CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky

Lists services, procedures, diagnosis and drug codes that require prior authorization or notification for participating UnitedHealthcare Community Plan of Kentucky providers and describes submission methods and exceptions (e.g., emergency care). Applies to providers serving members of the Kentucky Community Plan.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Kentucky

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNov 1, 2025

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Portal + phonesubmission channels

888-397-8129drug PA phone

800-418-4994transplant/CAR-T phone

$500DME cost threshold

2025-11-01effective date

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria and Prior Authorization Requirements

Items requiring prior authorization in this fragment

The following items in this fragment require prior authorization or notification as indicated. Providers must submit requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by the listed phone numbers; some items include diagnosis or cost-based exemptions. Codes shown are examples extracted from the source.

Breast reconstruction and related reconstruction procedures: Prior authorization required for breast reconstruction (examples: 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350). Exemption/notification not required when performed for qualifying breast cancer diagnosis codes (examples: C50.011, C50.012, C50.019, C50.111 and additional C50/D05/Z90/Z42 series listed) — providers should confirm the member diagnosis on the prior authorization/notification submission.

Cancer supportive care — outpatient injectable drugs: Prior authorization is required for outpatient injectable cancer supportive care drugs (including intravenous, intravesical, intrathecal) for a cancer diagnosis. Examples of HCPCS that require prior authorization include J1454 (Cinvanti/aprepitant), J1453 (fosaprepitant/Emend), pegfilgrastim products (e.g., Nyvepria), J0885, and specified anti-emetics (Akynzeo/palonosetron-fosnetupitant).

Cochlear implants and other auditory implants: Prior authorization required when billed amount or cumulative rental cost is more than $500; CPT/HCPCS examples: 69710, 69714, 69717, 69930, and device codes L8619, L8627, L8628.

Continuous glucose monitoring (CGM): Prior authorization required when billed amount or cumulative rental cost is more than $500. Examples: 95250, 95251, A9276, A9277, A9278, A4239, E2102, E2103.

Durable medical equipment (DME): Prior authorization required for DME regardless of cost; specific A‑codes listed (A5500, A5501, A5503, A5504, A5505, A5506, A5508, A5510). Prosthetics noted as distinct from DME.

Enteral and parenteral therapy: Prior authorization required; sample HCPCS B41xx and K08xx mappings shown (e.g., B4150, B4158, B4159, B4160).

Genetic and molecular testing: Prior authorization/notification required for many genetic/molecular CPT codes (sample U-codes: 0209U, 0214U, 0173U, 0211U, 0215U, 0114U, 0170U, 0175U, 0102U, 0118U, 0171U, 0218U, 0239U, 0250U, 0258U, 0290U–0318U, 0355U). Ordering provider must notify laboratory and include lab/test name per the Genetic and Molecular Testing Prior Authorization process.

Hospice and hospice-related codes: Prior authorization required (examples: G0493, G0494, T2042, T2045, Q5001, Q5005).

Hysterectomy: Prior authorization required for multiple hysterectomy CPT codes (examples: 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58285, 58290–58294, 58541–58554, 58570–58573).

Injectable medications (general): Prior authorization required for many injectable medications (examples from list: Actemra, Beqvez Q5152, Berinert J0597, Botox J0585, Brineura J0567, Briumvi J2329, Lamzede J0217, Lanreotide J1932, Lemtrada J0202, Leqembi J0174, Leqvio, Lucentis J2778, Lumizyme J0221, Lupron depot J9217/J1950, Lutathera A9513, Luxturna J3398, Mepsevii). Unclassified/temporary codes J3490/J3590 require prior authorization when used for specific named products (Lantidra, Monoferric, Revcovi, Rivfloza, Zulresso) and subject to the portal/phone submission process.

Mastectomy: Prior authorization required (example CPT: 19300).

Neurostimulators and spinal cord stimulators: Prior authorization required for implant procedures and related codes (examples: 61867, 64553, 64595, 63650, 63655, 63661, 63662, 63663, 63664, 63688; additional device codes 64570, 20931, 20939).

Outpatient therapy and physical/occupational therapy: Prior authorization/notification required for certain outpatient therapy services; sample CPTs listed (e.g., 94667, 94668, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032–97036, 97110, 97112, 97130).

Pain injections and pain management procedures: Prior authorization required for many pain injection and pain management CPT codes (examples: 62280–62292 series, 20552, 20553, 62320–62327, 62350).

Potentially cosmetic procedures: Prior authorization required for procedures in the cosmetic/potentially cosmetic category (examples: 11440, 11960, 11970, 11971, 14020*, 14021*, 14040, 14060, 14061*, 14301, 15570, 15572, 15574, 15730, 15731, 15733, 15736, 15740, 15756, 15820).

Prostate procedures: Prior authorization required for many prostate interventions (examples: 37243, 52441, 52442, 55873, 55874, 53850, 53852).

Radiology / advanced outpatient imaging: Prior authorization/notification required for certain advanced outpatient imaging procedures (selected CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology). Providers must notify prior to scheduling via the Provider Portal or call 866-889-8054; visit UHCprovider.com/Kycommunityplan > Prior Authorization and Notification > Radiology Prior Authorization and Notification program for CPT-level details.

Spine surgery and related surgical categories: Prior authorization required for many spine surgery CPT codes (examples: 22100, 22101, 22102, 22103, 22110, 22112, 22114, 22116, 22206, 22207, 22208, 22214, 22216, 22220, 22222, 22224, 22226, 22510, 22511).

Surgery (various specialties): Prior authorization required across multiple surgical categories with representative CPT examples (cardio/hemic/lymphatic 33274, 33275; digestive 43647; eye/ear 69300; general surgery 32672).

Transplant and CAR T-cell therapy services: Prior authorization/notification required before pre-treatment or evaluation for organ/tissue transplants and CAR T-cell therapies (examples and special instructions: call 800-418-4994 or the notification number on the member's ID card; sample CPT/HCPCS: 32855, 38206, 38210, 38215, 38241, 44137, 47133, 47142, 48554, 50365, S2060, S2150, CAR-T, J3490, Q2042, Q2058, 32852, 33933, 38207, 38212, 38230, 38242, 44715, 47135, 47144, 50325, 50370, S2065, 33935, 38208, 38213, 38232, 44135, 44720, 47140; and specified CAR-T product guidance).

Transplant - corneal transplant: Prior authorization required (example CPT: 65710).

Ventricular assist devices (VAD): Prior authorization required; providers should call the notification number on the member's ID card and follow Optum VAD Case Management instructions. Representative CPTs: 33927, 33928, 33929, 33975, 33976, 33979, 33981, 33982, 33983.

Codes and Code Groups (CPT, HCPCS, ICD-10, J-/Q- and L-codes)

Covered HCPCS/J-codes - Anti-emetics and supportive injectablesHCPCSCovered

J1454	Cinvanti (aprepitant) - injectable anti-emetic
J1453	Emend (fosaprepitant) - injectable anti-emetic
J1456	Fosaprepitant (Injection Fosaprepitant) - injectable anti-emetic
J1449	Rolvedon / pegfilgrastim (colony stimulating factor) - example CSF
Q5120	Ziextenzo (pegfilgrastim-bmez) - biosimilar CSF
J2506	Neupogen (filgrastim) - CSF
J1439	Injectafer (ferric carboxymaltose) - IV iron
J2502	Signifor LAR (pasireotide) - injectable
J1447	Granix (tbo-filgrastim) - CSF

Covered Branded Drug Names (called out)mixedCovered

Cinvanti	(aprepitant) - oral/injectable anti-emetic formulation referenced with J1454
Emend	(fosaprepitant) - injectable anti-emetic referenced with J1453/J1456
Nyvepria	(pegfilgrastim-apgf) - pegfilgrastim product referenced among colony stimulating factors
Akynzeo	(palonosetron/fosnetupitant) - anti-emetic combination requiring prior authorization

Covered CPT — Arthroplasty and related examplesCPTCovered

23470	Arthroplasty, shoulder; total
27130	Arthroplasty, hip; total
27447	Arthroplasty, knee; total

Covered CPT — Arthroscopy examplesCPTCovered

29806	Arthroscopy, diagnostic, shoulder
29881	Arthroscopy, knee, with meniscectomy
29888	Arthroscopy, knee, with synovectomy

Covered HCPCS — Bone growth stimulator / DME examplesHCPCSCovered

E0748	Bone growth stimulator, e.g., electrical; external
E0760	Ultrasound bone growth stimulator
E0747	Bone growth stimulator, other

Covered HCPCS/J-codes — Injectable Cancer Supportive Care (expanded list)HCPCSCovered

J1454	Cinvanti (aprepitant) - injectable anti-emetic
J1453	Emend (fosaprepitant) - injectable anti-emetic
J1456	Fosaprepitant (Injection Fosaprepitant) - injectable anti-emetic
J1449	Rolvedon / pegfilgrastim - colony stimulating factor
Q5120	Ziextenzo (pegfilgrastim-bmez) - biosimilar CSF
J2506	Neupogen (filgrastim) - CSF
J1439	Injectafer (ferric carboxymaltose) - IV iron
J9355	Example chemotherapy supportive agent
J9390	Example oncology drug code

Neutral — Examples of CPT/HCPCS codes appearing in sectionmixed

95250	Ambulatory continuous glucose monitoring; initial
A9276	CGM supply
A9277	CGM supply
Q2042	CAR-T related HCPCS (example)

Covered HCPCS/J-codes — Additional injectables and examplesHCPCSCovered

J0597	Berinert - C1 esterase inhibitor
J0585	Botox - onabotulinumtoxinA
J0567	Brineura - cerliponase alfa
J2329	Briumvi - injectable monoclonal antibody
J0223	Givlaari - givosiran

Neutral — Selected HCPCS J-/Q- codes listed elsewhereHCPCS

J9333	Rystiggo - example J-code
Q5125	Releuko - pegfilgrastim biosimilar
Q5103	Inflectra - infliximab biosimilar
J9312	Roctavian - example gene therapy J-code

Covered HCPCS — DME and Device ExamplesHCPCSCovered

L2387	Lower extremity prosthetic, example L-code
L8619	Cochlear implant internal device
A9274	DME example
E1399	DME miscellaneous

Covered CPT — Selected surgical / procedure codes requiring prior authorizationCPTCovered

29826	Arthroscopy, shoulder, with rotator cuff repair - example
63650	Spinal cord stimulator trial/implant - example
30999	Unlisted procedure example

Key Billing Thresholdmixed

BILLED_THRESHOLD

DME and certain devices: billed amount or cumulative rental cost > $500 triggers prior authorization requirement

Annotationmixed

PA_NOT_REQUIRED_NOTE

* Prior authorization not required when billed with specified diagnosis codes as noted elsewhere in this section

Provider Submission, Notification, and Operational Guidance

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by phone at 888-702-2202, or by fax to 866-968-7582. Prior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all procedures and services.

Prior Authorization

Service categories requiring prior authorization

Prior authorization is required for many service categories including arthroplasty, arthroscopy, bariatric surgery (Center of Excellence requirement noted), body lengthening, bone growth stimulators, bone marrow/stem cell procedures, breast reconstruction (with diagnosis exemptions), and outpatient injectable cancer supportive care drugs.

Prior Authorization

Prior authorization — outpatient injectable cancer supportive care

Prior authorization is required for outpatient injectable cancer supportive care drugs (intravenous, intravesical and intrathecal) including listed agents such as Akynzeo and those billed with J‑series and Q‑series HCPCS codes (examples: J1454, J1453, Q5122, Q5120, J1456, J2820, J1449, J0885, J1627).

Definitions and Program Terms

Prior authorization — definition

DefinitionPrior authorization: an approval process providers must complete before performing certain services or procedures; not required for emergency or urgent care.

Submission channelsRequests may be submitted online via the Provider Portal, by phone, or by fax as listed in the document.

Applies toParticipating UnitedHealthcare Community Plan of Kentucky providers and out-of-network providers (out-of-network must request PA for all services).

UnitedHealthcare Provider Portal — Prior Authorization and Notification

Tool nameUnitedHealthcare Provider Portal Prior Authorization and Notification tool — online submission option on UHCprovider.com.

How to accessSign in with One Healthcare ID on UHCprovider.com, then select the Prior Authorization and Notification tab on the dashboard.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Kentucky

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNov 1, 2025

Next Review DateN/A

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

SourceLink

On This Page

Prior Authorization

Prior authorization required — Cardiology outpatient/office-based procedures

Participating physicians must obtain prior authorization for outpatient and office-based cardiology procedures including diagnostic catheterizations, electrophysiology implants and stress echocardiograms; submit via the Provider Portal Prior Authorization and Notification tool or the designated phone number and see the Cardiology Prior page for full CPT lists.

Prior Authorization

Prior authorization required for listed procedures and devices

Prior authorization is required for selected procedures and devices listed in the code sections, including carpal tunnel procedures, cartilage implants, chemotherapy injectable drugs, cochlear and other auditory implants where indicated in the code lists.

Carpal tunnel (e.g., CPT 29848, 64721) — prior authorization required
Cartilage implants (e.g., CPT 27412, 27415, 27416, 29866) — prior authorization required
Chemotherapy injectable drugs (multiple J‑codes listed) — prior authorization required

Prior Authorization

Cochlear implants and auditory implants — prior authorization

Cochlear implants and other auditory implants require prior authorization as indicated in the policy code lists.

Prior Authorization

Cochlear implant codes and $500 cost threshold

Cochlear implant device and related procedure codes (examples: L8619, L8627, L8628 and CPT 69710, 69714, 69717, 69930) require prior authorization when the billed amount or cumulative rental cost is more than $500.

Device/procedure codes: 69710, 69714, 69717, 69930; L8619, L8627, L8628
Prior authorization required when billed amount or cumulative rental cost > $500

Prior Authorization

Continuous glucose monitoring — prior authorization

Continuous glucose monitoring devices and supplies (examples: 95250, 95251, A9276‑A9278, A4239, E2102, E2103) require prior authorization when the billed amount or cumulative rental cost is more than $500.

Prior Authorization

Congenital heart disease–related services — prior authorization

Congenital heart disease–related services and numerous cardiac procedure CPT codes (examples: 33251, 33404, 33414–33417, 33476, 33478, 33502) are listed as requiring prior authorization.

Prior Authorization

Durable medical equipment (DME) — prior authorization and cost threshold

Durable medical equipment (DME) generally requires prior authorization in many listed categories; certain DME items and rentals require prior authorization when the billed amount or cumulative rental cost exceeds $500.

Prior Authorization

Cosmetic procedures — prior authorization

Cosmetic procedures (example CPT 21137) are noted as requiring prior authorization.

Prior Authorization

Enteral and parenteral therapy — prior authorization

Enteral and parenteral therapy supply codes B4150, B4158, B4159 and B4160 require prior authorization.

Codes: B4150, B4158, B4159, B4160

Prior Authorization

Experimental/investigational procedures — prior authorization

Certain items identified as experimental and investigational require prior authorization; examples of listed codes include 33477, 95966, 36514, 95967, 64722 and 95965.

Prior Authorization

Foot surgery — prior authorization

Foot surgery CPT codes listed (examples: 28285, 28295, 28299, 28289, 28296, 28291, 28297, 28292, 28298) require prior authorization.

Prior Authorization

FESS — prior authorization

Functional endoscopic sinus surgery (FESS) CPT codes listed (examples: 31237, 31254, 31239, 31255, 31267, 31240, 31256) require prior authorization.

Documentation Required

Laboratory prior authorization/notification — provider requirements

Care providers requesting laboratory testing must complete the prior authorization/notification process and indicate the performing laboratory and test name as part of submission.

Prior Authorization

Genetic and Molecular Testing — prior authorization/notification

Payment will be authorized for CPT codes that are registered with the Genetic and Molecular Testing Prior Authorization/Notification program; those tests must follow the program's prior authorization/notification process.

Prior Authorization

Service-specific prior authorization requirement

Specific service categories (for example: experimental/investigational procedures, foot surgery, FESS, home health, hospice, hysterectomy) are identified as requiring prior authorization; confirm the listed CPT/HCPCS codes before submission.

Prior Authorization

Prior authorization — selected services and injectables

Prior authorization is required for selected hospice HCPCS codes and numerous injectable medications; examples include hospice codes G0493/G0494/T2042/T2045 and several J‑codes listed in the injectable medication sections.

Prior Authorization

Prior authorization for unclassified/temporary HCPCS codes (J3490/J3590)

Unclassified or temporary HCPCS codes J3490 and J3590 require prior authorization only when used for specific products (Lantidra, Monoferric, Revcovi, Rivfloza and Zulresso). Submit requests via the Provider Portal Prior Authorization and Notification tool or call 888‑397‑8129.

Prior Authorization

Procedures requiring prior authorization — examples

Various procedures require prior authorization, for example injection arthrogram (CPT 27096), mastectomy (CPT 19300), specified medicine services (CPTs 96116, 96121, 96130, 96131) and neurostimulator procedures (CPTs 61867, 64553, 64595).

Prior Authorization

Orthognathic surgery and orthotics/prosthetics — prior authorization

Orthognathic surgery and orthotics/prosthetics require prior authorization; the policy lists multiple CPT/HCPCS and L‑codes for orthognathic procedures and prosthetic/orthotic items that must follow the prior authorization process.

Prior Authorization

Outpatient therapy — prior authorization

Outpatient therapy (physical, occupational and speech) CPT codes listed (examples include 97110, 97112, 97116, 97140, 92507) require prior authorization.

Prior Authorization

Pain management and injections — prior authorization

Pain injections and pain management procedures require prior authorization for many listed CPT codes (examples include 62280–62292, 20552, 20553, 62320–62327, 64405, 64408, 64415).

Prior Authorization

Additional procedures — prior authorization where indicated

Additional procedural codes related to pain management and other interventions (examples: 64600 series, certain E‑codes) are noted and require prior authorization where indicated in the listings.

Prior Authorization

Orthotics and prosthetics — prior authorization

Orthotics and prosthetics L‑codes are listed throughout the policy with prior authorization instructions; providers should follow the listed authorization fields when submitting requests for these items.

Note

Prior authorization exceptions — 'not required when billed'

Some codes are annotated with '* Prior authorization not required when billed.' Review the code list for this annotation to identify exceptions.

Prior Authorization

Radiology prior authorization — submission instructions

For radiology prior authorization, providers must provide notification prior to scheduling advanced outpatient imaging and submit prior authorization requests online via the Prior Authorization and Notification tool on the Provider Portal or by calling 866‑889‑8054.

Prior Authorization

Pediatric extended care and private duty nursing — prior authorization

Prescribed pediatric extended care services (PPEC) and private duty nursing require prior authorization (examples: T1025, T1026, T1000).

PPEC codes: T1025, T1026
Private duty nursing: T1000

Prior Authorization

Prostate procedures — prior authorization

Prostate procedures listed in the policy (examples: 37243, 52441, 52442, 55873) require prior authorization.

Prior Authorization

Sleep apnea procedures and sleep studies — prior authorization

Sleep apnea procedures and surgeries (examples include CPT 21685, 42145), and laboratory‑assisted sleep studies/polysomnography (CPTs 95805, 95807, 95808, 95810) require prior authorization; home sleep studies are excluded.

Sleep study CPTs: 95805, 95807, 95808, 95810
Excludes home sleep studies

Note

How to obtain radiology prior authorization (web resource)

For radiology prior authorization details and the CPT codes that require prior authorization, visit UHCprovider.com/Kycommunityplan > Prior Authorization and Notification > Radiology Prior Authorization and Notification program.

Prior Authorization

How to obtain prior authorization — transplant and CAR T

For transplant and CAR T‑cell therapy services (examples listed in the policy), contact 800‑418‑4994 or the notification number on the back of the member's ID to obtain prior authorization/notification.

Prior Authorization

Prior authorization requirement — multiple service categories

Multiple service categories across the document are flagged as 'Prior authorization required' (for example: sleep apnea procedures & surgeries, spine surgery, and various surgical categories); providers must complete prior authorization before services are rendered or billed.

Prior Authorization

Ventricular assist devices (VAD) — prior authorization routing

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

Prior Authorization

Corneal transplant (CPT 65710) — prior authorization

Corneal transplant requires prior authorization; CPT code 65710 is listed for corneal transplant and must follow the prior authorization process.

CPT example: 65710

Prior Authorization

Vein procedures and ablation — prior authorization

Vein procedures and removal/ablation of main trunks and named branches (examples: 36465, 36466, 36470, 36471, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37765) are indicated as requiring prior authorization.

Alternate routesIf not using the portal, phone numbers are provided in the document for specific programs and categories.

Prior authorization required — interpretation

Meaning'Prior authorization required' indicates the listed procedure, device, or drug requires submission and approval of a prior authorization request before services are rendered or billed.

ScopeApplied across multiple service categories (procedures, devices, injectables) as shown in code lists in the document.

Exception noteEmergency or urgent care is not subject to prior authorization per the document.

Cochlear implant — definition

DefinitionCochlear implant: a medical device within the inner ear with an external portion to assist persons with profound sensorineural hearing loss.

Codes referencedProcedure and device codes include CPT 69710, 69714, 69717, 69930 and HCPCS L8619, L8627, L8628 among others.

Authorization triggerPrior authorization required for cochlear implants; device/procedure codes with billed amount or cumulative rental cost over $500 require PA.

Durable medical equipment (DME) — definition

DefinitionDurable medical equipment (DME): equipment including prosthetics and orthotics; many DME items require prior authorization (DME generally requires PA regardless of cost in listed categories).

ExamplesListed HCPCS/A/E codes include A5500 series, E-codes and many others shown in the DME sections of the document.

Cost thresholdCertain DME rentals with billed amount or cumulative rental cost more than $500 require prior authorization as indicated.

Enteral and parenteral therapy — definition note

DefinitionEnteral and parenteral therapy: enteral/parenteral nutrition supplies and related services (examples: HCPCS B4150, B4158, B4159, B4160). Prior authorization is required for these codes.

Codes shownB4150, B4158, B4159, B4160 are explicitly listed as requiring prior authorization.

Experimental & investigational — definition note

DefinitionExperimental and investigational procedures: items labeled 'Experimental and investigational' in the document require prior authorization.

Example codesExamples include CPT codes 33477, 95966, 36514, 95967, 64722, 95965 listed as experimental/investigational and requiring PA.

Foot surgery — definition note

DefinitionFoot surgery: specified foot surgery CPT codes listed in the document require prior authorization.

Example codesExamples include CPT 28285, 28295, 28299, 28289, 28296, 28291, 28297, 28292, 28298 as listed.

Functional endoscopic sinus surgery (FESS) — definition note

DefinitionFunctional endoscopic sinus surgery (FESS): FESS CPT codes listed require prior authorization.

Example codesExamples include CPT 31237, 31254, 31239, 31255, 31267, 31240, 31256 as shown in the document.

Genetic / Molecular Testing Prior Authorization

ProgramGenetic/Molecular Testing Prior Authorization/Notification program — payment authorized for CPT codes registered with this program.

Laboratory requirementOrdering providers must complete the prior authorization/notification process and indicate the performing laboratory and test name.

Relevant codesMany U-codes and molecular/genetic CPTs are referenced in the genetic/molecular testing sections (see code lists).

Prior authorization / notification — definition and lab requirements

DefinitionPrior authorization/notification for laboratory testing: a process that requires indicating the performing laboratory and the test name; applies to laboratory and genetic tests listed.

Payment conditionPayment is authorized for CPT codes registered with the Genetic and Molecular Testing Prior Authorization/Notification program when requirements are met.

Provider actionComplete the prior authorization/notification process as instructed in the document before ordering the test.

Injectable medications — definition

DefinitionInjectable medications: drugs capable of being injected intravenously, subcutaneously or intramuscularly; many injectable medications listed require prior authorization.

Unclassified codes noteUnclassified/temporary HCPCS codes J3490 and J3590 require prior authorization only for specified products (e.g., Lantidra, Monoferric, Revcovi, Rivfloza, Zulresso).

SubmissionFor injectable medication PA, submit via Provider Portal or phone number(s) provided (document lists numbers for specific programs).

UnitedHealthcare Provider Portal — Prior Authorization and Notification (duplicate)

Tool nameUnitedHealthcare Provider Portal Prior Authorization and Notification tool (duplicate entry) — online submission method on UHCprovider.com.

Access stepsSign in with One Healthcare ID at UHCprovider.com, select the Prior Authorization and Notification tool on your Provider Portal dashboard.

Alternative contactIf not using the portal, use program-specific phone numbers listed in the document (e.g., 888-397-8129 for some injectables).

Outpatient therapy — definition

DefinitionOutpatient therapy (physical/occupational/speech): therapy services with listed CPT codes that require prior authorization as noted in the document.

ExamplesCodes include CPT 97110, 97112, 97116, 97140, 92507, 92508, 92526, 97129, 97130 among others listed.

RequirementProviders must obtain prior authorization for the outpatient therapy CPT codes listed before service delivery per the document.

Pain injections / pain management — definition

DefinitionPain injections / pain management procedures: procedural injections and related pain management CPT codes listed in the document that require prior authorization.

ExamplesIncluded CPT codes include 20552, 20553, 62320-62327, 64405, 64408, 64415-64421 and many others shown in the pain management lists.

ActionObtain prior authorization for listed pain injection and pain management CPT codes as indicated.

Advanced outpatient imaging procedure — definition

DefinitionAdvanced outpatient imaging procedure: certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures flagged in the radiology section that require notification or prior authorization.

Provider responsibilityCare providers ordering these procedures must provide notification prior to scheduling and submit PA via the Provider Portal or call the radiology phone number.

PPEC — definition

DefinitionPPEC = Prescribed pediatric extended care services — services identified in the document that require prior authorization (codes T1025, T1026).

Related servicesPrivate duty nursing (T1000) is also listed and requires prior authorization.

Laboratory-assisted sleep studies (polysomnography) — definition

DefinitionLaboratory-assisted sleep studies (polysomnography): in-lab polysomnography procedures requiring prior authorization; excludes home sleep studies.

Example codesCPT codes include 95805, 95807, 95808, 95810 as listed in the document.

Ventricular assist devices (VAD) — definition

DefinitionVentricular assist devices (VAD): a mechanical pump that takes over the function of the damaged ventricle and restores blood flow; VADs require prior authorization.

RoutingProviders should call the notification number on the member's ID card and then fax the form provided by the nurse to Optum VAD Case Management per instructions.

Example codesListed CPT/HCPCS examples include 33927, 33928, 33929, 33975-33983 in the VAD section.