CurrentUnitedHealthcarePolicy N/A

Prior Authorization Requirements for Pennsylvania Medicaid — UnitedHealthcare Community Plan

Lists services, procedures, and drugs that require prior authorization for participating providers in UnitedHealthcare Community Plan — Pennsylvania. Applies to inpatient and outpatient services and to participating in-network and out-of-network providers (except for emergency/urgent care).

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Requirements for Pennsylvania Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call the listed phone numbers.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PAapplies to

Provider Portalsubmission method

888-397-8129phone for injectable chemo

dozenscodes listed

$500DME cost 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.

Services and Procedures Requiring Prior Authorization

Cancer supportive care prior authorization criteria (summary)

Cancer supportive care — outpatient administration

Prior authorization required for colony-stimulating factor drugs and bone-modifying agents administered in an outpatient setting for a cancer diagnosis.

Examples of agents requiring prior authorization

Eflapegrastim (J1449)
Filgrastim (J1442) and filgrastim biosimilars (Q5110, Q5125, Q5101)
Pegfilgrastim (J2506) and pegfilgrastim biosimilars (Q5122, Q5120, Q5111, Q5108)
Sargramostim (J2820)
Tbo-filgrastim (J1447) and trilaciclib (J1448)
Bone-modifying agent: Denosumab (J0897)
Erythropoiesis-stimulating agents (J0885)

Some HCPCS/CPT codes listed (e.g., J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125) also require prior authorization when used for non-oncology diagnoses; see Injectable medications section.

Cardiology prior authorization criteria (summary)

Cardiology procedures

Prior authorization required for participating physicians for outpatient and office‑based diagnostic cardiac catheterizations, electrophysiology implants and stress echocardiograms prior to performance.

Providers should submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-889-8054; full CPT lists and details are available at UHCprovider.com/PAcommunityplan.

Prior authorization criteria (partial list)

Prior authorization requirements and submission instructions for specified injectable drugs, monitoring services, implants, CGMs, and cosmetic/reconstructive procedures.

Injectable chemotherapy drugs administered in an outpatient setting (including intravenous, intravesical and intrathecal) require prior authorization.

Scope includes chemotherapy injectable drug range J9000–J9999 and specified agents such as Leucovorin (J0640), Levoleucovorin (J0641/J0642) and Lupron Depot (J1950).

For chemotherapy injectable prior authorization, submit requests via the Provider Portal or call 888-397-8129.

Prior authorization required for inpatient cerebral seizure monitoring and inpatient video EEG; outpatient EEG does not require prior authorization.

Cosmetic and reconstructive procedures: prior authorization required for listed CPT/HCPCS codes; distinction made between cosmetic procedures (appearance only) and reconstructive procedures (treat a medical condition).

Prior authorization criteria by category

Codes and categories requiring prior authorization or special handling in this section:

Cosmetic & reconstructive: Prior authorization required for listed CPT/HCPCS codes; cosmetic procedures that change appearance versus reconstructive procedures that treat a medical condition are distinguished.

Diagnosis code exemptions: Certain ICD‑10 diagnosis codes listed may exempt prior authorization when billed with the procedure code (see diagnosis listings).

Durable Medical Equipment (DME): Prior authorization required only for listed DME codes when retail purchase or cumulative rental cost exceeds $500; prosthetics are not DME.

Enteral and in‑home nutritional services: Prior authorization required for listed HCPCS enteral formula and supply codes (e.g., B4034, B4100, B4150 series).

Prior authorization coverage criteria (section excerpt)

Prior authorization is required for the listed injectable medications, certain procedures, genetic/molecular tests, and ancillary services; some items are noted as experimental/investigational and require prior authorization.

Many injectable medications listed by HCPCS/CPT require prior authorization; providers should submit via the Provider Portal or call the listed prior authorization numbers.

Genetic and molecular testing codes (examples: 0018U, 0022U, 81163, 81400 series) require prior authorization; for BRCA testing the ordering provider must notify the laboratory, and the laboratory will notify UnitedHealthcare.

Home health and hospice: Home health services and hospice codes require prior authorization; home health prior authorization applies only in outpatient settings.

Prior authorization and special handling notes

Prior authorization requirements and special notes

Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 888-397-8129.

For unclassified and temporary codes (C9151, C9160, C9162, C9167, C9168, J3490, J3590) prior authorization is required only for specified products (Adzynma, Nulibry, Omvoh IV, Revcovi).

Code J0897 (Denosumab/Xgeva) requires prior authorization for non‑oncology indications.

Providers should check the Review at Launch for New to Market Medications policy for up‑to‑date information on newly approved drugs.

Prior authorization criteria — selected procedures and devices

Codes and conditions requiring prior authorization in this document section.

Selected procedures/devices requiring prior authorization

Joint, total hip and knee replacement procedures (multiple CPT codes such as 27130, 27447) — prior authorization required; facility types noted (critical access hospitals, long‑term acute care hospitals, skilled nursing facilities).
Non‑emergent air ambulance transport (A0430, A0431, A0435, A0436, S9960, S9961) — prior authorization required.
Orthognathic surgery procedure codes (e.g., 21121, 21123, up to 21299) — prior authorization required.
Orthotics and prosthetics L‑codes — prior authorization required only when retail purchase or cumulative rental cost exceeds $500.

Explicit prior authorization coverage criteria (excerpted)

Services explicitly noted as requiring prior authorization in this section include:

Pediatric day health services (PDHC) — prior authorization required (example code: T1024).

Private duty nursing — prior authorization required (example codes: T1000, T1002, T1003).

Potentially unproven services — prior authorization required (example codes: 33289, C2624).

Prostate procedures — prior authorization required (example codes: 37243, 52441, 52442, 53850).

Proton beam therapy — prior authorization required (codes 77520, 77522, 77523, 77525).

Rhinoplasty and septoplasty procedures — prior authorization required (codes 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465).

Prior authorization requirements (code index)

Services and codes requiring prior authorization or special notification as listed in this code index section:

Sleep apnea procedures and surgeries — prior authorization required.

Spinal surgery — prior authorization required (multiple spinal CPT codes listed).

Bone growth stimulator and neurostimulator devices — prior authorization required (multiple HCPCS E07xx and related CPT codes listed).

Transplants and CAR T‑cell therapy — prior authorization required; providers must call the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or the notification number on the member's ID card.

Prior authorization stance

Prior authorization requirements and contact/notification procedures for certain high-cost or specialized services/devices.

Transplant and CAR T‑cell therapy services (including named CAR T products) require contacting UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 for prior authorization/notification.

Ventricular assist devices (VAD) — prior authorization required; providers should call the notification number on the back of the member's ID card and then fax the form provided by the nurse to the Optum VAD Case team.

Wound VAC devices (example HCPCS E2402) — prior authorization required.

For many device and high‑cost services, specific CPT/HCPCS mappings are provided and prior authorization is indicated; follow the contact instructions in the code index for each item.

CPT/HCPCS/ICD-10 Codes and Code Groups

Selected CPT/HCPCS codes requiring prior authorizationCPTCovered

59840	Abortion - CPT/HCPCS code listed
59841	Abortion - CPT/HCPCS code listed
59850	Abortion - CPT/HCPCS code listed
59851	Abortion - CPT/HCPCS code listed
59852	Abortion - CPT/HCPCS code listed
59855	Abortion - CPT/HCPCS code listed
59856	Abortion - CPT/HCPCS code listed
59857	Abortion - CPT/HCPCS code listed
59866	Abortion - CPT/HCPCS code listed
43644	Bariatric surgery - CPT/HCPCS code listed

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Injectable oncology/supportive care HCPCS/CPT codesHCPCSCovered

J1449	Eflapegrastim-xnst (Rolvedon)
J1442	Filgrastim (Neupogen)
Q5110	Filgrastim-aafi (Nivestym)
Q5125	Filgrastim-ayow (Releuko)
Q5101	Filgrastim-sndz (Zarxio)
J2506	Pegfilgrastim (Neulasta)
Q5122	Pegfilgrastim-apgf (Nyvepria)
Q5120	Pegfilgrastim-bmez (Ziextenzo)
Q5111	Pegfilgrastim-cbqv (UDENYCA)
Q5108	Pegfilgrastim-jmdb (Fulphila)

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Injectable chemotherapy HCPCS codes requiring prior authorizationHCPCSCovered

J9000-J9999	Chemotherapy injectable drugs range
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin (additional)
J1950	Lupron Depot

EEG and seizure monitoring CPT codesCPTCovered

95700	Cerebral seizure monitoring
95711	Cerebral seizure monitoring
95712	Cerebral seizure monitoring
95713	Cerebral seizure monitoring
95714	Inpatient video EEG
95715	Inpatient video EEG
95716	Inpatient video EEG
95718	Inpatient video EEG
95720	Electroencephalogram (EEG)
95722	Electroencephalogram (EEG)

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Sample DME/HCPCS codes (partial list)HCPCSCovered

A9279	DME miscellaneous
E0194	Custom wheelchair-related code (example)

Enteral/nutrition codes (partial list)HCPCSCovered

B4034	Enteral formula
B4100	Enteral nutrition supplies

Selected injectable medicationsHCPCS

J3262	Actemra
J0801	Acthar
J0791	Adakveo
J0172	Aduhelm
J7192	Advate / Kogenate FS / Reombinate group
J7207	Adynovate
J7210	Afstyla
J1931	Aldurazyme

Genetic and molecular testing codesCPT

81400	Genetic testing (general molecular pathology)
81401	Genetic testing
81163	Genetic testing

Injectable medication HCPCS codes (sample)HCPCSCovered

J0179	Berinert
J0597	Boniva (ibandronate)
J1740	Botulinum toxins

Injectable medication HCPCS codes (additional sample)HCPCSCovered

J3060	Elevidys
J1413	Elfabrio
J2508	Eloctate

Joint replacement CPT codes (examples)CPTCovered

27130	Total hip arthroplasty (example listed among many joint replacement codes)
27132	Revision of hip replacement (example)

Examples of listed CPT/HCPCS codes requiring prior authorizationmixedCovered

27130	Total hip arthroplasty
27447	Total knee arthroplasty
A0430	Air ambulance, rotor‑wing
L0170	Prosthetic, lower limb

Orthotics and prosthetics L-codes (examples)HCPCSCovered

L3971	Skilled nursing facility orthotics/prosthetics prior authorization reference
L3975	Skilled nursing facility orthotics/prosthetics prior authorization reference
L3999	Orthotics/prosthetics assorted codes listed
L4010	Prosthetics code listed for prior auth
L5020	Orthotics/prosthetics L-code listed for prior auth
L8610	Orthotics/prosthetics L-code listed for prior auth
L8659	Orthotics/prosthetics L-code listed for prior auth

Proton beam therapy codesCPTCovered

77520	Proton beam therapy CPT/HCPCS code
77522	Proton beam therapy CPT/HCPCS code
77523	Proton beam therapy CPT/HCPCS code
77525	Proton beam therapy CPT/HCPCS code

Sinuplasty codesCPTCovered

31295	Sinuplasty CPT
31296	Sinuplasty CPT
31297	Sinuplasty CPT
31298	Sinuplasty CPT

Mixed procedural code mappings (sample)mixed

36832	Referenced repeatedly as a mapping anchor; appears alongside many procedure descriptions
66821	Listed with mappings to other ophthalmic procedure codes

Musculoskeletal / arthroscopy codesCPT

29806	Arthroscopy code listed in musculoskeletal group
G0260	Listed in arthroscopy / musculoskeletal section

Device HCPCS codesHCPCS

E0747	Bone growth stimulator / neurostimulator HCPCS code listed
L8680	Implantable device supply code listed

Neurostimulator HCPCSHCPCS

E0747	Neurostimulator related HCPCS
E0748	Neurostimulator related HCPCS
E0749	Neurostimulator related HCPCS
E0760	Neurostimulator related HCPCS

Device implant HCPCS/L-codesHCPCS

L8680
L8682
L8685

VAD and wound VAC codesmixed

33927	Ventricular assist device related CPT
33928	Ventricular assist device related CPT
33929	Ventricular assist device related CPT
33975	Ventricular assist device related CPT
33976	Ventricular assist device related CPT/HCPCS
33979	Ventricular assist device related CPT/HCPCS
33981	Ventricular assist device related CPT/HCPCS
33982	Ventricular assist device related CPT/HCPCS
33983	Ventricular assist device related CPT/HCPCS
Q0507

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Gene/CAR T/Gene therapy related codesmixed

0537T
0538T
0539T
0540T
Q2041
Q2042
Q2053
Q2054

DME prior authorization cost threshold

ThresholdPrior authorization required only for DME codes with a retail purchase or cumulative rental cost greater than $500.

Applies toDurable medical equipment codes listed in the policy (prosthetics are not considered DME for this threshold).

How measured

How to Request Authorization and Notification Workflows

Prior Authorization

How to request prior authorization and scope

To request prior authorization, submit online via the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal (UHCprovider.com -> Provider Portal -> Prior Authorization and Notification). Requests may also be submitted by phone or fax. Prior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all non-emergent procedures and services.

Online: Prior Authorization and Notification tool on UnitedHealthcare Provider Portal (UHCprovider.com).
Phone/fax options available (see Provider Portal/contact channels).
Emergency/urgent care is exempt from prior authorization.

Prior Authorization

Cancer supportive care and injectable agents requiring prior authorization

Prior authorization is required for colony-stimulating factor drugs and bone-modifying agents administered in an outpatient setting for a cancer diagnosis; specific HCPCS/J codes are listed and some also require prior authorization when billed for non‑oncology indications.

Key Terms and Thresholds

Prior authorization

DefinitionPrior authorization: a process where providers request approval before delivering certain services or supplies; requests submitted via the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal, by phone or fax.

Not required forEmergency or urgent care is exempt from prior authorization requirements.

ScopeApplies to participating in-network and out-of-network providers (out-of-network must request authorization except for emergent/urgent care).

How to submitOnline: Provider Portal Prior Authorization and Notification tool (UHCprovider.com); Phone/fax options available in the document.

Emergency/urgent care

DefinitionEmergency/urgent care: services that are exempt from prior authorization requirements.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Requirements for Pennsylvania Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call the listed phone numbers.

SourceLink

On This Page

Experimental / investigational services: Prior authorization required for codes flagged as experimental/investigational (multiple CPT/HCPCS codes listed).

Femoroacetabular impingement (FAI): Prior authorization required for code 29916.

Providers must follow site‑of‑service rules where applicable (e.g., prior authorization required when service is requested in an outpatient hospital setting; may not be required if performed at a participating ASC).

Sinuplasty (codes 31295–31298) — prior authorization required; site‑of‑service note: prior authorization required when requested in an outpatient hospital setting but not required if performed at a participating ASC.

Advanced outpatient imaging (selected CT/MRI/MRA/PET and nuclear medicine) — provider notification/prior authorization required prior to scheduling; contact 866-889-8054 or use Provider Portal.

Retail purchase price or cumulative rental cost for the item exceeds $500.

Reference actionSubmit prior authorization via the Provider Portal or phone as specified in the document when threshold is met.

Orthotics/prosthetics prior authorization threshold

ThresholdPrior authorization required only for orthotics and prosthetic codes with a retail purchase or cumulative rental cost of more than $500.

ScopeApplies to orthotics and prosthetics L‑codes listed in the policy.

ExclusionProsthetics are noted separately and not treated as DME for the DME threshold rule.

Provider actionIf retail purchase or cumulative rental cost exceeds $500, submit prior authorization via the Provider Portal or contact numbers provided in the policy.

Examples of listed codes: J1449, J1442, Q5110, Q5125, J2506, Q5122, Q5120, Q5111, Q5108, J0897, J2820, J0885.
Some listed codes (notably those marked *) require prior authorization for non‑oncology diagnoses as well.

Prior Authorization

Cardiology prior authorization

Participating physicians must obtain prior authorization for specified outpatient and office‑based cardiology services (diagnostic catheterizations, electrophysiology implants, stress echocardiograms); submission via the Provider Portal or by phone is required and full CPT lists are on the provider site.

Submit requests through the Prior Authorization and Notification tool on UHCprovider.com or call 866-889-8054.
See UHCprovider.com/PAcommunityplan for the detailed CPT code lists.

Prior Authorization

How to obtain prior authorization for injectable chemotherapy drugs

Injectable chemotherapy drugs administered in the outpatient setting (including J9000–J9999, leucovorin J0640/J0641/J0642, Lupron Depot J1950, Q‑codes and miscellaneous HCPCS for new agents) require prior authorization; submit requests via the Provider Portal or call 888-397-8129.

Scope includes intravenous, intravesical and intrathecal outpatient chemotherapy.
Acceptable submission methods: Provider Portal Prior Authorization and Notification tool or phone 888-397-8129.

Prior Authorization

Seizure monitoring and EEG prior authorization guidance

Prior authorization is required for inpatient cerebral seizure monitoring and inpatient video EEG services; outpatient EEG does not require prior authorization.

Inpatient codes: 95700, 95711–95713, 95714–95718 (inpatient video).
Outpatient EEG codes (e.g., 95720–95726) do not require prior authorization.

Prior Authorization

Cochlear implants and continuous glucose monitor prior authorization

Prior authorization is required for cochlear implant procedures and for certain continuous glucose monitor (CGM) devices when billed with a Type 2 Diabetes diagnosis; specific device HCPCS/L codes are listed.

Cochlear implant example codes: 69710, 69714, 69930, L8614.
CGM example codes: A4226, A9277, A4238, A9278, A4239, E0787, A9276, E2102 (prior auth required with Type 2 Diabetes diagnosis).

Prior Authorization

Cosmetic and reconstructive procedures prior authorization

Cosmetic and reconstructive procedures require prior authorization; the policy distinguishes cosmetic procedures that only change appearance from reconstructive procedures that treat a medical condition and lists numerous CPT codes that require prior authorization.

Providers must obtain prior authorization for listed CPT codes (examples include 11960, 14020–14061, 15820–15830, 17106–17108).
Reconstructive procedures treating a medical condition are also subject to prior authorization.

Documentation Required

Cosmetic and reconstructive — sample codes

Sample CPT/HCPCS codes for cosmetic and reconstructive procedures are listed in the policy and prior authorization instructions are provided for these codes.

Example codes shown: 28344, 30620, 67900–67906 (and many others) — providers should follow the prior authorization submission instructions in the policy.

Prior Authorization

Additional procedure codes requiring prior authorization

Additional CPT/HCPCS procedure codes listed (including eyelid/ocular and related codes) require prior authorization; the policy notes that certain code pairings (e.g., Q2026 with 67966) may be associated with gender dysphoria considerations.

Examples: 67908–67924, 67950, 67961, 67966, Q2026 — gender dysphoria may apply.
Check the policy code listings for full details and submission requirements.

Documentation Required

Diagnosis codes (ICD-10) referenced

The policy lists numerous ICD‑10 diagnosis codes alongside CPT/HCPCS codes; some diagnosis codes can exempt the prior authorization requirement when billed with the procedure.

Extensive ICD‑10 listings are in the document (examples shown in the diagnosis code blocks).
Providers should review the code/diagnosis pairings to determine if prior authorization is required.

Billing Rule

DME codes and prior authorization threshold

Durable medical equipment (DME) codes listed require prior authorization only when the retail purchase or cumulative rental cost exceeds $500; the policy clarifies that prosthetics are not treated as DME for this threshold.

Prior authorization cost threshold: retail purchase or cumulative rental cost > $500.
Examples of DME codes listed: A9279, A9280, A9900, E0194, E0265, E0328, E0445, etc.

Prior Authorization

Enteral and in-home nutritional therapy

Enteral nutrition and in‑home nutritional therapy services (specific B‑series HCPCS codes) require prior authorization.

Example enteral codes requiring prior authorization: B4034, B4100, B4150, B4152–B4161, B9002, B9998.
Submit prior authorization per the Provider Portal instructions in the policy.

Prior Authorization

Experimental/investigational codes

The document flags a set of CPT/HCPCS codes as experimental and/or investigational; prior authorization is required for those listed codes.

Examples of investigational codes listed: 33477, 36514, 64722, 65765, 66180, A4638, A6000, S1030, S9991, etc.
Providers must obtain prior authorization for services billed under these codes.

Prior Authorization

FAI procedure prior authorization

Femoroacetabular impingement (FAI) procedures require prior authorization; code 29916 is specifically listed.

FAI CPT code: 29916 requires prior authorization.

Prior Authorization

Prior authorization requirement (general)

The policy indicates that prior authorization is required for the experimental/investigational services and for the many CPT/HCPCS codes enumerated throughout the document; providers should consult the lists and submission instructions in the policy.

Many service categories and specific codes in the document are identified as requiring prior authorization.
Follow Provider Portal or phone submission instructions referenced in the policy.

Prior Authorization

Genetic and molecular testing prior authorization

Genetic and molecular testing codes require prior authorization/notification; the ordering provider must notify the laboratory performing BRCA/genetic testing and the laboratory will notify UnitedHealthcare as part of the authorization/notification process.

Example codes requiring authorization/notification: 0018U, 0022U, 0023U, 0026U, 0055U, 0060U, 0087U, 0129U, 0171U, 81400, 81401, 81163, 81522, 87505–87507.
Ordering provider action: notify the laboratory before DNA sequencing/BRCA testing; lab will notify UnitedHealthcare.

Prior Authorization

Home health and hospice prior authorization

Home health services and hospice require prior authorization when provided in outpatient settings; specific G‑series and T‑codes are listed.

Home health example codes: G0156, G0162, G0299, G0300, G0493–G0496, S9122–S9124, S9474.
Hospice example code: T2045.

Prior Authorization

Hysterectomy prior authorization

Hysterectomy procedures listed in the policy require prior authorization; numerous hysterectomy CPT codes are enumerated.

Example hysterectomy codes: 58150, 58152, 58180, 58260–58270, 58542–58573.
Providers must obtain prior authorization for the listed hysterectomy procedures.

Prior Authorization

Gender dysphoria treatment prior authorization

Gender dysphoria treatment procedures and associated CPT/HCPCS codes are identified and require prior authorization.

Examples of codes: 55970, 55980, 21121–21299 range (orthognathic and related), 21899, 31599, 31750, 31899, 45399, 45999, 53410, 54125, 54520–54690, 55175–55180, 56625, 56800–56805, 57110, 57335, 58541–58554, 58661, 58720, 58940, 58999, 64856, 64892, 64896, 69300, 90785, 96372.
Providers should follow prior authorization submission instructions in the policy.

Prior Authorization

Injectable medications prior authorization list

An extensive list of injectable medications (J‑ and Q‑codes) requires prior authorization; the policy provides many examples and instructs providers to submit prior authorization requests via the Provider Portal or phone.

Examples include: J3262 (Actemra), J0801 (Acthar), J0791 (Adakveo), J0172 (Aduhelm), J7192, J7207, J7210, J1931, J7186, J7193, J7201, J7214, J1426, J0225, J0739, J0256, J0881, J2793, J3145, and many others.
Submission methods: Provider Portal Prior Authorization and Notification tool or phone (see policy for contact numbers).

Prior Authorization

How to obtain prior authorization

For general prior authorization requests, submit via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-397-8129.

Online: UHCprovider.com -> Provider Portal -> Prior Authorization and Notification.
Phone contact: 888-397-8129 for many listed medications and services.

Documentation Required

Inpatient admission notification

Notification is required for inpatient admissions; prior authorization and notification of the admission date are required for specified post‑acute inpatient facilities.

Facilities requiring notification/authorization: acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long‑term acute care hospitals, skilled nursing facilities.
Providers must provide admission date notification per the policy.

Prior Authorization

Joint replacement prior authorization

Joint replacement procedures (total hip and knee and related CPT codes) require prior authorization; the policy lists numerous CPT codes and notes applicable facility types.

Examples: 27130 (total hip arthroplasty), 27447 (total knee arthroplasty), and multiple other hip/knee joint replacement CPT codes.
Facility types noted include critical access hospitals, long‑term acute care hospitals and skilled nursing facilities.

Prior Authorization

Prior authorization required — joint replacement procedures

Prior authorization is required for the listed joint, total hip and knee replacement procedure codes; participating providers should follow the prior authorization process and note facility type guidance in the policy.

Sample codes listed: 24363, 27120–27138 series, 27412, 27446–27487, 29866–29868, J7330, S2112.
Verify facility type requirements when submitting prior authorization requests.

Prior Authorization

Prior authorization required — non-emergent air ambulance transport

Non‑emergent air ambulance transports require prior authorization; applicable CPT/HCPCS codes are listed.

Air ambulance codes: A0430, A0431, A0435, A0436 and related S9960/S9961.
Prior authorization is required before non‑emergent air transport is provided.

Prior Authorization

Prior authorization — orthognathic surgery

Orthognathic surgery (treatment of maxillofacial/jaw functional impairment) procedure codes listed in the policy require prior authorization.

Examples of orthognathic codes: 21121, 21123, 21125, 21127, 21141–21299 (see policy for full list).
Prior authorization references and submission instructions are included in the policy.

Billing Rule

Prior authorization — orthotics and prosthetics (cost-threshold applies)

Orthotics and prosthetics codes require prior authorization only when the retail purchase or cumulative rental cost exceeds $500; prosthetics are treated separately from DME in the policy.

Prior authorization threshold: retail purchase or cumulative rental cost > $500.
Examples of L‑codes listed: L0112, L0170, L0456, L0462, L0480, L0482, L0484, L0486, L0624, etc.

Prior Authorization

How to request prior authorization

To request prior authorization for certain advanced outpatient imaging and other services, call 866-889-8054 or submit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal; providers ordering advanced outpatient imaging must provide notification prior to scheduling.

Phone: 866-889-8054 for advanced outpatient imaging prior authorization requests.
Online submission: Provider Portal -> Prior Authorization and Notification.

Prior Authorization

Site-of-service and sinuplasty prior auth notes

Sinuplasty procedures require prior authorization; site‑of‑service rules apply — prior authorization is required when performed in an outpatient hospital but not when performed at a participating Ambulatory Surgery Center (ASC).

Sinuplasty CPT codes: 31295–31298 require prior authorization.
Site‑of‑service rule: prior authorization required for outpatient hospital site; not required if performed at a participating ASC.

Prior Authorization

Sleep apnea procedures prior auth

Sleep apnea procedures and related surgeries require prior authorization as noted in the policy.

Includes procedures such as maxillomandibular advancement and tissue reduction for obstructive sleep apnea; see policy for CPT listings.
Providers must follow prior authorization submission requirements.

Prior Authorization

Spinal surgery prior auth

Spinal surgery procedures require prior authorization; multiple spinal CPT codes are listed in the policy and providers must obtain authorization before these services.

Spinal surgery example codes include 22100–22533 and many others referenced in the spinal surgery section.
Prior authorization is required prior to performance of the listed spinal procedures.

Prior Authorization

Device-based therapy prior auth

Device‑based therapies (bone growth stimulators, neurostimulators and related devices) require prior authorization; multiple E‑series HCPCS and related CPT codes are listed.

Examples: HCPCS E0747–E0760 mapping to various CPT codes (e.g., 64553, 64555, 64568, 64570, L8680, L8682, L8685).
Prior authorization required for these device-based services.

Prior Authorization

Transplant and CAR T-cell prior auth

Transplant and CAR T‑cell therapy services require prior authorization/notification; providers should call the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or use the notification number on the member's ID card.

Applies to named CAR T products (e.g., Abecma, Breyanzi, Kymriah, Tecartus, Yescarta) and transplant services.
Call 888-936-7246 or the notification number on the member's health plan ID card.

Prior Authorization

Transplant and CAR T-cell therapy prior authorization

For transplant and CAR T‑cell therapy (including specific CAR T products), call the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or the notification number on the member's ID card to initiate prior authorization/notification.

Named CAR T products referenced include Abecma, Breyanzi, Kymriah, Tecartus and Yescarta.
Use the transplant case management phone line or member ID notification number to start the process.

Prior Authorization

Ventricular assist device prior authorization workflow

Ventricular assist devices (VAD) require prior authorization; 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 team as instructed in the policy.

Provider action: call the notification number on the back of the member's ID card.
Follow-up: fax the form provided by the nurse to the Optum VAD Case team.

Prior Authorization

Wound VAC prior authorization

Wound vacuum (Wound VAC) devices require prior authorization; the policy lists E2402 as an example HCPCS code and notes prior authorization is required.

Example Wound VAC HCPCS code: E2402.
Obtain prior authorization before supplying or billing the device.

Note

General CPT/HCPCS prior authorization mapping

The policy maps numerous CPT and HCPCS codes to device and service categories and indicates prior authorization is required for many of the listed items; providers should consult the code index for specific code-to-service mappings and prior authorization instructions.

Device categories include neurostimulators, implantable device L‑codes, VAD and wound VAC codes, and gene/CAR T/gene therapy codes.
Refer to the document's code index to identify exact codes and submission requirements for each device/service.

Provider responsibilityNo prior authorization required for emergency or urgent care; providers should follow standard post‑admission notification processes as applicable.

Out-of-network noteOut-of-network providers still must request prior authorization for all other procedures/services except emergent/urgent care.

Provider Portal prior authorization

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

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

Alternate submissionRequests may also be submitted by phone (numbers listed in the policy) or fax.

EEG / seizure monitoring authorization distinction

DistinctionInpatient cerebral seizure monitoring and inpatient video EEG require prior authorization; outpatient EEG does not require prior authorization.

Relevant codesInpatient cerebral seizure monitoring: 95700, 95711, 95712, 95713; Inpatient video EEG: 95714, 95715, 95716, 95718; Outpatient EEG examples: 95720, 95722, 95724, 95726.

Provider actionSubmit prior authorization for inpatient seizure monitoring/video EEG via the Provider Portal or phone as directed in the policy.

DME prior authorization

DefinitionDME prior authorization rule: prior authorization is required only for the DME codes listed when the retail purchase or cumulative rental cost exceeds $500.

ExamplesSample DME HCPCS codes shown in the policy include A9279 and E0194 (among many others).

ExclusionProsthetics are explicitly noted as not being DME for this threshold.

SubmissionIf threshold exceeded, submit prior authorization via Provider Portal or phone per document instructions.

Gender dysphoria note

ContextGender dysphoria may apply to certain listed procedure codes (notation in the policy where codes such as 67966 and Q2026 appear together).

Codes referencedExamples in the policy include codes 67966 and Q2026; other gender dysphoria procedure codes are listed in the gender dysphoria treatment section.

Prior authorizationProcedures related to gender dysphoria treatment are identified and require prior authorization as listed in the policy.

Genetic/molecular testing notification

RequirementGenetic and molecular testing requires prior authorization/notification.

Ordering provider actionFor BRCA testing before DNA sequencing, the ordering care provider must notify the laboratory conducting the test; the laboratory will notify UnitedHealthcare as part of the authorization/notification process.

Examples of codesPolicy lists multiple test codes (e.g., 0018U, 0022U, 0023U, 0026U, 0055U, 0060U, 0087U, 0129U, 81400, 81401, 81163, 81522, 81546).

Home health outpatient limitation

LimitationHome health prior authorization applies only in outpatient settings as noted in the policy.

CodesHome health and hospice examples include G0156, G0162, G0299, G0300, G0493, G0494, G0495, G0496.

Provider actionSubmit prior authorization for outpatient home health services via the Provider Portal or phone per document instructions.

UnitedHealthcare Provider Portal prior authorization tool

ToolUnitedHealthcare Provider Portal — Prior Authorization and Notification tool (UHCprovider.com).

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

Alternate submissionRequests may also be submitted by phone (e.g., 888-397-8129 or other numbers listed) or fax per the document.

Prior authorization

DefinitionPrior authorization indicates services or codes that must be approved before delivery; see the policy code lists for items requiring authorization.

SubmissionSubmit authorization requests via the Provider Portal, phone or fax as provided in the policy.

Emergency careEmergency or urgent care is exempt from prior authorization requirements.

Orthotics/prosthetics prior authorization rule

RulePrior authorization required for orthotics and prosthetics L‑codes only when the retail purchase or cumulative rental cost is more than $500.

ExamplesPolicy lists many L‑codes as examples (e.g., L0112, L0170, L0456, L0462, L0480, L0482, L0484, L0486, L0624, etc.).

ExclusionProsthetics are noted separately and not treated as DME for the DME threshold rule.

Proton beam therapy

DefinitionProton beam therapy: focused radiation therapy using beams of protons.

Prior authorizationProton beam therapy requires prior authorization as indicated in the Radiology section.

CodesExamples of proton beam therapy codes listed: 77520, 77522, 77523, 77525.

Site of service (SOS) - outpatient hospital

DefinitionSite of service (SOS) - outpatient hospital: prior authorization is required only when requesting the service in an outpatient hospital setting.

ASC exceptionPrior authorization is not required if the service is performed at a participating Ambulatory Surgery Center (ASC) for listed procedures.

Provider actionWhen scheduling advanced outpatient imaging or procedures, verify site-of-service rules and submit authorization if outpatient hospital site is selected.

Site of service (SOS)

TermSite of service (SOS): the clinical setting where a procedure is performed (e.g., outpatient hospital, ASC).

Policy notePrior authorization rules in the document include site-of-service distinctions for multiple procedure groups; check the specific code entries for details.

Provider actionConfirm the planned site of service when submitting prior authorization to determine whether authorization is required.

Ventricular assist device (VAD)

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

Prior authorization workflowProviders 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 team to obtain prior authorization.

Example codesPolicy lists VAD‑related CPT codes such as 33927, 33928, 33929, 33975 and others associated with authorization requirements.