CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Pennsylvania CHIP Medicaid

Lists services and codes that require prior authorization for participating providers in UnitedHealthcare Community Plan Pennsylvania CHIP, and explains how to request authorization via portal, phone, or fax. Applies to participating and out-of-network providers for non-emergent/urgent care in Pennsylvania CHIP.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Pennsylvania CHIP Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, or by phone 800-600-9007, or fax 877-310-3826.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

800-600-9007prior authorization phone number

877-310-3826prior authorization fax number

UHCprovider.comonline prior authorization tool

requiredinjectable chemotherapy

>$500DME threshold

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.

888-936-7246transplant/CAR T contact

Services That Require Prior Authorization

Partial criteria list — Services requiring prior authorization (partial list in this segment).

The following is a partial list of services that require prior authorization for UnitedHealthcare Community Plan (Pennsylvania CHIP). Prior authorization requests should be submitted via the UnitedHealthcare Provider Portal (Prior Authorization and Notification tool), by phone, or by fax. Prior authorization is not required for emergency or urgent care. Out-of-network providers must request prior authorization for all procedures and services (excluding emergent/urgent) as identified below.

For assistance and submission: Online: Use the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal (UHCprovider.com) -> Prior Authorization and Notification. Phone: 800-600-9007 (general) or 866-889-8054 for specific programs (e.g., radiology/cardiology). Fax: 877-310-3826.

Abortion procedures (prior authorization required). CPT/HCPCS example codes listed in source (e.g., 59840–59857).

Bariatric surgery and specific obesity-related services (prior authorization required). Example CPT codes include 43644, 43645, 43659, 43770, 43775, 43842–43846, 43845.

Behavioral health services (prior authorization required).

Cancer supportive care: Prior authorization required for colony-stimulating factor drugs and bone-modifying agents administered in an outpatient setting for a cancer diagnosis. Examples: J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125; injectable colony-stimulating factor drugs (e.g., J1449 Rolvedon®, J1442 Neupogen® etc.); bone-modifying agents such as Denosumab (J0897).

Cardiology: Refer to UHCprovider.com/PAcommunityplan > Prior Authorization and Notification Resources > Cardiology Prior for full CPT lists. Phone: 866-889-8054 for prior authorization.

Chemotherapy (injectable, outpatient): Prior authorization required for injectable chemotherapy drugs administered in an outpatient setting (including IV, intravesical, intrathecal) for a cancer diagnosis. Includes chemotherapy injectable drugs billed J9000–J9999, Leucovorin (J0640), Levoleucovorin (J0641, J0642), Lupron Depot (J1950), agents with Q-codes, and miscellaneous HCPCS billed agents.

Cochlear and other auditory implants (prior authorization required). Example HCPCS: L8614, L8619, L8690–L8692.

Continuous glucose monitors: Prior authorization required with Type 2 Diabetes diagnosis. Examples: A4226, A4239, A9276, A9277.

Cosmetic procedures (prior authorization required). Examples include CPT codes 11960, 14020–14021, 14061, 15820–15823, 15830, 15847, 15877–15879, 17106–17108.

Reconstructive procedures: Prior authorization required for reconstructive procedures that treat a medical condition or restore physiologic function. Examples include CPT codes 17999, 21137–21139, 21230, 21235, 21256, 21275, 21280, 21282, 21295, 21740, 21742–21743, 28344, 30620, 67900–67914 and many others.

Durable medical equipment (DME): Prior authorization required only for listed codes with a retail purchase or cumulative rental cost > $500. Examples include A9279, A9280, A9900, E0194, E0265–E0277, E0300, E0328–E0329, E0445, E0457, E0460, E0465.

Enteral services / in-home nutritional therapy: Prior authorization required. Example HCPCS: B4034–B4036, B4100–B4104, B4149, B4150, B4152.

Femoroacetabular impingement syndrome (FAI): Prior authorization required. Example CPT: 29916.

Functional endoscopic sinus surgery (FESS): Prior authorization required. Examples: 31240, 31253–31259, 31267, 31276, 31287–31288.

Gender dysphoria treatment: Prior authorization required. Examples: 55970, 55980.

Genetic and molecular testing: Prior authorization required for many outpatient genetic/molecular tests. Example CPT-to-U codes referenced (e.g., 0018U, 0022U, 0023U, 0055U, 0060U, 0087U, 0088U, 0129U, 0171U, 0173U, 0175U, 0179U, 0209U, 0214U, 0215U, 0216U, 0217U, 0237U, 0238U).

Injectable medications (extensive list): Numerous injectable drugs require prior authorization. Examples include J2840, J7190, J7211, J0879, J2507, J0217, J1932, J0202, J0174, J1306, J2778, J0221, J1950, J9217, J3398, J3397, J0630, J0888, J1437, J1458, J0219, J7189, J2796, J2182, J7209, J7188, J2350, J2354, J2267, J0222, J0129, J0224, J1576, J0606, J2550, J1203, J7194, J0897, Q5104, Q5106, Q5123, J7178, J9312, J9311, J7200, J1412, J1449, J0596, Q5119, J2998, J9333 and many others (see full source list).

Joint replacement (total hip/knee and other joint procedures): Prior authorization required for numerous CPT and HCPCS codes (examples shown in source: 23470–23474, 24360–24371, 27120–27138, 27412, 27446–27447, 27486–27487, 29866–29868, J7330, S2112).

Non-emergent air ambulance transport: Prior authorization required. Example HCPCS: A0430–A0436, A0435.

Orthognathic surgery (maxillofacial/jaw functional impairment): Prior authorization required. Example CPTs: 21121, 21123, 21125, 21127, 21141–21147, 21150–21154, 21248–21255, 21296–21299.

Orthotics and prosthetics: Prior authorization required only for codes with retail purchase or cumulative rental cost > $500. Examples include L0112, L8609, L8610, L8612, L8631, L8659.

Pediatric day services (PDHC): Prior authorization required. Example: T1024.

Private duty nursing: Prior authorization required. Examples: T1000, T1002, T1003.

Potentially unproven services: Prior authorization required. Examples: 33289, C2624.

Prostate procedures: Prior authorization required. Examples: 37243, 52441–52442, 53850, 53852, 55866, 55873–55874.

Proton beam therapy: Prior authorization required. Examples: 77520, 77522, 77523, 77525.

Radiology/advanced outpatient imaging: Prior authorization required for certain CT, MRI, MRA, PET scans, nuclear medicine, and nuclear cardiology. Providers ordering advanced outpatient imaging must provide notification prior to scheduling. Call 866-889-8054 or use the Provider Portal.

Rhinoplasty and septoplasty for nasal functional treatment: Prior authorization required. Examples: 30400, 30410, 30420, 30430, 30435–30465, 30450, 30460.

Site-of-service changes and many outpatient hospital procedures (including urologic, spinal, and sleep apnea surgeries): Prior authorization required for listed CPTs (examples in source include urinary system codes 52276, 52287, 52320, 52344, 50590, 52000–52005, 52204, 52224, 52234–52235, 52260, 52281, 52310, 52332, 52351–52356, 54161, 55040, 55700, 57288, 52281, etc.).

Sleep apnea procedures/surgeries: Prior authorization required. Examples: 21685, 41599, 42145.

Spinal surgery (prior authorization required). Example CPTs include 22100–22114, 22206–22224, 22510, 22210, 22212, 22214, 22220, 22224, etc.

Implantable neurostimulation and similar device procedures: Prior authorization required for implantation of devices that send electrical impulses and related CPT/HCPCS codes. Examples include device codes E0747–E0760 and CPTs 61863–61886, 63650–63685, 64553, 64555, 64568, 64570, 64590 and ICD/device HCPCS L8680, L8682, L8685–L8688, L8690–L8692.

Transplants and CAR T-cell therapies (prior authorization required): For transplants and CAR T services (including Abecma®, Breyanzi®, Kymriah™, Tecartus™, Yescarta™), call UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or use the notification number on the member ID card.

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

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

Chemotherapy prior authorization — Injectable chemotherapy (outpatient) prior authorization requirements.

Chemotherapy prior authorization — Requirements for outpatient injectable chemotherapy agents.

Prior authorization is required for injectable chemotherapy drugs administered in an outpatient setting (including intravenous, intravesical and intrathecal) for a cancer diagnosis.

Covered/subject-to-authorization injectable chemotherapy examples: chemotherapy injectable drugs billed in the J9000–J9999 range; Leucovorin (J0640); Levoleucovorin (J0641, J0642); Lupron Depot (J1950); agents with Q-codes; and agents billed under miscellaneous HCPCS (unassigned codes).

How to obtain prior authorization: Submit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) -> Prior Authorization and Notification, or call the number on the provider portal if indicated.

COVERAGE CRITERIA — Neurology monitoring services.

Neurology monitoring services and electroencephalography (EEG) — coverage notes and prior authorization guidance.

Cerebral seizure monitoring: Prior authorization required for inpatient seizure monitoring. Example CPT codes: 95700, 95711–95713.

Inpatient video monitoring: Services and CPT codes 95714–95716, 95718 require authorization for inpatient settings.

Electroencephalogram (EEG): Prior authorization is not required for standard EEG services. Example CPTs listed include 95720, 95722, 95724, 95726.

Note: Some references in source indicate prior authorization required for injectable chemotherapy drugs administered in an inpatient hospital or ambulatory surgical center setting — follow chemotherapy-specific guidance for injectable agents.

COVERAGE CRITERIA — Device-related prior authorization.

Device-related prior authorization — examples of implantable devices and monitoring-related devices requiring prior authorization or special notification.

Cochlear and auditory implants: Prior authorization required. Example HCPCS: L8614, L8619, L8690–L8692.

Continuous glucose monitors: Prior authorization required for Type 2 Diabetes diagnosis. Example HCPCS: A4226, A4239, A9276, A9277.

Cochlear implant additional example code: L8691. For device-specific prior authorization contact and submission, use the Provider Portal.

Certain devices (e.g., infusion pumps, external prosthetics) may also appear elsewhere in DME/orthotics/prosthetics lists and require authorization when retail or cumulative rental cost exceeds $500.

COVERAGE CRITERIA — Cosmetic and reconstructive procedures.

Cosmetic and reconstructive procedures — differentiation between cosmetic (appearance) and reconstructive (restore function) services and prior authorization codes.

Cosmetic procedures (those that change or improve appearance without restoring physiologic function) require prior authorization for many codes. Examples include 11960, 14020–14021, 14061, 15830, 15847, 15877–15879, 17106–17108.

Reconstructive procedures that treat a medical condition or improve/restore physiologic function require prior authorization. Examples include 17999, 21137–21139, 21230, 21235, 21256, 21275, 21280, 21282, 21295, 21740, 21742–21743, 28344, 30620, 67900–67914.

Additional reconstructive examples across facial, oral, and other anatomic sites are included in the source (many CPTs listed). Providers should check specific CPTs on UHCprovider.com/PAcommunityplan prior authorization resources for full lists and clinical requirements.

Prior authorization and coverage notes (excerpt).

Prior authorization and coverage notes (excerpt) — assorted program-specific prior authorization rules for DME, enteral nutrition, linked services, FAI, FESS, gender dysphoria, and other services.

Durable medical equipment (DME): Prior authorization required only for listed codes with retail purchase or cumulative rental cost greater than $500. Example HCPCS: A9279, A9280, A9900, E0194, E0265–E0277, E0300, E0328–E0329, E0445, E0457, E0460, E0465.

Enteral/In-home nutritional therapy: Prior authorization required for enteral services and in-home nutritional therapy. Examples: B4034–B4036, B4100–B4104, B4149, B4150, B4152.

Linked services and miscellaneous HCPCS: Prior authorization required for certain linked services and vendor-specific codes (examples: A6000, A9274, E0231, E1831, S0810, S1030–S1031, S2102, S9988–S9991).

Femoroacetabular impingement (FAI): Prior authorization required. Example CPT: 29916.

Functional endoscopic sinus surgery (FESS): Prior authorization required. Examples: 31240, 31253–31259, 31267, 31276, 31287–31288.

Coverage requirements — prior authorization (partial list).

Coverage requirements — selected prior authorization rules (partial list).

Radiology: Prior authorization required for participating physicians ordering advanced outpatient imaging procedures (certain CT, MRI, MRA, PET scans, nuclear medicine). Care providers ordering such procedures are responsible for providing notification prior to scheduling. Phone for prior authorization: 866-889-8054.

Sleep apnea procedures and surgeries: Prior authorization required. Examples: 21685, 41599, 42145.

Gender dysphoria treatment: Prior authorization required (codes 55970, 55980).

Genetic and molecular testing: Prior authorization required for many tests performed in outpatient settings; see the CPT-to-U codes listed in the genetic testing block for examples. Providers requesting testing should follow outpatient genetic testing prior authorization procedures via the Provider Portal.

Prior authorization listings — informational (drug names and associated codes).

Prior authorization listings — informational (selected drug names and associated HCPCS/J-codes). This is an informational listing of injectable medications that commonly require prior authorization; it is not an exhaustive list.

Selected injectable medications (examples and HCPCS/J-codes) include: Inflectra® (Q5103); Injectafer® (J1439); IVIG (J1439 noted in source); J1555, J1557, J1554, J1559, J1561, J1568, J1572, J1599 (examples of various injectable drug codes referenced in source).

Kanuma® (sebelipase alfa) — J1290 referenced multiple times as an example of a drug requiring prior authorization.

Selected specialty therapies and biologics with prior authorization include: Rituxan® (rituximab) J9312, Rituxan Hycela® J9311, Remicade® J1745, Renflexis® Q5104, Retacrit Q5106, Rolvedon J1449, Ruxience Q5119, Roctavian J1412, Releuko® Q5125, Nplate® J2796, Nucala® J2182, Novoeight J0219, and many others listed in the source material.

Note: Many additional injectable medications and biosimilars are listed in the source; providers should consult the Provider Portal or the injectable medications list for the complete, current prior authorization drug list and billing guidance.

Coverage stance for injectable medications — enumerates injectable medications and associated HCPCS/CPT codes.

Coverage stance for injectable medications — selected enumerated injectable medications and HCPCS/J-codes that commonly require prior authorization (informational, non-exhaustive).

Examples from the injectable medication list: Koate, Hemofil M (J2840); Kovaltry (J7190); Korsuva® (J7211); Krystexxa® (J0879); Lamzede (J2507); Lanreotide (J0217); Lemtrada® (J1932); Leqembi® (J0202); Leqvio® (J0174); Lucentis (J1306); Lumizyme® (J2778); Lupron Depot® (J1950); Luxturna™ (J3398); Mepsevii® (J3397); Miacalcin J0630; Mircera J0888; Monoferric® J1437; Naglazyme® J1458; Nexviazyme® J0219; NovoSeven RT J7189; Nplate® J2796; Nucala® J2182.

Additional examples: Ocrevus™ J2350; Octreotide Acetate J2354; Onpattro™ J0222; Orencia® J0129; Oxlumo™ J0224; Panzyga® J1576; Parsabiv™ J0606; Phenergan (promethazine) J2550; Pombiliti J1203; Profilnine J7194; Prolia® J0897; Qalsody® J1304; Radicava® J1301; Rebinyn J7203; Reblozyl® J0896; and many more as listed in the source.

Providers should refer to the most current injectable medication prior authorization list on the Provider Portal for updates and complete code mappings.

Items requiring prior authorization — list of items that require prior authorization or notification as indicated.

Items requiring prior authorization — surgical procedures, joint replacements, transplants, air transport, and other high-cost services.

Joint replacement (total hip and knee) and related procedures require prior authorization for many CPT and HCPCS codes. Examples in source include CPTs 23470–23474, 24360–24371, 27120–27138, 27412, 27446–27447, 27486–27487, 29866–29868, and related HCPCS like J7330 and S2112.

Non-emergent air ambulance transport requires prior authorization. Examples include HCPCS A0430–A0436.

Orthognathic surgery (treatment of maxillofacial/jaw functional impairment) requires prior authorization. Example CPTs: 21121, 21123, 21125, 21127, 21141–21147, 21150–21154, 21248–21255, 21296–21299.

Transplants and CAR T-cell therapies require prior authorization and specific case management contact. For transplant and CAR T-cell therapy services (e.g., Abecma®, Breyanzi®, Kymriah™, Tecartus™, Yescarta™), call the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or the notification number on the member's ID card.

Authorization criteria for listed codes — prior authorization requirements and additional information notes for listed services.

Authorization criteria for listed codes — operational notes and contact instructions for device and procedural authorizations.

For certain devices and high-acuity procedures (e.g., ventricular assist devices, VAD), providers must call the notification number on the back of the member's ID card and follow the directions; VAD forms should be faxed to Optum VAD Case Management Team at 855-282-8929.

For cochlear implants, auditory implants, and other specialized devices, submit prior authorization requests via the Provider Portal or follow device-specific instructions and HCPCS L-codes (e.g., L8612, L8614).

For transplant and CAR T-cell therapy services, contact the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or use the notification number on the member ID card to initiate authorization and case management.

Prior authorization criteria (enumerated examples).

Prior authorization examples — additional categories that commonly require prior authorization.

Orthotics and prosthetics (example HCPCS: L8609, L8610, L8612, L8631, L8659).

Pediatric day services (PDHC) (example CPT/HCPCS: T1024) require prior authorization.

Private duty nursing (examples: T1000, T1002, T1003) requires prior authorization.

Potentially unproven services (examples include CPT 33289, HCPCS C2624) require prior authorization as noted in the source.

prior_authorization_criteria — Coverage is conditional and requires prior authorization for listed categories and codes.

Prior authorization — site-of-service, surgical specialties, spine, sleep apnea, neurostimulation, and transplant guidance.

Site of service (outpatient hospital) — many outpatient hospital procedures require prior authorization; providers should refer to the detailed CPT lists in the Provider Portal. Examples include urinary system CPTs 52276, 52287, 52320, 52344 and many others.

Sleep apnea procedures and surgeries require prior authorization. Examples: 21685, 41599, 42145.

Spinal surgery: Prior authorization required for many spinal surgery CPT codes (e.g., 22100–22114, 22206–22224, 22510 and others listed in source).

Implantable neurostimulators and device implantation procedures require prior authorization. Example device HCPCS E0747–E0760 and CPTs such as 61863–61886, 63650–63685, 64553–64570, 64590; implant device L-codes L8680, L8682, L8685–L8688.

Transplants: Prior authorization required. For transplant and CAR T-cell therapies contact UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or the notification number on the member ID card to initiate the authorization process.

Prior authorization criteria for listed services — procedures, devices, and therapies with specified contact instructions.

Prior authorization instructions — procedures, devices, therapies with contact instructions and special submission requirements.

For chemotherapy injectable agents and many specialty infusions, submit prior authorization via the Provider Portal (Prior Authorization and Notification tool). For program-specific numbers (e.g., radiology, cardiology) call 866-889-8054.

Ventricular assist devices (VAD): Call 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.

Transplant and CAR T-cell therapies: Call UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or the notification number on the member's ID card.

Gene therapy and unclassified/temporary codes (e.g., C9399, C9400, J3490, J3590) will require prior authorization; specific gene therapy products listed in the source will require authorization with case management involvement.

Relevant CPT / HCPCS / ICD-10 Codes

Covered CPT Codes (examples requiring prior authorization)CPTCovered

37220	Revascularization, endovascular, open or percutaneous (iliac artery)
37221	Transcatheter therapy, peripheral vessel; initial vessel
37224	Transcatheter therapy, peripheral vessel; each additional vessel
37225	Transcatheter therapy, peripheral vessel; pharmacologic/infusional treatment
37230	Transcatheter therapy, other peripheral vessel (iliac, femoral)
37231	Transcatheter therapy, other peripheral vessel; additional vessel
93580	Intravascular or intracoronary optical coherence tomography during diagnostic or therapeutic procedures

Covered HCPCS Codes (injectable / chemotherapy examples)HCPCSCovered

J9000-J9999	Chemotherapy injectable drugs (range) - prior authorization required
J0640	Leucovorin, injectable
J0641	Levoleucovorin, injectable (single dose)
J0642	Levoleucovorin, injectable (per mg)
J1950	Leuprolide acetate (e.g., Lupron Depot)

Covered HCPCS Codes (selected oncology support and injectables)HCPCSCovered

J1442	Filgrastim (Neupogen) - colony-stimulating factor
J1447	(listed CSF)
J1448	Trilaciclib (Cosela)
J2506	Pegfilgrastim (Neulasta)
J1449	Eflapegrastim-xnst (Rolvedon)
Q5101	Filgrastim-sndz (Zarxio)
Q5110	Filgrastim-aafi (Nivestym)
Q5125	Filgrastim-ayow (Releuko)
Q5122	Pegfilgrastim-apgf (Nyvepria)
Q5120	Pegfilgrastim-bmez (Ziextenzo)

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Covered CPT/HCPCS Codes (EEG / Seizure monitoring)CPTCovered

95700	Cerebral seizure monitoring; concise
95711	Ambulatory EEG; single
95712	Ambulatory EEG; multiple
95713	Ambulatory EEG; extended
95714	Inpatient video EEG monitoring
95715	Inpatient video EEG monitoring, continuous
95716	Inpatient video EEG monitoring, extended
95718	Inpatient video EEG monitoring, complete
95720	Electroencephalogram (EEG), routine
95722	EEG, prolonged

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Covered HCPCS Codes (Continuous Glucose Monitor devices)HCPCSCovered

A4226	External ambulatory glucose sensor (continuous), disposable
A4239	Blood glucose test system (CGM) transmitter
A9276	Sensor; disposable, single use
A9277	Sensor; non-disposable

Covered HCPCS/CPT Codes (DME threshold examples)HCPCS

A9279	Miscellaneous DME code (example)
A9280	Miscellaneous DME code (example)
A9900	Miscellaneous DME supply, accessory, and/or service component of another HCPCS code
E0194	Home oxygen supply
E0265	Surgical chair - power
E0266	Specialty seating

Covered HCPCS Codes (Orthotics & Prosthetics examples) HCPCSCovered

L0112	Thoracic-lumbar-sacral orthosis (TLSO)
L6713	Upper limb prosthesis component
L6880	Custom fabricated orthosis
L8690	Cochlear implant external processor
L8614	Cochlear device internal component

Covered CPT Codes (Selected surgical/procedure examples)CPTCovered

31240	Sinus surgery (FESS) - maxillary antrostomy
31253	FESS - ethmoidectomy
31254	FESS - frontal sinusotomy
31255	FESS - sphenoidotomy
31256	FESS - total ethmoidectomy
31257	FESS - additional procedures
31259	FESS - other
31267	FESS - extended

Covered CPT Codes (Joint replacement examples)CPTCovered

23470	Total shoulder arthroplasty
23472	Revision shoulder arthroplasty
23473	Complex shoulder reconstruction
23474	Other shoulder joint replacement procedures
27120	Total hip arthroplasty (primary)
27125	Hip replacement, revision
29868	Arthroscopy with ligament reconstruction

Covered HCPCS Codes (Non-emergent air ambulance)HCPCSCovered

A0430	Fixed wing air ambulance service, one way
A0431	Rotary wing air ambulance service, one way
A0435	Transfer by air ambulance (fixed wing)
A0436	Transfer by air ambulance (rotary wing)

Covered HCPCS/CPT Codes (Injectable medications - representative list)mixedCovered

J2840	Koate (antihemophilic factor)
J7190	Kovaltry
J7211	Korsuva
J0879	Krystexxa
J2507	Lamzede
J0217	Lanreotide
J1932	Lemtrada
J0202	Leqembi
J0174	Leqvio
J1306	Lucentis

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Covered CPT/HCPCS Codes (IVIG and related products)mixedCovered

90283	Immune globulin (IG), for intramuscular use
90284	Immune globulin, intravenous
J1555	Injection, immune globulin (Gamunex-C/others)
J1556	Injection, immune globulin
J1557	Injection, immune globulin

Covered CPT/HCPCS Codes (Genetic & Molecular testing examples)mixedCovered

0018U	Genetic test example (registered CPT category III)
0022U	Genetic test example
81413	Next-generation sequencing (panel)
81416	Genetic testing panel
81518	Tumor profiling by NGS

Covered HCPCS/CPT Codes (Wound care)HCPCSCovered

E2402	Negative pressure wound therapy (wound vac) supplies
Q2056	CAR T-cell therapy example code (transplant-related)

Covered CPT Codes (Neurostimulator / device implantation)CPTCovered

61863	Insertion or replacement of neurostimulator lead
61864	Insertion or replacement of additional leads
61867	Stereotactic implantation
63650	Laminectomy for implantation of neurostimulator
63655	Removal or revision of neurostimulator
63685	Insertion or replacement of neurostimulator pulse generator

Covered CPT Codes (Vein procedures)CPTCovered

36468	Endovenous ablation, radiofrequency
36473	Sclerotherapy; extensive
36475	Endovenous thermal ablation, percutaneous

Covered HCPCS/CPT Codes (Miscellaneous / gene therapy placeholders)mixed

C9399	Unclassified drug or biological (requires PA for certain gene therapies)
J3490	Unclassified drug (requires PA for certain gene therapies)
J3590	Unclassified biologic (requires PA for certain gene therapies)
C9400	Unclassified HCPCS, gene therapy related

Covered CPT Codes (Cardiology / electrophysiology examples)CPTCovered

37220	Transcatheter placement of stent in vessel (iliac/femoropopliteal)
37221	Transcatheter therapy, additional
37224	Transcatheter therapy, other peripheral vessel
37225	Transcatheter therapy, infusion or thrombolytic
37230	Revascularization, peripheral vessel by transcatheter
37231	Additional vessel transcatheter revascularization
93580	Intravascular imaging (e.g., OCT) during coronary procedures

How Providers Request Authorization and What To Do

Prior Authorization

How to request prior authorization

To request prior authorization, submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (go to UHCprovider.com and select Prior Authorization and Notification on the Provider Portal dashboard), or by phone at 800-600-9007, or by fax at 877-310-3826. Prior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all non-emergent services.

Online: Prior Authorization and Notification tool on UnitedHealthcare Provider Portal (UHCprovider.com).
Phone: 800-600-9007.
Fax: 877-310-3826.

Prior Authorization

Cardiology prior authorization instructions

Cardiology-specific prior authorization (outpatient and office-based diagnostic catheterizations, electrophysiology implants, and stress echos) must be submitted via the Provider Portal or by phone at 866-889-8054; see UHCprovider.com/PAcommunityplan > Prior Authorization and Notification Resources > Cardiology Prior for the specific CPT codes.

Key Definitions and Terms

Definition — Prior authorization process description

DefinitionPrior authorization is the process by which providers obtain approval from UnitedHealthcare before performing non-emergent services listed in this document.

When requiredRequired for the services and codes enumerated in this prior authorization list; not required for emergency or urgent care.

How to submitRequests may be submitted via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by phone, or by fax (see submission options).

Definition — Emergency or urgent care exemption (no prior authorization required)

DefinitionEmergency or urgent care services do not require prior authorization.

ContextOut-of-network providers must still request prior authorization for all non-emergent services; emergency/urgent care is explicitly exempt.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Pennsylvania CHIP Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, or by phone 800-600-9007, or fax 877-310-3826.

SourceLink

On This Page

Orthotics and prosthetics: Prior authorization required only for codes with retail purchase or cumulative rental cost > $500. Example: L0112, L8609, L8610, L8612, L8631, L8659.

Wound VAC: Prior authorization required (example HCPCS E2402).

Submit via the Prior Authorization and Notification tool on the Provider Portal or call 866-889-8054.

Refer to UHCprovider.com/PAcommunityplan > Prior Authorization and Notification Resources > Cardiology Prior for CPT code details.

Prior Authorization

Chemotherapy injectable drugs prior authorization

Prior authorization is required for injectable chemotherapy drugs administered in an outpatient setting (including IV, intravesical and intrathecal) for a cancer diagnosis; submit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

Includes chemotherapy injectable drugs billed J9000–J9999, leucovorin (J0640), levoleucovorin (J0641/J0642), Lupron Depot (J1950), Q-code chemotherapy, and miscellaneous HCPCS-billed agents.

Prior Authorization

Cerebral seizure monitoring / EEG

Inpatient video cerebral seizure monitoring requires prior authorization; routine EEGs do not require prior authorization.

Prior authorization required for inpatient video monitoring codes (e.g., 95714).
EEG codes (e.g., 95720, 95722, 95724, 95726) do not require prior authorization.

Prior Authorization

Cochlear implants prior authorization

Cochlear implants and other auditory implants require prior authorization; the policy lists the applicable CPT and HCPCS codes (e.g., 69710, 69714, 69930 and device L-codes such as L8614, L8619, L8690–L8692).

Submit prior authorization via the Prior Authorization and Notification tool on the Provider Portal.

Prior Authorization

Continuous glucose monitor prior authorization

Continuous glucose monitors require prior authorization when used with a Type 2 Diabetes diagnosis; applicable HCPCS codes include A4226, A4239, A9276 and A9277.

Prior authorization required when CGM is used for Type 2 Diabetes.

Prior Authorization

Cosmetic and reconstructive procedures prior authorization

Many cosmetic and reconstructive procedures require prior authorization; reconstructive procedures that treat a medical condition or restore physiologic function are listed separately with specific CPT/HCPCS codes.

Examples of cosmetic/reconstructive codes requiring prior authorization are listed throughout the policy (e.g., 11960, 14061, 15820–15823, 17106–17108, 21230, 21235, 21256, 21275).
Reconstructive procedures that restore function are explicitly identified and require prior authorization.

Prior Authorization

Oculoplastic / related codes prior authorization

For selected oculoplastic and related codes listed in the policy, follow the 'how to obtain prior authorization' instructions indicated (codes shown as requiring prior authorization).

Examples include multiple 679xx series codes and Q2026 that are listed with prior authorization instructions.

Prior Authorization

Durable Medical Equipment (DME) prior authorization rules

Durable medical equipment (DME) listed in the policy requires prior authorization only when the retail purchase or cumulative rental cost of the listed codes exceeds $500; prosthetics are addressed separately under orthotics/prosthetics.

Examples of DME HCPCS codes listed include A9279, A9280, E0194, E0265, E0266, E0270, E0277, E0300, E0328, E0329, E0445, etc.
Threshold: prior authorization required when retail purchase or cumulative rental cost > $500.

Prior Authorization

Enteral and in-home nutritional therapy prior authorization

Enteral services and in-home nutritional therapy require prior authorization; the policy lists enteral/gastrostomy-related HCPCS codes (e.g., B4034–B4036, B4100, B4102–B4104, B4149, B4150, B4152, B4153, B4155, B4158–B4161, B9002, B9998).

Submit prior authorization via the Prior Authorization and Notification tool on the Provider Portal.

Prior Authorization

Experimental/investigational and linked services prior authorization

Experimental and investigational items and linked services listed in the policy are flagged as requiring prior authorization; the document provides example procedure and HCPCS/CPT codes (e.g., 33477, 36514, 64722, A4638, A6000, A9274, E0231, E1831, S0810, S1030, S1031, S2102).

Prior authorization is required before providing these experimental/investigational services.

Prior Authorization

FAI prior authorization

Femoroacetabular impingement syndrome (FAI) procedures require prior authorization for the listed code(s) (e.g., 29916).

Submit requests via the Provider Portal Prior Authorization and Notification tool.

Prior Authorization

FESS prior authorization

Functional endoscopic sinus surgery (FESS) requires prior authorization for the listed CPT codes (e.g., 31240, 31253–31259, 31267, 31276, 31287–31288).

Prior authorization is required for the FESS CPT codes listed in the policy.

Prior Authorization

Gender dysphoria treatment prior authorization

Gender dysphoria treatment procedures require prior authorization for the listed CPT codes (e.g., 55970, 55980).

Prior authorization required before scheduling gender dysphoria treatment services.

Prior Authorization

Prior authorization required — procedures and conditions (partial)

The policy lists many procedures and conditions that require prior authorization or notification (partial list in the document); providers must follow the listed 'how to obtain prior authorization' instructions for each item.

Examples include FAI, FESS, gender dysphoria treatment, experimental/investigational items, and others shown throughout the policy.

Documentation Required

Prior authorization — genetic testing and home health (partial)

Genetic and molecular testing requires prior authorization/notification; the policy notes that ordering providers and laboratories have notification responsibilities before DNA sequencing (BRCA and other genetic tests) and lists numerous genetic test CPT codes.

Providers requesting genetic/molecular testing must follow the testing prior authorization/notification process described in the policy.

Prior Authorization

Prior authorization — injectables and hospice (partial)

Injectable medications and hospice services require prior authorization; many J-codes and drug names are listed in the policy and must be authorized before administration.

The document contains an extensive list of injectable medications and associated HCPCS/J-codes that require prior authorization (see policy lists).
Hospice services are noted as requiring prior authorization.

Prior Authorization

How to obtain prior authorization for listed injectable drugs

The policy provides general instructions for how to obtain prior authorization for many listed injectable drugs (examples: Inflectra Q5103, IVIG J1439, administration code 90283, Kanuma J1290) and indicates providers must follow the 'how to obtain prior authorization' entries for each drug.

Submit prior authorization requests via the Provider Portal Prior Authorization and Notification tool as indicated in the drug entries.

Prior Authorization

Prior authorization required for listed injectable medications

Providers must obtain prior authorization for the injectable medications listed in the policy; the document enumerates many HCPCS/CPT codes and drug names (partial examples: J1290, J2840, J7190, J7189, J7188, J0218, J3399, etc.).

Follow the specific 'how to obtain prior authorization' instructions for each listed injectable medication.

Prior Authorization

Submission methods

Prior authorization requests may be submitted online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone (policy lists an alternate phone 888-397-8129 for some submissions).

Online: Prior Authorization and Notification tool on UHCprovider.com.
Phone: 888-397-8129 (alternate number shown for some sections).

Prior Authorization

Joint replacement prior authorization

Total joint replacement procedures (hip and knee) require prior authorization for the listed facility types (acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long-term acute care hospitals) and for the CPT codes enumerated in the policy (examples include 23470, 27130, 27447, 29866, J7330).

Submit prior authorization via the Provider Portal or call 866-889-8054 as directed in the policy.

Prior Authorization

Air ambulance prior authorization

Non-emergent air ambulance transport requires prior authorization; the policy lists applicable HCPCS codes (e.g., A0430, A0431, A0435, A0436).

Prior authorization required before scheduling non-emergent air ambulance transport.

Prior Authorization

Orthognathic surgery prior authorization

Orthognathic surgery for maxillofacial/jaw functional impairment requires prior authorization for the listed CPT codes; several codes include 'Additional information = required' indicating extra documentation is needed for authorization.

Examples of orthognathic CPT codes requiring prior authorization include 21121, 21123, 21125, 21127, 21141–21147, 21150–21154, 21155, 21159, 21160, 21188, 21193–21196, 21206, 21248–21255, 21296, 21299.

Prior Authorization

Injectable medications prior authorization (extensive list)

The policy includes an extensive list of injectable medications (by name) with associated HCPCS/J-codes that require prior authorization; providers must obtain authorization per the listed entries.

Examples of listed injectable medications include Kanuma (J1290), Koate (J2840), Kovaltry (J7190), Lupron Depot (J0221/J1950), Luxturna (J9217), Roctavian (J7200), and many others shown in the document.

Billing Rule

Orthotics and prosthetics prior authorization

Prior authorization is required for orthotics and prosthetics L-codes listed in the policy when the retail purchase or cumulative rental cost exceeds $500; the document provides a long list of applicable L-codes.

Threshold: retail purchase or cumulative rental cost > $500 triggers prior authorization for listed L-codes.
Examples of L-codes are provided throughout the orthotics and prosthetics sections.

Documentation Required

Orthognathic surgery additional documentation required

Some orthognathic surgery CPT codes include an 'Additional information = required' note; when present, providers must include the additional documentation indicated to obtain prior authorization.

Codes marked 'Additional information = required' (various 211xx and 212xx codes) require extra documentation with the prior authorization request.

Prior Authorization

How to obtain prior authorization / notification

Providers must obtain prior authorization or notification for services such as proton beam therapy, certain advanced outpatient imaging, rhinoplasty/septoplasty, and sinuplasty; submit requests via the Provider Portal Prior Authorization and Notification tool or call 866-889-8054 as instructed.

Proton beam therapy CPTs include 77520, 77522, 77523, 77525 and require prior authorization.
Radiology: advanced outpatient imaging (certain CT/MRI/MRA/PET) requires notification/prior authorization and prior scheduling notification.

Prior Authorization

Additional services requiring prior authorization

Additional services identified as requiring prior authorization include pediatric day services (T1024), private duty nursing (T1000, T1002, T1003), potentially unproven services, and select prostate procedures; follow the policy's 'how to obtain prior authorization' instructions for each.

Pediatric day services (PDHC): T1024 requires prior authorization.
Private duty nursing: T1000, T1002, T1003 require prior authorization.
Prostate procedures listed in the policy (e.g., 52441, 52442, 53850, 53852, 55866, 55873, 55874) require prior authorization.

Billing Rule

Site of service prior authorization notes

Site-of-service may affect prior authorization requirements: some procedures require prior authorization only when performed in an outpatient hospital setting and may not require it if performed in a participating ambulatory setting.

Examples and specific codes are noted in the policy where site-of-service influences prior authorization requirements (e.g., certain outpatient hospital CPTs).

Prior Authorization

Prior authorization for listed outpatient procedures

Prior authorization is required for many listed outpatient hospital procedures and specific CPT/HCPCS codes across specialties (urologic, GI, ENT, spinal surgery, sleep apnea procedures, etc.); providers must follow the code-specific prior authorization instructions in the policy.

Examples include numerous urologic CPTs (e.g., 52276, 52287, 52320, 52344), spinal surgery ranges, and sleep apnea procedure codes shown in the document.

Prior Authorization

Device and transplant prior authorization

Implantation of bone growth stimulators, neurostimulators and other implantable devices requires prior authorization; the policy lists applicable HCPCS/CPT device codes (e.g., E0747–E0760, L8680–L8688, and device implantation CPTs).

Examples include E0747, E0748, E0749, E0760 for stimulators and L8680 series for neurostimulator supplies.
Transplant and CAR T-cell therapies have separate case management contact instructions (see transplant block).

Prior Authorization

Transplant & CAR T-cell therapy prior authorization contact

For transplant and CAR T-cell therapy services (including Abecma, Breyanzi, Kymriah, Tecartus, Yescarta), call the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or use the notification number on the back of the member's ID card to obtain prior authorization.

Contact transplant case management at 888-936-7246 for authorization and care coordination for listed transplant and CAR T-cell therapies.

Prior Authorization

VAD prior authorization process

For Ventricular Assist Devices (VAD), call the notification number on the back of the member's ID card, then fax the form provided by the nurse to the Optum VAD Case Management Team at 855-282-8929 to initiate prior authorization.

Follow the member ID notification instructions and fax the completed form to Optum VAD Case Management at 855-282-8929.

Prior Authorization

Wound VAC prior authorization

Wound VAC devices require prior authorization; E2402 is listed as an example HCPCS code that requires authorization.

Prior authorization required for wound VAC supplies and devices (e.g., E2402).

Prior Authorization

Gene therapy / unclassified codes and 38232 rules

Unclassified drug codes (C9399, J3490, J3590) will require prior authorization for specific gene therapy products (e.g., Amtagvi, Casgevy, Lantidra, Lenmeldy, Skysona); CPT code 38232 requires prior authorization only when used for an oncology diagnosis.

Unclassified HCPCS/drug codes must be prior authorized when used for the specific gene therapies named in the policy.
Code 38232: prior authorization required only for oncology diagnoses.

Prior Authorization

Codes listed with prior authorization requirement

A long list of CPT and HCPCS procedure and supply codes are indicated in the policy as requiring prior authorization; providers must consult the document's code lists and follow the specified prior authorization instructions for each code.

Refer to the policy code lists for the full set of CPT/HCPCS codes that require prior authorization and any associated submission notes.

Source guidanceStatement appears in the general information and in the EEG/seizure monitoring section specifying inpatient vs. emergency distinctions.

Definition — Prior Authorization and Notification tool (online portal)

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

Portal stepsGo to UHCprovider.com, click the UnitedHealthcare Provider Portal button, then select Prior Authorization and Notification on the dashboard.

Alternate contactPhone and program-specific numbers (e.g., radiology: 866-889-8054) are also provided where applicable.

Definition — EEG (codes listed) — prior authorization not required

EEG codesEEG CPT codes listed include 95720, 95722, 95724, 95726.

Authorization stancePrior authorization is not required for EEGs (routine electroencephalogram) per the document.

Related differentiationInpatient video cerebral seizure monitoring (e.g., 95714) does require prior authorization; distinction between EEG and inpatient video is specified.

Definition — Prior authorization required (general)

General requirementPrior authorization is required for the services and CPT/HCPCS codes specifically listed in this document unless an exemption applies.

ScopeCovers procedures, devices, injectables, DME, radiology, and other specified services when noted as 'Prior authorization required.'

Site-of-service noteSome requirements depend on site of service (outpatient hospital vs participating ambulatory facility); check individual entries for SOS rules.

Definition — DME (scope and exclusions related to $500 rule)

DME definition & ruleDurable medical equipment (DME) section lists HCPCS/CPT codes that require prior authorization only when retail purchase or cumulative rental cost exceeds $500.

Prosthetics noteProsthetics are explicitly noted as not DME for the $500 DME rule; see orthotics/prosthetics section for separate handling.

ExamplesDME example codes include A9279, E0445, E0466 and many E‑series codes listed in the DME section.

Definition — Notification/prior authorization for genetic testing workflow

Genetic testing workflowPrior authorization/notification is required for genetic and molecular testing; BRCA testing requires notification before DNA sequencing — the ordering provider must notify the laboratory, and the laboratory will notify UnitedHealthcare.

Applicable settingApplies to outpatient genetic/molecular testing codes listed in the genetic testing section.

Supporting codesExamples of listed genetic test CPT codes include 81163 and series in the 81400 range (detailed in the testing section).

Definition — Home health services prior authorization scope

ScopeHome health prior authorization is required only in outpatient settings, including services provided in the member's home.

Codes referencedHome health examples include G0156, G0162, G0299, G0300 and other listed home health HCPCS codes.

Relation to settingRequirement applies when services are outpatient; inpatient/home institutional rules differ and are noted elsewhere.

Definition — how to obtain prior authorization (general)

How to obtain prior authorizationSubmit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com).

Alternate submission methodsPhone and fax options are provided in the document for certain programs and general submissions (see program-specific contact numbers).

Radiology specificFor advanced outpatient imaging, providers must notify prior to scheduling and may call 866-889-8054 or use the portal as instructed.

Definition — Injectable medications listed requiring prior authorization

Examples of injectable medicationsThe document lists numerous injectable drugs (examples include J1290 Kanuma, J2840 Koate, J7190 Kovaltry, J7211 Korsuva, J0879 Krystexxa, and many others) that require prior authorization.

Codes and administrationMany entries pair HCPCS/J‑codes with administration codes (e.g., 90283) and include specific 'how to obtain prior authorization' notes for individual drugs.

Submission instructionProviders must obtain prior authorization for listed injectable medications via the Provider Portal or program contacts as specified.

Definition — Prior authorization submission options

Submission optionsPrior authorization requests may be submitted via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by phone, or by fax.

Portal access stepsGo to UHCprovider.com, click the Provider Portal button, then select Prior Authorization and Notification on the dashboard.

Program phone numbersProgram-specific contact numbers are provided (examples: general phone 800-600-9007; radiology 866-889-8054; portal alternative 888-397-8129 listed for some submissions).

Definition — Orthotics/prosthetics prior authorization threshold guidance

Orthotics/prosthetics threshold guidancePrior authorization is required only for orthotics and prosthetic L‑codes listed with a retail purchase or cumulative rental cost of more than $500.

Examples of codesThe orthotics/prosthetics section lists many L‑codes (e.g., L0112, L6925, L7170, L8040) that, if exceeding the threshold, require prior authorization.

Cross-referenceProsthetics are noted separately from DME; consult the orthotics/prosthetics code list when determining authorization need based on cost.

Definition — Orthognathic surgery authorization note about additional information requirement

Orthognathic surgery noteCertain orthognathic surgery CPT codes are marked 'Additional information = required', indicating extra documentation is needed for authorization.

Facility typesOrthognathic surgery prior authorization applies for procedures in acute care hospitals, acute inpatient rehabilitation, critical access hospitals and long‑term acute care hospitals as listed.

Example codesRepresentative orthognathic CPT codes include 21121, 21123, 21125, 21127 and extended series noted in the orthognathic section.

Definition — Prior authorization / notification (general)

Prior authorization / notificationThe document identifies services that require prior authorization or notification and provides instructions and contacts to obtain it.

ApplicabilityApplies to participating providers and out‑of‑network providers for non‑emergent services in the Pennsylvania CHIP program.

Where to find criteriaDetailed criteria and full code lists are available via the Provider Portal and program-specific resources referenced in the document.

Definition — Site of service (SOS) meaning regarding authorization impact

Site of service (SOS) meaningSite of service indicates that authorization requirements may depend on where the service is performed (for example, some procedures require prior authorization only when performed in an outpatient hospital setting).

ImplicationIf performed at a participating ambulatory facility, certain services may not require prior authorization; verify individual code entries for SOS rules.

ExamplesSOS notes appear throughout (e.g., outpatient hospital SOS entries and carpal tunnel example 64721) to clarify where prior authorization is required.

Definition — Prior authorization general requirement description

General requirement descriptionProviders must obtain prior authorization from UnitedHealthcare before performing the non‑emergent procedures and services listed in this document.

Where details liveSpecific CPT/HCPCS codes, facility types and program instructions are listed inline; see Provider Portal for complete criteria and code lists.

Notification vs authorizationThe document distinguishes between services that require notification prior to scheduling and those that require full prior authorization.

Definition — Ventricular assist devices (VAD) description

VAD descriptionVentricular assist devices (VAD) are mechanical pumps that take over the function of a damaged ventricle and restore blood flow.

Authorization processPrior authorization is required for VADs; providers should call the notification number on the member's ID card and then fax the form provided by the nurse to the Optum VAD Case Management Team at 855-282-8929.

Relevant codesVAD‑related procedure codes (e.g., 33927, 33928, 33929, 33975‑33983) are listed in the VAD section of the document.

Definition — CAR T-Cell Therapy / Gene Therapy description and prior authorization requirement

DefinitionCAR T‑Cell Therapy and Gene Therapy are high‑cost cellular and gene‑based treatments specifically called out in the document and require prior authorization or case management contact.

Contact for authorizationFor transplant and CAR T‑cell therapies (examples: Abecma, Breyanzi, Kymriah, Tecartus, Yescarta) providers must call the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or the notification number on the member ID card.

Special coding notesUnclassified drug codes (C9399, J3490, J3590) will require prior authorization for certain gene therapy products; CPT 38232 requires authorization only for oncology diagnoses.