UnitedHealthcare Prior Auth requirements MD

Services Requiring Prior Authorization — Coverage Criteria

Prior authorization coverage criteria (partial list)

Examples of coverage/authorization stance for listed services (partial, from this portion of the document):

Acupuncture: Prior authorization required for codes 97811, 97814, S8930.

Bariatric surgery and specific obesity-related services: Prior authorization required for listed CPT codes (examples: 43644, 43775, 43847, 43645, 43842, 43848, 43659, 43845, 43860, 43770, 43846).

Bone growth stimulator: Prior authorization required for codes 20975, 20979.

Cancer supportive care (outpatient): Prior authorization required for listed colony-stimulating factor drugs and related HCPCS/J codes (examples: J1442, Q5148, Q5101, Q5110, Q5125, Q5122, J2506, Q5120, J0185, J1434, J0885, A9615, J1453, J1454, J1627).

Abortion (pregnancy termination): Prior authorization required; carved out by the state — call the number on the back of the member's health plan ID card for authorization details.

Behavioral health services: Prior authorization required for many services; some plans route through a designated behavioral health network — call the number on the member's health plan ID card for referral/authorization details.

Prior authorization coverage criteria

Prior authorization coverage stance for outpatient injectable chemotherapy and selected services:

Injectable chemotherapy (outpatient intravenous, intravesical, intrathecal) for a cancer diagnosis requires prior authorization; includes drugs billed J9000-J9999 and specified J/Q codes (examples: leucovorin J0640; Lupron Depot J1950).

Many HCPCS/CPT/DME/prosthetic codes referenced in the document require prior authorization — examples include cochlear implant codes, continuous glucose monitor codes, and numerous E- and K- series DME codes.

DME prior authorization is required only for the DME codes listed when retail purchase or cumulative rental cost exceeds $500; prosthetics are excluded from that threshold.

Use the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com) or call 888-397-8129 to obtain prior authorization for injectable chemotherapy services.

Prior authorization requirements and exemptions

Listed items require prior authorization unless otherwise noted (some diagnosis codes exempt PA).

Large lists of HCPCS K- and V- codes and numerous CPT codes are designated as requiring prior authorization; specific code ranges and many individual codes are enumerated throughout the section.

Prior authorization is not required when services are billed with certain diagnosis codes (examples include many ICD-10 C43 and C44 codes listed in the document).

Genetic/molecular testing criteria (summary)

Prior authorization/notification required for genetic and molecular testing (including BRCA) and for listed CPT/HCPCS codes; ordering provider must notify the laboratory and include laboratory and test name.

Genetic and molecular testing requires prior authorization/notification; CPT codes listed include (examples) 81120, 81121, 81162-81166, 81194 and BRCA-related codes 81208, 81216, 81228, 81229, 81237, 81245, 81246, 81276, and additional specialized CPT/PLA/U codes (e.g., 81595, 87505-87507).

Notification/prior authorization is required for BRCA testing before DNA sequencing; the ordering provider must notify the laboratory conducting the test and include the laboratory and test name in the authorization/notification.

Hearing aid services

Hearing aid services require prior authorization using specified V-codes.

Hearing aid services: Prior authorization required for the listed HCPCS V-codes (examples include V5171, V5172, V5181, V5211-V5215, V5221, V5230, V5250-V5259, V5260-V5267, V5299).

Home health care

Home health care prior authorization required in outpatient settings (including the member's home) for listed CPT/HCPCS codes.

Home health care: Prior authorization required in outpatient settings (including the member's home) for the listed CPT/HCPCS codes (examples: G0162, G0299, G0493-G0496, G0156, S9122-S9124, and related V-codes as enumerated).

Hysterectomy

Hysterectomy procedures require prior authorization for enumerated CPT codes.

Hysterectomy: Prior authorization required for listed CPT codes (examples include 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58290, 58541-58544, 58550, 58552-58554, 58570-58573).

Infertility

Infertility services and selected medications require prior authorization for listed CPT/HCPCS codes.

Infertility: Prior authorization required for listed CPT/HCPCS codes (examples include 55870, 58825, 58970, 76948, 89254, 89257, 89259, 89264, 89337, 89398, and drug codes J0725, J3355, S0122, S0126, S0128, S4028, S4042).

Injectable medications

Multiple injectable medications are listed as requiring prior authorization; partial product and code list shown.

Injectable medications: Numerous specific injectable drugs and biologics require prior authorization; examples in the document include many J- and Q-codes and named products (Actemra J3262, Adakveo J0791, Avsola Q5121, Neupogen J1442, Lupron J9217/J1950, Lutathera A9513, Luxturna J3398, and many others).

Some injectable medications are grouped under broader rules (for example, chemotherapy injectable drugs J9000-J9999 require prior authorization when used outpatient for cancer diagnoses).

Prior authorization requirements (partial list)

Selected injectable medications and procedures require prior authorization as listed below.

Inpatient stays: Prior authorization required for all inpatient stays.

Joint total hip and knee replacement: Prior authorization required for listed codes (examples across the document include 27130, 27132, 27134, 27486, 27412, 27447, 29866).

Orthognathic surgery: Prior authorization required for listed maxillofacial/jaw CPT codes (examples include 21121-21150 series and additional related codes listed).

Prior authorization requirements — codes

Codes listed in this section require prior authorization.

Specific CPT codes referenced repeatedly as requiring prior authorization in the treatment/maxillofacial sections include 21145, 21146, 21147, 21150 (and related codes).

Prior authorization required codes

Codes in this section require prior authorization as indicated.

Enumerated maxillofacial/jaw CPT codes require prior authorization (examples include 21145-21150, 21151, 21154-21160, 21188, 21193-21199, 21206, 21208-21210, 21215, 21240-21249, 21255, 21296, 21299).

Orthotics and prosthetics: Prior authorization required only for the orthotics/prosthetic HCPCS L-codes listed when retail purchase or cumulative rental cost thresholds apply (examples include L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, etc.).

Prior authorization criteria sets (enumerative)

Prior authorization requirements by service category and CPT/HCPCS code as listed in this section.

L-series HCPCS codes and related orthotics/prosthetics devices listed across the section require prior authorization (examples: L8046, L8047, L8499, L8610, L8631, L8659 and many additional L-codes).

Outpatient therapy: Prior authorization required for listed CPT codes (examples include 92507-92633, therapeutic modalities 97010-97039, therapeutic procedures 97110-97158, 97530, 97533, 97537, 97545, 97750); some codes are limited to members age 21 and older where noted.

Pain injections and management: Prior authorization required for codes such as 64490 and 64493.

Private duty nursing: Prior authorization required for codes T1002 and T1003.

Potentially unproven services: Prior authorization required for listed codes (examples include 33289, C2624).

Prior authorization requirements (partial)

Prior authorization requirements and scope notes present in this section (partial).

Image-guided radiation therapy (IGRT) and stereotactic services: Prior authorization required for codes such as 77387 and stereotactic/SBRT codes 77371-77373; submit requests via the UHCprovider.com Prior Authorization and Notification tool or call 866-889-8054 as instructed in the radiation therapy section.

Proton beam therapy: Prior authorization required for proton beam codes (77520, 77522, 77523, 77525) and associated planning/delivery codes; prior authorization for 77402 is required only to manage fractionation for specified cancer ICD-10 codes listed in the document.

Prior authorization requirements (partial list)

Procedures requiring prior authorization or special handling in this section

Sleep apnea procedures: Prior authorization required for listed CPT codes (examples include 21685, 41599, 42145).

Sleep studies: Prior authorization required for sleep study CPT codes (examples 95805-95811, 95807-95810 as listed).

Spinal surgery: Prior authorization required for numerous spinal surgery CPT codes (examples include 22100-22612 and many additional codes enumerated).

Stimulators and implantable devices: Prior authorization required for listed HCPCS and CPT codes (examples include E0747-E0760, E0748, E0749, CPT implant codes and related L/HCPCS codes); transplant and CAR T-cell therapy services require contacting Optum Transplant Case Management at 888-936-7246 for authorization.

Prior authorization instructions

Prior authorization requirements and contact/claim submission instructions for listed services and devices.

Transplants and CAR T-cell therapy: Prior authorization required; contact Optum Transplant Case Management at 888-936-7246 or use the number on the member ID card for authorization instruction.

Ventricular assist devices (VAD): Prior authorization required; call the notification number on the back of the member's health plan ID card and fax required form to Optum VAD Case Management at 855-282-8929.

Wound VACs: Prior authorization required for listed HCPCS (example E2402); follow the standard prior authorization submission methods provided in the policy (UHCprovider.com or applicable contact numbers).

Codes and Code Groups Requiring Prior Authorization

Injectable medications HCPCS/J-codes requiring prior authorization (selected)HCPCSCovered

J3262	Actemra® (tocilizumab)
J0791	Adakveo® (crizanlizumab)
J7171	Adzynma™
J1931	Aldurazyme® (laronidase)
J7173	Alhemo
J1426	Amondys-45 (casimersen)
J0225	Amvuttra™
J0256	Aralast® NP / Prolastin®-C / Zemaira®
Q5121	Avsola™ (infliximab-axxq) — Q-code
Q5156	Avtozma — Q-code

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Additional injectable medications HCPCS/J/Q codes (selected)HCPCSCovered

J1302	Botulinum toxins (selected)
J0638	Ilumya™ (tildrakizumab-asmn)
J3245	Tezspire™ (tezepelumab)
J1950	Leuprolide acetate (Lupron Depot®)
J9217	Eligard®
A9513	Lutathera®
J3398	Luxturna™
J3397	Mepsevii®
J1437	Monoferric®
J1442	Neupogen® (filgrastim)

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Cancer supportive care — colony-stimulating factors (selected Q/J codes)HCPCSCovered

Q5148	Biosimilar (Zarxio®)
Q5101	Filgrastim (Neupogen®)
J1442	Filgrastim (Neupogen®)
Q5110	Filgrastim-aafi (Nivestym®)
Q5125	Filgrastim-ayow (Releuko®)
Q5122	Pegfilgrastim-apgf (Nyvepria®)
J2506	Pegfilgrastim (Neulasta®)
Q5120	Pegfilgrastim-bmez (Ziextenzo®)

DME and orthotics/prosthetics HCPCS/L-codes (selected)HCPCS

A9278	CGM supplies
A9276	CGM transmitter
A9277	CGM
L0112	Prosthetic, foot
L0624	Lower extremity orthosis
L0631	Prosthetic component
L0640	Prosthetic component
L1000	Breast prosthesis

HCPCS K- and V- codes referenced (selected)HCPCS

K0812	DME related K-code
K0830	DME related K-code
V2786	V code
V5270	V code

CPT codes referenced throughout section (examples)CPT

21145	Reconstruction codes (example)
45378	Colonoscopy
92507	Speech therapy
64490	Injection, diagnostic or therapeutic
21150	Maxillofacial procedure

ICD-10 diagnosis codes exempting prior authorization or referenced (selected)ICD-10

C43.0	Malignant melanoma of skin
C79.51	Secondary malignant neoplasm of bone
C61	Malignant neoplasm of prostate

Genetic/molecular CPT codes requiring prior authorization (selected)CPTCovered

81120	EGFR mutation analysis
81208	BRCA1 analysis
81401	Molecular pathology procedure

Selected surgical, device and drug codes requiring prior authorization (sectioned list, selected)mixedCovered

43644	Bariatric surgery
69710	Cochlear implant procedure
L8614	Cochlear implant device
E0747	Bone growth stimulator
T1002	Private duty nursing

Key thresholds and notesmixed

DME_threshold	Prior authorization required only for DME codes with retail purchase or cumulative rental cost > $500
Orthotics_prosthetics_threshold	Prior authorization required for orthotics/prosthetics codes listed with a retail purchase or cumulative rental cost > $500

How to Submit Requests and Administrative Requirements

Prior Authorization

How to submit prior authorization requests

To submit prior authorization requests, use one of the following methods: online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (go to UHCprovider.com, sign in with One Healthcare ID, then select Prior Authorization and Notification); fax to 866-968-7582 (use the fax form available at Prior Authorization Forms); or call 888-702-2202. For specialty programs (cardiology, radiology, transplant, chemotherapy injectables, etc.), follow the program-specific contact instructions listed with each service.

Online: Prior Authorization and Notification tool on UHCprovider.com (One Healthcare ID required).
Fax: 866-968-7582 (Prior Authorization Forms).
Phone: 888-702-2202.
Use program-specific contact numbers where noted in the service list (for example cardiology 866-889-8054, transplant/CAR T-cell 888-936-7246, injectable chemotherapy 888-397-8129).

Note

State-carved out services

Some services are carved out to the state or to designated behavioral health networks — call the number on the back of the member’s ID card for authorization routing when the entry indicates a carve-out or network requirement.

Definitions and Notes

UHC Provider Portal prior authorization tool

Tool namePrior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com)

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

Alternate submissionFax to 866-968-7582 or call 888-702-2202 for prior authorization requests

Service excluded from standard plan prior authorization process and managed per state-specific rules

DefinitionService carved out by the state and not handled through the standard plan prior authorization process

ExampleAbortion (pregnancy termination) — call the number on the back of the member's health plan ID card for authorization details

OpenPayer

Prior authorization requirements for UnitedHealthcare Community Plan of Maryland

Services Requiring Prior Authorization — Coverage Criteria

Codes and Code Groups Requiring Prior Authorization

How to Submit Requests and Administrative Requirements

Definitions and Notes