9145, J9150, J9151, J9153, J9155, J9160, J9165, J9171, J9172, J9173, J9175

Prior Authorization

Injectable medications — PA and predetermination notes

A large, non-exhaustive list of injectable (J-/C-/Q-/etc.) codes require prior authorization or predetermination. This includes many common biologics, monoclonal antibodies, enzyme therapies, colony-stimulating factors, and specialty injectables. For unclassified codes (for example J3490, J3590, C9151, C9167, C9168) prior authorization/predetermination is required only for specific products (Fylnetra, Nulibry, Revcovi, Rivfloza) — submit detailed product and diagnosis information.

Unclassified codes J3490/J3590/C9151/C9167/C9168 require PA only for specified products (Fylnetra, Nulibry, Revcovi, Rivfloza).
Many J-codes listed elsewhere in this section require PA (see injectable J-code lists).
Predetermination applies to a subset of high-cost injectables (separate list of J07xx/J08xx/J75xx series).

Prior Authorization

Injectable J-code lists and PA requirement

Extensive injectable J-code lists are included in the policy source and span multiple ranges (examples shown here are representative, not exhaustive). Providers must obtain prior authorization for the injectable HCPCS/CPT/J-codes listed throughout the document and use predetermination where indicated. Examples of many J-codes requiring prior authorization include (continued across policy): J0121, J0122, J0131-J0135, J0153, J0185, J0202, J0217-J0225, J0248, J0256-J026?, J0270-J0282, J0285-J0300, J0330, J0348, J0360, J0401, J0456, J0461, J0470-J0491, J0500, J0515-J0517, J0558, J0561, J0567, J0571-J0575, J0583-J0599, J0600-J0638, J0640-J0642, J0670, J0690-J0716, J0720-J0744, J0741-J0744, J0750-J0799, J0801, J0834-J0885, J0894-J0898, J1000-J1303, J1304-J1380, J1410-J1459, J1551-J1599, J1602-J1745, J1741-J1790, J1800-J1999, J2001-J2186, J2185-J2358, J2350-J2779, J2780-J2998, J3000-J3399, J3401-J3499, J7030-J7298, J7300-J7503, J7525-J7999, J7999-J8999, J8999-J9334, J9376-J9381, and many Q- and L- codes. Providers should reference the full policy code lists when preparing PA requests.

Providers must obtain PA for the many injectable HCPCS/CPT/J-codes listed in the policy.
Predetermination applies to specific high-cost injectables (see code headings in policy).
Unclassified codes are limited to named products for PA.

Billing Rule

Predetermination vs prior authorization for injectables

For injectables and specialty medications, some codes are listed under a "Predetermination" heading rather than standard prior authorization. Predetermination codes include numerous high-cost J-codes (examples: J0750, J0751, J0770, J0775, J0780, J0795, J0799, J0834, J0840, J0841, J0850, J7525, J7605–J7639, J7644, J7665, J7674, J7682, J7686, J7999, J8498–J8515, J8560, J8610–J8612, J8705, J8999). Check the policy headings to determine if predetermination (estimate/payment review) is required instead of or in addition to PA.

Predetermination applies to many high-cost injectables (see predetermination code lists).
Examples of predetermination J-codes: J0750, J0751, J0770, J0775, J0780, J0795, J0799, J0834, J0840, J0841.
Review predetermination vs PA requirement on the policy for each code.

Prior Authorization

Injection arthrogram prior authorization and site-of-service review

For injection arthrogram (code 27096) prior authorization is required in all states. In addition, the prior authorization review will include a site-of-service review for the procedure codes listed except in Texas.

Injection arthrogram — 27096 requires prior authorization in all states.
Site-of-service will be reviewed as part of the PA process for listed codes except in Texas.

Prior Authorization

Orthotics and prosthetics prior authorization

Orthotics and prosthetics items (L-codes) require prior authorization. A representative (partial) list of orthotics/prosthetics codes requiring prior authorization includes: L0112, L0220, L0452, L0482, L0484, L0486, L0622, L0624, L0629, L0632, L0634, L0636, L0638, L0640, L0999, L1300, L1840, L1844, L1845, L1846, L1950, L2005, L2020, L2034, L2036, L2037, L2038, L2232, L2330, L2387, L2520, L2526, L2755, L2840, L2850, L3671, L3674, L3763–L3766, L3806, L3900–L3905, L3921, L3935, L3961, L3967, L3971–L3978, L4030, L4631, L5010, L5050, L5060, L5100–L5160, L5200–L5280, L5301, L5321, L5331, L5530–L5590, L5610–L5651, L5673–L5683, L5703–L5728, L5780, L5795, L5814–L5859, L5930, L5960–L5961, L5979, L5980–L5988, L6010, L6020, L6026, L6055, L6120–L6130, L6200–L6370, L6400, L6450, L6570–L6590, L6611–L6624, L6638, L6648, L6693–L6697, L6707, L6880–L6885, L6895, L6900–L6925, L6930–L6975, L7007–L7009, L7040–L7045, L7170, L7180–L7191, L7259, L7499, L8039, L8629, L8699.

Orthotics/prosthetics L-codes require prior authorization (see full list).
Provide device details, diagnosis, and justification when submitting PA.

Prior Authorization

Cosmetic and reconstructive procedures prior authorization

Cosmetic and reconstructive procedures require prior authorization. Cosmetic procedures that are intended to change or improve appearance without restoring physiological function are subject to prior authorization. Reconstructive procedures that treat a medical condition or restore function also require prior authorization when listed. Many CPT codes for cosmetic/reconstructive surgery are listed (examples include: 15769, 15830, 21137, 15820–15823, 15570–15574, 15730–15757, 17380, 14020, 14021, 14060–14061, 14040, 17107, 14302, 15570, 15572, 15574, 15847, 15877–15879, 21138–21179, 67923–67966). Site-of-service review may apply; Texas and Wisconsin are commonly excluded from site-of-service review for some codes.

Cosmetic procedures that primarily change appearance require PA.
Reconstructive procedures for medical/functional reasons require PA.
Representative CPT examples: 15769, 15830, 21137, 14020, 14021, 14061, 17380, 21138, 21139, 21172–21179, 67923–67966.

Billing Rule

Site-of-service review rule

Site-of-service review: For many surgical, radiology, pain management, arthroscopy, foot surgery, and other procedural codes, a site-of-service review may be performed as part of prior authorization to determine the appropriate setting of care (e.g., inpatient vs outpatient vs ambulatory surgical center). Note that Texas and Wisconsin are frequently excluded from site-of-service review for certain code groups — both states still require prior authorization for listed codes but are excluded from site-of-service review.

Site-of-service review may apply to arthroscopy, pain injections, foot surgery, chemotherapy, and other listed services.
Texas and Wisconsin are often excluded from site-of-service review but still require PA for listed codes.

Prior Authorization

Proton beam therapy prior authorization

Proton beam therapy (focused radiation therapy using beams of protons) requires prior authorization. Indicate whether proton beam therapy is being performed as part of a clinical trial when submitting the request. Applicable CPT/HCPCS codes associated with proton beam therapy include 77385/77386 (IMRT-related G-codes listed elsewhere), 77520, 77522, 77523, and 77525; prior authorization is required.

Proton beam therapy requires prior authorization.
Indicate if treatment is part of a clinical trial.
Representative CPT codes: 77520, 77522, 77523, 77525.

RegistrationIf you do not have a One Healthcare ID, follow the registration instructions at UHCprovider.com/access.

Cancer supportive care — definition

DefinitionCancer supportive care includes colony-stimulating factors and bone-modifying agents administered in an outpatient setting for a cancer diagnosis.

Example HCPCS/J-codesExamples cited include J0897 (denosumab) and J1442 (filgrastim) among others listed for supportive care.

NoteSome listed codes also require prior authorization for non-oncology diagnoses (see injectable medications section).

Prior Authorization submission portal

Submission channelUse the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal to submit prior authorization and notification requests.

How to startGo to UHCprovider.com, click Sign In (top-right) and log in with One Healthcare ID; select the Prior Authorization and Notification tab.

Support noteIf you do not have a One Healthcare ID, follow registration steps at UHCprovider.com/access; portal is the required submission method referenced in the document.

Prior authorization — inpatient chemotherapy

RequirementPrior authorization is required for inpatient chemotherapy services.

Outpatient noteSome outpatient hospital or ambulatory surgical center chemotherapy services may not require prior authorization as noted in the extract.

Related codesChemotherapy J-codes and related CPT/HCPCS codes are enumerated in the chemotherapy section and require authorization as indicated.

Site-of-service note — exceptions TX and WI

Site-of-service exceptionSite-of-service review may apply broadly, but Texas and Wisconsin are exceptions — both still require prior authorization for listed codes but are excluded from site-of-service review.

ContextThis exception is noted across multiple service categories (e.g., arthroscopy, arthroplasty, pain injections) in the document.

Action for providersSubmit prior authorization per the portal instructions regardless of site-of-service; the review may include site appropriateness unless the member is in TX or WI where site-of-service review is excluded.

Clinical trials — definition/reference

DefinitionClinical trials are rigorously controlled studies of new drugs, medical devices, or other treatments on eligible human subjects under institutional oversight; prior authorization applies to clinical-trial related services as indicated (e.g., G0276, G0293, G0294).

Coding examplesClinical-trial related procedure codes referenced include G0276, G0293 and G0294 in the chemotherapy section.

Provider actionIndicate clinical trial participation where relevant when submitting prior authorization; some entries note clinical trials require prior authorization.

Cochlear implants and other auditory implants — definition

DefinitionCochlear implant — a medical device within the inner ear with an external portion that helps persons with profound sensorineural deafness achieve conversational speech; these devices require prior authorization.

Example codesExamples cited include CPT codes 69710, 69714, 69717 and HCPCS L8615–L8628 depending on device type.

Prior authorizationPrior authorization required for cochlear implants and other auditory implants as listed.

Prosthetics / DME distinction

DistinctionProsthetics are not considered Durable Medical Equipment (DME) in this document and are addressed under orthotics/prosthetics (HCPCS L-codes) which require prior authorization.

Where to findSee orthotics and prosthetics HCPCS L-code listings (many L-codes enumerated in the orthotics/prosthetics section) for prosthetic prior authorization requirements.

DME vs ProstheticsDME items (HCPCS E- and K- codes) are listed separately and also require prior authorization; prosthetics are managed under the orthotics/prosthetics listing.

Genetic and Molecular Testing PA/Notification — program note

Program noteGenetic and Molecular Testing Prior Authorization/Notification Program requires ordering providers to indicate the laboratory and test name; the laboratory will notify UnitedHealthcare as part of the process.

Coverage conditionPayment is authorized only for CPT codes registered with the Genetic and Molecular Testing Prior Authorization/Notification Program; many codes are listed and some are excluded in SC and WI.

BRCA-specific noteBRCA testing requires notification/prior authorization before DNA sequencing is performed, per the molecular testing section.

Notification/prior authorization — laboratory notification process

Laboratory notification processFor certain genetic/molecular tests, the ordering provider must indicate the laboratory and test name and the laboratory will notify UnitedHealthcare via the portal notification/prior authorization process.

Portal submissionSubmit notification/prior authorization using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com).

State exclusionsSome genetic/molecular testing codes are excluded in South Carolina and Wisconsin; check the code list and state-specific notes in the policy.

Prior authorization — definition

DefinitionPrior authorization — a requirement specified in this document for many services and codes; providers must obtain authorization before services are rendered except in emergency/urgent care situations.

Emergency care exceptionPrior authorization is not required for emergency or urgent care as noted in the general information section.

Member benefit referenceWhen determining whether prior authorization is required for a specific member, reference the member-specific benefit plan document.

Injectables (IV/SC/IM) — definition

DefinitionInjectables — drugs administered intravenously (IV), subcutaneously (SC), or intramuscularly (IM); the document lists numerous HCPCS/J-codes that require prior authorization.

Representative codesExamples of injectable codes listed include 90281, A9607, C9067 and many J-codes (see the injectables sections across the document).

Predetermination headingSections labeled 'Predetermination' indicate injectable HCPCS/J-codes that may require predetermination or prior authorization in advance of administration.

Injectables — definition

Injectables term'Injectables' refers broadly to medications administered IV, SC, or IM and includes an extensive enumerated list of HCPCS/J-codes requiring prior authorization or predetermination.

Predetermination contextSome injectable codes are listed under headings 'Predetermination' indicating an advance determination of coverage is required for those products.

Provider actionObtain prior authorization or predetermination for listed injectable codes using the portal before administration unless otherwise noted.

Prior authorization submission method — portal

Submission methodPrior authorization and predetermination requests must be submitted via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool.

Portal startGo to UHCprovider.com and click Sign In (top-right) to log in with One Healthcare ID; select the Prior Authorization and Notification tab to begin a submission.

SupportPortal instructions and support are provided in the document; providers without a One Healthcare ID should register at UHCprovider.com/access.

Unclassified code exception — applies only for certain named products

ScopeUnclassified HCPCS/CPT codes (e.g., J3490, J3590, C9151, C9167, C9168) require notification/prior authorization only when used for certain named products (Fylnetra, Nulibry, Revcovi, Rivfloza).

ActionFor these unclassified codes, indicate the specific product; notification/prior authorization is only required when the code is used for the listed products.

SubmissionUse the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal to submit requests for these cases.

Predetermination / Injectable medications — heading meaning

Heading meaning'Predetermination' headings indicate injectable medications that require advance determination (predetermination) or prior authorization prior to administration.

ExamplesMultiple J-codes are listed under 'Injectable medications' and 'Predetermination' sections to denote items requiring predetermination (e.g., J0741*, J0750, J7605, etc.).

Provider instructionObtain predetermination/prior authorization via the portal for listed injectable medications before delivery when indicated.

Prior authorization required — definition/context

Definition/contextPrior authorization required — the policy indicates many services and codes require approval prior to the service being rendered; emergency and urgent care are exceptions.

Member-specific requirementReference the member's benefit plan document to confirm whether prior authorization is required for a specific member and service.

Submission channelUse the Provider Portal Prior Authorization and Notification tool to request authorization as specified in the document.

Predetermination (prior authorization for injectable medications)

Predetermination definedPredetermination refers to advance review/authorization for injectable medications (often listed with HCPCS/J-codes) to determine coverage prior to administration.

List locationSee the 'Injectable medications - Predetermination' sections for the enumerated HCPCS/J-codes that require predetermination.

Provider actionSubmit predetermination requests via the UnitedHealthcare Provider Portal before administering listed injectables when predetermination is indicated.

Site of service review — definition

DefinitionSite-of-service review — an additional review to determine whether the setting where the service is provided affects authorization; may apply to many codes listed (e.g., arthroscopy, arthroplasty, pain injections).

ExceptionsTexas and Wisconsin: both states require prior authorization for listed codes but are excluded from the site-of-service review provision.

Provider implicationEven when site-of-service review applies, providers must submit prior authorization via the portal; the review may include assessment of the service location appropriateness.

Site of service review — exceptions for TX and WI

Exceptions reiteratedSite-of-service review may apply for services in most states; Texas and Wisconsin are explicitly excluded from site-of-service review though prior authorization is still required there.

Where notedThis exception is repeated across multiple service categories including arthroscopy, arthroplasty, and pain injections in the document text.

Action for providersSubmit the prior authorization request via the portal and expect a site-of-service review when applicable unless the member is in TX or WI.

Flap repair exemption — states where PA not required

ExemptionFlap repair CPT codes 14020, 14021, 14061 will not require prior authorization in Florida, Illinois, Maryland, Michigan, Virginia and Washington.

ScopeThis exception applies specifically to the listed flap repair CPT codes and the named states; other cosmetic/surgical codes may still require prior authorization.

Provider noteVerify state-specific exemptions when preparing prior authorization requests for flap repair procedures.

Proton beam therapy — definition

DefinitionProton beam therapy — focused radiation therapy that uses beams of protons; prior authorization is required for proton therapy and providers should indicate if performed as part of a clinical trial.

CodingProton beam related codes referenced include 77385, 77386 and HCPCS G6015–G6016 within the radiation therapy section.

Provider actionWhen requesting authorization for proton beam therapy, indicate whether the treatment is part of a clinical trial as requested in the policy.

SRS/SBRT and standard radiation therapy — definition

DefinitionSRS/SBRT — stereotactic radiosurgery / stereotactic body radiation therapy; identified as special/associated services that require prior authorization when applicable (e.g., 77331, 77370, 77371, 77372, G0340).

ExamplesExamples of SRS/SBRT codes include 77331, 77370 series, 77371, 77372 and HCPCS G0339/G0340 noted in the document.

Relation to standard therapySRS/SBRT entries are listed separately from standard 2D/3D radiation therapy and have distinct prior authorization triggers when paired with specified diagnoses.

Standard radiation therapy (2D/3D) — definition and PA trigger

Definition & triggerStandard radiation therapy (2D/3D) — conventional external beam radiation therapy codes for which prior authorization is required only when billed with certain diagnosis code ranges (e.g., C34.00–C34.92, C50.011–C50.929, C61, C79.51–C79.52, C84.7A).

Universal codesSome standard radiation therapy codes (e.g., 77401, 77402, 77407, 77412) are called out as requiring prior authorization for all states.

Provider actionEnsure diagnosis codes fall within the specified ranges when submitting authorization requests for standard radiation therapy codes.

SRS/SBRT — definition and examples

DefinitionSRS/SBRT — stereotactic radiosurgery and stereotactic body radiation therapy codes (examples: G0339, G0340, 77371, 77372, 77370) listed as special/associated services that require prior authorization when related diagnoses are present.

Examples & variationsDocument lists multiple SRS/SBRT codes and associates them with diagnostic code ranges and prior authorization rules separate from standard 2D/3D radiation therapy.

Provider instructionWhen submitting authorization for SRS/SBRT, include the relevant diagnosis codes and indicate whether the service is SRS/SBRT per the listed codes.