CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Virginia Cardinal Care LTSS

Lists prior authorization requirements and submission methods for UnitedHealthcare Community Plan of Virginia Long-Term Support Services (LTSS) participating providers; covers inpatient and outpatient services and procedures for Virginia Cardinal Care LTSS members.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Virginia Cardinal Care LTSS

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (Prior Authorization and Notification tab) or by phone at 844-284-0146.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Jan 1, 2025policy effective date (stated)

Online portalsubmission option

1primary submission channel

Yesinpatient EEG pa

Yesinjectable chemo pa

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.

~150+codes listed (approx)

Coverage and Prior Authorization Criteria

Coverage Criteria (partial): Overview and selected prior authorization requirements

Overview: Prior authorization is required for many services provided by participating UnitedHealthcare Community Plan of Virginia providers. Submit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) using a One Healthcare ID, or call 844-284-0146. Prior authorization is not required for emergency or urgent care. Out-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services.

Prior authorization is required for the following service categories and specific procedures (selected highlights):

- Bariatric surgery (inpatient and outpatient) — prior authorization required for listed CPT/HCPCS codes including 43644, 43645, 43659, 43770, 43846.

- Behavioral health services — many plans require authorization through a designated behavioral health network; contact the number on the member's ID card for specific codes and instructions (including applied behavior analysis submissions).

- Cancer supportive care — prior authorization required for colony-stimulating factors and bone-modifying agents administered outpatient for a cancer diagnosis (examples: biosimilar Zarxio Q5101; eflapegrastim Rolvedon).

- Cardiology — prior authorization required for outpatient and office-based diagnostic catheterizations, echocardiograms, electrophysiology implants and stress echocardiograms prior to performance; lower extremity angiogram requires prior authorization.

Operational note: Providers must follow portal submission instructions; prior authorization is required only when specified for outpatient vs inpatient per category.

Prior authorization coverage rules (excerpt)

Prior authorization coverage rules (excerpt) — selected inpatient monitoring and chemotherapy rules:

Cerebral seizure monitoring — Prior authorization is required for inpatient video electroencephalogram (EEG) services. Affected CPT codes include 95700, 95711–95718, 95720, 95722, 95724, 95726. Prior authorization is not required for outpatient hospital or ambulatory surgical center EEG services.

Chemotherapy — Prior authorization is required for injectable chemotherapy drugs administered in an outpatient setting (including intravenous, intravesical and intrathecal) for a cancer diagnosis. A list of injectable chemotherapy agents requiring prior authorization is maintained and must be referenced at time of request.

Operational note: Submit chemotherapy and inpatient EEG requests via the UnitedHealthcare Provider Portal; contact numbers provided in the header information for assistance.

Authorization notes and exceptions

Authorization notes and exceptions — coding-specific notes and submission instructions:

Providers should submit prior authorization requests online through the UnitedHealthcare Provider Portal (UHCprovider.com) or call the listed phone numbers where provided in category entries.

Coding exceptions: Effective January 1, 2023, codes 14020, 14021 and 14061 do not require prior authorization when billed with specified diagnosis codes (refer to full policy for the Dx list).

Operational note: For code-specific contact or exceptions, follow the guidance in the applicable category entry and include supporting diagnosis codes when submitting requests.

COVERAGE CRITERIA — Enteral services

Enteral services — home in‑home nutritional therapy prior authorization:

In‑home enteral nutritional therapy (including gastrostomy tube feedings) requires prior authorization. Affected HCPCS codes include B9002, B9004, B9006 and related enteral supply/product codes (examples include V52xx and E2298 where applicable).

Operational note: Prior authorization is required for home/outpatient settings; include clinical documentation supporting need for enteral nutrition and relevant supplies when submitting.

COVERAGE CRITERIA — Surgical procedures (FESS etc.)

Surgical procedures — selected prior authorization requirements:

Femoroacetabular impingement (FAI) surgery — Prior authorization required for arthroscopic procedures; relevant CPT codes include 29914, 29915, 29916.

Functional endoscopic sinus surgery (FESS) — Prior authorization required for FESS procedures. Relevant CPT codes include 31240, 31253–31259.

Operational note: For sinus surgery and FAI, submit imaging and prior conservative management documentation as part of the authorization request per specialty-specific requirements in the full policy.

COVERAGE CRITERIA — Genetic and molecular testing prior authorization criteria

Genetic and molecular testing — prior authorization requirements:

Genetic and molecular testing requires prior authorization. Examples of affected CPT/HCPCS codes include 81162–81164, 81228–81229, and the 81400–81420, 81431–81440 series (selected codes listed in policy).

Operational note: Include clinical indication, family history and any prior testing results when submitting genetic testing authorization requests.

COVERAGE CRITERIA — Injectable medications and home health/hysterectomy

Injectable medications, home health, hysterectomy — prior authorization requirements and drug lists (excerpt):

Injectable medications — Many specific injectable drugs require prior authorization. Examples (not exhaustive) include Actemra J3262, Acthar J0801, Aduhelm J0172, Amvuttra J0225, Avsola Q5121, Benlysta J0490, Tepezza J3241, Tezspire J2356, Synagis 90378 and various others (see full injectable medication list in policy).

Home health care — Prior authorization is required in outpatient settings (including services provided in the member's home) for certain HCPCS codes such as G0299, G0300, G0493–G0496 and S9123–S9124.

Hysterectomy — Prior authorization required for hysterectomy procedures. Relevant CPT codes include 58150, 58152, 58180, 58260, 58262–58292, 58542–58544, 58550–58572.

Operational note: Submit injectable drug and home health prior authorization requests via the Provider Portal; ensure medication-specific documentation and home health plan of care are included.

Prior authorization statements (partial)

Prior authorization statements (partial) — joint replacement, musculoskeletal procedures, and non‑emergent air ambulance:

Joint replacement — Total hip and knee replacement procedures require prior authorization. Affected CPT/HCPCS codes include multiple joint replacement procedure codes (see full policy list; examples include 27130, 27132, 27486 and listed joint procedure codes).

Musculoskeletal procedures — Shoulder and other major musculoskeletal procedures require prior authorization (example shoulder surgery CPT 23470, 23472 and related orthopaedic procedure codes listed in the policy).

Non‑emergent air ambulance transport — Prior authorization is required for non‑emergent air ambulance transport. Affected HCPCS codes include A0430, A0431, A0435, A0436 and related air ambulance transport codes. Requests must be authorized prior to transport except in emergency situations.

Operational note: For VADs, wound vacs, and other high-acuity devices/procedures, follow the category-specific prior authorization instructions (contact numbers, case management or Optum teams) included in the full policy.

Code Lists and Mappings

Covered CPT/HCPCS CodesCPTCovered

33982

Insertion or replacement of ventricular assist device, non-implantable, external (NOTE: included to consolidate VAD codes requiring prior authorization)

Covered HCPCS CodesHCPCSCovered

33927	Ventricular assist device, initial placement
33975	VAD related code
33976	VAD related code
33979	VAD related code
33981	VAD related code
33983	VAD related code
Q0507	VAD related HCPCS
Q0508	VAD related HCPCS
Q0509	VAD related HCPCS

Submission, Notifications, and Provider Instructions

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests via the UnitedHealthcare Provider Portal (Prior Authorization and Notification tab) or by phone at 844-284-0146. Prior authorization is not required for emergency or urgent care. Out-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services.

Prior Authorization

Examples of services and codes requiring prior authorization (partial)

Examples of services that require prior authorization include bariatric surgery, bone growth stimulators, brain injury case management, and various breast reconstruction/mastectomy-related procedures; specific CPT/HCPCS codes are listed in the document.

Bariatric surgery examples: 43644, 43645, 43659, 43770, 43846 ([[chunk 2]]).
Bone growth stimulator: 20975 (20979 also referenced) ([[chunk 3]]).
Brain injury case management: S0280, S0281 ([[chunk 3]]).
Breast reconstruction/mastectomy-related CPTs: 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19367–19371, 19380, 19396 ([[chunk 3]], [[chunk 4]]).

Key Terms and Definitions

Prior authorization — definition

Prior authorization — general definitionAn approval that participating providers must request before performing certain inpatient or outpatient procedures and services; not required for emergency or urgent care.

Who it applies toApplies to participating UnitedHealthcare Community Plan of Virginia LTSS providers; out-of-network providers must request prior authorization for all procedures and services.

How to obtainRequests may be submitted via the UnitedHealthcare Provider Portal (Prior Authorization and Notification tab) or by phone (844-284-0146 as listed).

Prior authorization required — note

Prior authorization required — definition noteA requirement that prior authorization be obtained before rendering specified services or billing certain CPT/HCPCS codes; the document explicitly marks many services as 'Prior authorization required.'

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Virginia Cardinal Care LTSS

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (Prior Authorization and Notification tab) or by phone at 844-284-0146.

SourceLink

On This Page

Prior Authorization

Cancer supportive care injectable drug prior authorization

Prior authorization is required for colony-stimulating factor drugs and bone‑modifying agents administered in an outpatient setting for a cancer diagnosis; specific J/Q codes are listed in the injectable medications sections.

Examples of listed agents and codes include J1449, J1442, J2506, Q5101, Q5125, J0885, J0897 (see injectable medications lists) ([[chunk 5]], [[chunk 8]]).

Prior Authorization

Cardiology prior authorization requirements

Prior authorization is required for outpatient and office‑based cardiology procedures including diagnostic catheterizations, echocardiography, electrophysiology implants and stress echoes; cardiology-specific CPTs are listed and providers may submit via the Provider Portal or call the cardiology contact for details.

Representative CPTs in this section include 37221–37230 series and 93580 for selected procedures ([[chunk 9]]).
Submit requests via the Provider Portal or call 888-397-8129 for cardiology details ([[chunk 9]]).

Prior Authorization

Injectable medications requiring prior authorization for non‑oncology diagnoses

Certain injectable HCPCS/J- and Q-codes require prior authorization when used for non‑oncology diagnoses; see the injectable medications section for the full list of codes.

Codes called out include J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125 (require authorization for non‑oncology Dx) ([[chunk 8]]).
Additional injectable codes are listed throughout the injectable medications sections (see chunks 73–80) ([[chunk 73]]).

Prior Authorization

Cochlear implants prior authorization

Prior authorization is required for cochlear implants and other auditory implants; submit requests online using the UnitedHealthcare Provider Portal or call the phone number shown in the cochlear implant section.

Representative CPT/HCPCS codes listed include 69710, 69714, 69930 and device HCPCS L8614, L8619, L8690–L8692 ([[chunk 28]], [[chunk 29]]).
Submission instruction: use UHCprovider.com or call the number shown in the section ([[chunk 28]]).

Prior Authorization

Cerebral seizure monitoring (Inpatient video EEG) prior authorization

Inpatient video EEG (cerebral seizure monitoring) requires prior authorization; outpatient hospital or ambulatory surgical center video EEG does not require prior authorization.

EEG CPTs listed include 95700, 95711–95718, 95720–95726 (inpatient video EEG requires authorization) ([[chunk 25]], [[chunk 26]]).

Prior Authorization

Outpatient injectable chemotherapy prior authorization

Prior authorization is required for injectable chemotherapy drugs administered in an outpatient setting (including IV, intravesical and intrathecal) for a cancer diagnosis; specific injectable chemotherapy agents are listed elsewhere in the document.

The policy states: "Prior authorization is required for injectable chemotherapy drugs administered in an outpatient setting including intravenous, intravesical and intrathecal for a cancer diagnosis." ([[chunk 26]]).

Prior Authorization

Continuous glucose monitors prior authorization

Continuous glucose monitor devices require prior authorization when used with a type 2 diabetes diagnosis; submit requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone.

Representative HCPCS codes include A4226, A4239, A9276, A9277, A9278 and related E‑codes (see continuous glucose monitor list) ([[chunk 29]], [[chunk 30]]).

Documentation Required

Submission instructions and example CPT/HCPCS codes

Submit prior authorization requests online via the UnitedHealthcare Provider Portal at UHCprovider.com to sign in, or call the phone contact shown in the submission instructions section for assistance.

Portal submission: go to UHCprovider.com, sign in and use the Prior Authorization and Notification tab ([[chunk 1]], [[chunk 36]]).
Phone contact references include 888-397-8129 (cardiology) and 866-889-8054 (radiology/advanced imaging) in relevant sections ([[chunk 9]], [[chunk 198]]).

Billing Rule

DME HCPCS codes and notes

Durable medical equipment (DME) and listed HCPCS codes require prior authorization; some items are subject to cost or cumulative rental thresholds (e.g., cumulative rental cost > $500 may trigger authorization).

Examples of DME HCPCS: A9279, A9280, A9900, E0194, E0265–E0277, E0300, E0328–E0329, E0445, E0457, E0465–E0471, etc. ([[chunk 53]], [[chunk 54]]).
Note: Certain DME items require authorization only when cumulative rental cost exceeds $500 ([[chunk 53]]).

Prior Authorization

Enteral services prior authorization

Enteral services (in‑home nutritional therapy delivered enterally or via gastrostomy) require prior authorization; listed B‑series HCPCS codes are provided.

Codes listed for enteral services include B9002, B9004, B9006 and B9998 ([[chunk 60]]).

Prior Authorization

FESS prior authorization

Functional endoscopic sinus surgery (FESS) requires prior authorization for the CPT codes listed in the sinus surgery section.

Listed FESS CPTs include 31240, 31253–31259, 31267, 31276, 31287–31288 (see the FESS list) ([[chunk 62]]).

Prior Authorization

Home health prior authorization

Home health services require prior authorization only when provided in outpatient settings, including the member's home; specific G‑series and S‑series codes are listed.

Home health codes requiring prior authorization include G0299, G0300, G0493–G0496, S9123, S9124 ([[chunk 72]]).

Prior Authorization

Hysterectomy prior authorization

Hysterectomy procedures require prior authorization for the CPT codes listed in the hysterectomy section.

Examples of listed hysterectomy CPTs include 58150, 58152, 58180, 58260, 58262–58263, 58267, 58270, 58290–58292, 58542–58544, 58550, 58552–58553, 58570–58573 ([[chunk 72]], [[chunk 73]]).

Prior Authorization

Genetic/molecular testing prior authorization

Genetic and molecular testing CPT codes require prior authorization; numerous CPT codes for molecular and genetic tests are listed.

Representative codes include 81162–81164, 81228–81229, 81400–81417, 81431–81448, 81460, 81465 and additional molecular test CPTs ([[chunk 67]], [[chunk 68]]).

Documentation Required

Injectable medications prior authorization (submission)

Submit injectable medication prior authorization requests online using the UnitedHealthcare Provider Portal; numerous J‑ and Q‑codes for injectables are listed requiring prior authorization.

Examples of injectable medications listed include Actemra J3262, Acthar J0801, Remicade J1745, Rolvedon J1449, Releuko Q5125, J9333, J1429 (Vyvgart) and J9334 (Vyvgart Hytrulo) among many others ([[chunk 73]], [[chunk 80]], [[chunk 90]], [[chunk 102]]).
Instruction: "Please submit requests online using the UnitedHealthcare Provider Portal: Go to UHCprovider.com to sign in." ([[chunk 73]]).

Prior Authorization

Procedure codes requiring prior authorization (selected)

Selected home health/outpatient and hysterectomy procedure codes require prior authorization when billed in outpatient settings; providers must obtain prior authorization before scheduling.

Procedure examples: G0299, G0300, G0493–G0496 (home health) and hysterectomy CPTs listed in the hysterectomy section ([[chunk 72]], [[chunk 73]]).

Prior Authorization

Injectable medications and radiopharmaceuticals requiring prior authorization (selected)

Numerous injectable medications and therapeutic radiopharmaceuticals are listed as requiring prior authorization; providers should submit requests via the UnitedHealthcare Provider Portal.

Injectable and radiopharmaceutical examples include J3262, J0801, J1745, J1449, J9333, J1429, J9334 and HCPCS A9513, A9590, A9696, A9699 (therapeutic radiopharmaceuticals) ([[chunk 73]], [[chunk 81]]).

Documentation Required

Online submission instruction (UHCprovider.com)

Please submit prior authorization requests online using the UnitedHealthcare Provider Portal at UHCprovider.com to sign in and use the Prior Authorization and Notification tab.

Prior Authorization

J1429 — Vyvgart (requires prior authorization)

HCPCS code J1429 is listed in the document in association with Vyvgart and is identified as requiring prior authorization in the injectable medication listings.

Prior Authorization

J9334 — Vyvgart Hytrulo (requires prior authorization)

HCPCS code J9334 (Vyvgart Hytrulo) is referenced repeatedly in the injectable medication listings and requires prior authorization.

Note

Placeholders and repeated entries in code lists

The document contains repeated placeholders and duplicated entries where CPT or HCPCS codes and prior authorization instructions appear; specific procedural details are provided elsewhere in the listing.

Multiple repeated placeholders indicate where codes and instructions are listed or continued (see injectable medication and Vyvgart references) ([[chunk 98]]).

Prior Authorization

Prior authorization required for listed services (examples)

Prior authorization is required for many listed services including joint replacement, musculoskeletal procedures, numerous injectable medications (e.g., Vyvgart J9334) and non‑emergent air transport codes.

Joint replacement and musculoskeletal examples referenced in the document (see chunk 117 for representative CPTs) ([[chunk 117]]).
Non‑emergent air transport HCPCS A0430–A0436 require prior authorization (see non‑emergent air entries) ([[chunk 120]]).

Prior Authorization

Non‑emergent air transport prior authorization

Non‑emergent air ambulance services require prior authorization when billed with HCPCS codes A0430, A0431, A0435 and A0436.

The policy explicitly repeats that prior authorization is required for A0430, A0431, A0435 and A0436 ([[chunk 126]], [[chunk 120]]).

Documentation Required

Prior authorization for non‑emergent air transport (A0430–A0436)

Prior authorization is required for non‑emergent air transport services represented by HCPCS codes A0430, A0431, A0435 and A0436; this requirement is repeated throughout the air transport sections.

Prior Authorization

Non‑emergent air ambulance prior authorization (action required)

Prior authorization is required for non‑emergent air ambulance transports billed with HCPCS codes A0430, A0431, A0435 and A0436; obtain authorization before scheduling non‑emergent air transport.

Documentation Required

How to submit prior authorization requests (portal or phone)

Submit prior authorization requests online via UHCprovider.com or call 866-889-8054 as indicated in the submission and radiology sections for certain requests.

Prior Authorization

Radiation and advanced imaging prior authorization

Many radiation therapy CPT/G codes and advanced outpatient imaging procedures require prior authorization; standard radiation therapy codes require authorization only when billed with diagnoses in specified cancer‑related code ranges.

Radiation examples include 77014, 77387 and grouped G6001–G6014 codes; prior authorization required when billed with diagnoses in ranges C34.00–C34.92, C50.011–C50.929, C61 ([[chunk 196]], [[chunk 198]]).
Advanced outpatient imaging (certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology) requires prior authorization ([[chunk 199]]).

Prior Authorization

Radiology prior authorization requirement

Participating physicians must obtain prior authorization for certain advanced outpatient imaging procedures (CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology) as listed in the radiology section.

Prior Authorization

Radiation therapy prior authorization by diagnosis

Standard radiation therapy CPT/HCPCS codes require prior authorization only when billed with diagnosis codes in the ranges C34.00–C34.92, C50.011–C50.929, or C61.

Documentation Required

Submission and notification instructions (portal + phone)

Submit prior authorization requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) or by calling the phone numbers provided in the document (e.g., 866-889-8054 for radiology requests).

Prior Authorization

Surgical and specialty procedure authorization

Many surgical categories and specialty procedures require prior authorization; the policy lists rhinoplasty/septoplasty, sinuplasty, shoulder and spinal surgeries, stimulators, transplants and other categories with CPT/HCPCS codes.

Examples of procedure groups requiring authorization include rhinoplasty/septoplasty (30400–30465), sinuplasty (31295–31298), arthroscopic shoulder surgery (29805–29828), and spinal surgery ranges (22100–22899, 63001–63308) ([[chunk 199]], [[chunk 203]]).

Documentation Required

Transplant/CAR T‑cell notification requirement

For transplant and CAR T‑cell therapy services, providers must call the UnitedHealthcare Community Plan Transplant Case Management team at 888-936-7246 or use the notification number on the back of the member's health plan ID card.

This contact applies to CAR T‑cell therapies and specified transplant services (listed product examples in the transplants section) ([[chunk 211]]).

Prior Authorization

Ventricular Assist Device (VAD) prior authorization and contact

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

Representative VAD procedure and HCPCS codes include 33927, 33975–33979, 33981–33983, and Q0507–Q0509 (see VAD section) ([[chunk 218]], [[chunk 219]]).

Prior Authorization

Wound VAC prior authorization

Wound VAC (negative‑pressure wound therapy) requires prior authorization; E2402 is listed as the referenced HCPCS code.

Wound VAC supply/equipment code referenced: E2402 ([[chunk 219]]).

Prior Authorization

Saphenous vein removal/ablation prior authorization

Removal and ablation of the main trunks and named branches of the saphenous veins (for venous disease/varicose veins) requires prior authorization; CPT/HCPCS codes listed in the venous procedure section must be authorized.

Representative codes include 36475, 36478, 37700, 37718, 37722, 37765 and 37766 ([[chunk 216]], [[chunk 217]]).

Not required for emergency or urgent care; some codes or settings (e.g., outpatient video EEG, certain DME under threshold) are noted as exceptions.

Provider responsibilityOrdering providers are responsible for obtaining prior authorization and for providing required diagnosis and procedural information when submitting requests.

Inpatient video EEG

Inpatient video EEG requirementInpatient video EEG (cerebral seizure monitoring) requires prior authorization (codes listed: 95700–95726 series as shown).

Outpatient/ASC exceptionPrior authorization is not required for outpatient hospital or ambulatory surgical center video EEG services.

Relevant codesExamples include CPT codes 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95722, 95724, 95726 as listed in the EEG section.

DME — durable medical equipment

DME — definitionDurable Medical Equipment (DME): items listed by HCPCS codes that require prior authorization; some items are subject to cost or rental thresholds.

Examples of codesExamples include E0470, E0445, E0636 and many other E-series and K/Q codes listed in the DME sections.

Cost-trigger noteCertain DME require prior authorization only when purchase or cumulative rental cost exceeds the stated threshold (e.g., > $500 for some items).

UHCprovider.com (online submission channel)

UHCprovider.com (UnitedHealthcare Provider Portal)Primary online submission channel for prior authorization requests: sign in at UHCprovider.com and select the Prior Authorization and Notification tab.

Alternate phone submissionPhone submission options are provided in the document for specific services; general phone number listed for prior auth is 844-284-0146.

Where referencedMultiple sections (e.g., cochlear implants, injectable medications, radiology) instruct providers to submit via the Provider Portal (UHCprovider.com).

Enteral services (in-home nutritional therapy)

Enteral services — definitionIn-home nutritional therapy delivered enterally or through a gastrostomy tube; specific HCPCS/B codes listed (e.g., B9002, B9004, B9006, B9998).

AuthorizationPrior authorization is required for enteral services provided in the home as noted in the Enteral services section.

Related codesDocument lists V5269 and multiple V52xx entries in the enteral services subsection alongside B9xxx codes for enteral supplies and services.

FESS (Functional endoscopic sinus surgery)

FESS — definitionFunctional endoscopic sinus surgery (FESS): endoscopic sinus surgery procedures identified by listed CPT codes (e.g., 31240, 31253–31259, 31256–31259, 31267, 31276, 31287–31288).

AuthorizationPrior authorization is required for the listed FESS CPT codes as indicated in the Surgical procedures section.

ExamplesExamples of CPT codes requiring prior authorization for FESS are provided in the document's surgical procedures list.

Home health (outpatient)

Home health (outpatient) — definition and scopeHome health refers to services provided in outpatient settings including the member's home; listed home health HCPCS/CPT codes include G0299, G0300, G0493–G0496, S9123–S9124.

Authorization scopePrior authorization is required only when these home health services are provided in outpatient settings, including the member's home, as noted.

SubmissionRequests should be submitted via the UnitedHealthcare Provider Portal per submission instructions in the document.

Outpatient/home health prior authorization

Outpatient/home health prior authorization notePrior authorization applies in outpatient settings including the member's home for the listed home health CPT/HCPCS codes (e.g., G0299, G0300, G0493–G0496, S9123–S9124).

LimitationThis prior authorization requirement is limited to outpatient/home settings and does not imply inpatient home health rules.

How to submitSubmit via UHCprovider.com or by phone as described in the general submission instructions.

Injectable medication submission

Injectable medication submission — channelRequests for injectable medications should be submitted online using the UnitedHealthcare Provider Portal (UHCprovider.com).

Supporting instructionSeveral injectable medication entries in the document explicitly instruct providers to 'Please submit requests online using the UnitedHealthcare Provider Portal.'

Phone alternativeFor certain specialties or drugs a phone number is provided in other sections, but the portal is the primary submission channel for injectables.

Vyvgart

Vyvgart — product referenceVyvgart is referenced in the injectable medications listing associated with HCPCS code J1429 and repeated mentions in the document.

Associated codesDocument links Vyvgart with HCPCS code J1429 (and Vyvgart Hytrulo with J9334 in other entries).

SubmissionPrior authorization for these products follows the injectable medication submission instructions (submit via Provider Portal).

Hytrulo

Hytrulo — product referenceHytrulo (referenced as Vyvgart Hytrulo in the document) is listed in injectable medication sections (associated entries reference J9334).

Related codeDocument associates Vyvgart Hytrulo with HCPCS code J9334 in repeated entries.

SubmissionFollow injectable medication submission instructions via UHCprovider.com for prior authorization requests involving Hytrulo.

Prior authorization

Prior authorization — repeated labelThe document uses 'Prior authorization' as the controlling requirement for many listed services and codes (approval required before service).

Primary instructionProviders must request prior authorization via the Provider Portal or phone and follow program-specific instructions in each section.

Exceptions notedEmergency/urgent care is explicitly excluded from prior authorization requirements in this document.

Non‑emergent air — definition

Non‑emergent air — definitionNon‑emergent air ambulance transport services that are not emergency transports and are represented by HCPCS codes A0430–A0436.

Typical codesCodes commonly referenced for non‑emergent air include A0430, A0431, A0435 and A0436 as listed throughout the document.

ContextThe document repeatedly labels these codes under the 'Non-emergent air' section and associates them with prior authorization requirements.

Prior authorization — non‑emergent air

Prior authorization required before rendering non‑emergent air servicesPrior authorization is required before providing non‑emergent air ambulance transport services (codes A0430, A0431, A0435, A0436).

Repetition in documentThe requirement that prior authorization is required for non‑emergent air appears repeatedly across multiple sections and chunks.

How to obtainFollow the general submission instructions (submit via UHCprovider.com or contact phone numbers in the document).

Non‑emergent air — HCPCS codes A0430–A0436

Non‑emergent air — HCPCS associationNon‑emergent air ambulance transport is associated with HCPCS codes A0430, A0431, A0435 and A0436 and described as non-emergent air ambulance transport.

ImplicationThese services require prior authorization when billed using the listed HCPCS codes.

Provider actionObtain prior authorization before scheduling non‑emergent air transport; follow submission channels in the document.

Potentially unproven services; private duty nursing; prostate procedures; radiation therapy

Grouped services noteThe document groups several categories (potentially unproven services; private duty nursing; prostate procedures; radiation therapy) and indicates prior authorization is required as noted per category.

ExamplesExamples include private duty nursing codes T1002/T1003, potentially unproven service code L8659, and listed prostate procedure CPT codes (52441, 52442, 53850, 53852, 55873, 55874).

ActionProviders should follow the category-specific prior authorization instructions provided in the document for these services.

Advanced outpatient imaging

Advanced outpatient imaging — definition and examplesAdvanced outpatient imaging includes certain CT, MRI, MRA, PET scans, nuclear medicine and nuclear cardiology procedures; these procedures require prior authorization as listed in the Radiology section.

Provider responsibilityOrdering providers are responsible for providing notification and obtaining prior authorization before scheduling advanced outpatient imaging procedures.

Where to find detailsFor more details and specific CPT codes visit the Radiology Prior Authorization and Notification resource referenced in the document.

Certain CT, MRI, MRA, PET scans, nuclear medicine and nuclear cardiology procedures

Certain CT, MRI, MRA, PET scans, nuclear medicine and nuclear cardiology procedures — definitionThese advanced outpatient imaging procedures are specifically identified in the Radiology section as requiring prior authorization when ordered by participating physicians.

ExamplesThe Radiology section calls out certain CT, MRI, MRA and PET scans and nuclear medicine/nuclear cardiology procedures; specific CPT codes are listed in the Radiology Prior Authorization resource.

SubmissionSubmit prior authorization requests via UHCprovider.com or call the phone number in Radiology section (866-889-8054) as applicable.

UnitedHealthcare Community Plan Transplant Case Management team (888-936-7246)

UnitedHealthcare Community Plan Transplant Case Management team — contactFor transplant and CAR T-cell therapy services call the UnitedHealthcare Community Plan Transplant Case Management team at 888-936-7246.

When to callCall the team for transplant and CAR T-cell therapy services (examples listed in the Radiology/Transplant section) or use the notification number on the member's ID card.

Additional instructionFollow the transplant notification instructions in the document when scheduling or requesting authorization for transplant/CAR T-cell therapies.

Ventricular assist device (VAD)

Ventricular assist device (VAD) — definitionA ventricular assist device (VAD) is a mechanical pump that takes over the function of the damaged ventricle of the heart and restores normal blood flow.

Authorization requirementPrior authorization is required for VADs; follow the notification number on the member's health plan ID card and fax instructions to Optum VAD Case Management as noted.

Contact/fax instructionAfter calling the notification number on the member's ID card, fax the form provided by the nurse to the Optum VAD Case Management team at 855-282-8929 per the document.