UnitedHealthcare Prior Auth Requirements — Policy Update

Coverage Criteria and Prior Authorization Rules

Prior authorization general criteria and examples

General prior authorization requirements, submission methods, and examples of service categories that require prior authorization.

Providers must submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone at 877-842-3210; Pediatric Care Network (PCN) requests use 833-802-6427 (8 a.m.–5 p.m. CT, M–F).

Prior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all procedures/services except emergent or urgent care.

Examples of services requiring prior authorization

Behavioral health services: many plans use a designated behavioral health network; for specific codes call the number on the member's health plan ID card; applied behavior analysis (ABA) via Provider Express.
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, J2820 and other J-/Q-codes).
Bariatric surgery: prior authorization required (examples of listed CPT codes include 43644, 43645, 43770, 43775, 43842, 43845, 43847, 43848).

Operational note: follow the portal workflow or phone instructions when submitting requests; see member ID card for specialty contact numbers.

Prior Authorization Criteria and Process

Categories and process details for obtaining prior authorization for specific service groups.

Injectable chemotherapy drugs administered in an outpatient setting require prior authorization, including J9000–J9999 chemotherapy injectables, leucovorin (J0640), levoleucovorin (J0641, J0642), Lupron Depot (J1950), Q-coded chemotherapy injectables, and miscellaneous HCPCS-billed chemotherapy injectables awaiting assigned codes.

Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) to submit requests or call 888-397-8129 for chemotherapy-related authorizations.

Durable medical equipment (DME) requires prior authorization only for listed DME codes with a retail purchase or cumulative rental cost greater than $500; prosthetics are not considered DME.

Prior authorization and code-based coverage requirements

Coverage interactions and code-based requirements that affect prior authorization and notification processes.

Enteral services (in‑home nutritional therapy delivered enterally or via gastrostomy tube) require prior authorization.

Genetic and molecular testing (outpatient), including specified BRCA and other panel tests, require prior authorization/notification; providers must indicate the laboratory and test name as part of the submission and complete the prior authorization/notification process for listed CPT/PLA/U codes (examples: 81401–81417 range, 81432, 81520 and listed U-codes).

Home health services require prior authorization only in outpatient settings (including the member’s home); listed CPT/HCPCS codes (examples include 97535, G0151 and other listed entries) are subject to authorization rules.

Extensive lists of U-codes and CPT/HCPCS entries are enumerated in the document and tied to the authorization/notification program; registered laboratories and listed codes will be notified/registered with UnitedHealthcare.

Coverage stance for listed injectable medications

Injectable medications listed in the document require prior authorization when billed as indicated.

Prior authorization is required for injectable medications listed in the chemotherapy/medication sections; providers must follow PA submission processes for these medications.

Examples of injectable medication codes: Multiple HCPCS J- and Q-codes are listed for specific drugs (examples include J7207, J7171, J9057, J9354, J9271 and many others in the injectable medication lists).

Predetermination / Prior authorization guidance

Guidance on predetermination (recommended prior authorization) for newly approved market medications.

Providers should check the 'Review at Launch for New to Market Medications - Community Plan Medical Benefit Drug Policy' for the most up-to-date information on newly FDA-approved drugs that may be included on the list.

Predetermination (prior authorization) is highly recommended for drugs included on the Review at Launch list.

Some specific HCPCS/J-codes are provided intermittently as examples; use the appropriate HCPCS/J-code when submitting a predetermination or prior authorization request.

Predetermination / Review at Launch guidance

Administrative recommendation regarding predetermination for new-to-market medications.

Predetermination is highly recommended for newly FDA‑approved drugs that are included on the Market Medications / Review at Launch list; consult the payer's Review at Launch process for specifics on authorization and coding requirements.

This excerpt references CPT and HCPCS codes and authorization procedures but does not list specific codes in this section; follow the Review at Launch and related medical/drug policies for details.

Predetermination and reference guidance

Reference guidance for coverage and process when drugs are newly approved and included on the Review at Launch list.

Predetermination (prior authorization) is highly recommended for drugs on the Review at Launch for New to Market Medications list.

Consult the 'Review at Launch for New to Market Medications - Community Plan Medical Benefit Drug Policy' for additional information on CPT/HCPCS codes and how to obtain prior authorization for newly approved drugs.

Predetermination and prior authorization guidance

Administrative recommendation reinforcing predetermination and referencing coding/authorization processes for newly marketed drugs.

Predetermination (prior authorization) is highly recommended for drugs included in the Review at Launch for New to Market Medications list.

Information on how to obtain prior authorization and applicable CPT or HCPCS codes for newly FDA‑approved drugs is provided via the Review at Launch policy and related Medical & Drug Policies and Coverage Determination Guidelines.

Where specific CPT/HCPCS codes are not listed in this excerpt, providers should follow the Review at Launch guidance and the portal submission process when requesting predetermination or prior authorization.

Authorization criteria (select)

Selected authorization and notification criteria for specific drugs, unclassified codes, and orthotics/prosthetics thresholds.

Prior notification for specific drugs

Obtain prior notification for Cimzia and Synagis through OptumRx prior notification services at 800-310-6826.

For unclassified and temporary codes (C9399, J3490, J3590), prior authorization is required only when used for specified high-cost drugs (examples listed in the policy such as Briumvi, Fyarro, Invega Hafyera, Kebildi, Nexviazyme, Pombiliti, Revatio, Saphnelo, Tegsedi, Tivdak, Uptravi, Uzedy, Vabysmo, Voxzogo).

Orthotics and prosthetics require prior authorization only when the retail purchase or cumulative rental cost exceeds $500; listed HCPCS L-codes identify affected items.

Prior authorization requirements

Services and procedures that require prior authorization or are not covered without medical necessity and authorization.

Prior authorization is required for the listed services and codes where indicated, including but not limited to: PET scans (not covered unless medically necessary and prior authorized), private duty nursing (T1000), personal care services (T1019), proton beam therapy (e.g., 77520, 77522, 77523, 77525), sinuplasty (listed CPTs), multiple spinal surgery CPTs, stimulators and implant device codes, ventricular assist devices (VADs), wound VACs, and transplant and CAR‑T therapies (contact Transplant Case Management at 888-936-7246 for transplant/CAR-T services).

Transplant and CAR‑T listings include numerous procedure and drug codes; some unclassified codes and CAR‑T related entries (e.g., J9999, Q2041, Q2054) are used and require prior authorization per the transplant/CAR‑T process.

PET scan coverage

Coverage condition for PET imaging.

Positron emission tomography (PET) scans are not a covered benefit unless medically necessary and prior authorization is obtained (examples of listed codes include 78459, 78609, 78814, 78491, 78811, 78815, 78492, 78812, 78813, 78608).

Unclassified codes and special provisions

Special provisions for unclassified codes and select product effective dates.

Some unclassified and miscellaneous drug/device codes require prior authorization only for specific products; for example, code 38232 requires prior authorization only when billed for an oncology diagnosis.

Prior authorization effective date noted for Aucatzyl: PA effective 12/22/2025 for listed codes where applicable.

Unclassified codes (e.g., C9399, J3490, J3590) are handled per policy — prior authorization is required when used for specified high‑cost products and technologies; contact the notification number on the member's ID card for guidance when needed.

CPT / HCPCS / ICD-10 Codes and Coding Notes

Bariatric surgery codes requiring prior authorizationCPTCovered

43644	Bariatric surgery CPT code listed requiring prior authorization
43645	Bariatric surgery CPT code listed requiring prior authorization
43770	Bariatric surgery CPT code listed requiring prior authorization
43775	Bariatric surgery CPT code listed requiring prior authorization
43842	Bariatric surgery CPT code listed requiring prior authorization
43845	Bariatric surgery CPT code listed requiring prior authorization
43847	Bariatric/obesity-related CPT code listed requiring prior authorization
43848	Bariatric/obesity-related CPT code listed requiring prior authorization

BRCA genetic testing codesCPTCovered

81162	BRCA genetic testing CPT/HCPCS code listed
81166	BRCA genetic testing CPT/HCPCS code listed
81163	BRCA genetic testing CPT/HCPCS code listed
81212	BRCA genetic testing CPT/HCPCS code listed
81164	BRCA genetic testing CPT/HCPCS code listed
81432	BRCA genetic testing CPT/HCPCS code listed
81165	BRCA genetic testing CPT/HCPCS code listed

Cancer supportive care J-/Q-codesHCPCSCovered

J1442	Injectable colony-stimulating factor drug code requiring prior authorization (example listed)
J1447	Injectable colony-stimulating factor drug code listed
J1448	Injectable colony-stimulating factor drug code listed
J2506	Injectable colony-stimulating factor drug code listed
J2820	Injectable colony-stimulating factor drug code listed
J0897	Medication code listed in cancer supportive care section

ICD-10 diagnosis codes referenced for cardiovascular / related sectionsICD-10

I70.*	Multiple I70.x ICD-10 codes listed under cardiovascular requiring prior authorization or noted
M86.*	Multiple M86.x ICD-10 codes listed (osteomyelitis related) requiring prior authorization or noted
T82.*	Device-related ICD-10 codes listed in cardiovascular section
L03.115	Cellulitis ICD-10 code listed
Q27.30	Congenital vascular anomaly ICD-10 code listed

Sample HCPCS/CPT/DME codes requiring prior authorization (partial list)mixedCovered

L8614	Cochlear implant HCPCS
L8619	Auditory implant HCPCS
L8690	Auditory implant HCPCS
L8691	Auditory implant HCPCS
L8692	Auditory implant HCPCS
E0787	Continuous glucose monitor HCPCS
69710	Cochlear implant CPT
69714	Cochlear implant CPT
69930	Cochlear implant CPT
11960	Cosmetic/reconstructive CPT (example listed)

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Selected K-codes from chemotherapy sectionHCPCS

K0005	HCPCS entry present in list
K0812	HCPCS entry present in list
K0884	HCPCS entry present in list

Selected CPT/PLA/U-code groups for genetic/molecular testingmixed

81401	Genetic/molecular testing code (BRCA panel identifiers included)
81414	Genetic/molecular testing code
81520	Molecular pathology/proprietary test code

Home health and miscellaneous service codesmixed

97535	Home health service CPT code
G0151	Home health-related HCPCS
S0315	Procedure/HCPCS entries listed

Sample HCPCS/J-codes from injectable medications listHCPCS

J7207	Adzynma (example from list)
J7171	Akynzeo (example from list)
J9057	Aliqopa (example from list)
J9354	Kadcyla
J9271	Keytruda
J9043	Jevtana
J0218	Sample HCPCS/J-code referenced
J0775	Sample HCPCS/J-code referenced
J1737	Sample HCPCS/J-code referenced
J2357	Sample HCPCS/J-code referenced

Additional HCPCS/J-codesHCPCS

J9354	Kadcyla
J9271	Keytruda
J9043	Jevtana

Sample HCPCS/J-codes referencedHCPCS

J0218
J0775
J1737
J2357
J9228
J9352
J9400
J3399
J3393
J2358

Unspecified chemotherapy drug codesCPT | HCPCS

CPT or HCPCS codes referenced but not specified in this section

Procedure/dispensing codes referencedmixed

Mentions CPT or HCPCS codes for chemotherapy/drugs

Billing codes referencemixed

CPT or HCPCS codes referenced for billing/prior authorization (specific codes not listed in this excerpt)

Selected joint replacement codesCPT | HCPCS

27120	Total hip replacement (listed as example CPT)
27412	Total knee replacement (listed as example CPT)
J7330	Prosthetic/implant code referenced

Selected orthognathic surgery codesCPT

21121	Orthognathic surgery CPT example
21150	Orthognathic surgery CPT example
21246	Orthognathic surgery CPT example

Selected orthotics/prosthetics HCPCS codesHCPCS

L0112	Orthotics/prosthetics HCPCS example
L0456	Orthotics/prosthetics HCPCS example
L0631	Orthotics/prosthetics HCPCS example
L0462	Orthotics/prosthetics HCPCS example

Selected HCPCS/CPT codes with PA requirementsmixedCovered

T1019	Personal care service
T1000	Private duty nursing
78459	PET scan code
78609	PET scan code

Drug/CAR-T related codesHCPCSCovered

J3402	Drug code listed under transplant
J3391	Drug code listed under CAR-T
J9999	Unclassified drug code for CAR-T

Outpatient administration requirement

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

Example codesExamples include J1442, J1447, J1448, J2506, J2820 (see documented J-/Q-code lists).

ScopeApplies to outpatient administration routes (intravenous, intravesical, intrathecal as noted for chemotherapy-related outpatient drugs).

DME prior auth cost threshold

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

ExclusionProsthetics are not considered DME for this threshold (see orthotics/prosthetics section).

Examples of DME codes listedExamples in document: A4618, A7027, A7044, A7045, A9900, E0194, E0265, E0266, E0270, E0277, E0300, E0328, E0329, E0445, E0457.

Prior authorization required for outpatient genetic testing

RequirementPrior authorization/notification is required for outpatient genetic and molecular testing, including BRCA panels.

Submission detailProviders must complete the prior authorization/notification process and indicate the laboratory and test name as part of the request.

Affected codesListed CPT/PLA/U codes include 81401, 81404, 81414, 81432, 81520 and numerous related 814xx/815xx entries referenced in the document.

Orthotics & prosthetics PA threshold

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

Examples of HCPCSSample orthotics/prosthetics HCPCS codes listed include L0112, L0456, L0462, L0464, L0484, L0486, L0624, L0631, L0632, L0634, L0637.

Repeated guidancePolicy repeats that PA is required only when retail purchase or cumulative rental cost exceeds $500 across multiple entries.

How to Request Prior Authorization and Provider Responsibilities

Prior Authorization

How to submit prior authorization requests and general PA rules

This list contains prior authorization requirements for participating UnitedHealthcare Community Plan of Kansas health care professionals providing inpatient and outpatient services. For prior authorization, submit your request in one of the following ways: • Online: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) — sign in with your One Healthcare ID. • Phone: Call 877-842-3210. • Pediatric Care Network (PCN) prior authorization: call 833-802-6427, 8 a.m. – 5 p.m. CT, Monday–Friday. Note: Prior authorization is not required for emergency or urgent care. Out-of-network providers must request prior authorization for all procedures and services except emergent or urgent care.

Prior Authorization

Behavioral health / ABA prior authorization instructions

For behavioral health services (including mental health, substance use and ABA therapy) many plans use a designated behavioral health network. To determine whether a service or CPT/HCPCS code requires prior authorization, call the number on the member's health plan ID card. For applied behavior analysis (ABA) therapy, submit requests via Provider Express.

Prior Authorization

Cancer supportive care PA note

Prior authorization is required for colony-stimulating factor drugs and bone‑modifying agents administered in an outpatient setting for a cancer diagnosis. Examples of HCPCS/J‑codes that require prior authorization include J0897, J1442, J1447, J1448, J1456, J1449, J2468, J2506, J2820 and L8600. Submit chemotherapy and supportive care PA requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call the number on the member's ID card.

Prior Authorization

Prior authorization for outpatient injectable chemotherapy

Prior authorization is required for outpatient injectable chemotherapy drugs (intravenous, intravesical, intrathecal) for a cancer diagnosis. Examples include: • Chemotherapy injectables billed under J9000–J9999 • Leucovorin (J0640), Levoleucovorin (J0641, J0642) • Lupron Depot (J1950) • Chemotherapy drugs with Q‑codes or billed under miscellaneous HCPCS when a permanent code is not yet assigned Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 888-397-8129.

Prior Authorization

DME prior authorization threshold

Prior authorization is required only for durable medical equipment (DME) items listed when the retail purchase or cumulative rental cost exceeds $500. Prosthetics are not considered DME for this threshold; see orthotics & prosthetics rules for those items.

Prior Authorization

How to obtain prior authorization

Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call the number on the member's ID card to obtain prior authorization. For many services (see code lists below) predetermination is recommended. Prior authorization is not required for emergency or urgent care.

Prior Authorization

Enteral services prior authorization

Prior authorization is required for enteral (in‑home nutritional) therapy and related supplies when performed in an outpatient setting. Submit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call the number on the member's ID card.

Prior Authorization

Genetic/molecular testing prior authorization/notification

Genetic and molecular testing performed in an outpatient setting requires prior authorization/notification. Providers requesting laboratory genetic testing (including BRCA and many other molecular assays) must complete the prior authorization/notification process. Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal; specific CPT/HCPCS/U‑codes are included on the portal guidance (examples: 81162, 81229, 81401, 81405, multiple 8xx/9xxU codes and S1040/T1999/V2786 code mappings).

Prior Authorization

Home health services prior authorization

Home health services require prior authorization when provided in outpatient settings, including services delivered in the member's home. Examples of codes that may require authorization include (but are not limited to) 97535, 97537, 99381–99395, 99391–99395, G0151–G0153, G0299, G0300 and associated H‑series behavioral health codes. Submit via the Prior Authorization and Notification tool or call the number on the member's ID card.

Prior Authorization

Transplant and CAR-T prior authorization and contact

For transplant and CAR‑T therapy services (including Abecma, Breyanzi, Carvykti, Kymriah, Lenmeldy, Lyfgenia, Ryoncil, Tecartus, Yescarta and other transplant/CAR‑T services), prior authorization is required. Contact 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 health plan ID card.

Transplant-related CPT/HCPCS examples requiring prior authorization: 32850, 32851, 32852, 32854, 32855, 32856, 33927, 33930, 33933, 33935, 33940, 33944, 33945, 33979, 33981, 33982, 33975, 33976, 33929, 33935, 33940, 33944, 33933, 33930, 33945, 33935, 33940, 33944, 33933, 33930 (note: list includes operative and transplant procedure codes)
CAR‑T therapy and related HCPCS/J‑codes that require prior authorization or notification: J3402, J3391, J3394, J9999, J3402, J3391, J3394, J3393, J3391, J3394, J3393, J3391, J3394, Q2041, Q2042, Q2054, Q2055, Q2056, Q2058, S2060, S2061, S2152

Prior Authorization

Unclassified / miscellaneous prior authorization guidance

Unclassified and temporary codes (for example J3490, J3590, C9399) require prior authorization only when used to bill for specific high‑cost drugs (examples include Briumvi, Fyarro, Invega Hafyera, Kebildi, Nexviazyme, Pombiliti, Revatio, Saphnelo, Tegsedi, Tivdak, Uptravi, Uzedy, Vabysmo, Voxzogo). For these cases, submit PA requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

Definitions and Terms

Prior authorization

DefinitionPrior authorization: administrative review required before specified services or items are performed or billed.

How to submitSubmit requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone at 877-842-3210; PCN uses 833-802-6427.

Emergency/Out-of-network rulePrior authorization is not required for emergency or urgent care; out-of-network providers must request PA for all procedures/services except emergent or urgent care.

Designated behavioral health network

DefinitionDesignated behavioral health network: many plans provide behavioral health services through a separate network; prior authorization/coding inquiries should use the number on the member's ID card.

ABA submissionApplied Behavior Analysis (ABA) therapy prior authorization/submission is handled via Provider Express.

Contact guidanceFor specific behavioral health codes requiring authorization, call the number on the member's health plan ID card.

Injectable chemotherapy drugs (outpatient)

RequirementPrior authorization is required for injectable chemotherapy drugs administered in an outpatient setting for a cancer diagnosis.

Included agents/codesIncludes chemotherapy injectable drugs (J9000–J9999), Leucovorin (J0640), Levoleucovorin (J0641, J0642), Lupron Depot (J1950), Q-coded chemotherapy injectables, and miscellaneous HCPCS for unassigned drugs.

How to obtainUse the Prior Authorization and Notification tool on UHCprovider.com or call 888-397-8129 to request authorization for these outpatient injectable chemotherapy drugs.

Durable medical equipment (DME)

DefinitionDurable medical equipment (DME): items listed require prior authorization only when the retail purchase or cumulative rental cost exceeds $500.

Prosthetics noteProsthetics are not classified as DME for this purpose—see orthotics and prosthetics section for separate threshold guidance.

Sample codesDocument lists multiple DME HCPCS such as A4618, A7027, A7044, A7045, A9900 and various E-codes (E0194, E0265, E0266, E0270, E0277, E0300, E0328, E0329, E0445, E0457).

Prior authorization/notification

RequirementPrior authorization/notification required for genetic and molecular testing performed in outpatient settings; providers must indicate the laboratory and test name.

Covered code groupsAffected codes include numerous 814xx/815xx PLA/U codes and specified U-codes (examples shown across the genetic testing lists).

Registration/program noteSpecified genetic tests (series of U-codes) are subject to the authorization/notification program and laboratories/listed codes will be registered with UnitedHealthcare.

Enteral services (in-home nutritional therapy)

RequirementEnteral services (in-home nutritional therapy delivered enterally or via gastrostomy tube) require prior authorization.

Sample codesDocument references codes such as S1040 (mapped to B9002), T1999 (mapped to B9998) and V2786 among enteral service entries.

SettingApplies when services are provided in outpatient settings including the member's home.

Prior authorization

How to obtain PAUse the Prior Authorization and Notification tool on UHCprovider.com or call 888-397-8129; general portal submission also available via UHCprovider sign-in. For other PA phone assistance call 877-842-3210.

Predetermination recommendedPredetermination (prior authorization) is highly recommended for drugs listed on the Review at Launch for New to Market Medications - Community Plan Medical Benefit Drug Policy.

OptumRx prior notificationObtain prior notification for Cimzia and Synagis through OptumRx prior notification services at 800-310-6826.

Review at Launch

DefinitionReview at Launch for New to Market Medications: payer process/policy (Community Plan Medical Benefit Drug Policy) used to evaluate newly FDA-approved drugs.

ActionPredetermination (prior authorization) is highly recommended for drugs included on the Review at Launch list.

Reference instructionProviders should consult the Review at Launch - Community Plan Medical Benefit Drug Policy for the most up-to-date inclusion and authorization guidance for new-to-market medications.

Predetermination

DefinitionPredetermination: recommended process (prior authorization) for newly FDA-approved drugs on the Review at Launch list.

When to useRecommended before providing/dispensing drugs newly added to the Market Medications or Review at Launch lists to ensure coverage and appropriate coding guidance.

Where to find listSee Review at Launch for New to Market Medications - Community Plan Medical Benefit Drug Policy and Market Medications - Community Plan Medical Benefit Drug Policy referenced in the document.

Market Medications - Community Plan Medical Benefit Drug Policy

Policy referenceMarket Medications - Community Plan Medical Benefit Drug Policy: referenced source for drugs newly approved by the FDA and for which predetermination is recommended.

GuidancePredetermination is highly recommended for drugs on the Market Medications/Review at Launch lists; specific CPT/HCPCS codes and PA instructions are provided via those policies.

Operational noteThe document repeatedly directs providers to consult the Market Medications/Review at Launch policy for up-to-date authorization requirements for new-to-market drugs.

Review at Launch for New to Market Medications

RecommendationReview at Launch for New to Market Medications: predetermination is highly recommended for drugs on the list; obtain PA before service when possible.

ScopeApplies to newly FDA-approved medications included on the payer's Review at Launch list; consult the Community Plan Medical & Drug Policies and Coverage Determination Guidelines for details.

Submission guidanceFor prior authorization, submit requests online via the Prior Authorization and Notification tool on UnitedHealthcare or follow instructions in the Review at Launch policy.

Prior notification for specific drugs (Cimzia and Synagis) via OptumRx

Prior notificationObtain prior notification for Cimzia and Synagis through OptumRx prior notification services at 800-310-6826.

Unclassified code PA ruleFor unclassified and temporary codes (C9399, J3490, J3590), prior authorization is required only when used for specific listed high-cost drugs (examples provided in the document).

How to submit PAFor prior authorization, submit requests online using the Prior Authorization and Notification tool on UnitedHealthcare.

Orthotics and prosthetics requiring prior authorization when purchase/rental cost exceeds $500

ThresholdOrthotics and prosthetics require prior authorization only when retail purchase or cumulative rental cost exceeds $500.

Representative HCPCSDocument lists multiple HCPCS for orthotics/prosthetics such as L0112, L0456, L0462, L0464, L0484, L0486, L0624, L0631, L0632, L0634, L0637.

Cross-referenceThis threshold is reiterated in the orthotics/prosthetics sections to distinguish prosthetics from DME rules.

Proton beam therapy

RequirementProton beam therapy requires prior authorization.

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

Example CPT/HCPCS codesCodes listed include 77520, 77522, 77523, 77525 among proton beam therapy entries.

Ventricular assist device (VAD)

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

PA requirementPrior authorization is required for VAD devices and related supplies; unclassified code entries note PA for specific products (e.g., Casgevy, Omisirge) and VAD-related codes.

Associated codesDocument references unclassified and procedure codes in the VAD/wound VAC section (examples include 33976, 33979, 33981, 33982 and E2402 for wound VACs).

OpenPayer

Prior Authorization Requirements — UnitedHealthcare Community Plan of Kansas

Coverage Criteria and Prior Authorization Rules

CPT / HCPCS / ICD-10 Codes and Coding Notes

How to Request Prior Authorization and Provider Responsibilities

Definitions and Terms