UnitedHealthcare prior auth requirements (NM)

Services and Codes That Require Prior Authorization

Prior authorization coverage criteria (partial — document continued)

Specific services and codes require prior authorization; certain diagnoses or services may be exempt as noted.

Prior authorization is required for the following services and listed CPT/HCPCS codes unless otherwise noted.

Examples

Abortion — CPT codes: 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857 (Prior authorization required).
Augmentative and alternative communication — CPT/HCPCS codes: 92607, 92608, 92609, A9901, E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, E2599, V5336 (Prior authorization required).
Bariatric surgery — example CPT codes: 43644, 43645, 43659, 43770, 43775, 43842, 43845, 43846, 43847, 43848, 43860 (Prior authorization required).
Behavioral health services — Prior authorization required; providers should consult the Behavioral Health Prior Authorization Code List (services available through the RBHA program).
Cancer supportive care (outpatient) — Injectable colony-stimulating factor and bone-modifying agents require prior authorization for outpatient administration for a cancer diagnosis (examples include J1442, Q5110, Q5125, Q5101, J2506, Q5122, Q5120, Q5111, Q5108, J2820, J1448, J0897).

Prior authorization requirements (partial list)

Selected services and codes with stated prior authorization requirements in the excerpt.

Injectable chemotherapy: Chemotherapy injectable drugs billed J9000–J9999 and specific listed J/Q codes (and miscellaneous HCPCS for unassigned codes) require prior authorization for outpatient administration; submit requests via the Provider Portal or phone per instructions.

EEG / monitoring

Inpatient video EEG (Cerebral seizure monitoring) — CPT codes 95700, 95711–95716, 95718: Prior authorization is required for inpatient services.
Electroencephalogram (EEG) outpatient hospital or ambulatory surgical center — CPT codes 95720, 95722, 95724, 95726: Prior authorization required for outpatient hospital or ASC.

Continuous glucose monitors and selected DME/HCPCS entries: some codes require prior authorization as listed.

Chemotherapy prior authorization criteria

Injectable chemotherapy

Injectable chemotherapy drugs (including J9000–J9999 range, leucovorin J0640/J0641/J0642, Lupron Depot J1950, Q-coded chemotherapy agents, and miscellaneous HCPCS-billed agents) require prior authorization when administered in an outpatient setting for a cancer diagnosis.

Submit prior authorization requests online using UnitedHealthcare Provider Portal (UHCprovider.com) or call 888-397-8129 as provided in the policy.

EEG prior authorization criteria

Video EEG monitoring

Inpatient video electroencephalogram (Cerebral seizure monitoring) — CPT codes 95700, 95711–95716, 95718: Prior authorization is required for inpatient services.

Outpatient EEG — Routine EEG CPT codes 95720, 95722, 95724, 95726: Prior authorization is required when performed in outpatient hospital or ambulatory surgical center settings.

Some inpatient video monitoring entries indicate 'prior authorization not required' for specific scenarios; refer to the code list and settings in the policy for details.

DME prior authorization criteria

Durable Medical Equipment

DME items listed in the policy require prior authorization when billed as a retail purchase or when cumulative rental cost exceeds $500 (examples: E0787, E0194, E0265, E0266, E0270, E0300, E0445, E0457, E0465, E0466, E0483, E0486, E0620, E0636, E0638, E0641, E0642, E0656, etc.).

Dental prior authorization instruction

Dental services

For prior authorization requirements for dental services, providers should call UnitedHealthcare dental at 855-812-9208.

Reconstructive/cosmetic prior authorization guidance

Reconstructive and cosmetic procedures

Reconstructive procedures that treat a medical condition or improve/restore physiologic function require prior authorization (multiple CPT codes listed throughout the policy).

Cosmetic procedures that change or improve appearance without significantly improving or restoring physiologic function are distinguished from reconstructive procedures; some entries note that prior authorization may not apply when billed with specified diagnosis codes (see policy).

Prior authorization required

Services and codes listed below require prior authorization as noted.

Many surgical procedures, home health services, enteral services, and specific device/procedure codes in the policy explicitly require prior authorization (examples include FESS codes 31240–31267, femoroacetabular impingement codes 29914–29916, home health G0151–G0153, selected injectable medications and others).

Enteral services and outpatient genetic/molecular testing require prior authorization; genetic testing requests must indicate the laboratory and test name.

Prior authorization list (partial)

Listed injectable medications require prior authorization as indicated by the table entries.

Numerous injectable medications and therapeutic radiopharmaceuticals listed in the policy require prior authorization. See the drug/J-code list in the policy (examples across the J‑code listings include J1931, J1552, J1426, J0225, J0256, Q5121, J0490, J0179, J1414, J0597, etc.).

Prior authorization and notification criteria (partial)

Prior authorization/notification requirements and submission instructions for listed services and codes.

Inpatient admissions and post-acute services: Notification and prior authorization of admission date are required for acute care hospitals and acute inpatient rehabilitation facilities.

Non-emergent air ambulance transport — CPT/HCPCS codes A0430, A0431, A0435, A0436 require prior authorization.

Joint replacement procedures (examples: 24360–24363, 27120, 27125, 27130, 27132, 27134, 27137–27138, 27412, 27446–27447, 27486–27487, 29866–29868) require prior authorization.

Orthotics and prosthetics: extensive list of L‑codes require prior authorization (examples include L0480, L0482, L0484, L0486, L0624, L0629, L0631–L0640, L0700–L0830, etc.).

Submission instructions: submit requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) or call 888-397-8129; use the Prior Authorization and Notification tool for non-oncology white blood cell colony stimulating factors and the Contact Us page for 24/7 assistance.

Radiation therapy prior auth criteria

Standard Radiation Therapy (2D/3D) prior authorization condition by diagnosis codes:

Standard Radiation Therapy (2D/3D) — CPT/HCPCS codes 77372, 77373 (and related radiation therapy codes 77402, 77407, 77412) require prior authorization only when billed with diagnosis codes in the ranges C34.00–C34.92, C50.011–C50.929, C61, or C79.51–C79.52.

General prior authorization requirements

Out-of-network services and other categories explicitly requiring prior authorization:

Out-of-network services — Prior authorization is required for all out-of-network services.

Outpatient therapy — Prior authorization is required for listed outpatient therapy CPT codes (examples: 92507, 92508, 92526, 92630, 92633, 97110, 97112, 97113, 97116, 97124, etc.).

Private duty nursing — Prior authorization is required (examples: T1002, T1003 referenced in policy).

Prior authorization coverage criteria (enumerated)

Prior authorization is required for the following service categories and listed codes; providers must submit requests via the Provider Portal or phone and include supporting clinical documentation where indicated.

ENT / Rhinoplasty / Septoplasty — Prior authorization required for listed CPT codes (30400, 30410, 30420, 30430, 30460, 30465 and related entries).

Sinuplasty — Prior authorization required for CPT codes 31295 and 31296.

Sleep apnea procedures — Prior authorization required for listed sleep apnea procedure codes (examples include 31295 and other specified entries).

Spinal surgery and instrumentation — Prior authorization required for multiple spinal surgery and instrumentation codes (examples: 22101, 0098T, 0164T, 22110, 22100, 22600, 22802, 22810 and related codes).

Sterilization procedures — Prior authorization required for listed codes (e.g., 52601, 52630, 52647, 55250, 58600 series).

Prior authorization rules (excerpt)

Authorization requirements and code mappings in this excerpt

Unclassified drug codes J3490, J3590 and C9399 — For specific cell/gene therapies (Amtagvi, Casgevy, Lantidra, Lenmeldy, Skysona), prior authorization is required through Optum Transplant per policy instructions.

Vein procedures and saphenous vein removal/ablation — CPT codes 36468, 36473, 36475, 36478 and 37700, 37718, 37722, 37765, 37766, 37780 require prior authorization.

Ventricular assist devices (VAD) — Prior authorization is required; providers must call the notification number on the member's health plan ID card and then fax the form provided by the nurse to the Optum VAD Case Management team at 855-282-8929.

Wound VAC devices (example E2402) — Prior authorization is required.

Relevant CPT, HCPCS and ICD-10 Codes

ICD-10 codes (cancer / skin) requiring prior authorizationICD-10

C43.0 - C43.9	Melanoma codes (all sublocations)
C44.x	Other malignant neoplasms of skin (multiple specific C44.* codes referenced)
C4A.x	Malignant neoplasm of accessory sinuses / related (range referenced)
C79.2	Secondary malignant neoplasm of skin

ICD-10 codes (vascular / wound / device)ICD-10

I70.*	Atherosclerosis and related peripheral arterial disease codes (many specific I70.* codes referenced)
T82.338A	Displacement of vascular device, initial encounter
T82.392A	Other mechanical complication of other vascular device, initial encounter
T82.398A	Other complications of other vascular device, initial encounter
T82.399A	Unspecified complication of other vascular device, initial encounter
T82.898A	Other complication of other specified implant and internal device, initial encounter

Colony-stimulating factors and supportive oncology J/Q codesHCPCSCovered

J1442	Filgrastim (Neupogen)
Q5110	Filgrastim-aafi (Nivestym)
Q5125	Filgrastim-ayow (Releuko)
Q5101	Filgrastim-sndz (Zarxio)
J2506	Pegfilgrastim (Neulasta)
Q5122	Pegfilgrastim-apgf (Nyvepria)
Q5120	Pegfilgrastim-bmez (Ziextenzo)
Q5111	Pegfilgrastim-cbqv (Udenyca)
Q5108	Pegfilgrastim-jmdb (Fulphila)
J2820	Sargramostim (Leukine)

1–10 of 12

1/2

Specific injectable chemotherapy-related J-codes and misc HCPCSHCPCSCovered

J9000-J9999	Chemotherapy injectable drugs range (J-codes) - prior authorization required
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin (additional)
J1950	Lupron Depot
Q-codes	Chemotherapy injectable drugs that have a Q code (various Q2xxx codes listed elsewhere)
J3490, J3590, C9399	Unclassified drug codes - Amtagvi, Casgevy, Lantidra, Lenmeldy, Skysona require Optum Transplant prior authorization when billed under unclassified codes

ICD-10 codes referenced (radiation oncology trigger)ICD-10

C34.00 - C34.92	Malignant neoplasm of bronchus and lung (range)
C50.011 - C50.929	Malignant neoplasm of breast (range)
C61	Malignant neoplasm of prostate
C79.51 - C79.52	Secondary malignant neoplasm of respiratory organs (lung metastasis codes)

Durable Medical Equipment (DME) / HCPCS codes requiring prior authorizationHCPCS

E0787	Powered wheelchair, other (prior auth required)
E0194	Prescription item - ventilator/accessory (prior auth required)
E0265	Custom-molded seating system component
E0266	Custom-molded seating system component
E0270	Motorized wheelchair power base
E0300	Multi-positional bed
E0445	Insulin pump supplies/monitoring (example)
E0457	Cervical traction device (example)
E0465	Powered pressure-reducing support surface
E0466	Powered pressure-reducing support surface

1–10 of 50

1/5

Genetic and molecular testing CPT / Proprietary codes requiring prior authorizationmixed

81229, 81228, 81265	BRCA and related hereditary breast/ovarian cancer testing
81162-81166	BRCA sequencing and related panels (multiple CPTs referenced)
81212, 81215-81217	Hereditary cancer panels
81400-81471	Genetic and molecular oncology panels and multigene tests (multiple CPTs referenced; many require prior auth)
0395U, 0398U, 0409U, 0411U, 0417U, 0419U, 0423U, 0425U, 0426U, 0444U, 0448U, S3870	Proprietary (PLA) genetic test codes listed
88291-88295, 88261-88275, 88280, 88283-88289	Cytogenetics and related molecular codes
81427, 81431, 81432, 81439, 81443, 81445-81451, 81455-81458, 81464, 81471	Additional molecular pathology / genomic panel CPT codes referenced

Hearing services and hearing aid V / V50x codesHCPCS

92590	Hearing aid assessment and selection
92591	Hearing aid check
92592	Hearing aid check
92593	Hearing aid check
92594	Hearing aid fitting
92595	Hearing aid fitting
V5010 - V5336	Hearing aid and hearing device V-codes (many V5xxx codes listed)
S3870	Proprietary genetic test code also listed in genetic section

Sample injectable HCPCS / J-codes (partial list) requiring prior authorizationHCPCSCovered

J1931	Injectable medication (Alyglo)
J1552	Amondys 45
J1426	Amvuttra
J0225	Aralast NP / Prolastin-C / Zemaira
J0256	Avsola
Q5121	Avsola (biosimilar)
J0490	Benlysta
J0179	Beovu
J1414	Beqvez
J0597	Berinert

1–10 of 15

1/2

Intravenous immunoglobulin (IVIG) codesHCPCSCovered

J1459	IVIG product (J1459)
J1556	IVIG product (J1556)
J1561	IVIG product (J1561)
J1572	IVIG product (J1572)
J2782	IVIG product (J2782)
90283-90284	Administration codes associated with IVIG (as listed)

Miscellaneous CPT / HCPCS codes requiring prior authorization (sample)mixed

24360-24363	Joint replacement related codes (sample range included)
27120-27138	Total hip / knee arthroplasty related codes (sample)
27412, 27446	Knee arthroplasty / related procedures
31257, 31259, 31267	Endoscopic sinus surgery (FESS) codes
30400-30430, 30460-30465	Rhinoplasty / septoplasty and nasal procedures that may require prior auth
22100-22114, 22101, 22102	Spinal surgery codes (many 22xxx series codes listed)
22802-22899, 22812, 22818, 22819, 22830, 22849-22865	Spinal instrumentation and fusion codes
33927-33983	Ventricular assist device implantation and related codes
36468, 36473, 36475, 36478	Vein procedure codes

L-code orthotics / prosthetics requiring prior authorization (sample)HCPCS

L0480, L0482, L0484, L0486	Lower extremity prosthetic codes (sample)
L0624, L0629, L0631-L0638, L0640, L0700, L0710	Prosthetic component codes
L5301, L5312, L5321, L5331, L5341	L-codes for orthotic/prosthetic supplies
L5400, L5420, L5460, L5500-L5560, L5570-L5595	Additional L-code device/prosthetic items listed
L5600-L5661, L5673, L5682-L5683, L5700-L5728	Extensive L-code list present in source document

Outpatient therapy CPT codes (partial list)CPT

92507, 92508, 92526, 92630, 92633	Hearing/communication therapy and related CPTs
96105	Neuropsych testing
97012, 97014, 97016, 97018, 97022, 97026, 97028	Physical therapy modalities
97110, 97112, 97113, 97116, 97124, 97140, 97535	Therapeutic exercise and outpatient therapy CPTs
G0281, G0283, 97530	Other therapy/functional codes

Radiation therapy CPT / HCPCS codesmixed

77372, 77373	Stereotactic or complex radiation therapy planning codes referenced
G0339	Stereotactic body radiation therapy (SBRT) - HCPCS
77402, 77407, 77412	Radiation treatment delivery codes

ENT / nasal / sinuplasty codes requiring prior authorizationCPT

31295, 31296	Sinuplasty (balloon dilation) codes
31257, 31259, 31267	Endoscopic sinus surgery series
29819	Nasal/sinus endoscopy with surgery

Spinal surgery and instrumentation codes requiring prior authorizationCPT

22100-22114	Spinal repair/decompression codes (range)
22600, 22610	Arthrodesis codes
22802, 22804, 22808, 22810, 22812, 22818, 22819	Spinal instrumentation/fusion codes
22830, 22849-22856, 22861, 22864-22865	Additional spinal device/instrumentation codes

Sterilization and related codesCPT

52601, 52630, 52647, 52648, 52649	Male sterilization / vasectomy and related codes
55250, 55801, 55821, 55831	Sterilization and related pelvic procedures
58600-58611, 58615, 58670, 58671	Female sterilization / tubal procedures series

Neurostimulators, spinal cord stimulators and related device codesCPT

61864, 61867, 61868, 61885, 61886	Intracranial / neuromodulation device implantation codes
63650, 63655, 63685	Spinal cord stimulator implantation and revision codes
64553, 64555, 64568, 64570, 64590	Peripheral nerve/neuromodulation codes
L8680-L8688	Implantable neurostimulator device L-codes

Drug, CAR-T and gene therapy codesmixedCovered

J9999	Unclassified single source drug code (used for new therapies)
Q2041, Q2042, Q2053-Q2056	CAR-T related Q-codes
C9399	Unclassified drug code (Amtagvi, Casgevy, Lantidra, Lenmeldy, Skysona require Optum Transplant prior authorization)
38232	Apheresis/procedural code requiring oncology-specific prior authorization when for oncology

Peripheral vein procedure / saphenous vein codesCPT

36468, 36473, 36475, 36478	Peripheral venous procedures
37700, 37718, 37722, 37765, 37766, 37780	Removal/ablation of saphenous veins and related procedures

Ventricular assist device (VAD) and related codesCPT

33927, 33928, 33929	VAD implantation and management codes
33975-33983	VAD device function and related CPTs
Q0507-Q0509	VAD related Q-codes

Wound VAC codesHCPCS

E2402

Negative pressure wound therapy pump (wound VAC)

K-code seating and mobility / wheelchair K-codes requiring prior authorizationHCPCS

K0005, K0008, K0013	Standard wheelchair bases and components
K0108	Seating system component
K0800 - K0886	Complex rehabilitation wheelchair and seating product codes (extensive range)
K0890	Power wheelchair base or accessory code

How Providers Submit Requests and What They Must Do

Prior Authorization

How to submit prior authorization requests

This list contains prior authorization requirements for participating UnitedHealthcare providers. Submit requests using one of the options below:

Online: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal. Go to UHCprovider.com and sign In with your One Healthcare ID and password; select the Prior Authorization and Notification tab on your dashboard. If you don't have a One Healthcare ID, visit UHCprovider.com/access.
Phone: Call 888-702-2202 (for general prior authorization requests) or other specialty numbers noted below (for example, 888-397-8129 for injectable medications and therapeutic radiopharmaceuticals; 866-889-8054 for advanced outpatient imaging and cardiology-related requests).
Fax: 866-968-7582. Fax forms are available at Prior Authorization Forms.

Prior Authorization

Cancer supportive care prior authorization (drug HCPCS/J-codes)

Prior authorization is required for colony-stimulating factor drugs and certain supportive cancer medications administered in the outpatient setting for a cancer diagnosis. Submit requests online via the UnitedHealthcare Provider Portal or call 888-397-8129.

White blood cell colony stimulating factors (examples that require prior authorization include J1442, Q5110, Q5125, Q5101, J2506, Q5122, Q5120, Q5111, Q5108)
Erythropoiesis-stimulating agents and other supportive oncology injectables (see portal guidance)

Prior Authorization

Cardiology prior authorization requirements

Prior authorization is required for many cardiology services including outpatient diagnostic catheterizations, electrophysiology implants, and stress echocardiograms. Please submit requests online using the UnitedHealthcare Provider Portal or call 866-889-8054 for assistance.

Diagnostic catheterizations and selected CPT codes (see Cardiology Prior Authorization and Notification page for full code list)
Electrophysiology device implants and related procedures
Stress echocardiography and selected cardiovascular interventional CPT codes (examples in source: 37220, 37221, 37224–37231, 93580)

Prior Authorization

How to obtain prior authorization (instructions)

Submit prior authorization requests for injectable chemotherapy, specialty injectables and therapeutic radiopharmaceuticals online using the UnitedHealthcare Provider Portal. For questions about the online authorization process or Specialty Guidance Program, contact Optum Specialty Guidance Program at 877-881-7618 or call 888-397-8129.

Chemotherapy injectables (J9000–J9999) and related HCPCS (including J0640, J0641, J0642, J1950)
Drugs billed with a Q-code and miscellaneous HCPCS codes for drugs not yet assigned permanent codes
Therapeutic radiopharmaceuticals and other high-cost injectables (see Therapeutic radiopharmaceuticals listing below)
Unclassified/temporary drug codes (C9399, J3490, J3590) — prior authorization required for certain products (see Review at Launch guidance)

Prior Authorization

EEG / cerebral seizure monitoring (codes and prior auth notes)

Some EEG services require prior authorization. Inpatient video EEG / cerebral seizure monitoring prior authorization is required for inpatient services; outpatient hospital or ambulatory surgical center EEGs are generally not required. Submit requests via the Provider Portal.

Inpatient video EEG CPT codes: 95700, 95711, 95712, 95713
Prior authorization required for inpatient video electroencephalogram monitoring

Prior Authorization

Injectable chemotherapy outpatient prior authorization

Certain injectable chemotherapy and specialty medications administered in outpatient settings require prior authorization. Submit via the Provider Portal or call 888-397-8129.

Chemotherapy injectable drugs and related HCPCS/J-codes (J9000–J9999)
Leucovorin (J0640), levoleucovorin (J0641, J0642), Lupron Depot (J1950)
Drugs billed with Q-codes and miscellaneous HCPCS for unassigned drugs

Prior Authorization

Reconstructive/cosmetic procedure prior authorization

Prior authorization is required for many reconstructive and cosmetic procedures that meet medical necessity criteria. Providers must submit clinical documentation to support medical necessity.

Large set of reconstructive/cosmetic CPT codes require prior auth when not primarily to improve physiologic function (examples in source include multiple 2xxx and 6xxx series CPT codes)
When billed with certain diagnosis codes (e.g., specified C43 and D04 ranges) prior authorization may not be required — see code-level guidance

Prior Authorization

Prior authorization required for enteral services and lab-based genetic/molecular testing

Prior authorization is required for enteral services and many lab-based genetic/molecular tests. Submit via the Provider Portal.

Enteral product HCPCS examples: B4034, B4035
Ancillary codes for feeding supplies and formula may also require prior auth

Prior Authorization

Prior authorization for specified procedures and home health services

Prior authorization is required for a broad set of outpatient procedures and home health care services. Use the Provider Portal to submit requests; specialty phone numbers may apply for certain services.

Outpatient therapy CPT examples requiring prior auth: 92507, 92508, 92526, 92630, 92633, 96105
Physical/occupational therapy, speech therapy and select modality codes: 97012, 97014, 97016, 97018, 97110, 97112, 97113, 97116, 97124, 97140, 97535
G-codes and HCPCS used for home health and other therapy services: G0152, G0153, G0299, G0300, S9123, S9124, S9128, S9129, S9131

Note

Support for online authorization

For questions about online authorization, contact the Optum Specialty Guidance Program or the Provider Portal help resources. The Specialty Guidance Program phone number is 877-881-7618.

Online submissions: Prior Authorization and Notification tool at UHCprovider.com
Optum Specialty Guidance Program (SGP) support: 877-881-7618
General portal support and contact resources available at UHCprovider.com

Prior Authorization

Surgical, pain management, and radiation oncology prior authorization

UnitedHealthcare requires prior authorization for many outpatient therapies, radiation oncology, and surgical/pain management procedures. Providers must submit clinical documentation and the applicable CPT/HCPCS codes through the Provider Portal. Out-of-network services require prior authorization for all such services.

Outpatient therapy: see callout above for CPT codes (e.g., 92507, 97110, 97124, 97535, G0281, G0283)
Pain injections/management: CPT examples include 64490, 64493
Radiation oncology: IMRT/IGRT/Proton and related codes (examples include 77385, 77386, 77331, 77402, 77407, 77412, IGRT 77014)
Surgical prior authorization: many specified surgical CPT codes require prior auth (examples across sections include joint replacement codes 27130, 27447, hysterectomy codes 58150–58571, and ENT/orthognathic codes)
Out-of-network requirement: Prior authorization is required for all out-of-network services; contact the plan prior to scheduling

Prior Authorization

ENT procedures prior authorization and codes

Prior authorization is required for many ENT procedures. Submit requests through the Provider Portal and include supporting clinical documentation.

Rhinoplasty and septoplasty CPT codes: 30400, 30410, 30420, 30430
Functional nasal and septal procedures: 30460, 30465, 30465-related codes
Endoscopic sinus and FESS codes: 31240, 31253, 31254, 31255, 31256
Sinuplasty codes: 31295, 31296; sleep apnea-related nasal procedures may also require prior auth

Prior Authorization

Vein procedures prior authorization

Prior authorization is required for many vein procedures and ablations. Providers must submit requests with the appropriate CPT codes and clinical justification via the Provider Portal.

Vein procedure CPT examples requiring prior auth: 36468, 36473, 36475, 36478
Open/major vein procedures and trunk removal/ablation examples: 37700, 37718, 37722, 37765, 37766, 37780
Include clinical documentation supporting treatment of venous disease or varicosities

Note

Dental prior authorization contact

Dental prior authorization requests and questions should be directed to UnitedHealthcare Dental.

UnitedHealthcare Dental prior authorization contact: 855-812-9208

Prior Authorization

Therapeutic radiopharmaceuticals / injectable medications listing

Therapeutic radiopharmaceuticals and certain injectable medications require prior authorization. Submit requests online via the UnitedHealthcare Provider Portal or call 888-397-8129. For products included in Review at Launch or requiring specialty guidance, follow the special submission instructions.

Examples and codes (not exhaustive): J9332, J9334, J0218, J9202, J3399, J0791 — check Provider Portal for complete and updated list
If billed with unclassified/temporary codes (C9399, J3490, J3590), some products require prior authorization through Optum Transplant or other specialty teams (see Review at Launch guidance)
White blood cell colony stimulating factors are listed separately (see Cancer supportive care section); prior authorization required for both oncology and non-oncology diagnoses

Key Terms and Submission Channels

Prior authorization

DefinitionPrior authorization is a payer requirement that approval be obtained before the service or medication is provided

Authorized submission channelsOnline via the Prior Authorization and Notification tool on UHCprovider.com, phone and fax options are also provided

When requiredApplies to numerous inpatient and outpatient services listed throughout the document (see service-specific entries)

How to obtain prior authorization

Primary channelOnline: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) with One Healthcare ID

Phone optionsCall the prior authorization phone numbers shown in the document (examples: 888-702-2202; 888-397-8129 for certain services)

Fax optionFax requests to the number provided (example: 866-968-7582) and use the fax form available at Prior Authorization Forms

EEG / cerebral seizure monitoring

Codes coveredCerebral seizure monitoring and EEG CPT codes (examples: 95700, 95711, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95722, 95724, 95726)

Inpatient EEGInpatient video EEG monitoring codes (95700–95718 range) — prior authorization is required for inpatient services

Outpatient EEGRoutine EEG codes for outpatient hospital or ambulatory surgical center are noted as requiring prior authorization

Reconstructive procedure (as used in this section)

DefinitionReconstructive procedure: procedures that treat a medical condition or improve or restore physiologic function

DistinctionContrasted with cosmetic procedures that primarily change appearance without restoring physiologic function

Authorization noteMany reconstructive procedure CPT entries in this section indicate prior authorization is required

Cosmetic procedure (as used in this section)

DefinitionCosmetic procedure: procedures that change or improve physical appearance without significantly improving or restoring physiologic function

Contrast to reconstructiveCosmetic procedures are distinguished from reconstructive procedures which treat medical conditions or restore function

Authorization implicationEntries list both reconstructive and cosmetic codes; many reconstructive entries require prior authorization

Enteral services

RequirementEnteral services require prior authorization (listed HCPCS codes include B4034, B4035, B4036, B4100, B4102, B4103 and others)

Process for genetic testingProviders requesting outpatient genetic/molecular testing must complete the prior authorization/notification process and indicate the laboratory and test name

Examples of enteral codesB4034, B4035 (partial list shown)

Genetic and molecular testing (outpatient)

RequirementOutpatient genetic and molecular testing requires prior authorization/notification and providers must indicate laboratory and test name

Example codesGenetic testing examples listed: 81229, 81401, 81403, 81411, 81313 (among others)

Submission instructionPayment will be authorized for listed CPT codes when prior authorization/notification process is completed

Prior authorization is a payer requirement that approval be obtained before the service or medication is provided.

DefinitionPrior authorization is a payer requirement that approval be obtained before the service or medication is provided

ImplicationProviders must obtain authorization for services and medications listed as requiring prior authorization prior to providing them

Where statedThis definition is used throughout the document to indicate services requiring prior authorization

Review at Launch

Policy referenceReview at Launch for New to Market Medications policy — check for most up-to-date information on newly FDA-approved drugs

RecommendationPredetermination is highly recommended for drugs on the Review at Launch list

Submission guidanceSubmit requests online via the UnitedHealthcare Provider Portal or call 888-397-8129 as noted

Submission channels

Online portalUse the Prior Authorization and Notification tool on UHCprovider.com (sign in with One Healthcare ID) — primary submission channel

PhoneCall the documented phone numbers for prior authorization (examples in document: 888-702-2202; 888-397-8129)

FaxFax prior authorization forms to the provided fax numbers (example: 866-968-7582) and use the fax form available at Prior Authorization Forms

Proton beam therapy (definition)

DefinitionProton beam therapy: focused radiation therapy using beams of protons (tiny particles with a positive charge)

ContextListed under radiation therapy and Review at Launch references; specific prior authorization details appear elsewhere in radiation oncology section

CodingCPT/HCPCS codes for proton beam therapy may be listed in the radiation oncology code sections

Clinical documentation to support the need for transplants

Documentation requirementClinical documentation to support the need for transplants must accompany and establish medical necessity for the service request

Contact routeFor transplant and CAR T-Cell therapy services, call the UnitedHealthcare Transplant Case Management Team (number provided in document) to obtain prior authorization

ExamplesCAR T products listed include Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta — clinical documentation required

Third-party review route for prior authorization of certain unclassified codes and specified gene therapies

Third‑party routeOptum Transplant is the required prior authorization route for certain unclassified drug codes and listed cell/gene therapies

ApplicabilityApplies to unclassified codes J3490, J3590, and C9399 when used for specified products (Amtagvi, Casgevy, Lantidra, Lenmeldy, Skysona)

ActionSubmit prior authorization through Optum Transplant for the specified unclassified codes and products

Optum Transplant prior authorization

DesignationOptum Transplant prior authorization: required route for specific unclassified drug codes and listed cell/gene therapies

Codes/productsUnclassified codes J3490, J3590, C9399 for Amtagvi, Casgevy, Lantidra, Lenmeldy, Skysona require prior authorization via Optum Transplant

Provider actionProviders must route prior authorization requests for these items to Optum Transplant rather than standard channels

Optum VAD Case Management

ProgramOptum VAD Case Management handles VAD prior authorization notifications

Notification processCall the notification number on the back of the member's health plan ID card, then fax the form provided by the nurse to Optum VAD Case Management at 855-282-8929

ScopeApplies to ventricular assist devices and related mechanical pump/function codes (examples: 33927, 33928, 33929, 33975, 33976, etc.)

OpenPayer

Prior authorization requirements for UnitedHealthcare Community Plan of New Mexico

Services and Codes That Require Prior Authorization

Relevant CPT, HCPCS and ICD-10 Codes

How Providers Submit Requests and What They Must Do

Key Terms and Submission Channels