CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for UnitedHealthcare Complete

Lists procedures, drugs, and services that require prior authorization (or notification) for UnitedHealthcare Complete members; explains provider submission methods and notes that member-specific benefit plans and site-of-service reviews may alter requirements.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Complete

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) with One Healthcare ID.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2026-04-01Effective

Online portalSubmission method

Multiple categoriesPA required (sample)

CPT/HCPCS/ICD-10Codes included

Multiple UnitedHealthcare entitiesApplies to

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.

Prior Authorization Coverage Criteria

Prior authorization code listings

Code listings for services that may require prior authorization. This consolidates the HCPCS/CPT/ICD code mentions extracted from the source. Codes are grouped by topical headings as presented in the source; entries with repeated or placeholder values were omitted where no explicit code was provided.

all of the following codes referenced in the source may require prior authorization depending on the service and member plan:

- Arthroplasty / Related surgical codes: 23470, 23472, 23473, 23474, 24360, 24361, 24362, 24363, 24365, 24366, 24370, 24371, 25441, 25442, 25443, 25444, 25445, 25446

- Bone growth stimulators / Biophysical stimulation: 20974, E0748, 20975, E0749, 20979, E0760, E0747

- Bone marrow / stem cell procedures: 38204, 38232, 38205, 38243, 38211, 38230

- Breast reconstruction (examples shown): 19342, Z42.1

- Cancer supportive care (colony-stimulating factors, bone-modifying agents and related J/Q codes): J0185, J0897, J1442, J1447, J1448, J1453, J1454, J1627, J1449, Q5148, J2506, J2820, Q5101, Q5110, Q5111, Q5120, Q5122, and others in series

- Carpal tunnel procedures: 29848, 64721

- Cartilage implants / related: 27412, 27415, 29868, 27416, J7330, 29866, S2112

- Inpatient video EEG / cerebral seizure monitoring: 95700, 95711, 95712, 95713, 95724, 95726

- Chelation therapy / related HCPCS: M0300, S9355

- Chemotherapy and oncology drug J-codes (selected examples from listing): J0640, J1323, J0641, J1326, J0642, J1932, J1299, J1950, J9024–J9039 (series), J9046–J9071 (series), J9393, J9394, J9395, J9400, J9600, Q2043, Q2050, Q2055

- Durable medical equipment examples (DME): E0147, E0193, E0194, E0265, E0266, E0277, E0296, E0297, E0300, E0302, E0303, E0304, E0316

- Implant/device diagnosis codes / repair: T82.399A, T82.818A, T82.868A, T82.898A

- Cerebral/neurology device / cardiac device (examples): 33213, 33214, 33221, 33224, 33225, 33227, 33228, 33229, 33230, 33231, 33240, 33249, 33262, 33263, 33264, 33270

- Carpal tunnel and related site-of-service notes (site of service review may apply)

- Continuous glucose monitoring / diabetes-related HCPCS and supply codes: A4226, A4238, A4239, A9276, A9277, A9278, E2103; ICD-10 examples listed for type 2/gestational diabetes: E11.00, E11.01, E11.10, E11.11, E11.21, E11.22, E11.49, E11.51, E11.52, E11.59 (mapped to pregnancy codes like O24.430, O24.434, O24.435, O24.439 in source)

- Genetic and molecular testing / BRCA and other panels: 55970, 55980, 57335, 81162, 81163, 81164, 81402, 81403, 81406, 81407, 81411, 81412, 81415, 81416, 81425, 81426, 81435, 81439, 81443, 81449, 81450, 81451, 81455, 81457, 81458, 81459, 81460, 81462, 81463, 81464, 81471, 81519, 81520, 81521, 81541, 81542, 81546, 81552, 81558, 87506, 87797, and multiple CPT/PLA/U codes (e.g., 0022U, 0048U, 0088U, 0129U, 0212U, 0237U etc.)

- Cosmetic and reconstructive procedure examples: 15769, 15773, 15830, 21137, 15738, 19303, 54520, 55180, 57110, 15750, 53410, 54660, 56625, 15757, 53430, 54690, 56800, 58720

- Foot surgery examples: 28285, 28295, 28299, 28289, 28296, 28291, 28292, 28298

- Functional endoscopic sinus surgery (FESS): 31240, 31253, 31254, 31255, 31256, 31257, 31259

- Home health / surgical/procedure mappings (examples from source mapping series): many hysterectomy/procedure mappings such as 58150→58262, 58152→58267, 58180→58270 and multiple 58x→58x mappings noted in source

- Intensity-modulated radiation therapy (IMRT): listed as prior authorization required (codes not explicitly enumerated in extracted chunks)

- Injectables and specialty J-codes listed under Home health / Injectables examples: J0121, J0122, J0131, J0132, J0133, J0134, J0136, J0137, J0602, J0603, J0605, J0607, J0608, J0609, J0612, J0613, J0614, J0615, J0616, J0618, J0630, J0636, J0637, J0650, J0651, J0652, J0654

- Vaccines / immunologics and biologics examples: CPT/HCPCS entries in the 90xxx and 90xxx-series vaccines (e.g., 90281, 90291, 90371, 90375, 90376, 90377, 90380, 90688, 90694, 90702, 90714, 90715, 90732, 90739, 90740)

note: The source contains many additional series and repeated placeholders; providers must reference the member-specific benefit plan and the Prior Authorization and Notification tool for the definitive, plan-level code list and any site-of-service constraints.

General information (no actionable coverage rules)

General procedural information and operational guidance from the source. These are informational points that do not create additional clinical coverage rules but explain how to request prior authorization and key applicability notes.

Please submit prior authorization requests using the UnitedHealthcare Provider Portal: sign in at UHCprovider.com (One Healthcare ID required). Select the Prior Authorization and Notification tab on your dashboard. If you do not have a One Healthcare ID, visit UHCprovider.com/access.

Member-specific benefit plan documents determine coverage — terms vary by state. Always reference the member's benefit plan for coverage determinations.

Site-of-service review may apply to certain codes on the prior-authorization lists; site-of-service constraints are plan- and code-specific.

Prior authorization is not required for emergency or urgent care.

Some benefit plans have no non-emergent out-of-network coverage and no coverage outside of the service area — check the member's plan.

No criteria provided

Entries where the source records that prior authorization is required but provides no specific clinical criteria within the extracted content. These are placeholders that indicate authorization is required; providers must use the Portal or plan documents for details.

Disease-related services including pretreatment evaluation — Prior authorization required (no criteria provided in source extract).

Prior authorization required — multiple entries in the source indicate prior authorization is required but no criteria or codes were provided in the extract (placeholders present).

Prior authorization required for various listed services (placeholders) — providers must consult the Prior Authorization and Notification tool for clinical criteria and required documentation.

Examples where the source shows 'Prior authorization required' without additional criteria: entries grouped under 'Prior authorization required' and repeated statements in the source chunks; these are actionable only via Portal or plan documentation.

CPT / HCPCS / ICD-10 Code Listings

Selected arthroplasty CPT codes (partial)CPTCovered

23470	Arthroplasty code listed in arthroplasty section
23472	Arthroplasty code listed in arthroplasty section
23473	Arthroplasty code listed in arthroplasty section
23474	Arthroplasty code listed in arthroplasty section

Selected bone growth and cancer supportive care codes (partial)mixedCovered

20974	Bone growth stimulator — electronic stimulation
E0748	Bone growth stimulator HCPCS
J0185	Cancer supportive care medication example
J0897	Colony-stimulating factor (listed as requiring prior authorization)

Cancer supportive care HCPCS codesHCPCSCovered

J0897	HCPCS code listed as requiring prior authorization for outpatient cancer supportive care
J1442	HCPCS code listed as requiring prior authorization for outpatient cancer supportive care
J1447	HCPCS code listed as requiring prior authorization for outpatient cancer supportive care
J2506	HCPCS code listed as requiring prior authorization for outpatient cancer supportive care
J2820	HCPCS code listed as requiring prior authorization for outpatient cancer supportive care
Q5101	HCPCS code listed as requiring prior authorization for outpatient cancer supportive care
Q5110	HCPCS code listed as requiring prior authorization for outpatient cancer supportive care
Q5111	HCPCS code listed as requiring prior authorization for outpatient cancer supportive care
Q5120	HCPCS code listed as requiring prior authorization for outpatient cancer supportive care
Q5122	HCPCS code listed as requiring prior authorization for outpatient cancer supportive care

Cardiovascular diagnosis codes (examples)ICD-10

I70.221	Cardiovascular diagnosis codes listed in association with prior authorization requirements
I70.222	Cardiovascular diagnosis codes listed in association with prior authorization requirements
I70.223	Cardiovascular diagnosis codes listed in association with prior authorization requirements

Peripheral/cardiovascular ICD-10 codesICD-10

I70.531
I70.532
I70.533
I70.534
I70.535
I70.538
I70.539
I70.541
I70.542
I70.543

1–10 of 22

1/3

Vascular ICD-10 codes (continued)ICD-10

I72.3
I72.4
I72.8
I72.9
I73.00
I73.01
I73.1
I73.81
I74.3
I74.4

1–10 of 18

1/2

Example CPT/HCPCS codes with PA instructionsmixed

29848
64721
95700
95711
95712
95713
95724
95726
M0300
S9355

1–10 of 15

1/2

J926x series (examples)HCPCS

J9260
J9261
J9262
J9263

Q5xxx series (examples)HCPCS | Q-code

Q5127
Q5115

HCPCS codes mentioned in general informationHCPCS

Q5152	HCPCS — referenced repeatedly
L8622	HCPCS — referenced repeatedly
L8618	HCPCS — referenced
L8619	HCPCS — referenced
L8627	HCPCS — referenced
L8628	HCPCS — referenced
S9991	HCPCS — referenced

CPT/HCPCS fields (placeholder)mixed

No codes listed

CPT/HCPCS codes referenced (unspecified)mixed

No codes listed

CPT/HCPCS codesmixed

No codes listed

CPT/HCPCS placeholdersmixed

No codes listed

CPT/HCPCS codes (placeholder)mixed

No codes listed

CGM and diabetes diagnosis codesHCPCS | ICD-10Covered

A4226
A4238
A4239
A9276
A9277
A9278
E2103
E11.00	Type 2 diabetes mellitus codes (examples present)
E11.01
E11.10

1–10 of 12

1/2

Sample surgical CPT codes requiring prior authorizationCPTCovered

28285	Foot surgery CPT code listed requiring prior authorization
31240	Functional endoscopic sinus surgery (FESS) CPT code listed requiring prior authorization

Sample DME HCPCS/E-codesHCPCSCovered

E0147	Durable medical equipment HCPCS/E-code listed
E1233	Durable medical equipment HCPCS/E-code listed

Experimental/investigational codes (sample)CPTNot Covered

33477

Listed as experimental/investigational (prior auth required)

Selected surgical/procedure codesCPTCovered

28285	Foot surgery CPT code listed as requiring prior authorization
31240	FESS CPT code listed as requiring prior authorization

Genetic/molecular testing codesCPTCovered

81432	Genetic testing code (example) requiring prior authorization
81162	BRCA/genetic test code listed for prior authorization

Injectable J-codesHCPCSCovered

J0256	Alpha1-proteinase inhibitor injectable
J9334	Antineoplastic/biologic injectable (example listed)

Injectable J-codes (partial list from section)HCPCS

J2507
J0180
J0217
J0218
J0219
J0221
J0567
J1203
J1322

Vaccine CPT codes (examples)CPT

90688	vaccine CPT code listed
90694	vaccine CPT code listed
90702	vaccine CPT code listed

Injectable J‑codes (examples)HCPCS

J0121	injectable medication J-code listed
J0131	injectable medication J-code listed
J0169	injectable medication J-code listed

Submission, Documentation, and Provider Requirements

Prior Authorization

Submission instructions and general rules

Please submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com). Sign in with a One Healthcare ID; if you do not have one, visit UHCprovider.com/access. When requesting authorization reference the member-specific benefit plan document; terms vary by state and site-of-service review may apply. Prior authorization is not required for emergency or urgent care. For questions about specialty or injectable medications, providers may contact the Optum Specialty Guidance Program (SGP) at 888-397-8129.

Submit requests online via Prior Authorization and Notification tool on UHCprovider.com
Reference member-specific benefit plan; terms vary by state
Prior authorization not required for emergency/urgent care
For specialty/injectable questions call Optum SGP: 888-397-8129

Prior Authorization

Arthroplasty — prior authorization required

Arthroplasty procedures require prior authorization for all states. Common CPT codes that typically require authorization include (not exhaustive): 23470, 23472, 23473, 23474, 24360–24371 series, 25441–25446, and related arthroplasty codes. Site-of-service review may apply.

Key Definitions and Terms

Prior authorization

DefinitionPrior authorization: a required approval obtained before certain services, procedures, drugs or devices are provided; member-specific benefit plan documents must be referenced as terms vary by state.

When not requiredPrior authorization is not required for emergency or urgent care.

Submission channelUse the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) and sign in with a One Healthcare ID.

Site-of-service noteSite of service review may apply to certain codes; some outpatient/ASC services may be exempt as noted in specific entries.

One Healthcare ID

DefinitionOne Healthcare ID: the credentials used to sign in to UHCprovider.com to access the Prior Authorization and Notification tool.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Complete

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) with One Healthcare ID.

SourceLink

On This Page

Certain programs (for example, Genetic and Molecular Testing Prior Authorization/Notification Program, Optum Specialty Guidance Program) require submitting specific test names or using specialty guidance phone lines as noted.

For some services, prior authorization applies only to members above a specified age (example in source: certain adult-only requirements); verify member eligibility and age-based applicability in the member's plan.

When codes are listed without an explicit mapping in the source, providers should use the Provider Portal tool to confirm whether authorization is required and to obtain current code lists and submission instructions.

When 'Prior authorization required' appears with no further guidance in the source, treat the service as requiring authorization submission and follow Portal prompts and member plan details to determine approval conditions.

Prior authorization required for arthroplasty (all states)
Example CPT codes: 23470, 23472, 23473, 23474, 24360–24371, 25441–25446

Prior Authorization

Bariatric and Breast Reconstruction — prior authorization/requirements

Bariatric surgery and related obesity services require prior authorization. Coverage may require use of an approved Center of Excellence for bariatric surgery; some benefit plans exclude bariatric services. Notification/prior authorization is required for listed bariatric procedure codes (for example 43860, 43865) when submitted with the relevant diagnosis codes.

Prior authorization required for bariatric procedures
Center of Excellence requirement may apply for coverage
Example bariatric procedure codes requiring notification/prior authorization: 43860, 43865

Prior Authorization

Musculoskeletal, Bone Growth, Bone Marrow, and Cancer Supportive Care — prior authorization required

Musculoskeletal services such as body lengthening, bone growth stimulators (electronic stimulation or ultrasound), bone marrow/stem cell procedures, and certain cartilage implants require prior authorization. Bone growth stimulator example codes include 20974 (E0748), 20975 (E0749), 20979 (E0760), E0747. Bone marrow/stem cell procedures include codes 38204, 38205, 38211, 38230, 38232, 38243. Cartilage implants require prior authorization and may include CPT/HCPCS codes such as 27412, 27415, 27416, 29866 and J7330, S2112.

Prior authorization required for body lengthening and bone growth stimulation
Bone growth stimulator examples: 20974 (E0748), 20975 (E0749), 20979 (E0760), E0747
Bone marrow/stem cell examples: 38204, 38205, 38211, 38230, 38232, 38243
Cartilage implant examples: 27412, 27415, 27416, 29866, J7330, S2112

Prior Authorization

Cancer supportive care — prior authorization required

Cancer supportive care (colony-stimulating factors, bone-modifying agents, erythropoiesis-stimulating agents, antiemetics) administered in an outpatient setting for a cancer diagnosis require prior authorization. Several J- and Q-codes require authorization even for non-oncology diagnoses — examples include J0897, J1442, J1447, J2506, J2820, Q5101, Q5110, Q5111, Q5120, Q5122. Submit prior authorization requests via the Provider Portal.

Prior authorization required for colony-stimulating and bone-modifying agents in outpatient cancer care
Codes requiring prior authorization (oncology and some non-oncology): J0897, J1442, J1447, J2506, J2820, J1448–J1456 series, Q5101, Q5110, Q5111, Q5120, Q5122
Submit requests using Prior Authorization and Notification tool on UHCprovider.com

Prior Authorization

Chemotherapy — prior authorization (HCPCS J‑codes examples)

Chemotherapy agents administered in outpatient settings require prior authorization. Representative HCPCS J-codes listed include (partial list): J0640, J0641, J0642, J1299, J1323, J1326, J1932, J1950, J9024–J9036 series, J9040–J9065 series, J9071, J9393–J9400, J9600, J9046–J9065, J9054–J9064, and many additional J-codes. Use the Provider Portal to submit chemotherapy prior authorization requests.

Prior authorization required for chemotherapy (outpatient)
Examples of chemotherapy HCPCS J-codes: J0640, J0641, J0642, J1299, J1323, J1326, J1932, J1950, J9024–J9036, J9040–J9065, J9071, J9393–J9400
Submit chemotherapy prior authorizations via the Prior Authorization and Notification tool

Prior Authorization

HCPCS drug codes (examples) and J-/Q-code considerations

HCPCS J- and Q-codes are used to identify injectable and biologic therapies that often require prior authorization. Examples called out in the policy include J0256, J0257 (alpha1-proteinase inhibitors); anemia agents J0896, J1437, J1439; complement inhibitors J2781, J2782; and numerous vaccine and biologic Q-codes (Q2043, Q2050, Q2055, Q5152, Q5149, etc.). Unclassified injectable codes (J3490, J3590) require prior authorization/notification only for specified products (e.g., Revcovi, Rivfloza, Starjemza).

Examples of J-/Q-codes requiring authorization: J0256, J0257, J0896, J1437, J1439, J2781, J2782
Vaccine and biologic Q-codes examples: Q2043, Q2050, Q2055, Q5152, Q5149
Unclassified codes J3490/J3590: prior authorization/notification required only for listed products (Revcovi, Rivfloza, Starjemza)

Note

L-series HCPCS (clinical study identifiers)

L-series HCPCS codes are used for clinical study identifiers and implantable medical devices in investigational or study contexts. Examples referenced include L8618, L8619, L8622, L8627, L8628. Prior authorization may be required for devices or device-related services; L86xx codes should be mapped to the specific device/study context when submitting requests.

L86xx examples: L8618, L8619, L8622, L8627, L8628
L-series codes denote clinical study/device context — map to device/study when requesting authorization

Documentation Required

L86xx codes — clinical study / device context

L8622 and related L86xx codes are used to indicate devices associated with clinical studies or investigational devices and may appear with inner-ear or implantable device entries. When submitting prior authorization for device implantation or study-related services, include device identifiers and study documentation as applicable.

L8622 commonly referenced for study/device contexts
For inner-ear and implantable devices include device identifiers and study documentation with the PA request

Prior Authorization

Inner ear / implantable device HCPCS codes

Inner ear and implantable device entries reference L86xx codes (for example L8627) and may require prior authorization. For procedures involving implantable inner-ear devices or study devices include supporting clinical documentation and device model/identifier details when requesting authorization.

Inner ear / implantable device example code: L8627
Include device model/identifier and clinical rationale when submitting authorization requests

Prior Authorization

Reinforced prior authorization requirement

The policy reinforces that many services and supplies across categories require prior authorization — including surgical procedures, injectables, genetic testing, home health, DME, and experimental/investigational services. Prior authorization is required for the listed categories and specific codes throughout this section; providers should not assume payment without prior approval.

Reinforced: prior authorization is required for many listed services and codes
Do not assume payment without prior authorization

Documentation Required

Reinforcement of prior authorization requirement

This document contains numerous reminders that prior authorization is required for many services (procedures, medications, DME, genetic testing, etc.). Providers must follow the Provider Portal submission processes and include required clinical documentation to avoid denials.

Providers must use the Prior Authorization and Notification tool and include clinical documentation
Failure to obtain prior authorization may result in claim denials

Note

General information — CPT/HCPCS and prior authorization (placeholder)

General coding and prior authorization mapping note: CPT and HCPCS codes listed throughout the policy are representative examples; code lists are not exhaustive. When submitting prior authorization requests map the procedure or drug CPT/HCPCS code(s) to the clinical indication and attach all supporting documentation. Site-of-service review may apply for certain codes.

CPT/HCPCS examples in the policy are representative, not exhaustive
Map CPT/HCPCS codes to clinical indication and attach supporting documentation
Site-of-service review may apply for some codes

Documentation Required

General information — prior authorization coding placeholder

Prior authorization coding operational note: when using unclassified J-codes (J3490, J3590) include the specific drug name, dose, NDC (if available), and clinical justification. For device- or study-related L-codes include study identifiers and device model information.

Unclassified J-codes: include drug name, dose, NDC, clinical justification
L-codes: include study identifiers and device model information

Prior Authorization

Cosmetic and reconstructive procedures — prior authorization

Cosmetic procedures that change or improve appearance without restoring physiological function require prior authorization. Reconstructive procedures that restore physiologic function also require prior authorization when listed. Example cosmetic/reconstructive CPT codes called out include 15769, 15773, 15830, 21137.

Prior authorization required for cosmetic and reconstructive procedures
Example codes: 15769, 15773, 15830, 21137

Prior Authorization

Experimental and investigational — prior authorization

Experimental and investigational services and linked procedures require prior authorization. Examples called out include CPT/HCPCS and investigational procedure codes such as 33477, 95966, 0570T, 36514, 95965. Submit supporting clinical evidence and investigational study documentation when applicable.

Prior authorization required for experimental/investigational services
Example codes referenced: 33477, 95966, 0570T, 36514, 95965
Include supporting evidence and study documentation

Prior Authorization

Foot surgery / FESS / specified treatments — prior authorization

Foot surgery and Functional Endoscopic Sinus Surgery (FESS) require prior authorization. Example foot surgery CPT codes include 28285, 28295, 28299, 28289, 28296, 28291, 28292, 28298. FESS examples include 31240, 31253–31259 series and 31255.

Prior authorization required for foot surgery — example codes: 28285, 28295, 28299, 28289, 28296, 28291, 28292, 28298
Prior authorization required for FESS — example codes: 31240, 31253, 31254, 31255, 31256–31259

Prior Authorization

Home health and procedure prior authorization

Home health services and many procedure-related home services require prior authorization. Examples include a wide range of CPT codes for gynecologic, radiation therapy (IMRT G6015/G6016), and other home-based treatments. For home health and related services submit PA requests with clinical documentation via the Provider Portal.

Prior authorization required for home health services (all states)
IMRT prior authorization examples: G6015, G6016
Submit home health prior authorization via the Provider Portal with clinical documentation

Prior Authorization

Injectables prior authorization

Injectable medications generally require prior authorization. The policy lists many injectable classes and representative J-codes (central nervous system agents, complement inhibitors, enzyme replacement, endocrine therapies, vaccines, etc.). Include drug name, dose, diagnosis, and site of care when submitting.

Injectables require prior authorization
Provide drug name, dose, diagnosis, and site of care with request
Representative injectable J-codes: J0174, J0175, J0222, J0225, J1301, J1426, J1427, J1428, J1429, J2326, J3032, J9256, J9332–J9334, J2781, J2782, J0606, J0879, J0224, J0584, J0801, J0802, J3241, J2507, J0180, J0217, J0218, J0219, J0221, J0567, J1203, J1322, J1458, J1743, J1786, J1931, J2508, J1809, J2840, J3060, J3385

Documentation Required

Unclassified injectable code authorization note

Unclassified injectable codes (J3490, J3590) require notification/prior authorization only for specific products listed by the plan (for example Revcovi, Rivfloza, Starjemza). When one of these products is billed under an unclassified code include the drug name and supporting documentation.

J3490 and J3590: PA/notification required only for specified products (Revcovi, Rivfloza, Starjemza)
Include drug name and supporting documentation when using unclassified J-codes

Note

Portal submission and Optum SGP contact

Portal submission and specialty support: For most prior authorizations submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com). For questions about specialty medications or complex injectable therapies contact the Optum Specialty Guidance Program (SGP) at 888-397-8129.

Use the Prior Authorization and Notification tool on UHCprovider.com to submit requests
Optum Specialty Guidance Program (SGP) phone: 888-397-8129 for specialty/injectable questions

Documentation Required

How to obtain prior authorization / contact

How to obtain prior authorization: Sign in to UHCprovider.com, select the Prior Authorization and Notification tab, and complete the online submission. Include relevant CPT/HCPCS codes, diagnosis codes, clinical notes, device identifiers (if applicable), NDCs for drugs, and any study documentation for investigational items. If you need assistance call Optum SGP (888-397-8129).

Sign in at UHCprovider.com → Prior Authorization and Notification tab
Include CPT/HCPCS, diagnosis codes, clinical notes, device identifiers, NDCs, and study documentation as applicable
For assistance call Optum SGP: 888-397-8129

Prior Authorization

Sample injectable codes

Sample injectable and vaccine codes (representative, not exhaustive) that appear in the policy and commonly require prior authorization or notification include: J0013, J0174, J0217, J0218, J0219, J0221, J0567, J1203, J1322, J1458, J1743, J1786, J1931, J2507, J2508, J2840, J3060, J3385, J9256, J9332–J9334, vaccine/immunobiologic codes 90611, 90623, 90626, 90653, 90656, 90657, 90661, 90662, 90688, 90694, 90702, 90714, 90715, 90732, 90739, 90740, and specialty product codes C9818, 91323.

Representative injectable/sample codes: J0013, J0174, J0217, J0218, J0219, J0221, J0567, J1203, J1322, J1458, J1743, J1786, J1931, J2507, J2508, J2840, J3060, J3385
Vaccine/immunobiologic examples: 90611, 90623, 90626, 90653, 90656, 90657, 90661, 90662, 90688, 90694, 90702, 90714, 90715, 90732, 90739, 90740
Specialty/product examples: C9818, 91323

How to get oneIf you don't have a One Healthcare ID, visit UHCprovider.com/access to register.

UseOne Healthcare ID and password are required to select the Prior Authorization and Notification tab on the provider portal dashboard.

Prior Authorization and Notification tool (UHC Provider Portal)

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

Access stepsGo to UHCprovider.com, click Sign In at top-right, log in with One Healthcare ID, then select the Prior Authorization and Notification tab.

Alternate accessIf no One Healthcare ID, go to UHCprovider.com/access for registration instructions.

Prior authorization

General meaningPrior authorization indicates that approval must be obtained before services coded with CPT or HCPCS are provided; the document repeatedly states 'Prior authorization required.'

Reference requirementWhen deciding coverage, the member-specific benefit plan document must be referenced as terms vary by state.

Provider actionProviders must submit authorization requests via the Provider Portal unless otherwise directed in specific sections.

Site of service exception

DefinitionSite of service exception: outpatient hospital or ambulatory surgical center (ASC) services may not require prior authorization where noted.

ExampleInpatient video EEG: prior authorization is required for inpatient services but not required for outpatient hospital or ASC EEG.

Provider noteSite-of-service review may apply to certain codes; check member-specific plan terms.

Clinical study / Institutional review context

DefinitionClinical study / Institutional review context: a study of a new drug, medical device or other treatment on eligible human subjects subject to oversight by an institutional review, as noted for L‑series HCPCS codes.

Codes referencedL8618, L8619, L8622 are cited in the clinical study / institutional review context.

clinical study / investigational use

DefinitionClinical study / investigational use: study of a new drug, device or treatment on human subjects under institutional review oversight; entries reference investigational L‑series codes.

ImplicationServices or codes designated as investigational may require prior authorization or be handled under investigational review processes.

external portion (hearing device)

DefinitionExternal portion (hearing device): an external component that helps persons with profound sensorineural deafness achieve conversational speech (contextual definition in the document).

ContextReferenced alongside inner ear and implantable device HCPCS codes (L8627/L8628) in device-related entries.

Prior authorization required

StatementPrior authorization required: the document repeatedly notes that prior authorization must be obtained for disease-related services, many CPT/HCPCS-coded procedures, and listed drugs/devices.

ScopeApplies to numerous service categories (e.g., arthroplasty, cardiovascular procedures, injectables, DME); individual plan terms may alter requirements.

Provider actionSubmit prior authorization requests via the Provider Portal or follow specific program instructions (e.g., Genetic and Molecular Testing program) as listed.

Example clinical contexts

ExamplesExample clinical contexts include profound sensorineural deafness (to achieve conversational speech) and congenital heart disease where prior authorization entries reference these conditions.

UseThese clinical examples are illustrative of service areas where prior authorization may be relevant; check specific code entries for details.

Prior authorization

General noteMultiple template placeholders appear in the document for CPT® or HCPCS codes and 'how to obtain prior authorization' with no populated instructions in these segments.

ActionProviders should use the Provider Portal sign‑in to view populated code-specific prior authorization instructions rather than relying on placeholder text.

ReferenceWhen populated, these fields will indicate the CPT/HCPCS codes and instructions for obtaining prior authorization.

General information (placeholder)

Placeholder natureSections labeled 'General information' repeat placeholder lines referencing CPT/HCPCS codes and how to obtain prior authorization without specific details in this file segment.

Provider instructionSign in to the UnitedHealthcare Provider Portal to view the populated instructions and code lists for prior authorization requests.

General information (placeholder)

DefinitionCPT/HCPCS prior authorization information: template fields are present that will contain code-specific prior authorization instructions when populated.

Current stateIn this document extract many of these fields are unpopulated; providers must use the portal to access final instructions.

CPT/HCPCS prior authorization information

Portal requirementProviders must sign in to the UnitedHealthcare Provider Portal to view exact CPT/HCPCS codes and prior authorization requirements for each service listed.

Examples of codesDocument lists many CPT/HCPCS/J-codes (chemotherapy and injectable examples) but instructs providers to use the portal to submit requests and view details.

Help lineFor assistance or questions about injectable/vaccine codes, call the Optum Specialty Guidance Program (SGP) at 888-397-8129.

Continuous glucose monitoring

ScopeContinuous glucose monitoring (CGM) requires prior authorization for members ages 18 and older when used with type 2 and gestational diabetes diagnoses.

Relevant codesCGM-related HCPCS device and supply codes referenced include A4226, A4238, A4239, and A9276–A9278; DME code E2103 also appears in the CGM context.

Age requirementPrior authorization is required for members ages 18 and older (as stated in this section).

Cosmetic procedures

Cosmetic procedures — definitionCosmetic procedures: procedures that change or improve physical appearance without significantly improving or restoring physiologic function.

Prior authorizationCosmetic procedures listed require prior authorization (document notes 'Prior authorization required').

Contrast with reconstructiveReconstructive procedures are defined as treating a medical condition or improving/restoring physiologic function and are distinguished from cosmetic procedures in the document.

Reconstructive procedures

DefinitionReconstructive procedures: procedures that treat a medical condition or improve/restore physiologic function (distinct from cosmetic procedures).

AuthorizationReconstructive procedures that treat a medical condition or restore function may require prior authorization as indicated in specific entries.

Provider noteCheck specific CPT/HCPCS entries for reconstructive procedures to determine authorization requirements.

Genetic and Molecular Testing Prior Authorization/Notification Program

Program nameGenetic and Molecular Testing Prior Authorization/Notification Program: a required registration/authorization program for genetic and molecular tests (e.g., BRCA).

Lab requirementLabs and test names must be indicated; payment will be authorized only for CPT codes registered with the program for the specified genetic test.

Example codesExamples of genetic testing CPT codes listed include 81162 and many other CPT and proprietary codes enumerated in the genetic testing section.

Optum SGP

DefinitionOptum SGP: Optum Specialty Guidance Program, a phone support resource for provider questions and assistance with injectable prior authorization.

How to contactCall the Optum Specialty Guidance Program (SGP) at 888-397-8129 for questions or assistance.

Use caseReferenced for injectable and vaccine prior authorization questions and submission help when providers sign in to the Provider Portal.

Provider Portal

DefinitionProvider Portal: UnitedHealthcare Provider Portal Prior Authorization and Notification tool used for online prior authorization submission.

Access stepsGo to UHCprovider.com, click Sign In at the top-right, log in with One Healthcare ID, then select the Prior Authorization and Notification tab.

When to useUse the Provider Portal to submit prior authorization requests for the many CPT/HCPCS/J codes listed in the document and to view code-specific instructions.

SGP contact

ContactOptum Specialty Guidance Program (SGP) phone line: 888-397-8129 for questions about prior authorization and help with portal submissions.

Portal sign-in reminderSign in at UHCprovider.com (top-right) to submit prior authorization requests and view code-specific instructions.

Use caseReferenced repeatedly in context of injectable and vaccine CPT/HCPCS codes and home health prior authorization entries.