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Prior authorization requirements for UnitedHealthcare Complete

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Lists services, CPT/HCPCS and ICD-10 codes, and submission instructions for prior authorization and notification for UnitedHealthcare Complete plans; affects providers submitting requests for covered members and notes site-of-service reviews and emergency/urgent care exceptions.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Complete

Policy CodePolicy N/A

Change TypeAdministrative (no material changes)

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call the listed phone numbers.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2026-05-01Effective

hundredsCode volume

portal+phoneSubmission methods

18+Age-based PA

colony-stimulating factors

Services and Code-Level Prior Authorization Requirements

Genetic / Molecular Testing — Prior Authorization and Lab Notification

Genetic and molecular testing (including BRCA) — laboratory notification and prior authorization requirements.

Notify the laboratory conducting the test; the laboratory will notify UnitedHealthcare to complete the prior authorization/notification process.

Prior authorization (or lab-notification followed by UnitedHealthcare notification) is required for listed genetic and molecular tests related to breast cancer (BRCA) and other specified panels.

Providers should use the UnitedHealthcare Prior Authorization and Notification tool on the Provider Portal (UHCprovider.com) to submit requests when required, or follow laboratory notification instructions as indicated by the lab performing the test.

Applicable CPT/HCPCS/CPT® Category I/II/III U codes requiring prior authorization or lab-notify include (but may not be limited to) the following: 0326U, 0334U, 0341U, 0364U, 0379U, 0388U, 0389U, 0391U, 0395U, 0398U, 0417U, 0425U, 0444U, 0449U, 0465U, 0471U, 0473U, 0474U, 0475U, 0478U, 0480U, 0481U, 0483U, 0484U, 0485U, 0493U, 0495U, 0499U, 0500U, 0504U, 0505U, 0506U, 0529U, 0530U, 0536U, 0539U, 0540U, 0543U, 0562U, 0567U.

Operational note: For certain laboratories the provider must notify the laboratory and the laboratory will initiate notification to UnitedHealthcare; check laboratory-specific instructions to ensure authorization/notification is completed prior to testing.

CPT / HCPCS / ICD-10 Code Lists and Groups

Cardiovascular / Interventional (Potentially unproven)CPT

33364	Cardiac procedure code
33365	Cardiac procedure code
33366	Cardiac procedure code
33369	Cardiac procedure code
C2624	HCPCS code (cardiac)

Diabetes-related ICD-10 (behavioral/complication codes)ICD-10

E08.52	Diabetes due to underlying condition with peripheral angiopathy
E09.52	Drug or chemical induced diabetes with peripheral angiopathy
E10.52	Type 1 diabetes with peripheral angiopathy
E11.52	Type 2 diabetes with peripheral angiopathy

Osteomyelitis ICD-10ICD-10

M86.68	Other chronic osteomyelitis, unspecified site
M86.69	Other chronic osteomyelitis, multiple sites

Vaccines / Immunizations (Covered / Home health injectables referenced)HCPCSCovered

90683	Influenza vaccine, recombinant, preservative-free, for intramuscular use
90684	Influenza vaccine, cell culture, for intramuscular use
90685	Influenza vaccine, quadrivalent (cell-based)
90686	Influenza vaccine, quadrivalent
90687	Influenza vaccine, quadrivalent, preservative-free
90688	Influenza vaccine, intradermal
90694	Influenza vaccine, high-dose, trivalent
90702	DTaP (age-specific)
90714	Hepatitis A vaccine
90715	Hepatitis B vaccine

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COVID / SARS-CoV-2 Vaccines (91300–91322; 91323)HCPCSCovered

91300	SARS-CoV-2, mRNA, spike protein, stabilized (first listed)
91301	SARS-CoV-2 vaccine
91302	SARS-CoV-2 vaccine
91303	SARS-CoV-2 vaccine
91304	SARS-CoV-2 vaccine
91305	SARS-CoV-2 vaccine
91306	SARS-CoV-2 vaccine
91307	SARS-CoV-2 vaccine
91308	SARS-CoV-2 vaccine
91309	SARS-CoV-2 vaccine

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Other Vaccines (90382, 90612, 90613, 90635)HCPCSCovered

90382	Rabies vaccine, for use in humans
90612	Pneumococcal conjugate vaccine
90613	Pneumococcal conjugate vaccine
90635	Pneumococcal vaccine

Selected Covered HCPCS / J-codes (sample, covered)HCPCSCovered

C9818	Miscellaneous HCPCS (example)
J0139	Injection, unspecified antibiotic
J0153	Injection, drug
J0162	Injection, drug
J0163	Injection, drug
J0164	Injection, drug
J0168	Injection, drug
J0169	Injection, drug
J0171	Injection, drug
J0173	Injection, drug

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Additional J-codes (sample list)HCPCS

J0248	Injection
J0270	Injection
J0275	Injection
J0278	Injection
J0280	Injection
J0281	Injection
J0282	Injection
J0283	Injection
J0285	Injection
J0287	Injection

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Extended J-code list (sample)HCPCS

J0561	Injection
J0565	Injection
J0570	Injection
J0571	Injection
J0572	Injection
J0592	Injection
J0593	Injection
J0594	Injection
J0602	Injection
J0607	Injection

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Q-codes (example)HCPCS

Q0139	Home health nursing
Q0144	Home infusion
Q0161	Infusion
Q0162	Infusion
Q0163	Infusion
Q0164	Infusion
Q0166	Infusion
Q0167	Infusion
Q0169	Infusion

A- and miscellaneous supply HCPCSHCPCS

A4557	Supply
A4600	Supply range start
A9597	Supply range end
A4913	Supply
A9598	Supply
A9274	Supply

Selected CPT codes (neurostimulator / surgical examples)CPT

43647	Gastric procedure / example
43648	Gastric procedure
43881	Bariatric procedure
43882	Bariatric procedure
61863	Spinal neurostimulator
61864	Spinal neurostimulator
61867	Spinal neurostimulator
61868	Spinal neurostimulator
64553	Neurostimulator lead
64555	Neurostimulator lead

L-code Orthotics / Prosthetics (selected range)HCPCS

L0112	Orthotic / example
L5220	Orthotic example (many L-codes listed)
L5610	Orthotic example end range

Urinary / Genitourinary ICD-10 (Home health / Prior auth relevant)ICD-10

R15.0	Incontinence of feces
R15.1	Incomplete defecation
R15.2	Fecal incontinence
R15.9	Unspecified fecal incontinence
R30.0	Dysuria
R30.1	Painful micturition
R30.9	Unspecified pain associated with micturition
R32	Unspecified urinary incontinence
R33.0	Retention of urine
R33.8	Other retention of urine

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Orthotics / Prosthetics L-code group (covered_with_criteria)HCPCSCovered

L0112	Orthotic — requires prior authorization and diagnosis mapping
L0220	Orthotic — example
L0452	Orthotic — example
L0482	Orthotic — example
L0484	Prosthetic — example
L0486	Prosthetic — example
L0622	Prosthetic — example
L0624	Prosthetic — example
L2036	Prosthetic — example
L2037	Prosthetic — example

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Influenza / Immunization series (home health vaccine examples)HCPCSCovered

90670	Influenza vaccine, quadrivalent, preservative-free
90671	Influenza vaccine
90672	Influenza vaccine
90673	Influenza vaccine
90674	Influenza vaccine
90675	Influenza vaccine
90677	Influenza vaccine
90678	Influenza vaccine

Home health injectable predetermination J-code examples (selected)HCPCSCovered

J0578	Injectable medication example
J0582	Injectable medication example
J0583	Injectable medication example
J0585	Injectable medication example
J0586	Predetermination required
J0587	Predetermination required
J0588	Predetermination required
J0589	Predetermination required
J0591	Predetermination required
J0592	Predetermination required

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Additional sample HCPCS / Q-codes and suppliesHCPCS

Q2057	Example
Q2043	Example
Q2058	Example
Q2050	Example
Q2055	Example
Q5105	Example
Q5106	Example
Q5134	Example
Q5137	Example
Q5140	Example

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Miscellaneous clinical / procedure CPT codes (home health / reconstructive)CPT

11960	Removal of small lesion
14021	Flap repair (requires context)
14301	Reconstructive procedure
15574	Tissue rearrangement
15756	Graft procedure
15823	Skin graft
17380	Destruction of premalignant lesion
21175	Maxillofacial procedure
21182	Maxillofacial procedure
21235	Maxillofacial procedure

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Selected immunization-related HCPCS (Q/Codes) and examplesHCPCS

Q5101	Colony-stimulating factor (example)
Q5110	Colony-stimulating factor (example)
Q5111	Colony-stimulating factor (example)
Q5120	Colony-stimulating factor (example)
Q5122	Colony-stimulating factor (example)
Q5148	Colony-stimulating factor (example)

Additional single HCPCS examples (C2624 repeated)HCPCS

C2624

Cardiac HCPCS code (also listed earlier)

Home health — Q-code injections and supplies examplesHCPCS

Q0139	Home infusion/visit
Q0144	Home infusion/visit
Q0161	Home infusion
Q0162	Home infusion
Q0163	Home infusion
Q0164	Home infusion
Q0166	Home infusion
Q0167	Home infusion
Q0169	Home infusion

Supply HCPCS A-codesHCPCS

A4600	Supply range start (A4600-A9597 referenced)
A9597	Supply range end
A4913	Surgical supply
A9598	Supply
A9274	Supply

Selected COVID / Immunization codes (91300-91323 consolidated)HCPCSCovered

91300	SARS-CoV-2 vaccine
91301	SARS-CoV-2 vaccine
91302	SARS-CoV-2 vaccine
91303	SARS-CoV-2 vaccine
91304	SARS-CoV-2 vaccine
91305	SARS-CoV-2 vaccine
91306	SARS-CoV-2 vaccine
91307	SARS-CoV-2 vaccine
91308	SARS-CoV-2 vaccine
91309	SARS-CoV-2 vaccine

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How to Submit Requests and Operational Guidance for Providers

Prior Authorization

Submit PA requests via UHC Provider Portal (One Healthcare ID)

Submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal using your One Healthcare ID and password (go to UHCprovider.com → Sign In → Prior Authorization and Notification tab). Reference the member-specific benefit plan document when deciding coverage; site‑of‑service review may apply. Prior authorization is not required for emergency or urgent care. Some benefit plans have no non‑emergent out‑of‑network coverage and no coverage outside the service area.

Prior Authorization

Arthroplasty procedures require prior authorization

Prior authorization is required for arthroplasty procedures listed in the document; examples of CPT codes that require authorization include 23470, 23472, 23473, 23474, 24360–24363, 24365–24371, 25441–25446, 25449, 26530–26536, 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27437–27447, 27486, 27487, 27702.

Examples shown are a partial list; consult the full listing in the document for all arthroplasty CPT codes requiring prior authorization.

Key Terms and Administrative Notes

Prior authorization submission requirement summary

Primary submission methodSubmit prior authorization and notification requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal using One Healthcare ID

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

Phone alternateIf needed, callers may use the listed contact number 866-889-8054 as an alternative to online submission

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

Center of Excellence — bariatric surgery

Center of Excellence requirementSome plans require use of a designated Center of Excellence for coverage of bariatric surgery and related services

Submission Channels, Phone Numbers, and Specialty Guidance

Note

Optum SGP contact (duplicate)

Optum SGP phone line888-397-8129 is listed as the phone number for the Optum Specialty Guidance Program (SGP)

When to callUse this line for specialty guidance on injectable medications and for questions about submitting prior authorization requests via the portal

Portal requirementEven when contacting SGP, providers are directed to sign in to the Provider Portal to submit prior authorization requests

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Complete

Policy CodePolicy N/A

Change TypeAdministrative (no material changes)

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call the listed phone numbers.

SourceLink

On This Page

Prior Authorization

Bariatric surgery: prior authorization and Center of Excellence note

Bariatric surgery requires prior authorization; the document notes a Center of Excellence requirement for coverage for some plans and specifies notification/prior authorization is required when billing CPTs 43860 and 43865 with qualifying obesity diagnosis codes (E66.* and Z68.*).

Notification/prior authorization required for diagnosis codes: E66.01, E66.09, E66.1–E66.3, E66.8, E66.9, Z68.1, Z68.20.
Some benefit plans may not cover bariatric services in certain situations—refer to member benefit plan document.

Prior Authorization

Cancer supportive‑care drugs require prior authorization

Prior authorization is required for outpatient cancer supportive care drugs; colony‑stimulating factors, bone‑modifying agents, antiemetics, and erythropoiesis‑stimulating agents administered in an outpatient setting for a cancer diagnosis require prior authorization. Specific J‑ and Q‑codes (examples: J0897, J1442, J1447, J2506, J2820, Q5101, Q5110, Q5111, Q5120, Q5122, Q5148, Q5136, Q5157–Q5159) are listed.

Some of the listed J/Q codes also require prior authorization when used for non‑oncology diagnoses.
Submit requests via the Prior Authorization and Notification tool (Provider Portal) as indicated for these drugs.

Prior Authorization

Arthroscopy CPT codes require prior authorization (continued list)

Arthroscopy procedures listed in the document require prior authorization; examples include CPTs 29805, 29806, 29807, 29819–29830, 29834–29840, 29843–29863, 29870–29889, 29891–29899, 29914–29916 (partial/continued list).

This is a continued/partial list — consult the full document for all arthroscopy CPT codes requiring authorization.

Prior Authorization

Outpatient colony‑stimulating/bone‑modifying/ESA drugs require PA

Prior authorization is required for selected outpatient injectable drugs administered outside the inpatient setting—specifically colony‑stimulating factor drugs, bone‑modifying agents, and erythropoiesis‑stimulating agents. Example HCPCS/J and Q codes listed include J0897, J1442, J1447, J1449, J2506, J2820, J1434, J2468, Q5101, Q5110, Q5111, Q5120, Q5122, Q5148.

Some of these codes also require prior authorization for non‑oncology diagnoses (document notes which codes are dual‑indication).

Prior Authorization

How to submit PA/notification requests — portal + phone

Submit prior authorization and notification requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com → Sign In → Prior Authorization and Notification). Providers may also call 866‑889‑8054; the document also references an alternate phone number 888‑397‑8129 for specialty guidance.

Use the Provider Portal as the primary submission mechanism.
Phone submissions available at 866‑889‑8054; Optum SGP specialty line 888‑397‑8129 for questions.

Denial Risk

Cardiovascular/interventional codes flagged 'Potentially unproven' — PA may be required

Selected cardiovascular/interventional procedure codes are labeled 'Potentially unproven' and may require prior authorization or notification; examples include CPTs 37225–37231 and 93580, 93653, 93656 and HCPCS E0616. These codes may have special notes including age‑ or diagnosis‑based prior authorization rules.

Some codes are marked * indicating PA not required for specific diagnosis codes; codes marked ** indicate PA required for members age 18 and older (see cardiovascular/congenital heart guidance).

Documentation Required

Age‑based PA notes: ** = 18+ ; * = PA exception for specific Dx

Some CPT/HCPCS codes in the document include age‑based prior authorization notes: codes marked ** indicate prior authorization is required for members ages 18 and older; codes marked * indicate PA is not required for specific diagnosis codes. See the congenital heart disease section for guidance on members under age 18.

Examples of codes with age‑based notes include 93580** and segments referencing E08.52–I70.238 series.
Always check the code annotations in the document for '*' or '**' markers before submitting.

Documentation Required

ICD‑10 diagnosis codes shown with PA instruction (age‑based note)

The document lists ICD‑10 diagnosis codes that carry prior authorization instructions; for example E08.52, E09.52, E10.52, E11.52, E13.52 and multiple I70.* codes are shown with the note that prior authorization is required for members ages 18 and older (see congenital heart disease guidance for pediatric members).

Diagnosis codes listed with 'how to obtain prior authorization' require following the payer's PA process.
Refer to the cardiovascular/congenital sections for age‑specific exceptions.

Note

Codes listed throughout the document are informational and tied to PA process

The document repeatedly lists CPT®, HCPCS and ICD‑10 codes as general information for providers; examples include I70.344–I70.349 and many CPT/HCPCS entries—these code lists indicate items subject to the prior authorization and notification process.

Use the Provider Portal to determine whether a listed code requires prior authorization for the specific member and diagnosis.

Prior Authorization

Follow PA process for cardiovascular diagnosis codes (I70.*)

For cardiovascular‑related diagnosis codes (many I70.* entries), the document annotates 'how to obtain prior authorization'—providers must follow the payer’s prior authorization process for services associated with those ICD‑10 codes as listed in the cardiovascular sections.

Examples include I70.35, I70.361–I70.369 and extended I70.x series entries; consult the Cardiovascular section for full code lists and instructions.

Prior Authorization

Continued cardiovascular diagnosis codes require PA per listing

Additional cardiovascular diagnosis codes continued in the listing include I70.531–I70.549 and related I70.* entries with 'how to obtain prior authorization' annotations—obtain PA per the document for services tied to these codes.

Review the full cardiovascular code segments to determine required documentation and age‑based exceptions.

Prior Authorization

Vascular ICD‑10 codes annotated with PA instructions

Vascular and related ICD‑10 codes (for example I72.3, I72.4, I72.8, I72.9, I73.00–I73.81, I74.*) are listed with 'how to obtain prior authorization'—providers must follow the indicated prior authorization process for services tied to these vascular codes.

Consult the Vascular section in the document for full code lists and PA instructions.

Prior Authorization

Infection/osteomyelitis ICD‑10 codes require PA (how to obtain PA noted)

Infectious and osteomyelitis‑related ICD‑10 codes (examples: L03.116, M86.05x–M86.9 series) are listed with repeated 'how to obtain prior authorization' notes; providers must submit PA requests for services associated with these diagnosis codes as indicated.

Many specific M86.x subcodes appear—follow the document's PA instructions for each code.

Prior Authorization

Congenital/trauma diagnosis codes annotated for PA (follow instructions)

Congenital/structural and trauma‑related ICD‑10 codes (examples: Q27.30, Q27.32, Q27.39, Q27.8, Q27.9, Q87.2, S35.511A/S35.512A) are annotated with 'how to obtain prior authorization'; providers must follow the documented PA process for services linked to these codes.

See congenital heart disease guidance for members under age 18 where age‑specific rules apply.

Prior Authorization

Cartilage implants and inpatient video EEG require prior authorization

Examples of services explicitly requiring prior authorization include cartilage implants (CPTs 27412, 27415, 27416, 29866, 29868; J7330; S2112) and inpatient video EEG (CPTs 95700, 95711–95713); the document states PA is required for these services.

Inpatient video EEG: prior authorization required for inpatient services and required for outpatient hospital/ASC settings per document.
Cartilage implants: listed CPT/HCPCS codes show prior authorization required.

Prior Authorization

EEG, chelation, chemotherapy agents require prior authorization

The document lists inpatient video EEG and chelation therapy as requiring prior authorization; chemotherapy and multiple J‑codes used in chemotherapy administration are also listed as requiring prior authorization.

Chemotherapy J‑codes are enumerated across the chemotherapy sections—submit PA for each applicable agent as listed.
Chelation therapy (example J0641/M0300) requires prior authorization.

Prior Authorization

Clinical trials and cochlear/auditory implants require PA

Clinical trials and cochlear/other auditory implants are marked as requiring prior authorization; examples include HCPCS/CPT codes G0276, S9988, S9990, G0294, S9991, G2000, 69717 and L8617.

Clinical trials: 'Prior authorization required' is explicitly stated.
Cochlear and auditory implants: prior authorization required for listed device/procedure codes.

Prior Authorization

Carpal tunnel procedures require prior authorization (site‑of‑service may apply)

Carpal tunnel procedures are flagged as prior authorization required; the document also notes site‑of‑service review may apply for all states.

Example CPTs listed include 29848 and 64721; check site‑of‑service applicability when submitting PA.

Prior Authorization

Mastectomy, supplies, medicine services and neurostimulators require PA

Mastectomy services and numerous home health‑related medical/surgical supplies, medicine services (e.g., CPTs 96130–96139, 96136–96137), and neurostimulator implantation procedures are listed with 'Prior authorization required'—submit PA for these services and codes as indicated.

Example mastectomy CPT: 19300.
Neurostimulator implantation codes shown include 43647, 43648, 43881, 43882, 61863–61868, 64553, 64555 and related codes.

Prior Authorization

Home health injectable medications require PA/predetermination (J‑code lists)

The Home Health section requires prior authorization for many injectable medications (long J‑code lists). Providers must obtain prior authorization or predetermination for the listed J‑codes when furnishing injectables in home health settings.

Examples of J‑codes requiring PA/predetermination include (partial): J0578, J0582, J0583, J0585, J0586–J0595, J0600–J0618, J0630, J0636–J0654, J0665–J0716, and many additional J‑codes enumerated in the home health sections.
For unclassified codes J3490/J3590, notification/prior authorization is required only for Revcovi, Rivfloza, Starjemza (see document).

Documentation Required

J3490/J3590 require PA only for specified products (Revcovi, Rivfloza, Starjemza)

For unclassified injectable codes J3490 and J3590, notification/prior authorization is required only when they represent specific products (Revcovi, Rivfloza, Starjemza); the document instructs providers to submit prior authorization requests online via the Provider Portal.

Use the Prior Authorization and Notification tool on UHCprovider.com to submit requests for these unclassified codes when applicable.

Note

Contact Optum SGP (888‑397‑8129) and use Provider Portal for submissions

For specialty questions or assistance obtaining prior authorization (including home health injectables), contact the Optum Specialty Guidance Program (SGP) at 888‑397‑8129; sign in to the UnitedHealthcare Provider Portal (top‑right) to submit PA requests and access PA instructions.

Primary portal submission remains the Prior Authorization and Notification tool at UHCprovider.com.
Optum SGP (888‑397‑8129) is the contact for specialty guidance and questions.

Notification/prior authorizationBariatric CPTs (e.g., 43860, 43865) are noted with notification/prior authorization requirements when billed with specified diagnosis codes (E66.*, Z68.*)

Plan variabilityCoverage and Center of Excellence requirements vary by member-specific benefit plan and by state; reference the benefit plan document

Prior authorization — supportive cancer care drugs

Drug groups requiring prior authorizationColony‑stimulating factors, bone‑modifying agents, and erythropoiesis‑stimulating agents administered in an outpatient setting for a cancer diagnosis require prior authorization

Example HCPCS/J/Q codesCodes called out include J0897, J1442, J1447, J1449, J2506, J2820 and Q5101/Q5110/Q5111/Q5120/Q5122 (some also require auth for non‑oncology Dx)

Submission instructionFor prior authorization requests for these drugs, submit online via the Provider Portal per general submission guidance

Submission portal — Prior Authorization and Notification tool

Primary portal toolThe Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal is the primary online submission mechanism for prior authorization/notification requests

Portal accessSign in at UHCprovider.com with a One Healthcare ID and select the Prior Authorization and Notification tab

Alternate phoneAn alternate submission/contact phone number appears in the document (866-889-8054) for callers who cannot submit online

Age‑based prior authorization note

Age‑based prior authorization markerCodes marked with ** indicate prior authorization is required for members ages 18 and older; see the congenital heart disease section for guidance on members under age 18

Where it appearsThe ** age marker is applied to selected CPT/HCPCS entries in cardiovascular/interventional code lists (e.g., 93580 appears with **)

Action for pediatric membersFor members under age 18, follow the congenital heart disease section instructions referenced alongside the age‑based note

Prior authorization exception marker (*)

Exception marker (*)Codes marked with * indicate prior authorization is NOT required when billed with the specified diagnosis codes

Applied sectionsThe * marker is used in cardiovascular/interventional code lists to show diagnosis‑based exceptions (see code lists for specifics)

Provider actionWhen a code is marked with *, confirm the allowed diagnosis codes to determine if prior authorization may be waived

CPT/HCPCS and ICD‑10 code references

Code systems referencedThis document repeatedly references CPT®, HCPCS (including J‑ and Q‑codes), and ICD‑10 diagnosis codes across sections

Where to find codesSee the CPT/HCPCS code lists and ICD‑10 diagnosis groupings throughout the procedural and home health sections for specific code entries

Use in determinationsProviders must supply the applicable CPT/HCPCS and ICD‑10 codes when submitting prior authorization requests per portal instructions

UnitedHealthcare Individual & Family plans — applicable issuers

Applicable UnitedHealthcare entitiesUnitedHealthcare Individual & Family plans medical coverage is offered by multiple regional entities including UnitedHealthcare of Arizona, Rocky Mountain HMO (CO), UnitedHealthcare of Florida, Georgia, Illinois, UnitedHealthcare Insurance Company (AL, KS, LA, MO, NJ, TN), Optimum Choice (MD, VA), UnitedHealthcare Community Plan (MI), UnitedHealthcare of Mississippi, New Mexico, North Carolina, Ohio, Oklahoma, South Carolina, Texas, Oregon (in WA), and Wisconsin

Administrative servicesAdministrative services are provided by United HealthCare Services, Inc. or its affiliates

Plan variabilityMember‑specific benefit plans and state applicability vary; providers should reference the member’s plan document

Clinical trials — definition and notes

Clinical trials definitionClinical trials are defined as a rigorously controlled study of a new drug, medical device, or other treatment on eligible human subjects, subject to institutional oversight; prior authorization is required

Prior authorization requirementClinical trials listed in the document require prior authorization (sample codes include G0276, G0294, G2000, S9988–S9991)

Provider noteProviders should follow the authorization process and submit documentation of trial oversight as part of the request

Cochlear and other auditory implants

DefinitionCochlear implants and other auditory implants are medical devices involving an internal component in the inner ear with an external portion to assist persons with profound sensorineural hearing loss

Prior authorizationCochlear and related auditory implants require prior authorization (example codes: 69717, 69930, L8617–L8628, L8615–L8619, V5273)

Associated servicesSurgical and device HCPCS/CPT codes are listed and must be included when requesting authorization

Clinical trials — key term (duplicate)

Clinical trials — key termClinical trials: rigorously controlled studies of new drugs/devices/treatments requiring oversight; prior authorization required

Codes referencedSample clinical trial codes called out include G0276, G0294, G2000, S9988–S9991

Cochlear implants — provider clarity (duplicate)

Cochlear implants — term repeatCochlear and other auditory implants described as inner‑ear medical devices with an external portion; prior authorization required

Sample codesExamples in the document include L8617, L8618, L8619, L8622, L8627, L8628 and CPTs 69717, 69930

Continuous glucose monitoring — prior authorization

Coverage triggerPrior authorization is required for continuous glucose monitoring when the member has a type 2 or gestational diabetes diagnosis

Example HCPCS supply codesDocument references CGM‑related HCPCS supply codes such as A4226, A4238, A4239, A9276, A9277, E2103 in the monitoring section

Provider actionSubmit prior authorization requests for CGM supplies via the Provider Portal and include diagnosis documentation (type 2 or gestational diabetes)

Cosmetic procedures — definition

Cosmetic procedures — definitionCosmetic procedures are those that change or improve physical appearance without significantly improving or restoring physiologic function

Authorization stanceCosmetic procedures listed require prior authorization per the document

Contrast with reconstructiveReconstructive procedures are distinguished as treating a medical condition or restoring physiologic function (separate authorization guidance)

Reconstructive procedures — definition

Reconstructive procedures — definitionReconstructive procedures treat a medical condition or improve or restore physiologic function

Authorization noteReconstructive procedures listed in the document require prior authorization; see specific CPT/HCPCS entries for requirements

Relation to cosmetic codesProviders should reference diagnosis and procedure codes to determine whether a case is cosmetic versus reconstructive when submitting requests

Durable medical equipment (DME) — definition

DME definitionDurable medical equipment (DME) refers to equipment items listed by HCPCS E‑ and K‑ codes; prosthetics are explicitly not DME (see prosthetics section)

Prior authorization stanceDME entries (many E‑ and K‑ HCPCS codes) are marked as requiring prior authorization

Provider tipConfirm whether an item is classified as DME or prosthetic before submitting authorizations, and include the HCPCS E/K code on requests

Home health and injectables — definitions & contacts

Home health — prior authorization requiredPrior authorization is required for home health services and for injectable medications furnished in home health (see listed HCPCS/J‑codes)

Injectables definitionInjectables are drugs intended for intravenous, subcutaneous, or intramuscular administration and are listed by J‑codes in the Home health section

Specialty guidance contactFor questions or specialty guidance about injectable authorizations, contact the Optum Specialty Guidance Program (SGP) at 888-397-8129

UHC Provider Portal — Prior Authorization and Notification tool

UHC Provider Portal — tool referenceThe Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) is the required submission path for most prior authorization requests

Portal sign‑inSign in at the top‑right of UHCprovider.com using One Healthcare ID to access the Prior Authorization and Notification tab

Optum SGP phoneIf portal assistance or specialty guidance is needed, contact Optum Specialty Guidance Program (SGP) at 888-397-8129

Optum SGP — contact & function

Optum SGP purposeOptum Specialty Guidance Program (SGP) provides specialty guidance and assistance for prior authorization questions related to injectable medications and other specialty services

Phone numberContact Optum SGP at 888-397-8129 for questions or specialty guidance

Portal interactionSGP guidance references portal submission; providers should sign in to the UnitedHealthcare Provider Portal to submit or check requests

Optum SGP phone line for prior authorization inquiries

Optum SGP phone for PA inquiriesCall 888-397-8129 for prior authorization and specialty guidance inquiries (Optum SGP)

Portal sign‑in reminderSign in to UHCprovider.com to use the Prior Authorization and Notification tool when submitting requests referenced by SGP guidance

Use caseSGP supports questions about injectable medications, clinical complexity, and documentation expectations for authorization