CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for inpatient and outpatient services

Lists prior authorization requirements and submission methods for providers participating with UnitedHealthcare Community Plan in the Mississippi Children's Health Insurance Program (CHIP). Applies to in-network and out-of-network providers except in emergencies and urgent care.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for inpatient and outpatient services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by phone at 877-842-3210, or by fax at 888-310-6858.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

877-842-3210phone number for prior authorization requests

888-310-6858fax number for prior authorization requests

No PA requiredemergency or urgent care

Provider Portalprimary online submission

877-743-8734behavioral health contact

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.

Prior Authorization Coverage Criteria

The following lists services, procedures, devices and drugs that require prior authorization or notification for UnitedHealthcare Community Plan (Mississippi CHIP) participating providers. Emergency and urgent care are exempt. Submit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, by phone, or by fax (see policy header for contact details). Some items reference clinical policies or specialty networks (Optum Behavioral Health, VAD Case Management, Review at Launch for New to Market Medications) — follow those pathways when indicated.

Prior authorization is required for the categories and examples below (not exhaustive). Providers must obtain authorization before scheduled services when noted; services performed in emergent or urgent situations are exempt.

Bariatric surgery and obesity-related procedures require prior authorization (example CPT/HCPCS: 43644, 43645, 43659, 43770).

Behavioral health services delivered through the designated behavioral health network require prior authorization or referral per network rules; contact Optum/Provider Express for specific codes and submission instructions (behavioral health referral line 877-743-8734). ABA therapy has separate submission instructions (fax or Provider Express).

Bone growth stimulators (electronic stimulation/ultrasound for fracture healing) require prior authorization (example CPT/HCPCS: 20975, 20979).

Breast reconstruction (non-mastectomy) procedures require prior authorization (example CPT: 11971, 19316, 19318, 19325, 19328, 19330, 19340, 19367, 19370).

Cancer supportive care: prior authorization is required for outpatient administration of colony-stimulating factors, pegfilgrastim/filgrastim products, sargramostim, trilaciclib, certain anti-emetics, and bone-modifying agents (examples: J1449, J1442, Q5110, Q5125, J2506, Q5122, Q5111, J2820, J1447, J1448, J1454, J1456, J0185, J0897). Refer to the Review at Launch for New to Market Medications policy for newly approved agents; predetermination is recommended. For some unclassified/temporary codes (C9162, C9167, C9168, J3490, J3590) authorization applies only for specific products listed in policy.

Chemotherapy injectable drugs administered outpatient (J9000-J9999 and related codes such as J0640-J0642, J1950, J1952) require prior authorization.

Cardiology: certain outpatient electrophysiology implants, stress echocardiography, and select cardiovascular procedures require prior authorization; providers should submit via the Provider Portal or call the listed prior auth number (866-889-8054) for code-level guidance (example code referenced: J0885; select procedure codes 37220, 93580).

Cochlear and other auditory implants require prior authorization (examples: 69710, 69714, 69930, L8614).

Cosmetic and reconstructive procedures (cosmetic-only or reconstructive when not meeting coverage criteria) require prior authorization (example CPTs: 11960, 14061, 14020, 15820, 15821, 15830, 17106-17108, 17999).

Durable medical equipment (DME) requires prior authorization only for listed codes with retail purchase or cumulative rental cost exceeding $500 (examples include A6549, A9280, B4152, B4161, E0194, E0265, E0266, E0270, E0277, E0300, E0328, V5288, V5290).

Enteral and parenteral nutrition and related supplies require prior authorization (examples: B4034-B4036, B4100, B4102-B4104, B4149-B4153).

Functional endoscopic sinus surgery (FESS) requires prior authorization (examples: 31253-31259, 31267, 31276, 31287, 31288).

Genetic and molecular testing (including BRCA testing) requires prior authorization (examples: 81162-81164, 81228).

Hearing aid services and related audiology require prior authorization (examples: 92590-92595, S0618, V5010-V5060, V5095, V5100, V5120, V5170, V5180, V5259, V5260-V5263, V5267, V5298).

Home health care requires prior authorization when provided in outpatient settings including the member's home (examples: G0299, G0300, S9474).

Injectable medications (selected specialty and high-cost agents) require prior authorization — examples include many J-codes and temporary/unclassified codes listed in the policy (see full drug list in source). For some drugs (e.g., J0897) authorization is required for non-oncology indications. Follow specialty review pathways and the Provider Portal for submission.

Orthognathic surgery requires prior authorization for treatment of jaw functional impairment (example codes: 21255, 21296, 21299).

Orthotics and prosthetics require prior authorization only for items with retail purchase or cumulative rental cost > $500 (examples: L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631-L0638, L8047, L8499, L8610, L8612, L8631, L8659).

Outpatient therapies (speech therapy) require prior authorization (example CPT: 92507).

Pain injections and interventional pain management procedures require prior authorization (example CPTs: 64490, 64493).

Prostate procedures require prior authorization (example CPT: 37243; urology-related codes such as 52441 referenced).

Radiation therapy: prior authorization required for outpatient radiation services when obtained with specified diagnosis code ranges and for specific CPTs (examples: 77401, 77402, 77407, 77412, G6003-G6006).

Advanced outpatient imaging (certain CT, MRI, MRA, PET, nuclear medicine/nuclear cardiology) requires prior authorization or notification; ordering providers are responsible for notification/authorization via the Provider Portal or by calling 866-889-8054.

Septoplasty, rhinoplasty, and sinuplasty for functional impairment require prior authorization (examples: 30400, 30410, 30420, 30430; sinuplasty codes 31295-31298).

Site-of-service considerations: prior authorization is required when services are requested in an outpatient hospital setting for many listed procedures; procedures performed at an in-network Ambulatory Surgery Center (ASC) may not require prior authorization (examples referenced: auditory system 69205, cardiovascular 36590/36832, carpal tunnel surgery 64721).

Sleep studies require prior authorization (examples: 95805, 95807-95811).

Spinal surgery requires prior authorization (examples: 22100-22102, 22110, 22112, 22114, and a broad list of spinal CPTs in policy).

Implantable stimulators and certain device implantations (including bone growth stimulators, spinal stimulators, and other electrical impulse devices) require prior authorization (example HCPCS: E0747).

Ventricular assist devices (VAD) require prior authorization/notification; contact the notification number on the member's ID card and follow Optum VAD Case Management fax instructions (fax 855-282-8929). Example CPT/HCPCS codes: 33927-33929, 33975-33983, Q0507-Q0509.

Wound VAC systems require prior authorization (example HCPCS: E2402).

Codes and Coding Notes

Bone growth stimulator codesCPT | HCPCSCovered

20975	Electrical stimulation for bone healing
20979	Ultrasound for bone healing

Bariatric and breast reconstruction codes (examples from document)CPT | HCPCSCovered

43644	Bariatric surgery code listed
43645	Bariatric surgery code listed
43659	Bariatric surgery code listed
43770	Bariatric surgery code listed
11971	Breast reconstruction related code
19316	Breast reconstruction related code
19318	Breast reconstruction related code
19325	Breast reconstruction related code
19328	Breast reconstruction related code
19330	Breast reconstruction related code

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CPT/HCPCS codes mentionedCPT | HCPCS

19367	Referenced in multiple entries as a code requiring prior authorization
19368	Referenced in multiple entries as a code requiring prior authorization
19369	Referenced in multiple entries as a code requiring prior authorization
19370	Referenced in multiple entries as a code requiring prior authorization

Surgical CPT codes referenced (partial)CPT

19367	Code referenced repeatedly in CPT/HCPCS list
19368	Code referenced in list
19369	Code referenced in list
19370	Code referenced in list

Cancer supportive care HCPCS/J/Q codesHCPCSCovered

J1449	Filgrastim (Neupogen) - injectable colony-stimulating factor
J1442	Eflapegrastim-xnst (Rolvedon)
J2506	Pegfilgrastim (Neulasta)
Q5110	Filgrastim-ayow (Releuko)
Q5125	Filgrastim-sndz (Zarxio)
Q5122	Pegfilgrastim-apgf (Nyvepria)
Q5111	Pegfilgrastim-cbqv (UDENYCA)
Q5108	Pegfilgrastim-jmdb (Fulphila)
J2820	Sargramostim (Leukine)
J1447	Tbo-filgrastim (Granix)

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Cardiology HCPCS codes (partial)HCPCS

J0885

Cardiology-related J-code referenced

Cardiology CPT examplesCPT

37220	Cardiovascular diagnostic/therapeutic code referenced
93580	Cardiovascular diagnostic code referenced

Cardiology submission groupmixed

No codes listed

Drugs and chemotherapyHCPCSCovered

J1447	Tbo-filgrastim (Granix) or Trilaciclib/Cosela mapping mentioned
J0897	Denosumab (Xgeva) listed as bone-modifying agent requiring prior authorization
J1454	Anti-emetic drug (palonosetron/fosnetupitant) requiring prior authorization
J9000-J9999	Chemotherapy injectable drugs requiring prior authorization

Implants and DMECPT | HCPCSCovered

69710	Cochlear implant procedure code
69930	Cochlear implant insertion/revision
L8614	Cochlear implant internal device
A6549	DME code listed

Sample DME/related codesHCPCS

E2325
E2213
K0108

Genetic/molecular test codesCPTCovered

81162	BRCA related genetic test code
81479	Unlisted molecular pathology procedure

Hearing aid codes (partial list)CPTCovered

92590	Hearing aid assessment/related service
92591	Hearing assessment
92592	Hearing services
92593	Hearing services

Home health codesHCPCSCovered

G0299	Home health care visit (HCPCS)
G0300	Home health care (HCPCS)
S9474	Home health/home-based services

Injectable medication codes (sample)HCPCSCovered

J0177	Injection — specified drug (example list of injectable meds)
J3262	Specific injectable medication (listed)
J1745	Infliximab
J9312	Rituximab (example)

Selected injectable medication HCPCS/CPT codes shownHCPCS

J1576	Panzyga (listed injectable medication)
J0256	Prolastin C
J0897	Prolia (note: PA required for non-oncology diagnosis)
J1745	Remicade
J2326	Spinraza
J2353	Sandostatine LAR
90378	Synagis

Therapeutic radiopharmaceutical codesHCPCS

A9513	Therapeutic radiopharmaceutical (listed)
A9590	Therapeutic radiopharmaceutical (listed)
A9606	Therapeutic radiopharmaceutical (listed)

Example orthotics/prosthetics and related HCPCS L-codesHCPCSCovered

L5460
L5500
L5505
L5510
L5520
L5530
L5535
L5540
L5560
L5570

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Selected CPT codes from service categories requiring prior authorizationCPTCovered

92507	Speech therapy
64490	Pain injection (example)
64493	Pain injection (example)
37243	Prostate procedure (embolization)
52441	Prostate procedure (example)
53850	Prostate procedure (example)

Radiation therapy CPT/G-codes and descriptorsmixedCovered

77401	Radiation therapy management, complex (example)
77402	Radiation therapy management, standard (example)
77385	IMRT guidance
77386	IMRT planning

Selected CPT examples from listCPTCovered

30400	Septoplasty/rhinoplasty
31295	Sinuplasty
66821	Cataract surgery (example code listed)

Additional procedure codesmixedCovered

10121	Integumentary system procedure (example code listed)
29806	Arthroscopy procedure (example code listed)
G0260	Multiple imaging/other HCPCS example

Ophthalmology codesCPT

67040	Ophthalmologic procedure (listed)
67228	Ophthalmologic procedure (listed)
67311	Ophthalmologic procedure (listed)
67312	Ophthalmologic procedure (listed)

Spinal surgery codesCPT

22100	Spinal surgery code (listed)
22101	Spinal surgery code (listed)
22102	Spinal surgery code (listed)

CAR T-Cell / advanced therapy codesCPT

0537T	CAR T-Cell related code
0538T	CAR T-Cell related code

VAD and wound VAC codesmixed

33927	VAD implantation
33928	VAD-related code
E2402	Wound VAC

VAD and wound vac codesCPT | HCPCSCovered

33927	Ventricular assist device procedure (listed in document near VAD)
33928	VAD-related procedure code
33929	VAD-related procedure code
33975	VAD-related procedure code
33976	VAD-related procedure code
33979	VAD-related procedure code
33981	VAD-related procedure code
33982	VAD-related procedure code
33983	VAD-related procedure code
Q0507	VAD device/perfusion code referenced

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None specifiedNo threshold or special key/value provided in this section of the brief.

Guidance sourceRefer to full code lists and submission instructions in the policy document for specifics.

Action

How to Submit and Operational Requirements

Prior Authorization

How to submit prior authorization requests

Providers must submit prior authorization requests using the UnitedHealthcare Provider Portal Prior Authorization and Notification tool whenever prior authorization is required for a service, device, or drug. Alternate submission methods: phone and fax numbers are provided in the policy for specific request types (examples: general PA phone 877-842-3210; specialty lines listed throughout the policy). Prior authorization is not required for emergency or urgent care. Ordering providers are responsible for obtaining prior authorization or providing required notification when listed in this section (for example, advanced outpatient imaging, cardiology outpatient procedures, radiation therapy).

Provider Portal: Sign in at UHCprovider.com and select the Prior Authorization and Notification tile to submit requests online — this is the preferred method for outpatient, office-based services and drugs.
Phone: Use the phone numbers listed for specific service areas (examples appear in the policy; see general contact 877-842-3210 and specialty lines such as 866-889-8054 or 888-397-8129).
Fax: Submit to the fax numbers listed where applicable (examples appear in the policy; e.g., VAD forms to 855-282-8929).

Prior Authorization

Behavioral health prior authorization pathway

Key Definitions and Scope

Prior authorization (definition)A requirement that providers obtain approval from UnitedHealthcare before performing or billing for specified services or supplies, except for emergency or urgent care.

ExceptionsPrior authorization is not required for emergency or urgent care services.

Submission methodsRequests may be submitted online via the Provider Portal Prior Authorization and Notification tool, by phone, or by fax as listed in the policy.

Emergency/urgent care exemptionEmergency and urgent care services do not require prior authorization.

ApplicabilityApplies to in-network and out-of-network participating providers; emergent or urgent care is excluded from PA requirements.

ReferenceSee submission instructions for non-emergent services that do require prior authorization.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for inpatient and outpatient services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by phone at 877-842-3210, or by fax at 888-310-6858.

SourceLink

On This Page

When in doubt, use the Prior Authorization and Notification tool or contact the phone numbers listed in the policy.

DME PA financial thresholdRetail purchase or cumulative rental cost greater than $500 requires prior authorization.

Applies toDurable Medical Equipment (DME) codes listed in the policy and other DME items when cost exceeds threshold.

How to submit PASubmit via Provider Portal Prior Authorization and Notification tool, phone, or fax as listed in the policy.

Purchase/rental thresholdPrior authorization is required when retail purchase or cumulative rental cost exceeds $500.

Orthotics/prosthetics relationThreshold also referenced specifically for orthotics and prosthetics L-codes in the policy.

Provider actionObtain prior authorization before billing or providing DME items that meet the cost threshold.

Orthotics/prosthetics PA cost thresholdPrior authorization required only for orthotics and prosthetic codes with a retail purchase or cumulative rental cost of more than $500.

ScopeApplies to the L-code series and other orthotics/prosthetics codes listed in the policy when cost threshold exceeded.

SubmissionSubmit prior authorization requests via the Provider Portal Prior Authorization and Notification tool or by phone/fax per policy instructions.

Conditional PA for radiation therapyPrior authorization required only when radiation therapy is obtained with diagnosis codes in specified ranges; some radiation therapy codes are conditional based on diagnosis coding.

ExamplesIncludes IMRT, Proton Beam, SBRT/SRS and other specialized radiation categories which may require PA depending on diagnosis codes.

How to submitUse the Prior Authorization and Notification tool and select Radiology/Oncology/Radiation Therapy as applicable; phone assistance is available per policy.

Behavioral health and substance use services are managed through the designated behavioral health vendor. Prior authorization, referral, or notification must be obtained through that network as described below.

Optum Behavioral Health network handles behavioral health referrals and authorizations — call 877-743-8734 or the number on the member’s ID card for mental health and substance use services.
For ABA therapy and other specified behavioral services, follow submission instructions (fax or Provider Express) as directed by the behavioral health network.

Prior Authorization

Bone growth stimulator prior authorization

Bone growth stimulators (electrical stimulation or ultrasound devices) require prior authorization when billed under the listed CPT/HCPCS codes.

Covered example codes: 20975, 20979.
Implantable stimulators and related device codes (see Stimulators / Neurostimulator entries) also require prior authorization.

Prior Authorization

Surgical procedures requiring prior authorization

Selected surgical procedures require prior authorization. This includes bariatric surgery, breast reconstruction (non-mastectomy), and other major reconstructive or elective surgeries listed in the policy.

Bariatric surgery examples: 43644, 43645, 43659, 43770.
Breast reconstruction and mastectomy-related codes: 11971, 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19367–19371, 19380, 19396, L8600 (and related codes).
Providers must obtain prior authorization before scheduling these procedures; follow Provider Portal or phone submission instructions.

Note

General CPT/HCPCS prior authorization guidance

Certain CPT/HCPCS examples are included throughout the surgical and reconstructive code lists; these are representative and not exhaustive. Providers should confirm PA requirements for the exact code being billed.

Breast reconstruction examples repeated in policy include CPT 19367–19370 and related reconstructive codes.
When uncertainty exists, submit an online PA request via the Provider Portal or call the applicable authorization phone line.

Prior Authorization

Prior authorization for outpatient drugs and cancer supportive care

For outpatient cancer supportive care drugs and other specified outpatient drugs/procedures, submit prior authorization requests via the Provider Portal. Alternate phone numbers are listed for specialty areas when applicable.

Cancer supportive care agents requiring prior authorization include colony-stimulating factors (e.g., filgrastim and pegfilgrastim variants — J1449, Q5110, Q5125, J2506, Q5111, Q5122, Q5111, J1447, J1448) and bone-modifying agents (denosumab Xgeva® J0897).
Prior authorization is required for outpatient injectable chemotherapy (J9000–J9999) and many other injectable agents listed in the policy; use Provider Portal for submission.

Prior Authorization

Device, DME, orthotics and prosthetics prior authorization rules

Certain device, DME, orthotics and prosthetics, and high-cost supplies require prior authorization only when the listed HCPCS/CPT codes are used or when retail purchase/cumulative rental costs exceed the specified threshold.

Cochlear and auditory implants and related codes: 69710, 69714, 69930, L8614 — require prior authorization.
DME and orthotics/prosthetics require prior authorization only for listed codes or when retail purchase/cumulative rental cost exceeds $500 (examples: A6549, A9280, B4152, B4161, E0194, E0265, E0266, E0270, E0277, E0300, E0328, V5288, V5290).
Orthotics/prosthetics examples: L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, etc.; see full list in policy.

Prior Authorization

Enteral and parenteral prior authorization

Enteral and parenteral nutritional services, in‑home nutritional therapy, and related supplies require prior authorization when billed under the listed HCPCS codes.

Enteral/parenteral supply examples: B4034, B4035, B4036, B4100, B4102–B4104, B4149–B4161, B9002, B9998, B9999.
In-home nutritional therapy and gastrostomy-related supplies (B4150–B4161, B4152, etc.) require PA prior to provision.

Prior Authorization

Experimental / investigational services require prior authorization

Experimental, investigational, or unproven services require prior authorization. Providers should obtain authorization before scheduling or delivering such services.

Examples of investigational/unproven codes listed: 36514, 64722, 65765, 65767, 66180, A4226, A4638, A6000, A9274, E0231, E1831, S0810, S1030, S1031, S2102, S9988, S9990, S9991.
Contact Provider Portal for submission and review guidance for experimental or investigational services.

Prior Authorization

FESS and FAI prior authorization

Functional endoscopic sinus surgery (FESS) and femoroacetabular impingement (FAI) procedures require prior authorization when billed under the listed CPT codes.

FESS example codes: 31240, 31253–31257, 31259, 31267, 31276, 31287, 31288.
FAI example codes: 29914–29916.

Prior Authorization

Genetic / molecular testing prior authorization/notification

Genetic and molecular testing (including BRCA testing) must be submitted through the Genetic and Molecular Testing Prior Authorization/Notification program. The ordering provider must follow the program’s notification/prior authorization steps before testing is performed.

Genetic testing example codes: 81162–81164, 81228, 87505–87507, S3870 and others listed in the Genetic and Molecular Testing program.
Ordering provider must notify the laboratory and ensure the laboratory notifies UnitedHealthcare per program instructions before DNA sequencing or BRCA testing.

Prior Authorization

Hearing aid services prior authorization

Hearing aid services and fittings require prior authorization when billed under the listed CPT/HCPCS codes.

Hearing-related codes requiring PA include CPT 92590–92595 and HCPCS codes S0618, V5010–V5263, V5267, V5298, V5250–V5258, and others listed in the policy.
Confirm specific code requirements and submit PA via Provider Portal.

Prior Authorization

Home health prior authorization

Home health services provided in outpatient settings and to include services delivered in the member’s home require prior authorization when billed under the listed codes.

Home health example codes: G0299, G0300, S9474.
Prior authorization is required for home health care arranged in outpatient/home settings — submit via Provider Portal.

Prior Authorization

Injectable medications prior authorization

Numerous injectable medications and specialty drugs administered in outpatient or office settings require prior authorization; see the comprehensive injectable medication lists and J-/Q-/C- codes in the policy.

Injectable drug examples include many biologics and specialty agents (e.g., J3316, J9381, J1303, J0597 series, botulinum toxin codes J0585–J0588, and many others listed).
Refer to the Unclassified/Temporary Codes section for guidance on miscellaneous/unlisted billing codes (see next callout).

Billing Rule

Unclassified / temporary code prior authorization (exceptions)

Unclassified and temporary HCPCS/CPT codes (including J3490, J3590 and certain C-codes) have special prior authorization rules. Prior authorization for these codes is limited to specific products identified by name — providers should not assume PA applies to every use of an unclassified/temporary code.

Unclassified/temporary codes included in the policy: C9159, C9162, C9167, C9168, J3490, J3590, J1823 and others listed in the Unclassified/Temporary Codes section.
PA exceptions: For unclassified and temporary codes C9162, C9167, C9168, J3490 and J3590, prior authorization is required only for the following products: Adynxxa; Nulibry™; Omvond IV; and Purified Cortrophin™ Gel (as specified in the policy).
Code-specific note: J0897 requires prior authorization when used for non-oncology diagnoses (i.e., J0897 for oncology may follow other PA rules; for non-oncology use PA is explicitly required).
Operational note: When billing a drug or product under an unclassified/temporary or J3490/J3590 billing code, include the product name and supporting clinical documentation in the PA request so the reviewer can determine whether the listed exceptions apply.

Prior Authorization

High-acuity device, transplant, gene/CAR T therapies and specialized PA pathways

Joint replacement, orthognathic surgery, neurostimulator implantation, CAR T-cell therapies, gene therapies, VADs, wound VACs, and other high-acuity services require prior authorization or specialized case management pathways. Follow the policy code lists and operational instructions for contacting case management or specialty teams when required.

Joint replacement codes (total hip/knee and related) require PA — see detailed code lists in the policy (examples throughout chunks 116–117).
Neurostimulator and stimulator device implantation codes (e.g., E0747–E0760, L8680, and implant procedure CPTs) require PA.
CAR T-cell and gene therapy requests require clinical coordination — call the Transplant/CAR T-cell team or UnitedHealthcare Community and State Transplant Case Management team at the number listed in the policy.
Ventricular assist devices: call the notification number on the back of the member’s ID card and fax required forms to the Optum VAD Case Management team at 855-282-8929.
Wound VACs (E2402) require prior authorization before provision.

Prior Authorization

Site-of-service prior authorization rule

Site-of-service prior authorization rules apply when services are provided in an outpatient hospital setting. Prior authorization is required for services scheduled in an outpatient hospital unless the same procedure is performed at a participating Ambulatory Surgery Center (ASC), in which case PA may not be required. Providers should confirm site-of-service PA rules when scheduling.

Site-of-service examples: certain auditory, cardiovascular, and carpal tunnel procedure codes identified in the policy may require PA when performed in an outpatient hospital.
If performing in a participating ASC for the same procedure, prior authorization may not be required — confirm participation status and PA requirements before scheduling.

Prior Authorization

Radiation therapy and advanced imaging prior authorization/notification

Radiation therapy and many advanced outpatient imaging procedures require prior authorization or notification. Ordering providers are responsible for initiating the authorization/notification via the Provider Portal prior to scheduling.

Radiation therapy codes requiring PA include a range of CPT and G codes (e.g., 77401, 77402, 77407, 77412, 77385, 77386, 77387, G6001–G6017 series) and related procedure codes listed in the policy.
Advanced imaging (CT, MRI, MRA, PET, nuclear medicine) requires notification or PA — use the Radiology, Cardiology, Oncology, and Radiation Therapy pathway in the Provider Portal or call 866-889-8054 for assistance.

Documentation Required

Predetermination and Review-at-Launch guidance

When in doubt about whether a code or service requires prior authorization, submit a predetermination/PA request through the Provider Portal with supporting clinical documentation. Predetermination is recommended for high-cost or newly approved drugs and for services billed under unclassified or temporary codes.

Review at Launch: Check the 'Review at Launch for New to Market Medications' policy and the Review at Launch Medication List on UHCprovider.com for newly FDA-approved drugs requiring review.
Include product name, clinical indications, and supporting documentation when submitting PA requests for unclassified/temporary codes (J3490/J3590) or newly marketed therapies.

Behavioral health administrationBehavioral health services are administered through the Optum Behavioral Health network; referrals or prior authorization require calling 877-743-8734 or the number on the member's ID card.

ABA therapy submissionsFor ABA therapy, submit via fax or Provider Express as directed by the behavioral health program.

Provider resourceSee ProviderExpress.com for additional behavioral health referral and authorization guidance.

PA submission contentPrior authorization requests must include applicable CPT/HCPCS codes (examples: 19367-19370 and many others) and be submitted via the Provider Portal Prior Authorization and Notification tool; phone submission options also provided in the policy.

Use Portal tileSelect the Prior Authorization and Notification tile on the Provider Portal dashboard and choose the relevant service category (Radiology, Cardiology, Oncology, Radiation Therapy) when prompted.

Alternate contactWhen required, providers may call the phone numbers listed in the policy for assistance or to submit prior authorization requests.

Cancer supportive care (definition)Outpatient colony-stimulating factor drugs and bone-modifying agents used for cancer supportive care require prior authorization.

Included agentsExamples include filgrastim, pegfilgrastim, eflapegrastim and denosumab (J- and Q-codes listed in the policy).

SettingPA applies when these agents are administered in an outpatient setting for a cancer diagnosis.

Prior authorization (restatement)Providers must obtain prior authorization for services and supplies enumerated in the policy; unclassified/temporary codes may have exceptions described in the document.

Review at launchSee the 'Review at Launch for New to Market Medications' policy for newly approved drugs and predetermination guidance.

ExceptionsCertain unclassified/temporary codes require PA only for specific drugs as noted (e.g., C9162, C9167, C9168, J3490, J3590 exceptions listed).

DME PA threshold (definition)Durable medical equipment prior authorization is required only for listed codes or when the retail purchase or cumulative rental cost is more than $500.

Code listsSpecific HCPCS codes subject to this rule are enumerated in the policy (examples include A6549, A9280, B4152, etc.).

Provider actionVerify DME cost and code against the policy list before furnishing or billing; obtain PA if threshold met.

Submission channelsSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, by phone (numbers provided in policy), or by fax where applicable.

Portal access stepsSign in to UHCprovider.com, click the Provider Portal button, and select the Prior Authorization and Notification tile on the dashboard.

Phone and faxPhone and fax contact options are provided in the policy for alternate submission methods and specific services.

DME PA threshold (restated)Prior authorization required when retail purchase or cumulative rental cost is greater than $500 for listed DME items.

Orthotics/prosthetics noteThe same $500 threshold specifically applies to orthotics and prosthetic L-codes listed in the policy.

Genetic/molecular testing notificationNotification/prior authorization is required for specified genetic tests (including BRCA) through the Genetic and Molecular Testing Prior Authorization/Notification program; the ordering provider must notify the laboratory and the laboratory will notify UnitedHealthcare before DNA sequencing.

Program requirementFollow the Genetic and Molecular Testing PA/Notification program procedures as described in the policy.

CodesSpecific CPT/HCPCS codes for tests are listed in the policy and must be checked when ordering genetic testing.

Home health PA scopePrior authorization is required for home health care only in outpatient settings, including the member's home.

Applicable codesExamples include G0299, G0300 and S9474 among codes listed for home health services.

Provider actionObtain PA before initiating home health services in outpatient/home settings as specified.

Injectable medications requiring PANumerous injectable medications listed in the policy require prior authorization; see the enumerated J-codes and drug list in the document.

ExamplesThe policy lists many J-codes (e.g., J0177, J3262, J1745, J9312) and specific biologics that require PA when administered outpatient.

SubmissionSubmit PA via Provider Portal Prior Authorization and Notification tool or call the phone contact provided in the policy.

Review at Launch referenceSee the 'Review at Launch for New to Market Medications' policy for information on newly approved FDA drugs and predetermination recommendations.

LocationAvailable at UHCprovider.com > Menu > Policies and Protocols > Community Plan Policies > Medical & Drug Policies and Coverage Determination Guidelines for Community Plan.

PredeterminationPredetermination is highly recommended for drugs on the Review at Launch list.

Proton Beam (definition)Focused radiation therapy that uses beams of protons (tiny particles with a positive charge); listed as a radiation therapy category in the policy.

PA implicationProton Beam therapy is included among radiation modalities that require prior authorization per the radiation therapy rules.

Related codesAssociated CPT/HCPCS codes and examples (e.g., 77520-77525, 77385, 77386) are listed in the policy.

PA conditionality by diagnosis codesSome prior authorizations are required only when services are billed with diagnosis codes within specified ranges; radiation therapy includes this conditional rule.

Provider checkProviders must verify diagnosis coding against the specified ranges in the policy to determine PA requirements.

ExamplesSee the radiation therapy section for examples of codes that are conditional on diagnosis ranges.

Prior Authorization and Notification toolAn online tool accessible via the UnitedHealthcare Provider Portal used to submit prior authorization and notification requests (select Radiology, Cardiology, Oncology, and Radiation Therapy boxes as applicable).

Access stepsSign in to UHCprovider.com, click the Provider Portal button, and select the Prior Authorization and Notification tile on the dashboard.

Alternate optionsPhone and fax options are available and listed in the policy for providers who cannot use the online tool.

Site of Service (SOS) definitionClassification of service setting; prior authorization is required when a service is performed in an outpatient hospital but not required if performed at a participating Ambulatory Surgery Center (ASC).

Provider implicationProviders should confirm the site-of-service to determine whether prior authorization is required under the policy.

ExamplesThe policy lists specific procedure groups (auditory, cardiovascular, cataract surgery, etc.) with SOS considerations.

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

Provider actionCall the notification number on the member's ID card and fax the form provided by the nurse to the Optum VAD Case Management team at 855-282-8929.

Associated codesRepresentative procedure codes include 33927, 33928, 33929 and related Q-codes as listed in the policy.

Stimulators / NeurostimulatorsImplantation of a device that sends electrical impulses (neurostimulators, bone growth stimulators) — prior authorization required for implantation and related device codes.

Examples of device codesIncludes E0747, E0748, E0749, E0760 and L8680 among other CPT/HCPCS codes listed for neurostimulator procedures.

Bone growth stimulator noteBone growth stimulators (electrical stimulation or ultrasound) specifically require prior authorization (e.g., 20975, 20979).

VAD (duplicate)Ventricular assist devices (VAD): A mechanical pump that takes over the function of the damaged ventricle and restores normal blood flow; prior authorization required and specific operational steps provided.

Contact stepsCall the notification number on the member's ID card and fax the nurse-provided form to Optum VAD Case Management at 855-282-8929.

Representative codesIncludes 33927, 33928, 33929, 33975, 33976 and related Q-codes.

Wound VAC (definition)Negative pressure wound therapy device which requires prior authorization (E2402 listed in the policy).

Associated codeE2402 is the representative HCPCS code listed for wound vacuum therapy requiring prior authorization.

Provider actionObtain prior authorization prior to providing wound VAC therapy as specified in the policy.