CurrentUnitedHealthcarePolicy N/A

Prior Authorization Requirements for New York Medicaid

This document lists services, codes, and procedures that require prior authorization for participating UnitedHealthcare Community Plan of New York providers, and describes how to submit prior authorization requests. It applies to providers participating with UnitedHealthcare Community Plan of New York.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Requirements for New York Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-362-3368.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-07-01effective date

866-362-3368contact

UHCprovider.comprovider portal

elective inpatientinpatient PA rule

no PAemergency exception

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$500orthotics threshold

Prior Authorization Coverage Criteria

Service-specific requirements (excerpt)

Service-specific prior authorization requirements and examples. The entries below summarize services, whether prior authorization is required, and example CPT/HCPCS/J-codes when provided in the source.

Bariatric surgery — Prior authorization required. Example CPT codes: 43644, 43645, 43659, 43770, 43775, 43842, 43845, 43846, 43847, 43848, 43860.

Behavioral health services — Some behavioral health services require referral/prior authorization through the plan's behavioral health network. For specific codes and referral instructions, call the number on the member's ID card; applied behavior analysis (ABA) therapy may require fax submission per plan instructions.

Bone growth stimulator — Prior authorization required. Example CPT: 20975, 20979.

Breast reconstruction (non-mastectomy and mastectomy-related procedures) — Prior authorization required for many reconstructive and mastectomy-related codes. Example CPT codes: 11971, 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 19396, L8600.

Cancer supportive care / colony-stimulating factors — Prior authorization required for outpatient administration for cancer diagnoses and for certain colony-stimulating factor drugs both for oncology and non-oncology diagnoses. Example J-/Q-codes: J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111 and many others listed in drug-specific lists.

Cerebral seizure monitoring / EEG — Some EEG and inpatient video EEG entries note prior authorization rules: inpatient video EEG prior authorization is not required for outpatient hospital or ambulatory settings; example monitoring codes include 95700, 95711-95716, 95718.

Chemotherapy — Prior authorization is not required for certain outpatient hospital or ASC settings (per source) but many chemotherapy injectable drugs require prior authorization. Example inpatient/outpatient administration codes listed alongside J9000–J9999 range, J0640–J0642, J1950 and Q-codes; miscellaneous/unassigned HCPCS (e.g., unassigned codes) will require prior authorization.

Cochlear implants and auditory implants — Prior authorization required. Example CPT/HCPCS: 69710, 69714, 69930, L8614.

Continuous glucose monitors — Prior authorization required. Example HCPCS: A4238, A4239, E2102, E2103.

Cosmetic and reconstructive procedures — Prior authorization required for many cosmetic codes; reconstructive procedures that treat a medical condition may be covered and have specific code guidance. Examples (cosmetic): 11960, 14020, 14021, 14061, 15820-15823. Reconstructive examples: 21280, 21282, 21295, 21740-21743, 28344, 30620, 67900-67903, 67904, 67906, 67908-67917, 67921-67924, 67950, 67961, 67966, Q2026. Note: some reconstructive procedures may not require prior auth when billed with skin cancer diagnoses per the source.

Durable medical equipment (DME) — Prior authorization required only for listed DME codes with a retail purchase or cumulative rental cost above plan thresholds. Example HCPCS codes listed include A4575, A9279, A9280, E0194, E0265, E0266, E0270, E0277, E0300, E0328, E0329, E0445, E0457, E0465, E0466, E0470, E0471, E0483, E0486, E0620 and many orthotics/prosthetic L-codes noted separately.

Erectile dysfunction procedures and supplies — Prior authorization required for some procedures and medications; examples include procedural CPTs (37788, 37790, 54400-54417) and J-/L-codes for medications/supplies (e.g., J0275, J0775, J2440, L7900, L7902).

Functional endoscopic sinus surgery (FESS) / sinus surgery — Prior authorization required. Example CPTs: 31240, 31253-31259, 31267, 31276, 31287, 31288, 31296–31299 according to source entries.

Genetic and molecular testing (including BRCA) — Prior authorization/notification required for many genetic tests, including BRCA sequencing and numerous CPT/HCPCS codes listed (examples: 81162–81164, 81228–81229, 81400–81417, 81431–81437, 81440, 81445, 81448, 81460, 81465, 81479, 81518–81521, 81546, 81595, 81599, 87505–87507, and many proprietary/temporary codes such as 0006M, 0007M, 0018U, 0022U–0023U, 0026U, 0055U, 0060U, 0087U, 0088U, 0111U, 0129U, S3870). The source requires laboratories and ordering providers to complete the plan's authorization/notification process.

Hysterectomy — Prior authorization required for many hysterectomy CPTs listed with diagnostic linkage; examples include 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270 and related codes.

Injectable medications / specialty drugs — Prior authorization required for many injectable and specialty medications. The source lists numerous J-codes (see drug list) including high-cost and specialty agents (e.g., Actemra J3262; many oncology, immunologic, enzyme replacement, monoclonal antibodies, and radiopharmaceutical agents). Some products require notification through third-party services per the source (e.g., Cimzia via Magellan). Unclassified/temporary codes (C9090, C9149, C9151, C9166, C9172, C9399, J3490, J3590) may have specific prior authorization rules.

Joint replacement (total hip and knee) — Prior authorization required for joint replacement procedures. Example CPTs referenced (multiple codes repeated in source) and instructions to submit online via the Prior Authorization and Notification tool or call 888-397-8129.

Non-emergent air ambulance transport — Prior authorization required. Example HCPCS: A0430, A0431, A0435. Submit via Provider Portal or call 888-397-8129 per source.

Orthognathic surgery — Prior authorization required for treatment of maxillofacial/jaw functional impairment. Example CPTs: 21121, 21123, 21125, 21127, 21299 and related codes. Submit via Provider Portal or call 888-397-8129.

Orthotics and prosthetics — Prior authorization required only for listed orthotic and prosthetic codes with retail purchase or cumulative rental cost above plan thresholds. Example L-codes: L0112, L0170, L0484, L0486, L0624, L0629, L0631, L0632, L0634, L0636, L0637, L0638 and others; some entries reference threshold (more than $500) or other dollar limits.

Outpatient therapy — Prior authorization required. Example therapy CPTs referenced include 97530, 92507, 97542, S9152 depending on service type and code mapping provided in source.

Potentially unproven services — Prior authorization required. Source lists example codes (e.g., 33289, C2624) as potentially unproven requiring prior authorization.

Private duty nursing — Prior authorization required. Example HCPCS/T-codes: T1000, T1002, T1003.

Prostate procedures — Prior authorization required. Example CPTs: 37243, 52441, 52442, 53850, 53852, 55873, 55874 and others.

Proton beam therapy — Prior authorization required. Example CPTs: 77520, 77522, 77523, 77525.

Radiology / advanced outpatient imaging — Prior authorization required for advanced outpatient imaging (certain CT, MRI, MRA, PET, nuclear medicine). Providers must notify/prior authorize via Provider Portal or call 866-889-8054; see Radiology Prior Authorization details for exact CPT lists (examples include temporary CPTs 0710T–0713T and other advanced imaging codes).

Rhinoplasty and septoplasty / sinuplasty — Prior authorization required when for treatment of nasal functional impairment; example sinuplasty CPTs: 31296, 31297, 31298.

Sleep studies and sleep apnea procedures — Prior authorization required for many sleep procedures and sleep studies (examples: 95805, 95807–95811, etc.). Note: New York long-term services and supports (LTSS) may be exempt per source.

Spinal surgery — Prior authorization required. Numerous spinal surgery CPTs listed in source (examples include 22100–22224, 22510–22515, 22532–22533, 22548, 22551, etc.).

Stimulators / implantation of electrical impulse devices — Prior authorization required. Example HCPCS: E0747, E0748, E0749, E0760.

Transplants and CAR T-cell therapies — Prior authorization required. For transplant and CAR T-cell therapy services (including specific CAR-T products listed), contact UnitedHealthcare Community and State Transplant Case Management at 888-936-7246 or the number on the member's ID card per source instructions.

Ventricular assist devices (VAD) — Prior authorization required. Contact notification number on member ID and fax required forms to Optum VAD Case Management at 855-282-8929 per source.

Wound VAC — Prior authorization required. Example HCPCS: E2402.

Codes and Code Groups Requiring Prior Authorization

Bariatric and obesity-related procedure codesCPTCovered

43644	Bariatric surgery procedure code listed as requiring prior authorization
43645	Bariatric surgery procedure code listed as requiring prior authorization
43659	Bariatric surgery procedure code listed as requiring prior authorization
43770	Bariatric surgery procedure code listed as requiring prior authorization
43775	Bariatric/obesity-related service code listed
43842	Bariatric/obesity-related service code listed
43845	Bariatric/obesity-related service code listed
43846	Bariatric/obesity-related service code listed
43847	Obesity-related service code listed
43848	Obesity-related service code listed

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Breast reconstruction and mastectomy-related codesCPTCovered

11971	Breast reconstruction (non-mastectomy) code listed
19316	Breast reconstruction (non-mastectomy) code listed
19318	Breast reconstruction (non-mastectomy) code listed
19325	Breast reconstruction code listed
19328	Breast reconstruction code listed
19330	Breast reconstruction code listed
19340	Breast reconstruction code listed
19342	Breast reconstruction code listed
19350	Breast procedure code listed
19357	Breast procedure code listed

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Cancer supportive care injectable drugs (HCPCS/J-codes)HCPCSCovered

J1442	Filgrastim (Neupogen) - injectable colony-stimulating factor requiring prior authorization
J1447	Tbo-filgrastim (Granix) - injectable colony-stimulating factor requiring prior authorization
J2506	Pegfilgrastim (Neulasta) - injectable colony-stimulating factor requiring prior authorization
Q5101	Filgrastim-sndz (Zarxio) - requires prior authorization
Q5108	Pegfilgrastim-jmdb (Fulphila) - requires prior authorization
Q5110	Filgrastim - listed
J0185	Cinvanti (aprepitant) - antiemetic listed
J1454	Akynzeo (palonosetron/fosnetupitant) - listed
J1453	Emend (fosaprepitant) - listed
J1627	Sustole (granisetron ER) - listed

Bone growth stimulator codesCPTCovered

20975	Bone growth stimulator CPT code requiring prior authorization
20979	Bone growth stimulator CPT code requiring prior authorization

Cardiology/example code referencesCPT

93319

Echocardiography-related code referenced in cardiology section

ICD-10 osteomyelitis codes (partial)ICD-10

M86.369	ICD-10 diagnosis code referenced in the list
M86.371	ICD-10 diagnosis code referenced in the list
M86.372	ICD-10 diagnosis code referenced in the list

Drug and device HCPCS/J-code groups shownHCPCS

J9000-J9999	Chemotherapy injectable drug J-codes (range)
A4238	Continuous glucose monitor supplies
L8614	Cochlear implant device code

HCPCS, V-, E-, K- codes (partial list)HCPCS

E2329
E2331
E2351
E2373
E2510
E2511
E2512
E2599
E2626
E2627

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Enteral, B-codes, and FESS CPT codes (partial)mixedCovered

B4034
B4035
B4036
B4102	Enteral services
B4103	Enteral services
B4104	Enteral services
B4150	Enteral services
B4152	Enteral services
B4153	Enteral services
B4158	Enteral/gastrostomy therapy

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Select injectable medication HCPCS/CPT codes (partial list)HCPCSCovered

J3262	Actemra (example listed in section)
J0597	Berinert
J0585	Botulinum toxins
J0567	Brineura
J1786	Cerezyme
J3380	Entyvio
J1745	Remicade
J9312	Rituxan
J1306	Leqvio

Unclassified and temporary codesmixed

C9090	Unclassified/temporary code (example)
J3490	Unclassified drug code
J3590	Unclassified drug code

Joint replacement CPT codes (partial list)CPTCovered

24360	Joint replacement procedure code listed
27120	Hip replacement procedure code listed
27125	Hip replacement procedure code listed

Joint replacement and related implant codes (examples)mixed

27130	Total hip replacement (example code listed)
27132	Total hip replacement (example code listed)
27447	Knee replacement (example code listed)
J7330	Prosthetic implant code listed

Non-emergent air ambulanceHCPCS

A0430

Non-emergent air ambulance transport

Orthotics and prosthetics (examples)HCPCS

L0638

Orthotic/prosthetic code (example)

Listed HCPCS L-codesHCPCSCovered

L0484	Orthotics and prosthetics (listed HCPCS L-code)
L0486	Orthotics and prosthetics (listed HCPCS L-code)
L0624	Orthotics and prosthetics (listed HCPCS L-code)
L0629	Orthotics and prosthetics (listed HCPCS L-code)
L0631	Orthotics and prosthetics (listed HCPCS L-code)
L0632	Orthotics and prosthetics (listed HCPCS L-code)
L0634	Orthotics and prosthetics (listed HCPCS L-code)
L0636	Orthotics and prosthetics (listed HCPCS L-code)
L0637	Orthotics and prosthetics (listed HCPCS L-code)
L0638	Orthotics and prosthetics (listed HCPCS L-code)

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Examples of CPT/HCPCS codes requiring prior authorizationmixedCovered

L6885	Listed therapeutic radiopharmaceuticals / outpatient therapy
L6895	Listed therapeutic radiopharmaceuticals / outpatient therapy
77520	Proton beam therapy
0712T	Advanced outpatient imaging (example code listed)

Selected procedural codes (non-exhaustive) listed in documentCPTCovered

45378	Colonoscopy (example listed under how to obtain prior authorization)
30400	Rhinoplasty (listed as prior authorization required)
31295	Sinuplasty (prior authorization required)
29805	Shoulder surgery (prior authorization required)

mixed procedure codes enumeratedmixed

15240	Skin grafting/related procedure code referenced
19020	Procedural code listed in outpatient hospital site of service
19120	Procedural code listed
19125	Procedural code listed
20680	Injections/aspiration codes listed
20552	Injection procedure code listed
20553	Injection procedure code listed

Referenced CPT/HCPCS codes for VAD and wound VACmixedCovered

33927
33928
33929
33975
33976
33979
33981
33982
33983
Q0507

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DME cost threshold (definition/operational note)

Operational rulePrior authorization is required only for the DME codes listed when the item meets the retail purchase or cumulative rental cost threshold; request submission via UHCprovider.com or listed phone number.

ScopeApplies only to DME codes explicitly listed in the document (examples include A4575, A9279, A9280, E0194, E0265).

Cost condition wording

How Providers Submit Prior Authorization and Required Actions

Prior Authorization

Cerebral seizure monitoring / Inpatient video EEG

Prior authorization is required for cerebral seizure monitoring and inpatient video EEG when performed as an inpatient service. Prior authorization is not required for outpatient hospital or ambulatory EEG services. To request prior authorization, submit online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com › Sign In › Prior Authorization and Notification) or call the phone number on the member's ID card or 888-397-8129 when applicable.

CPT/HCPCS examples: 95700, 95711, 95712, 95713, 95714, 95715, 95716, 95718

Prior Authorization

Cosmetic and reconstructive procedures

Cosmetic and many reconstructive procedures require prior authorization. Reconstructive procedures done to improve or restore physiological function or to treat a medical condition may be covered but still typically require prior authorization; some reconstructive procedures billed with skin cancer diagnoses may not require prior authorization. Submit requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com › Sign In › Prior Authorization and Notification) or call 888-397-8129.

Definitions and Thresholds

Prior authorization definition

DefinitionPrior authorization is the requirement to obtain approval from the plan before providing planned, elective inpatient services (and certain outpatient services) so that the service will be covered.

Submission methodsRequests may be submitted online via the Prior Authorization and Notification tool on UHCprovider.com or by phone (866-362-3368).

ExceptionsEmergent or urgent care does not require prior authorization; all planned elective inpatient services do require prior authorization.

Cancer supportive care drugs (definition)

DefinitionCancer supportive care drugs include injectable colony-stimulating factors and bone-modifying agents administered in an outpatient setting for a cancer diagnosis that require prior authorization.

Example codes

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Requirements for New York Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-362-3368.

SourceLink

On This Page

Threshold language in source: 'Prior authorization is required only for the DME codes listed with a retail purchase or cumulative rental cost of more' / 'cumulative rental cost of more'.

Orthotics/prosthetics retail purchase or cumulative rental cost threshold

Threshold amount>$500 retail purchase or cumulative rental cost triggers prior authorization for orthotics and prosthetics.

ApplicationApplies only to the HCPCS L-codes listed in the orthotics and prosthetics section (examples: L0484, L0486, L0624, L0629, L0631-L0638).

How to submitSubmit prior authorization requests online via the Prior Authorization and Notification tool at UHCprovider.com or call 888-397-8129.

Cost threshold for additional info

Documented noteSome listed DME and orthotics/prosthetics entries include an 'Additional information' reference to a cost threshold (source text: 'Additional information = only for the DME codes listed.' and 'Additional information = more than S500').

Interpretation'More than $500' language is used in the source to indicate when additional information / prior authorization is required for items listed in orthotics and prosthetics sections.

ActionProviders should check the listed HCPCS/L- and E-/K-codes and the associated 'Additional information' field to determine if the cost threshold applies before submitting a PA request.

Representative CPT codes requiring prior authorization include: 11960, 14020, 14021, 14061, 15820–15823, 15830, 15847, 15877–15879, 17106–17108, 17999, 21137–21139, 21172–21184, 21230, 21235, 21256, 21275, 21280, 21282, 21295, 21740–21743, 28344, 30620, 67900–67917, 67921–67924, 67950, 67961, Q2026

Note: Codes listed are representative; review the full policy/code list for completeness.

Prior Authorization

Prior authorization required — select V-codes

Certain V-codes and related device supply V-codes require prior authorization. Prior authorization must be obtained before scheduling. Submit online via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call the provider phone number for assistance.

Representative V-codes: V5270, V5271, V5272, V5274, V5281–V5283, V5286–V5290
Associated supplies: B4034, B4035, B4036

Prior Authorization

Prior authorization required — erectile dysfunction

Erectile dysfunction procedures, devices and some related drug therapies require prior authorization. Providers should obtain prior authorization for surgical procedures, penile implants, injectable therapies, and certain prosthetic codes prior to service.

Representative CPT/HCPCS codes: 37788, 37790, 54400, 54405, 54408, 54416, 54417
Representative drug/prosthetic codes: J0275, J0775, J2440; L7900, L7902

Prior Authorization

Prior authorization — gender dysphoria surgical procedures

Surgical procedures related to treatment of gender dysphoria require prior authorization and must be submitted with the appropriate diagnosis codes. Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call the number on the back of the member's ID card for case-specific instructions.

Examples: surgical codes mapped to gender dysphoria diagnoses (F64.0–F64.9) include multiple procedure codes across specialties — verify code-to-diagnosis mapping before submitting.
Note: Prior authorization requirements vary by procedure; include supporting clinical documentation with the request.

Prior Authorization

Prior authorization — home health, hysterectomy, injectables

Home health services, hysterectomy procedures, and many injectable medications require prior authorization or notification. Home health prior authorization is generally required for outpatient settings (including services to the member's home). Hysterectomy and many injectables require prior authorization prior to scheduling or administration.

Home health example codes: G0156, G0162, G0299, G0300, G0493–G0496, S9122–S9124, S9474
Hysterectomy example codes: 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58275, 58290–58292, 58541–58544, 58550, 58552–58554, 58570–58573
Injectables: many J-codes require prior authorization — see the injectable medication list and specialty drug guidance

Prior Authorization

Joint replacement prior authorization

Total hip and knee joint replacement procedures require prior authorization. Submit requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com › Sign In › Prior Authorization and Notification) or call 888-397-8129.

Representative CPT codes: 24360–24363, 24370–24371, 27120, 27125, 27130, 27132, 27134, 27137 (and additional hip/knee replacement codes listed in the policy)

Prior Authorization

Services requiring prior authorization (examples)

Many services across specialties require prior authorization. This includes advanced outpatient imaging, proton beam therapy, spinal surgery, stimulators/device implantation, private duty nursing, outpatient therapy, potentially unproven services, prostate procedures, and more. Providers are responsible for obtaining authorization or notification before scheduling non-emergent services.

Advanced imaging: certain CT, MRI, MRA, PET and nuclear medicine procedures (see Radiology Prior Authorization and Notification) — call 866-889-8054 for imaging prior authorizations.
Proton beam therapy: CPT 77520–77525 — prior authorization required.
Spinal surgery and stimulators: numerous CPT/HCPCS codes listed in the policy — prior authorization required.
Outpatient therapy and private duty nursing: prior authorization required.

Prior Authorization

Site of service prior authorization rule

Site-of-service rules: prior authorization is required when services are requested in an outpatient hospital setting. Prior authorization is not required when the same services are performed at a participating ambulatory surgical center (ASC). Verify the site of service when submitting authorization requests.

Examples where SOS matters: certain cardiovascular, auditory, and other procedures; specific CPT examples include 36590, 36832, and others noted in the policy.
Operational note: When requesting services in an outpatient hospital, include justification for site selection to avoid denials.

Prior Authorization

Transplants and CAR-T cell therapy

Transplants and CAR-T cell therapies require special handling and prior authorization through UnitedHealthcare's transplant case management team. Providers must contact the Transplant Case Management team for authorization and program coordination before scheduling.

Call UnitedHealthcare Community and State Transplant Case Management at 888-936-7246 (or the number on the back of the member's ID card) for transplants and CAR-T services including but not limited to: Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta, Zynteglo.
Representative transplant/CAR-T related CPT/HCPCS codes are listed in the policy — obtain case management guidance before submission.

Prior Authorization

Vein procedures / Ventricular Assist Devices (VAD)

Vein procedures and Ventricular Assist Device (VAD) services require prior authorization and specific notification steps. For VADs, providers must contact the member's plan notification number and fax required forms to the Optum VAD Case Management team. For vein procedures, obtain prior authorization before treatment.

Vein procedure examples requiring prior authorization: 36473, 36475, 37700, 37718, 37722, 37766.
VAD steps: Call the notification number on the back of the member's health plan ID card, then fax the nurse-provided form to Optum VAD Case Management at 855-282-8929.
Representative VAD procedure/device codes requiring prior authorization: 33927–33929, 33975–33983, Q0507–Q0509.

Prior Authorization

VAD procedure codes (PA required)

Some specific VAD procedure codes always require prior authorization; verify and obtain authorization before scheduling implantation or related procedures. Contact Optum VAD Case Management for case initiation and required documentation.

Common VAD-related CPT/HCPCS codes requiring prior authorization: 33927, 33928, 33929, 33975, 33976, 33979, 33981, 33982, 33983, Q0507, Q0508, Q0509

Note

Prior authorization and contact instructions

How to obtain prior authorization and contact instructions: submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com › Sign In › Prior Authorization and Notification). If you do not have portal access, call the appropriate phone number shown in this policy for the service type (examples: 866-362-3368 general; 888-397-8129 for many surgical and drug requests; 866-889-8054 for radiology; 888-936-7246 for transplant case management). Include clinical documentation, relevant diagnosis codes, and justification for site of service when applicable.

Online portal (preferred): UHCprovider.com › Sign In › Prior Authorization and Notification tab.
Phone contacts (examples): General prior auth/notifications: 866-362-3368; Surgical/oncology portal support: 888-397-8129; Radiology prior authorization: 866-889-8054; Transplant Case Management: 888-936-7246; Optum VAD Case Management fax: 855-282-8929.
Operational notes: All planned elective inpatient services require prior authorization. Emergent or urgent care does not require prior authorization. Non-emergent out-of-network services require prior authorization regardless of place of service.

Examples shown in the document include J1442, J1447, J2506 and Q5101/Q5108/Q5110/Q5111 (white blood cell colony-stimulating factors).

Submission guidanceSubmit PA requests online via the Prior Authorization and Notification tool on UHCprovider.com or call 888-397-8129 for cancer supportive care drugs.

Inpatient video EEG prior auth note

Operational noteInpatient video EEG (inpatient video electroencephalogram) requires prior authorization; outpatient/ambulatory EEG does not require prior authorization.

Relevant CPT codesListed codes include 95700, 95711–95713 and inpatient video EEG codes 95714, 95715, 95716, 95718.

Provider actionFollow standard PA submission routes when scheduling inpatient video EEG (use portal or phone as specified for prior authorization).

DME prior authorization threshold

RulePrior authorization for DME applies only to the DME codes listed in the document when the item meets the retail purchase or cumulative rental cost threshold noted in the item's 'Additional information'.

Examples of listed DME codesExamples in the DME section include A4575, A9279, A9280, E0194, E0265 and many E-/K- codes.

Submission instructionSubmit PA requests for listed DME items via the Prior Authorization and Notification tool on UHCprovider.com or by the phone numbers provided in the document.

F64.x diagnosis mapping

MappingGender dysphoria surgical procedure codes in the document are associated with ICD-10 F64.x diagnoses mapping (DX.F64.0, DX.F64.1, DX.F64.2, DX.F64.8) to align procedures and diagnosis codes.

PurposeThe F64.x mapping is used to associate listed surgical CPT/HCPCS codes with gender dysphoria diagnostic codes for prior authorization processing.

Provider noteInclude the appropriate F64.x diagnosis code when submitting authorization requests for gender dysphoria–related surgical procedures as shown in the list.

Genetic test notification/prior authorization

RequirementGenetic and molecular testing (including BRCA and other specified tests) require prior authorization or notification; ordering provider must indicate the laboratory and complete the authorization/notification process.

Example codesExamples include 81228, 81229 and an extensive list of 814xx/815xx codes referenced for authorization/notification.

Process detailThe source instructs providers to supply lab identification and complete the prior authorization/notification process as part of the submission.

Prior notification (term)

TermPrior notification: providers requesting certain advanced outpatient imaging procedures (CT, MRI, MRA, PET, nuclear medicine/nuclear cardiology) are responsible for providing notification prior to scheduling; some drugs/devices may also require prior notification.

Where usedUsed for advanced outpatient imaging and some injectable/ specialty medications that require notification before scheduling or administration.

How to notifyFollow the Provider Portal instructions (Prior Authorization and Notification tab) or use the phone numbers provided in the document for notification requirements.

Prior authorization submission (term)

DefinitionPrior authorization submission: the methods and contact routes to request authorization (online via the Prior Authorization and Notification tool at UHCprovider.com or by phone using the numbers listed in the document).

Portal instructionTo submit online, sign in at UHCprovider.com with One Healthcare ID and select the Prior Authorization and Notification tab on the dashboard.

Phone alternativesPhone numbers cited for PA submission/assistance include 866-362-3368 and 888-397-8129; specific sections reference which number to use for particular services.

UHCprovider.com prior authorization tool

Tool nameThe Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) is the primary online submission route for PA requests.

Access stepsLog in at UHCprovider.com using One Healthcare ID, then select the Prior Authorization and Notification tab on your dashboard.

AlternativeIf unable to submit online, phone numbers in the document (e.g., 888-397-8129 or 866-362-3368) are provided as alternatives depending on the service line.

>$500 threshold for orthotics/prosthetics

Threshold statementOrthotics and prosthetics listed require prior authorization only when the retail purchase or cumulative rental cost is more than $500.

Where statedSource text: 'Additional information = more than S500.' and adjacent HCPCS L-code listings in orthotics and prosthetics sections.

Provider actionVerify the item's retail or cumulative rental cost against the >$500 threshold before submitting a PA; submit via UHCprovider.com or call 888-397-8129.

UHCprovider.com PA tool (duplicate)

Duplicate referenceUHCprovider.com Prior Authorization and Notification tool is emphasized throughout the document as the route to submit PA requests (see joint replacement and other sections).

Access guidanceSign in at UHCprovider.com with One Healthcare ID and select the Prior Authorization and Notification tab on the dashboard to start a request.

Phone backupIf online submission is not used, the document provides phone numbers for PA support (e.g., 888-397-8129 for many service lines).

888-397-8129 (phone contact)

Phone contactCall 888-397-8129 for prior authorization assistance for many service lines (document repeatedly lists this number as the PA contact).

When to callListed as the contact for joint replacement and multiple orthotics/prosthetics and other PA submissions when not using the portal.

Portal alternativeProviders are encouraged to use the Prior Authorization and Notification tool on UHCprovider.com as the primary submission path.

Proton beam therapy (term)

DefinitionProton beam therapy: focused radiation therapy using beams of protons; source indicates prior authorization is required for proton beam therapy codes (examples: 77520, 77522, 77523, 77525, and L68xx entries).

Codes citedCited CPT codes for proton beam therapy include 77520, 77522, 77523, 77525 and related L-codes (e.g., L6885, L6895, L6900, L6905 in source).

Provider actionPrior authorization required; submit online via UHCprovider.com or follow the portal/phone instructions in the advanced imaging/proton beam therapy section.

Stimulators (term)

DefinitionStimulators: implantation of a device that sends electrical impulses; the document states implantation of stimulators requires prior authorization.

Example HCPCS/CPT codesSource lists device codes including E0747, E0748, E0749, E0760 and CPT codes such as 61863, 61864, 61867, 61868, 61885, 61886, 63650, 63655, 63685, 64553, 64555, 64568, 64590.

Operational noteProviders must obtain prior authorization for stimulator implantations per the device/procedure codes listed in the stimulator section.

Ventricular assist devices (VAD) (term)

DefinitionVentricular assist devices (VAD): a mechanical pump that assists the damaged ventricle and restores normal blood flow; prior authorization is required for VAD services.

Provider instructionsCall the notification number on the back of the member's health plan ID card, then fax the nurse‑provided form to Optum VAD Case Management at 855-282-8929 as directed in the source.

Example codesCited VAD procedure codes include 33927, 33928, 33929, 33975, 33976, 33979, 33981–33983 and Q0507–Q0509 in the VAD section.

Transplant / CAR-T processes (term)

Process summaryTransplant and CAR-T cell therapy services require prior authorization and coordination with UnitedHealthcare Community and State Transplant Case Management; call the Transplant Case Management team at 888-936-7246 (or the number on the member's ID card) as instructed.

ScopeApplies to listed transplant procedures and CAR-T therapies (examples and product names are provided in the source text).

Provider actionContact the Transplant Case Management team for authorization and coordination prior to scheduling transplant or CAR-T services.

Ventricular assist device (VAD) definition

DefinitionVentricular assist device (VAD): a mechanical pump that assists the damaged ventricle of the heart and restores normal blood flow.

PA requirementPrior authorization required for VAD-related services and listed VAD procedure codes (examples: 33927–33929, 33975–33983, Q0507–Q0509).

Administrative stepFollow the VAD-specific notification instructions in the document (call member ID number then fax form to Optum VAD Case Management at 855-282-8929).

Wound VAC definition

DefinitionWound VAC: negative pressure wound therapy device; prior authorization is required for wound VAC devices listed (source associates E2402 with the Wound VAC PA requirement).

Associated codeHCPCS E2402 is specifically listed for wound VAC and requires prior authorization.

Provider actionSubmit PA for wound VAC devices per the document's PA submission instructions (UHCprovider.com or specified phone contacts).