UnitedHealthcare Prior Auth Requirements

Prior authorization coverage criteria (excerpt)

General coverage stance and requirements for prior authorization

Prior authorization is required for elective services and many listed CPT/HCPCS codes; prior authorization is not required for emergency or urgent care.

The ordering physician is responsible for obtaining prior authorization; the facility must verify that coverage approval is on file before performing the service. Payment may be denied for services rendered without prior authorization.

Submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or via 24/7 chat.

Site-of-service will be reviewed as part of the prior authorization process for specified arthroscopy codes except in AK, MA, PR, RI, TX, UT, VI and WI.

Genetic counseling is required prior to BRCA testing and supporting documentation (genetic counseling attestation) is required as specified on the Oncology Prior Authorization and Notification page.

Prior authorization criteria (partial)

Cancer supportive care prior authorization requirements

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

Colony-stimulating factors (CSFs): Prior authorization is required for colony-stimulating factors and related supportive care injectables when administered in the outpatient setting for a cancer diagnosis (examples: J1449, J2506, Q5101, Q5110, Q5125, J1442, J1447).

Non-oncology uses noted: Certain Q-codes (Q5108, Q5110, Q5111, Q5120, Q5122, Q5125) also require prior authorization when used for non-oncology diagnoses as specified.

Breast reconstruction (non-mastectomy): Multiple CPT codes for breast reconstruction (non-mastectomy) are listed and require prior authorization.

Prior authorization exemptions

Diagnosis codes exempt from prior authorization (partial list)

Exempt ICD-10 codes: A list of specified ICD-10 diagnosis codes (examples include C50.xx series and D05.xx series) are identified as not requiring prior authorization.

Prior authorization criteria (partial)

Prior authorization requirement for inpatient services and specific drug categories

Inpatient video EEG (cerebral seizure monitoring) requires prior authorization; outpatient video EEG monitoring does not require prior authorization.

Surgical center/outpatient administration: prior authorization is required for injectable chemotherapy drugs (includes J9000–J9999 and specified J- and Q-codes) when administered in an outpatient setting.

Specific chemotherapy-related J- and Q-codes are listed in the document and require prior authorization.

VAD / congenital heart disease authorization guidance

VAD and congenital heart disease procedural codes

Prior authorization is required for listed congenital heart disease procedure codes and related device evaluations (L8692); providers should call the Optum VAD Case Management Team at 888-936-7246 or the notification number on the member's health plan ID card for authorization/notification.

Multiple congenital heart disease CPT mappings (examples in the 33250–337xx ranges) are enumerated and require prior authorization or notification through the VAD Case Management process.

Prior authorization criteria (partial)

Prior authorization requirements and code listings shown in this section.

For VAD/congenital heart disease notifications and authorizations, call the Optum VAD Case Management Team at 888-936-7246 or the notification number on the member's ID card.

Continuous glucose monitors require prior authorization when used for type 2 diabetes (examples: A4226, A4238, A4239, A9276, E0787, E2102, E2103).

Cosmetic and reconstructive procedures require prior authorization for all states; many CPT codes are listed and site-of-service review applies for specified codes except in certain states.

Prior authorization criteria by service

Prior authorization requirements and exceptions by service type and code

Cosmetic & reconstructive procedures: Prior authorization required for listed CPT/HCPCS codes in all states; site-of-service review applies for specified codes except in AK, MA, PR, RI, TX, UT, VI and WI.

Durable Medical Equipment (DME): Prior authorization is required for DME codes when retail purchase or cumulative rental cost exceeds $1,000; certain devices (e.g., lymphedema pumps) may require authorization regardless of cost; prosthetics are not considered DME.

ESRD dialysis: Prior authorization is required for listed ESRD dialysis CPT/HCPCS codes (examples include 90935, 90937, 90945, 90947 and related HCPCS); providers may contact via 24/7 chat for authorization.

Foot surgery: Prior authorization required for listed foot surgery CPT codes; site-of-service review applies for specified codes with state exceptions.

Prior authorization criteria (partial)

Prior authorization requirements and applicable codes for procedures and medications in this document segment.

Prior authorization is required for Functional Endoscopic Sinus Surgery (FESS) codes listed in the document.

Gender dysphoria treatments require prior authorization when submitted with diagnosis codes F64.0, F64.1, F64.2, F64.8, F64.9 or 287.890 for the listed procedures.

Prior authorization is required for specified hysterectomy inpatient and outpatient CPT codes listed (examples include 58267, 58270, 58292, 58294 and 58150).

Infertility diagnostic and treatment services listed require prior authorization; many associated CPT/HCPCS codes are enumerated across continuations.

Prior authorization is required for many injectable medications listed (multiple therapeutic classes); some require specialty pharmacy submission or use of the Provider Portal Specialty Pharmacy Transactions tile.

MRgFUS coverage criteria and conditions

MRgFUS coverage and member/facility requirements

Prior authorization is required for MR-guided focused ultrasound (MRgFUS) to treat uterine fibroid (codes OO71T, 0072T).

Members have no out-of-network benefits for MRgFUS; the member must provide written consent acknowledging limited published evidence and release UnitedHealthcare from liability for unsatisfactory results.

Physician and facility must demonstrate experience and expertise in MRgFUS and follow FDA labeled indications; the facility must be contracted with UnitedHealthcare and coverage confirmed for the member prior to service.

Injectable medications prior authorization

Injectable medication prior authorization notes

Prior authorization is required for many listed J- and Q-codes for injectable medications; some codes are restricted to specific places of service (e.g., certain multiple sclerosis codes limited to POS 19 and 22).

Prior authorization is not required for members with an ESRD diagnosis for certain injectable codes where noted.

For unclassified or temporary HCPCS codes (C9399, J3490, J3590), prior authorization is required only for specified drugs (e.g., Nulibry, Rivfloza, Revcovie); portal and phone contact information for authorization is provided.

Orthotics coverage rule

Orthotics prior authorization

Prior authorization is required for the listed orthotics L-codes when the retail purchase or cumulative rental cost exceeds $1,000.

Specific orthotics L-codes requiring prior authorization are enumerated in the document (examples include L0220, L0484, L0486, L0636, L0638, L1640, L1680, L1685, L1700, L1710, L1720, L1755, L1844, L1846).

Potentially unproven services authorization criteria

Potentially unproven or experimental services

Services and medications identified as potentially unproven or experimental require prior authorization; examples of CPT/HCPCS codes listed include 26340, 33363, 33369, 33289, 33364, 36514, 33361, 33365, 33362, 33366, A9274, C2624, 64722.

These determinations are based on insufficient clinical evidence from well-conducted randomized controlled trials or cohort studies.

Rehabilitation services authorization criteria

Outpatient rehabilitation prior authorization and referral limits

Prior authorization is required for outpatient rehabilitation services (physical, occupational, speech) provided by network or out-of-network providers; the initial referral is valid for up to 8 visits per condition within 6 months from the referral date.

If a referral does not indicate the number of visits, the referral is valid for one visit; requests may be faxed to Clinical Care Coordination at 888-831-5080 using the Rehabilitation Services Extension Request Form.

Out-of-network services criteria

Out-of-network referral authorization

Prior authorization is required when a network physician or health care professional directs a member to an out-of-network facility, physician, or other health care professional when the member's benefit plan includes out-of-network benefits.

Members may face increased out-of-pocket expenses or no coverage when using out-of-network providers; provider agreements may restrict directing members outside the health plan service area.

Prior authorization criteria (Part 9)

Prior authorization criteria and stance for procedures and codes in this part:

Sinuplasty (CPT 31295–31297) requires prior authorization.

Spinal cord stimulator implantation codes require prior authorization for all states; site-of-service will be reviewed as part of authorization for specified codes with exceptions for certain states.

Spinal surgery CPT codes listed (many examples provided) require prior authorization for all states; site-of-service review applies for some codes with state exceptions.

Sleep apnea procedures: prior authorization is not required if performed at a network ambulatory surgery center; prior authorization is required when services are requested in an outpatient hospital setting (home sleep studies excluded).

Transplant-related services, bone-growth stimulators, and related neurostimulator codes require prior authorization; providers must request authorization before pre-treatment or evaluation for organ/tissue transplant services.

Coverage stance and prior authorization requirements

Prior authorization stance and code mappings for specific service categories in this section.

Transplant/pre-treatment: Providers must request prior authorization before pre-treatment or evaluation for organ or tissue transplant services; listed HCPCS/CPT mappings and bone-growth stimulator codes (e.g., E0747–E0760) require authorization.

Cellular & Gene Therapy: Cellular and gene therapy services (examples and mappings listed) require prior authorization.

Vein procedures: Prior authorization is required for vein procedures involving removal and ablation of main trunks and named branches of the saphenous veins; multiple HCPCS to CPT mappings are provided (examples: A9513, A9590, A9606, A9607 mapped to CPT codes such as 36470–36479, 37243, 37700, 37718, 37722).

Prior authorization requirements

Authorization requirements stated for listed services.

Prior authorization is required for services listed in this section, including veins of the extremities procedures (example HCPCS: A9513, A9590, A9606, A9607, A969G) and ventricular assist device (VAD) related CPT/HCPCS codes (examples: 33927–33929, 33975–33983, Q0507–Q0509).

For VAD services, providers should call the notification number on the member's health plan ID card to obtain prior authorization and/or contact Optum VAD Case Management as instructed.

CPT/HCPCS/ICD-10 Codes and Mappings

Arthroscopy and related CPT codesCPTCovered

29826	Arthroscopy code listed as prior authorization required
29843	Arthroscopy code listed as prior authorization required
29871	Arthroscopy code listed as prior authorization required
29837	Arthroscopy code listed in continuation
29888	Arthroscopy code listed in continuation

Bariatric surgery codesCPTCovered

43644	Bariatric surgery CPT code requiring prior authorization
43771	Bariatric surgery CPT code requiring prior authorization
43860	Bariatric surgery CPT code (asterisked) listed

BRCA and genetic testing codesmixedCovered

81162	BRCA genetic testing code
81432	Genetic testing code listed
81441	Genetic testing code listed
S3854	BRCA-related HCPCS code

Breast reconstruction (non-mastectomy)CPTCovered

19330	Breast reconstruction (non-mastectomy) CPT code requiring prior authorization
19350	Breast reconstruction (non-mastectomy) CPT code requiring prior authorization

Breast reconstruction (non-mastectomy) sample codesCPTCovered

15771	Breast reconstruction procedure code
19300	Breast reconstruction procedure code
19316	Breast reconstruction procedure code
19318	Breast reconstruction procedure code
19325	Breast reconstruction procedure code
19328	Breast reconstruction procedure code

Cancer supportive care injectable codesHCPCSCovered

J1449	Eflapegrastim-xnst (Rolvedone) or HCPCS injectable
J2506	Pegfilgrastim (Neulasta) or HCPCS injectable
Q5101	Filgrastim biosimilar
J0897	Denosumab (Xgeva/Prolia)

Diagnosis codes not requiring prior authorization (examples)ICD-10

C50.011	Malignant neoplasm of unspecified site of breast (example from list)
D05.90	Unspecified carcinoma in situ of breast (example from list)

Injury/implant-related ICD-10 codesICD-10

T82.818A
T82.868A
S81.801A
S81.802A
S81.809A
S91.301A
S91.302A
S91.309A

Osteomyelitis and related ICD-10 codesICD-10

M86.051
M86.052
M86.059
M86.061
M86.062
M86.069
M86.071
M86.072
M86.079
M86.08

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EEG monitoring CPT codesCPTCovered

95700	Cerebral seizure monitoring inpatient video EEG
95711	Cerebral seizure monitoring inpatient video EEG
95712	Cerebral seizure monitoring inpatient video EEG
95713	Cerebral seizure monitoring inpatient video EEG

Congenital heart disease / device codesmixed

L8692	HCPCS code referenced for device (repeated in document)
33250-33255	Listed CPT/congenital heart disease mapping to various codes in series

Continuous glucose monitor HCPCSHCPCSCovered

A4226	Continuous glucose monitor - HCPCS
A4238	Continuous glucose monitor - HCPCS
A4239	Continuous glucose monitor - HCPCS
A9276	Continuous glucose monitor - HCPCS
A9277	Continuous glucose monitor - HCPCS
A9278	Continuous glucose monitor - HCPCS
E0787	Continuous glucose monitor - HCPCS
E2102	Continuous glucose monitor - HCPCS
E2103	Continuous glucose monitor - HCPCS

Cosmetic and reconstructive CPT codesCPTCovered

11960	Cosmetic/reconstructive procedure CPT
11970	Cosmetic/reconstructive procedure CPT
11971	Cosmetic/reconstructive procedure CPT
14061-	Cosmetic procedure CPT series
14302	Cosmetic procedure CPT
15570	Cosmetic/reconstructive CPT
15730	Cosmetic/reconstructive CPT
15820-15830	Improving or restoring appearance CPT codes
21137-21295	Reconstructive CPT code range
30545	CPT listed

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ICD-10-CM congenital heart disease codesICD-10

Q20.0-Q28.3	ICD-10-CM congenital heart disease codes listed across multiple chunks
127.83	Listed numeric code (appears in document)

Selected cosmetic/reconstructive and related codesmixedCovered

21172	Listed cosmetic/reconstructive CPT code
21235	Listed cosmetic/reconstructive CPT code
67961	Listed eyelid/ocular CPT code
Q2026	HCPCS code listed under cosmetic/reconstructive

Durable medical equipment (DME) codesHCPCSCovered

E1003	DME - lymphedema or related device
E2502	DME code listed

ESRD dialysis CPT codesCPTCovered

90935	Hemodialysis outpatient CPT
90947	Peritoneal dialysis CPT

Selected procedural CPT codes with noted prior authCPTCovered

31240	FESS
31253	FESS
58267	Hysterectomy inpatient only
58150	Hysterectomy inpatient/outpatient

Representative injectable HCPCS/J-codesHCPCSCovered

J0256	Alpha1-proteinase inhibitor
J1437	Injectable agent (anemia/other)
J1300	Injectable agent

Enzyme replacement / deficiency injectable medication codesHCPCSCovered

J0567	Enzyme replacement therapy (listed)
J1203	Enzyme replacement therapy (listed)
J0885	Enzyme deficiency (Gaucher disease); POS 19 and 22 only
J3385	Enzyme deficiency (Gaucher disease)

Immune globulin and related injectable codesHCPCSCovered

J0739	Procedure/code referenced multiple times
90284	Immune globulin (administration/billing)
J1459	Immune globulin related
J1556	Immune globulin related

Selected therapeutic injectable codes requiring prior authorizationHCPCSCovered

J1442	Therapeutic injectable code (prior auth required)
J1447	Therapeutic injectable code (prior auth required)
J2506	Therapeutic injectable code (prior auth required)

Orthotics L-codesHCPCSCovered

L0220	Orthotics prior authorization code listed
L0484	Orthotics prior authorization code listed
L0486	Orthotics prior authorization code listed
L0636	Orthotics prior authorization code listed
L0638	Orthotics prior authorization code listed
L1640	Orthotics prior authorization code listed
L1680	Orthotics prior authorization code listed
L1685	Orthotics prior authorization code listed
L1700	Orthotics prior authorization code listed
L1710	Orthotics prior authorization code listed

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Prosthetics L-codesHCPCSCovered

L5010	Prosthetic prior authorization code listed
L5105	Prosthetic prior authorization code listed
L5150	Prosthetic prior authorization code listed
L5160	Prosthetic prior authorization code listed
L5210	Prosthetic prior authorization code listed
L5230	Prosthetic prior authorization code listed
L5250	Prosthetic prior authorization code listed
L5270	Prosthetic prior authorization code listed
L5280	Prosthetic prior authorization code listed

Radiology and radiation therapy CPT/HCPCS/G-codesmixedCovered

77014	IGRT (radiation therapy) listed
G6017	Radiation therapy/care management code
77385	Radiation therapy code listed
77386	Radiation therapy code listed
77520	Proton therapy code listed
77371	SRS/SBRT code listed
70450	CT head/brain
70460	CT chest
70553	MRI brain/other
71250	CT chest w/ contrast

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Radiology codesCPTCovered

74263	Radiology CPT/HCPCS code listed for prior authorization
75557	Radiology CPT/HCPCS code listed for prior authorization
75559	Radiology CPT/HCPCS code listed for prior authorization
75561	Radiology CPT/HCPCS code listed for prior authorization
75563	Radiology CPT/HCPCS code listed for prior authorization

Spinal device and surgery codesCPTCovered

63650	Spinal cord stimulator implantation
63661	Spinal cord stimulator lead placement (example) - site of service reviewed
22859	Spinal instrumentation code listed

Bone-growth stimulator codesHCPCSCovered

E0747	Bone-growth stimulator (HCPCS)
E0748	Bone-growth stimulator (HCPCS)
E0749	Bone-growth stimulator (HCPCS)
E0760	Bone-growth stimulator (HCPCS)

Transplant and Cellular & Gene Therapy code mappingsCPT | HCPCS | mixedCovered

50300	Kidney transplant related mapping listed
38232	Bone marrow / transplant-related code (authorization for oncology diagnosis only)
0537T	Cellular & Gene Therapy code series mapping to 0538T/0539T/0540T
C9399	Mapping to J3393/J3394/J3490 for cellular & gene therapy

Vein procedure code examplesHCPCS | CPTCovered

A9607	HCPCS used in mapping to multiple vein procedure CPT codes
36474	CPT mapping for A9607 in some vein procedures

Veins of the extremities codesHCPCSCovered

A9513	HCPCS code referenced for veins of the extremities
A9590	HCPCS code referenced for veins of the extremities
A9606	HCPCS code referenced for veins of the extremities
A9607	HCPCS code referenced for veins of the extremities
A969G	HCPCS code referenced for veins of the extremities

Ventricular assist device codesCPT | HCPCSCovered

33927	CPT code referenced for VAD
33928	CPT code referenced for VAD
33929	CPT code referenced for VAD
33975	CPT code referenced for VAD
33976	CPT code referenced for VAD
33979	CPT code referenced for VAD
33981	CPT code referenced for VAD
33982	CPT code referenced for VAD
33983	CPT code referenced for VAD
Q0507	HCPCS code referenced for VAD

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DME prior authorization cost threshold

DME prior authorization cost thresholdRetail purchase or cumulative rental cost of more than $1,000 requires prior authorization for listed DME codes.

Exception — certain devicesSome lymphedema pumps and other devices may require authorization regardless of cost; prosthetics are not considered DME.

How to submit authorizationSubmit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or 24/7 chat.

Orthotics prior authorization cost threshold

Orthotics prior authorization thresholdPrior authorization required when retail purchase or cumulative rental cost exceeds $1,000 for listed orthotics L‑codes.

Prosthetics threshold notedPrior authorization required only for prosthetic codes listed with retail purchase or cumulative rental cost of more than $1,000.

Example L‑codesOrthotics L0220, L0484, L0486, L0636, L0638, L1640 (among others) are listed in the policy.

Place of service restriction

Place of service restriction (examples)Certain injectable codes (e.g., J0885 and multiple sclerosis codes) are restricted to place of service POS 19 and 22 only.

Enzyme deficiency J‑codesJ0885 and J3385 (enzyme deficiency/Gaucher disease examples) are explicitly noted as POS 19 and 22 only.

ApplicabilityPlace‑of‑service restrictions apply to the listed injectable medications in the policy; consult code entries for specific POS requirements.

Retail purchase / cumulative rental cost threshold

Retail purchase / cumulative rental thresholdPrior authorization required for listed orthotics/prosthetics when retail purchase or cumulative rental cost is more than $1,000.

Orthotics L‑codes listedPolicy enumerates orthotics L‑codes (e.g., L0220, L0484, L0636, L1640) subject to the $1,000 threshold.

Prosthetics L‑codes listedProsthetic codes (examples: L5010, L5105, L5150) are subject to the same >$1,000 prior authorization requirement when listed.

Site‑of‑service prior authorization threshold

Site‑of‑service PA thresholdPrior authorization is required when services are requested in an outpatient hospital setting; prior authorization is not required if the procedure is performed at a network ambulatory surgery center (ASC) for listed codes.

State exceptions and reviewSite‑of‑service will be reviewed as part of prior authorization for many codes, with noted exceptions for specific states (e.g., AK, MA, PR, RI, TX, UT, VI, WI).

Examples of affected servicesSleep apnea procedures and many listed surgical codes are subject to the outpatient hospital vs ASC site‑of‑service PA rule.

How Providers Request Authorization and Important Notices

Prior Authorization

How to request prior authorization

Submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com — sign in with One Healthcare ID) or call 888-397-8129. Chat is also available 24/7 via the Contact Us page. Prior authorization is not required for emergency or urgent care. Out-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services when applicable to the member's plan.

Online: Prior Authorization and Notification tool on UnitedHealthcare Provider Portal
Phone: 888-397-8129
Chat: Contact Us page — 24/7

Prior Authorization

Site-of-service review exception

Site of service will be reviewed as part of prior authorization for certain procedure codes. Review will not apply in AK, MA, PR, RI, TX, UT, VI and WI for the listed codes.

Site-of-service review applies to select procedure codes as noted in the policy
Exceptions: Alaska (AK), Massachusetts (MA), Puerto Rico (PR), Rhode Island (RI), Texas (TX), Utah (UT), Virgin Islands (VI) and Wisconsin (WI)

Prior Authorization

Clinical trials prior authorization

Prior authorization is required for clinical trial participation when billed under clinical trial procedure codes.

Clinical trials codes: S9988, S9990, S9991 — prior authorization required

Prior Authorization

Cartilage implant prior authorization

Prior authorization is required for cartilage implant procedures and associated device codes.

Cartilage implant procedure codes: 27412, 27415, 27416
Arthroscopic/cartilage-related codes: 29866, 29867, 29868
Device/drug codes: J7330, S2112

Prior Authorization

Prior authorization requirement — continuous glucose monitor

Continuous glucose monitors (CGMs) require prior authorization when used with a diagnosis of type 2 diabetes.

Affected HCPCS/Codes: A4226, A4238, A4239, A9276, A9277, A9278, E0787, E2102, E2103
Additional Information: Prior authorization required with type 2 diabetes diagnosis

Prior Authorization

Gender dysphoria prior authorization

Gender dysphoria treatments and related procedures require prior authorization when submitted with specified diagnosis codes.

Prior authorization required when submitted with diagnosis codes F64.0, F64.1, F64.2, F64.8, F64.9 or 287.89
Examples of procedure codes that require prior authorization when submitted with the above diagnoses: 14000, 14001, 14041, 15734, 31287, 31288, 31298, 55970, 55980

Prior Authorization

Injectable medications prior authorization and submission

Most injectable medications (including many therapeutic classes such as enzyme replacement, erythropoiesis-stimulating agents, colony-stimulating factors, oncology injectables, blood-modifying agents, CNS agents, endocrine agents, and others) require prior authorization. Submit injectable medication authorization requests using the Provider Portal or the Specialty Pharmacy Transactions tile as directed, or call Optum/UnitedHealthcare for assistance.

Prior authorization required for many J- and Q-codes and select unclassified/temporary codes (examples in policy)
Submit via: Specialty Pharmacy Transactions tile on Provider Portal or online Prior Authorization tool
For oncology and cancer-supportive injectables, follow Cancer Supportive Care section guidance (outpatient injectable chemotherapy and colony-stimulating factors require authorization)
If requirements are not met, UnitedHealthcare will notify the provider office within 3 days; if authorized, provider and member will receive authorization number and coverage dates

Prior Authorization

Non-emergency air transport prior authorization

Non-emergency air transport (non-urgent ambulance transportation by air) requires prior authorization.

Affected HCPCS/Codes: A0430, S9960, A0431, A0435, A0436
Additional Information: Prior authorization required for non-urgent air ambulance transport

Prior Authorization

Orthognathic surgery prior authorization

Orthognathic (jaw) surgery for treatment of maxillofacial functional impairment requires prior authorization.

Examples of orthognathic procedure codes requiring prior authorization: 21050, 21060, 21121, 21123, 21125, 21127, 21141–21151, 21154–21156, 21159–21215, 21240–21246, 21296, 21299 (see policy for full code list)

Prior Authorization

Sinuplasty prior authorization

Sinuplasty procedures require prior authorization.

Sinuplasty CPT codes: 31295, 31296, 31297

Prior Authorization

Spinal cord stimulator prior authorization

Spinal cord stimulators and associated implantable device codes require prior authorization for all states. Site-of-service review applies to certain codes except in AK, MA, PR, RI, UT, VI and WI.

Spinal cord stimulator procedure/device codes requiring authorization: 63650, 63655, 63662, 63664, 63685, 63688, 64553, 64570
Device supply codes: L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688
Site-of-service review exception states: Alaska, Massachusetts, Puerto Rico, Rhode Island, Utah, the Virgin Islands and Wisconsin

Prior Authorization

Spinal surgery prior authorization requirements

Spinal surgery procedures require prior authorization for all states. In addition, site-of-service will be reviewed as part of prior authorization for many spinal procedure codes (with state exceptions).

Spinal surgery example codes (not exhaustive): 22859, 22513, 22514, 63005, 63011, 63016, 63017, 63035, 63040, 63044, 63045, 63048, 63050, 63056, 63057, 63064, 63075, 63076, 63077, 63081, 63082, 63085, 63087, 63088, 63090, 63101–63103, 63172–63197, 63251–63308, 0098T
Additional Information: Site-of-service review applies for many codes; exceptions include Alaska, Massachusetts, Puerto Rico, Rhode Island, Texas, Utah, the Virgin Islands and Wisconsin

Prior Authorization

Transplant and device-related prior authorization requirements

Transplant services, organ or tissue transplants, and related pre-treatment or evaluation services (including bone marrow harvest and associated procedures) require prior authorization. Some transplant-related devices and therapies (e.g., bone-growth stimulators, neurostimulators) also require authorization. Care providers must request authorization prior to pre-treatment or evaluation.

Transplant and transplant-related procedure examples: bone marrow harvest (38240–38242), certain transplant procedure codes (see policy code listings such as 47145, 50325 and transplant-specific S/C codes)
Bone-growth stimulator and neurostimulator device HCPCS examples: E0747, E0748, E0749, E0760 — prior authorization required
Operational requirement: Request prior authorization before pre-treatment or evaluation; follow specialty-case or vendor instructions where noted

Key Terms and Contacts

Prior authorization — definition & overview

Definition — Prior authorizationA requirement for certain procedures and services where the physician (or facility) must obtain approval before performing elective services; not required for emergency or urgent care.

Provider responsibilityPhysician is responsible to obtain relevant prior authorization; facility must verify approval is on file before performing the service.

Submission methodsRequests may be submitted via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or via 24/7 chat.

Genetic counseling attestation form

Genetic counseling attestationGenetic counseling is required prior to BRCA testing; a genetic counseling attestation form and supporting documentation are available on the Oncology Prior Authorization and Notification page.

Relevant BRCA codesPolicy lists BRCA testing CPT/HCPCS codes (examples: 81162, 81163, 81164, 81277, 81418) that require prior authorization and counseling.

Provider actionOrdering provider must notify the laboratory; UnitedHealthcare will send member notification after receiving lab information.

Cancer supportive care (injectable chemotherapy & CSFs)

Cancer supportive care — scopePrior authorization required for injectable chemotherapy supportive care agents and colony‑stimulating factors administered in an outpatient setting for a cancer diagnosis.

Representative HCPCS/J‑codesExamples include J1449, J2506, Q5101, Q5110, Q5125 and other listed J/Q codes in the policy.

Non‑oncology use noteSome Q‑codes (Q5108, Q5110, Q5111, Q5120, Q5122, Q5125) may also require prior authorization for non‑oncology diagnoses as noted.

How to submit prior authorization requests

Submission methods — Provider PortalSubmit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) — select the Prior Authorization and Notification tab after signing in.

Phone optionProviders may also call 888‑397‑8129 to submit authorization requests when applicable.

Chat optionConnect via 24/7 chat using the Contact us page as an alternative submission method.

Chemotherapy injectable drugs prior authorization

Chemotherapy injectable drugs — coverageInjectable chemotherapy drugs billed under J9000–J9999 and specified J‑codes require prior authorization for outpatient administration for a cancer diagnosis.

Included specific J‑codesPolicy lists examples such as Leucovorin (J0640), Levoleucovorin (J0641, J0642), Leuprolide (J1950, J1952) and Lanreotide (J1932).

Surgical center noteSurgical center injectable chemotherapy requires prior authorization when administered in outpatient settings.

Optum VAD Case Management

Optum VAD Case Management contactFor VAD or congenital heart disease prior authorization/notification, call the Optum VAD Case Management Team at 888‑936‑7246 or the notification number on the member's health plan ID card.

L8692 evaluationsPolicy references L8692 evaluations in conjunction with contacting Optum VAD Case Management for listed congenital heart disease codes.

Prior authorization requiredPrior authorization is required for listed congenital heart disease procedure codes and VAD CPT/HCPCS codes.

Optum VAD Case Management Team

Optum VAD Case Management Team phoneContact Optum VAD Case Management Team at 888‑936‑7246 or use the notification number on the member's ID card for VAD/congenital heart disease cases.

When to callCall prior to evaluation or device implantation for codes that reference L8692 and listed congenital heart disease procedures.

Authorization requirementPrior authorization/notification must be obtained as directed in the policy for VAD‑related services.

Continuous glucose monitor

Continuous glucose monitor PA requirementPrior authorization is required for continuous glucose monitor devices when used for type 2 diabetes.

Representative HCPCS codesExamples listed include A4226, A4238, A4239, A9276, A9277, A9278, E0787, E2102, E2103.

ApplicabilityAuthorization applies to the CGM devices and use with a type 2 diabetes diagnosis as specified in the policy.

DME prior authorization threshold

DME prior authorization requirementPrior authorization is required only for DME codes listed with a retail purchase or cumulative rental cost of more than $1,000.

Examples of DME codesPolicy lists numerous DME HCPCS codes (e.g., A7025, E0194, E0265, E0745, E2502, E2504) subject to the threshold.

Prosthetics distinctionProsthetics are not considered DME; prosthetic codes have separate prior authorization rules and thresholds.

Site of service review

Site‑of‑service review — overviewSite‑of‑service will be reviewed as part of prior authorization for listed codes; prior authorization is required when requesting service in an outpatient hospital setting but not required if performed at a network ASC for many codes.

State exceptionsState exceptions apply for site‑of‑service review for certain codes (exceptions include AK, MA, PR, RI, TX, UT, VI, WI).

Example servicesThe rule applies to multiple service groups including sleep apnea procedures, spinal and other listed surgical codes as identified in the policy.

Injectable medications — definition & notes

Injectable medications — definitionInjectable medications are drugs capable of being injected intravenously (infusion), subcutaneously or intramuscularly and many listed therapeutic classes require prior authorization.

Representative categoriesIncludes enzyme replacement, alpha1‑proteinase inhibitors, anemia agents, immune globulins and other specialty injectables listed in the policy.

Submission guidanceSome injectable medications require specialty pharmacy submission or prior authorization via the Provider Portal; see specific code entries for instructions.

Injectable medications — place of service & code notes

Injectable medications — POS restrictions and examplesCertain injectable J‑codes (e.g., J0885, J3385) are limited to POS 19 and 22 only, as noted for enzyme deficiency therapies.

Enzyme replacement examplesPolicy lists enzyme replacement therapy codes (J0567, J1203, J1786, J3060) and notes POS restrictions for specific agents.

Unclassified codes guidanceUnclassified/temporary codes (C9399, J3490, J3590) may require prior authorization only for specific drugs as identified in the policy.

MRgFUS

MRgFUS definition & requirementMR‑guided focused ultrasound (MRgFUS) to treat uterine fibroid requires prior authorization; members have no out‑of‑network benefits for MRgFUS.

Consent & liabilityMember must provide written consent acknowledging limited published evidence and agree not to hold UnitedHealthcare responsible if unsatisfied with results.

Provider/facility requirementsPhysician and facility must demonstrate experience/expertise and follow FDA labeled indications; facility must be contracted with UnitedHealthcare.

Orthotics prior authorization threshold

Orthotics prior authorization threshold (concise)Prior authorization required for orthotics L‑codes when retail purchase or cumulative rental cost exceeds $1,000.

Listed orthotics examplesOrthotics codes enumerated include L0220, L0484, L0486, L0636, L0638, L1640, L1680, L1685 and others.

How to requestSubmit prior authorization via the Provider Portal or phone per the general submission instructions in the policy.

Out‑of‑network services recommendation

Out‑of‑network services — recommendationPrior authorization is required when a network physician directs a member to an out‑of‑network facility, physician or other provider; members may face increased out‑of‑pocket costs or lack coverage.

Provider agreement cautionProvider agreements with UnitedHealthcare may include restrictions on directing members outside the health plan service area.

Action for providersObtain prior authorization per policy before referring to out‑of‑network providers to avoid denial or unexpected member liability.

Potentially unproven services

Potentially unproven services — requirementServices and medications determined to be potentially unproven or experimental require prior authorization as listed in the policy.

Evidence basisDeterminations are based on insufficient clinical evidence from well‑conducted randomized controlled trials or cohort studies in the peer‑reviewed literature.

Example CPT/HCPCS codesExamples include 26340, 33363, 33369, 33289, 33364, 36514, A9274, C2624, 64722 among others listed.

Rehabilitation referral validity

Rehabilitation referral validityInitial referral for physical or occupational therapy is valid for up to 8 visits per condition within 6 months; if referral lacks number of visits, it's valid for one visit.

Prior authorization requirementPrior authorization is required for outpatient rehabilitation services provided by network or out‑of‑network professionals.

Submission optionRequests may be faxed to Clinical Care Coordination at 888‑831‑5080 using the Rehabilitation Services Extension Request Form.

Site‑of‑service PA threshold — sleep apnea procedures

Site‑of‑service PA rule — sleep apneaPrior authorization is not required if sleep apnea procedures are performed at a network ambulatory surgery center (ASC); PA is required when requested in an outpatient hospital setting.

Home sleep studies excludedHome sleep studies are excluded from the outpatient hospital site‑of‑service PA requirement.

State exceptionsCertain states are noted where PA requirements or exceptions may differ (e.g., AK, MA, PR, RI, TX, UT, VI, WI).

Prior authorization — key facts

Prior authorization — concise termPrior authorization: pre‑approval required for elective services and specific procedures; not required for emergency/urgent care.

Provider/facility responsibilitiesPhysician obtains authorization; facility must verify coverage approval before performing services to avoid payment denial.

Effective datePolicy effective Sept 1, 2024 (applies to participating UnitedHealthcare Mid‑Atlantic Health Plans providers).

OpenPayer

Prior Authorization Requirements for UnitedHealthcare Mid-Atlantic Health Plans

Prior Authorization Coverage Criteria

CPT/HCPCS/ICD-10 Codes and Mappings

How Providers Request Authorization and Important Notices

Key Terms and Contacts