CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for UnitedHealthcare West commercial plans

Governs prior authorization and notification requirements for participating health care professionals and facilities under UnitedHealthcare West commercial plans (Non‑Capitated Supplement). Describes which services and codes require prior authorization and how to submit requests.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare West commercial plans

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by chat, or by phone (866-889-8054 for cardiology).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

online/chat/phonesubmission channels

prior auth + counselingBRCA testing

prior auth requiredCardiology

prior authCGM (type 2/gestational)

100+codes referenced

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Services and Procedures That Require Prior Authorization or Notification

Prior authorization criteria by service group

Specific services and procedure groups listed below require prior authorization or notification as indicated.

Arthroplasty procedures require prior authorization; applicable CPT examples include 23470, 23472, 23473, 23474, 24360-24363, 24365, 24370-24371, 25441-25446, 25449, 27120-27138, 27446-27487, 27700-27703.

Arthroscopy procedures require prior authorization; applicable CPT examples include 29914-29916.

Bariatric surgery and obesity-related services require prior authorization or notification; applicable CPT examples include 43644, 43645, 43659, 43770-43775, 43842-43849, 43860, 43865, 43886-43888. Certain diagnosis codes (e.g., E66.01, E66.09, E66.1–E66.3, E66.8, E66.9 and Z68.* ranges) trigger notification/prior authorization.

Bone growth stimulation / electronic stimulation or ultrasound to heal fractures requires prior authorization (per section referencing these services).

BRCA genetic testing (DNA sequencing for BRCA1/BRCA2) requires prior authorization before sequencing is performed; genetic counseling by a qualified professional is required prior to testing.

Cardiology outpatient and office‑based diagnostic procedures require prior authorization (including diagnostic catheterizations, echocardiograms, electrophysiology implants and stress echoes); submit via the Prior Authorization and Notification tool on the Provider Portal or call 866-889-8054 for cardiology.

Vascular procedures (lower-extremity angiograms)

Prior authorization is required for specified vascular procedures.

Lower‑extremity angiograms (vascular codes for lower‑extremity angiograms) require prior authorization.

Cardiology specialty prior authorization applies to outpatient and office-based diagnostic catheterizations, echocardiograms, electrophysiology implants and stress echoes; refer to Cardiology Prior Authorization and Notification page for details and CPT codes.

Continuous glucose monitor

Continuous glucose monitoring devices have coverage and prior-authorization requirements that depend on diabetes type.

Continuous glucose monitor (CGM) prior authorization not required for type 1 diabetes.

CGM prior authorization is required for type 2 diabetes and gestational diabetes diagnoses; the policy lists multiple E11.* and O24.* diagnosis codes associated with this requirement (examples referenced in the CGM entries).

HCPCS/product codes and device entries for CGM and supplies are referenced in the document; submit prior authorization as indicated when diagnosis and device/codes meet the listed conditions.

Implants (cartilage, cochlear/auditory)

Implantable cartilage and auditory devices require prior authorization.

Cartilage implants require prior authorization; example CPT codes referenced include 27412, 27415, 27416, 29866.

Cochlear and other auditory implants require prior authorization; example CPT/HCPCS codes referenced include 69710, 69714, 69930 and HCPCS device codes L8619, L8690, L8614.

Prior authorization criteria by diagnosis

When services are billed with the listed diagnosis codes, prior authorization is required for associated procedures.

Prior authorization is required when the service is associated with the listed type 2 diabetes (E11.*) and gestational diabetes (O24.*) diagnosis codes; examples cited include E11.00, E11.01, E11.10, E11.11, E11.319, E11.3211, E11.3213, and multiple other E11.* variants.

Cardiovascular code mappings (no criteria)

This section provides cardiovascular ICD‑10 mappings and references to prior authorization instructions; it does not state separate coverage criteria in the excerpt.

Cardiovascular ICD‑10 code mappings are provided linking vascular and device complication codes to multiple E11.* diabetes codes; these mappings are informational and accompanied by prior‑authorization references (see listed ICD and device codes).

Cardiovascular coding and prior authorization notes

Notes linking cardiovascular diagnosis codes to CPT/HCPCS and prior authorization instructions appear in this excerpt.

Cardiovascular coding notes map I73.1 and related codes to numerous E11.* diagnosis codes and include repeated references to obtaining prior authorization for associated CPT/HCPCS codes.

Cosmetic procedures

Cosmetic procedures that primarily improve appearance generally require prior authorization when billed.

Cosmetic procedures that change or improve physical appearance without significantly improving or restoring physiologic function require prior authorization; example CPT codes include 11960, 11970, 11971, 14020, 14021, 14061, 14302, 15570, 15572, 15574, 15730, 15733, 15740, 15756, 15769, 15773, 15820-15823, 15830, 15847, 15877, 15878 and related codes.

Reconstructive procedures (those that treat a medical condition or restore physiologic function) are listed separately and may have different prior authorization expectations; example CPT codes listed in reconstructive category include 15878-15879, 17106-17108, 17999, 21137-21139, 21172, etc.

Continuous glucose monitors

CGM entries and associated diagnosis/HCPCS codes are listed with prior-authorization references.

CGM coverage entries reference numerous E11.* and O24.* diagnosis codes (examples include E11.641, E11.649, E11.65, E11.69, O24.111–O24.119, O24.12–O24.13) and note prior authorization requirements tied to diabetes type and diagnosis.

Diagnosis-based prior authorization exemptions

Certain diagnosis codes exempt services from prior authorization when billed together.

Prior authorization is not required when procedures are billed with the listed diagnosis codes shown in the document (examples include multiple C43.* and C44.* skin cancer codes and other specified diagnosis codes cited in the 'Prior authorization not required when billed with the following Dx codes' section).

DME prior authorization criteria

Notification or prior authorization is required for specific DME HCPCS codes; some items have additional cost‑threshold notes.

Notification/prior authorization is required for the listed DME HCPCS codes (examples include A7025, A7026, E0194, E0265, E0266, E0277, E0296, E0297, E0300, E0302, E0304, E0328, E0329, E0466, E0471, E0483, E0745, E0764, E0766, E0770 and many others).

Some DME and orthotics/prosthetics items require prior authorization only when retail purchase or cumulative rental cost exceeds $1,000; prosthetics are noted as distinct from DME.

Procedure prior authorization guidance

Procedure codes are categorized; many require prior authorization while reconstructive procedures are distinguished from cosmetic procedures.

Procedure codes classified as cosmetic generally require prior authorization (see cosmetic procedures block).

Reconstructive procedures are listed separately and may have different review expectations; applicable CPT examples are provided in the document.

Prior authorization criteria (excerpt)

Prior authorization or notification is required for the listed services and codes in these excerpts.

Functional endoscopic sinus surgery (FESS) requires prior authorization for listed CPT codes (examples: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31288).

Notification or prior authorization is required when specified procedures are submitted with diagnosis codes F64.0, F64.1, F64.2, F64.8, F64.9 or Z87.890; listed CPT examples include 14000,14001,14041,15734,15738,15750,15757,15758,19303,53410,53430,54125 and others.

Home health/private duty nursing requires notification/prior authorization in outpatient settings (including patient’s home) for listed codes (examples include T1000, T1002, T1003 and related codes).

Infertility diagnostic and treatment services require prior authorization for numerous CPT/HCPCS codes referenced in this section.

Injectable medications (including hemophilia products, immune globulin, HP Acthar and other specialty drugs) require prior authorization; many J‑codes are listed and drug‑specific prior authorization programs apply.

MRgFUS—Covered with conditions

MRgFUS is covered for certain plans only under specified conditions and requires prior authorization.

MR‑guided focused ultrasound (MRgFUS) to treat uterine fibroid is covered for certain benefit plans but requires prior authorization before the procedure.

Coverage conditions include: physician/facility confirmation of member coverage; hospital/facility must be in‑network (no out‑of‑network benefits for MRgFUS); member must provide written consent acknowledging limited published evidence and agree not to hold UnitedHealthcare responsible; physician and facility must demonstrate experience and expertise as determined by UnitedHealthcare.

Applicable CPT codes referenced for MRgFUS include 0071T and 0072T.

Orthotics and Pain Management—Prior authorization required

Orthotics and pain management services have prior authorization requirements and cost thresholds.

Orthotics require prior authorization for listed orthotics HCPCS/L‑codes and when retail purchase or cumulative rental cost exceeds $1,000 (examples: L1685, L1700, L1710, L1720, L1755, L1844, L1846, L2005, L2020, L2034, L2036, L2037).

Pain management and injection procedures require prior authorization for the listed CPT codes (examples include 62320–62327, 62350–62361, 64451, 64484, 64520, 64620, 64640 and others).

Submit prior authorization requests with applicable codes and supporting documentation per the Provider Portal instructions.

Admissions and Transport—Prior authorization

Prior authorization and notification requirements for facility admissions and transport.

Prior authorization and notification of admission date are required for post‑acute inpatient services provided by acute care hospitals, critical access hospitals and acute inpatient rehabilitation; LTAC and skilled nursing facilities require prior authorization for post‑acute services.

Non‑emergency air transport requires prior authorization; applicable HCPCS examples include A0430, A0431, A0435, A0436, S9960, S9961.

Experimental/Investigational Services—Prior authorization

Services determined to be experimental, investigational, ineffective, or otherwise potentially unproven require prior authorization.

Prior authorization is required for services identified as potentially unproven, experimental, investigational or ineffective; multiple CPT/HCPCS codes are listed in the document as examples (e.g., 26340, 33289, 33361 and others).

When submitting requests for potentially unproven services, reference the specific codes listed in the document and provide rationale/evidence as requested.

Prior authorization criteria and instructions

Prior authorization instructions and category‑level requirements; submission channels noted.

Proton beam therapy: Prior authorization required; indicate whether therapy is performed as part of a clinical trial; applicable codes include 77520, 77522, 77523, 77525 and numerous L‑codes (see document).

Advanced radiology and imaging: Certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures require prior authorization before scheduling; submit requests via the UnitedHealthcare Provider Portal or call 866-889-8054.

Prosthetics cost threshold: Prior authorization is required for prosthetic codes when retail purchase or cumulative rental cost exceeds $1,000 (examples include L5010, L5105, L5050, L5150, L5060).

Rhinoplasty / sinuplasty / ENT: Prior authorization required for listed CPT codes (examples include 30400–30430 series, 31295–31298).

Prior authorization criteria - high level

High‑level categories and example codes that require prior authorization.

Sleep apnea surgical procedures require prior authorization (examples: 95805, 95807, 95808, 95810, 95811) — applies only to surgical procedures, not diagnostic sleep studies.

Spinal cord stimulators when implanted for pain management require prior authorization (examples: 63650, 63655, 63685, 64570, 64553).

Spinal surgery procedures listed throughout the document require prior authorization (examples provided across fragments include 20931, 22100, 22532, 22630, 22800 series, 63001, 63170, 63272, 63308).

Organ/tissue transplant and CAR T‑cell therapy services require prior authorization before pre‑treatment or evaluation; providers may be instructed to contact Optum for certain therapies (examples include codes 38241, 38242, 0537T–0540T, C9098, Q2042).

Prior authorization requirements (partial)

Partial cardiovascular procedure list with prior authorization implications.

Cardiovascular section lists additional codes with prior authorization implications, including CAR T‑cell related codes (0537T–0540T), HCPCS/CPT misc codes (C9098, C9399, J3490, J3590, Q2042, Q2053–Q2055) and vein procedure codes (36470, 36471, 36473, etc.); vein procedures require prior authorization.

CPT, HCPCS and ICD-10 Codes Referenced

Examples of CPT codes requiring prior authorizationCPTCovered

23470	Arthroplasty (example listed)
27120	Arthroplasty (hip)
29914	Arthroscopy example
43644	Bariatric surgery example
43860	Bariatric surgery example (notification/prior auth for listed diagnosis codes)

Examples of ICD-10 diagnosis codes referenced for breast reconstruction/notificationICD-10

C50.019	Breast cancer diagnosis code listed (no prior auth required for some diagnosis codes noted)
Z90.10	Breast reconstruction related codes and diagnoses

BRCA genetic testing CPT/HCPCS examplesCPTCovered

81162	BRCA testing
81433	BRCA testing

ICD-10 diagnosis mappings (cardiology)ICD-10

I70.221	Example mapped ICD-10 code from listed mappings
I70.423	Example mapped ICD-10 code from listed mappings

Procedure codes referencedCPT

27412	Cartilage implant CPT
69710	Cochlear implant CPT

Sample ICD-10 E11.* codes referencedICD-10Covered

E11.00	Type 2 diabetes mellitus without complications (as listed)
E11.01	Type 2 diabetes mellitus with diabetic nephropathy (example listed)
E11.11	Type 2 diabetes mellitus with unspecified complications (listed)
E11.3211	Type 2 diabetes mellitus with foot ulcer codes (examples listed)
E11.638	Type 2 diabetes mellitus with other specified complications (frequently repeated)

Cardiovascular ICD mappingsICD-10

S35.511A	Encounter code shown in mapping lines
T82.319A	Encounter/device complication code shown in mapping lines
T82.399A	Device complication code shown in mapping lines
I73.1	Peripheral vascular disease code shown in mapping lines
E11.638	Type 2 diabetes mellitus with other specified complications (mapped)
Q27.8	Other specified congenital malformations of peripheral vascular system
S35.512A	Encounter code variant shown
T82.338A	Device complication code variant shown
T82.898A	Other specified device complications
E11.622	Type 2 diabetes mellitus with foot ulcer (mapped)

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Sample ICD-10 and other codes referencedICD-10

I73.1	Peripheral vascular disease / related cardiovascular condition mapping shown to multiple E11.x codes
Q27.8	Congenital malformations referenced with prior authorization instructions
S35.511A	Injury code referenced alongside prior authorization mapping
T82.319A	Device-related complication code referenced
E11.638	Type 2 diabetes with other specified complications (used in mappings)

Referenced ICD-10 and related diagnosis/device codes in excerptICD-10

E11.00
E11.11
E11.21
E11.31
E11.32
E11.33
E11.34
E11.35
E11.36
E11.37X2

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Example HCPCS/product codes referenced for CGM or suppliesHCPCS

A9277
A4226
A4239
A4238
E0787

Selected CPT codes (cosmetic vs reconstructive examples)CPT

15574	Cosmetic procedure (listed)
15730	Cosmetic procedure (listed)
15878	Reconstructive procedure (listed)
17999	Unlisted procedure code (reconstructive listed)

Diagnosis codes exempting prior authorization when presentICD-10Covered

C43.0	Melanoma of skin - example Dx codes listed as prior-auth not required when billed with listed procedures
C44.01	Squamous cell carcinoma in situ - example Dx codes listed

Diagnosis codes that trigger notification/prior authorization for listed proceduresICD-10Covered

F64.0	Gender identity disorder of childhood (example listed as Dx triggering authorization requirements)
F64.1	Gender identity disorder of adolescence/adulthood
F64.2	Combined gender identity disorders
F64.8	Other gender identity disorders
F64.9	Unspecified gender identity disorder
Z87.890	Personal history of sex reassignment

Injectable medication J-codesHCPCSCovered

J7180-J7211 (various)	Hemophilia and other injectable drug J-codes listed
J0800	HP Acthar
90283-90284	Therapeutic, prophylactic, and/or diagnostic injection administration codes
J1459	Unclassified biologics/other injectables

Selected HCPCS/J-codes referencedHCPCS

J7180
J7181
J7182
J7183
J7185
J7186
J7187
J7188
J7189
J7190

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Transport and MRgFUS related codesCPT

0071T	MRgFUS uterine fibroid
0072T	MRgFUS uterine fibroid
A0430	Non-emergency air transport
A0431	Non-emergency air transport
A0435	Non-emergency air transport
A0436	Non-emergency air transport

Pain management CPT codesCPTCovered

62320	Pain management/injection
62322	Pain management/injection
62324	Pain management/injection
62325	Pain management/injection
62326	Pain management/injection
62327	Pain management/injection
62350	Pain management/injection
62351	Pain management/injection
62360	Pain management/injection
62361	Pain management/injection

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Orthotics HCPCS/L-codesHCPCSCovered

L0220	Orthotics
L0482	Orthotics
L0484	Orthotics
L1685	Orthotics
L1700	Orthotics
L1710	Orthotics
L1720	Orthotics

Cardiovascular and related T-codes and potentially unproven codesCPT | HCPCS

0617T	Listed cardiovascular-related T-code requiring authorization reference
0618T	Listed cardiovascular-related T-code requiring authorization reference
0619T	Listed cardiovascular-related T-code requiring authorization reference
0620T	Listed cardiovascular-related T-code requiring authorization reference
0621T	Listed cardiovascular-related T-code requiring authorization reference
0622T	Listed cardiovascular-related T-code requiring authorization reference
0632T	Listed cardiovascular-related T-code requiring authorization reference
0639T	Listed cardiovascular-related T-code requiring authorization reference
0643T	Listed cardiovascular-related T-code requiring authorization reference
0644T	Listed cardiovascular-related T-code requiring authorization reference

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Radiology and proton beam therapy HCPCS codesHCPCS

L6884	Radiology/proton therapy-related HCPCS code
L6910	Radiology/proton therapy-related HCPCS code
L6590	Radiology-related HCPCS code
L6450	Radiology-related HCPCS code
L6584	Radiology-related HCPCS code
L6570	Radiology-related HCPCS code
L6586	Radiology-related HCPCS code
L6370	Radiology-related HCPCS code
L6582	Radiology-related HCPCS code
L6638	Radiology-related HCPCS code

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ENT / rhinoplasty / sinuplasty / sleep apnea CPT codesCPTCovered

30400	Rhinoplasty
30410	Rhinoplasty
30420	Rhinoplasty
30430	Rhinoplasty
31295	Sinuplasty
31296	Sinuplasty
31297	Sinuplasty
31298	Sinuplasty
21685	Sleep apnea procedures (listed)
41599	Sleep apnea procedures (listed)

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Highlighted transplant/CAR T and related codesCPT | HCPCS | mixedCovered

38232	Collection of hematopoietic progenitor cells; note indicates conditional prior authorization requirement
0537T	CAR T-cell therapy related codes
C9098	Miscellaneous CAR T / cellular product code

Spinal cord stimulator codesCPT | HCPCSCovered

63650	Spinal cord stimulator implant
64570	Spinal neurostimulator pulse generator

Cardiovascular CPT/HCPCS codes (partial list)mixed

36470	Vein procedure (specific procedure unspecified in snippet)
36471	Vein procedure (specific procedure unspecified in snippet)
36473	Vein procedure (specific procedure unspecified in snippet)
36474	Vein removal/ablation (listed in section)
36475	Removal and ablation of main trunks/named branches (listed)
37243	Endovascular procedure for venous disease (listed)
37700	Venous procedure code listed
37718	Venous procedure code listed
37722	Venous procedure code listed
37780	Procedure for varicose veins of extremities (listed)

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Bariatric diagnosis notification list

Bariatric diagnosis notification listE66.01; E66.09; E66.1-E66.3; E66.8; E66.9; Z68.1; Z68.20-Z68.22; Z68.30-Z68.39; Z68.41-Z68.45

Associated actionNotification or prior authorization required when these diagnosis codes are present for bariatric surgery/obesity-related services

How to Submit Requests and Key Provider Requirements

Prior Authorization

How to submit prior authorization requests

Please submit prior authorization requests using one of the following methods: 1) Chat: Connect 24/7 via the Contact us page; 2) Online: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) — sign in with One Healthcare ID. 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.

Online: Prior Authorization and Notification tool on UnitedHealthcare Provider Portal
Emergency/urgent care: No prior authorization required
Out-of-network providers: Prior authorization required for all services

Prior Authorization

BRCA genetic testing prior authorization

BRCA genetic testing requires prior authorization before DNA sequencing is performed. An ordering provider must notify the laboratory; the laboratory will notify UnitedHealthcare. Genetic counseling by a qualified health care professional is required prior to testing to review hereditary history and treatment impact. Note: genetic testing/counseling may not be covered under some benefit plans.

Definitions and Term Notes

Prior authorization — definition

Prior authorization (definition)A review requirement that must be obtained before certain services or procedures are performed; requests submitted via chat, the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, or phone where specified

Emergency rulePrior authorization is not required for emergency or urgent care

Out-of-network ruleOut-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services

Genetic counseling — BRCA testing requirement

Genetic counseling requirementGenetic counseling by a qualified health care professional is required prior to BRCA (BRCA1/BRCA2) DNA sequencing testing

BRCA testing PA

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare West commercial plans

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by chat, or by phone (866-889-8054 for cardiology).

SourceLink

On This Page

Sleep apnea surgical procedures: Prior authorization required for surgical sleep apnea procedures (not sleep studies); example CPTs include 95805, 95807, 95808, 95810, 95811.

Spinal surgery and stimulators: Prior authorization required for listed spinal surgery CPTs and spinal cord stimulator implant codes (examples include 20931, 22100, 22532, 22630, 22800 series, 63001, 63170, 63272, 63650, 64570).

Use the Provider Portal Prior Authorization and Notification tool or call 866-889-8054 to submit requests; refer to the document for full code lists and any special instructions.

Referenced CPT examplesSee related bariatric CPT entries (e.g., 43845, 43846, 43847, 43848, 43860, 43865, 43886-43888) in the bariatric surgery section

DME retail purchase cost threshold

DME retail purchase thresholdRetail purchases costing more than $1,000 require prior authorization

ContextApplies to specified DME HCPCS codes listed in the DME section; some items reference retail purchase or cumulative rental cost notes

Example DME codes referencedExamples include E0266, E0277, E0296, E0297, E0300, E0302, E0304 (see DME list)

Cumulative retail rental cost / DME threshold

Cumulative retail rental thresholdCumulative retail rental cost thresholds apply (plan-specific); see Home health care section for threshold details

Related codes/notesCertain E/K DME codes (e.g., E2502, E2504, E2506, E2508, E2510, E2511, E2512) reference cumulative rental cost and threshold

Action requiredPrior authorization or notification required when cumulative rental exceeds the plan-specific threshold

Orthotics prior authorization cost threshold

Orthotics PA cost thresholdRetail purchase or cumulative rental cost greater than $1,000 requires prior authorization

Applies toListed orthotics HCPCS/L-codes (examples: L1685, L1700, L1710, L1720, L1755, L1844, L1846, L2005, L2020, L2034, L2036, L2037)

Submission guidanceSubmit prior authorization with applicable HCPCS codes and documentation via the Provider Portal or other stated channels

Prosthetic prior authorization cost threshold

Prosthetic PA cost thresholdRetail purchase or cumulative rental cost greater than $1,000 requires prior authorization

Applies toListed prosthetic HCPCS codes (examples: L5010, L5105, L5050, L5150, L5060)

NoteProsthetics are distinguished from DME in the document; refer to prosthetics section for listed codes and PA rules

BRCA sequencing CPT/HCPCS: 81162, 81163, 81164, 81432, 81433
Genetic counseling required prior to testing
Laboratory must notify UnitedHealthcare to initiate member communication

Prior Authorization

Cardiology specialty prior authorization

Outpatient and office-based diagnostic cardiology procedures (e.g., diagnostic catheterizations, echocardiograms, electrophysiology implants, stress echoes) require prior authorization. Submit requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 866-889-8054. For full CPT/HCPCS lists and specialty instructions visit the Cardiology Prior Authorization and Notification — Commercial page.

Prior authorization required for outpatient/office diagnostic catheterizations, echocardiograms, electrophysiology implants and stress echoes
Submit via Prior Authorization and Notification tool or call 866-889-8054
See Cardiology Prior Authorization and Notification — Commercial for CPT/HCPCS details

Prior Authorization

Vascular lower-extremity angiograms prior authorization

Prior authorization is required for lower-extremity angiograms and other specified vascular procedures. Refer to the cardiovascular CPT/HCPCS code lists and diagnostic (ICD-10) groupings when submitting requests.

Lower-extremity angiograms: prior authorization required
Include relevant ICD-10 vascular diagnosis codes (e.g., I70.533, I70.534, I70.535) when applicable
See cardiovascular code references for full code sets

Prior Authorization

Cartilage implants prior authorization

Cartilage implant procedures require prior authorization. When submitting, include the procedure CPT along with any related diagnosis codes.

CPT codes: 27412, 27415, 27416, 29866
Related diagnosis/other codes noted in source (examples include Q27.8, Q27.9, Q87.2, S35.511A, S35.512A, T82.*)
Prior authorization required before scheduling

Prior Authorization

Cochlear / auditory implants prior authorization

Cochlear and other auditory implants require prior authorization.

Cochlear/auditory implant CPT/HCPCS examples: 69710, 69714, 69930, L8614, L8619, L8690
Include pertinent diagnosis and device HCPCS codes when requesting prior authorization

Prior Authorization

Continuous glucose monitor prior authorization conditions

Continuous glucose monitors (CGMs) require prior authorization for members with type 2 diabetes and gestational diabetes. Prior authorization is not required for type 1 diabetes. When submitting, include the applicable diabetes diagnosis code(s) from the list below.

Prior authorization required for CGM when submitted with type 2 or gestational diabetes Dx codes (examples include: E11.00, E11.01, E11.10, E11.11, E11.22, E11.29, E11.319, E11.3211–E11.3213, E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9, O24.111–O24.13, O24.119–O24.13)
Prior authorization not required for type 1 diabetes

Prior Authorization

Continuous glucose monitor prior authorization references

When requesting prior authorization for CGM devices and supplies, include HCPCS/device codes and the member’s diabetes diagnosis code(s). Consult DME and device code references for the exact HCPCS entries and device descriptions.

Include CGM HCPCS/device codes and supplies (see DME/device code listings)
Provide supporting clinical information and the specific diabetes Dx code(s) used to justify the device
If benefit plan limits or exclusions apply, coverage may vary

Prior Authorization

Procedure codes requiring prior authorization or classification

Many procedures and services across specialties have specific CPT/HCPCS codes that require prior authorization or have special classification rules. Providers should check the listed CPT/HCPCS groups and supply the indicated diagnosis codes and clinical documentation when submitting requests.

Examples include numerous CPTs listed in the cardiovascular and surgical sections (spinal surgery, pain management injections, cosmetic procedures, reconstructive procedures, IMRT, proton beam therapy, etc.)
Specific pain management CPT examples: 62320–62327, 62350–62351, 62360–62361; stimulators and device codes noted elsewhere
Always include associated diagnosis codes and clinical rationale per the code list

Prior Authorization

Prior authorization — Home health / private duty nursing

Home health services and private duty nursing delivered in outpatient settings, including the patient's home, require notification or prior authorization. Include the appropriate service and HCPCS/CPT codes and clinical justification when submitting.

Private duty nursing/home health codes examples: T1000, T1002, T1003, S4011–S4016, S4013–S4015, 89354, 89356
Notification/prior authorization required for outpatient/home settings
Check home health care thresholds and DME cumulative rental rules when relevant

Prior Authorization

Prior authorization — DME and cardiovascular-related DME/prosthetics

Certain durable medical equipment (DME) and prosthetics require prior authorization — particularly items with a retail purchase or cumulative rental cost greater than $1,000. Include HCPCS codes, cost information (purchase vs rental), and clinical justification.

DME examples requiring notification/PA: A7025, A7026, E0194, E0265, E2502, E2504, E2506, E2508, E2510–E2512, E2599
Cardiovascular-related E/K/L codes noted (e.g., E2102, E2103, A4226, A9277, A4238, A9278)
Prosthetics requiring PA when retail purchase/cumulative rental > $1,000 (examples: L5010, L5105, L5050, L5150, L5060)

Prior Authorization

Non-emergency air transport prior authorization

Non-emergency air transport (non-urgent ambulance by air) requires prior authorization. Provide transport details, clinical necessity, and the applicable HCPCS codes when requesting approval.

Non-emergency air transport HCPCS examples: A0430, A0431, A0435, A0436, S9960, S9961
Prior authorization required for air ambulance transports that are non-urgent

Prior Authorization

Potentially unproven / experimental services prior authorization

Potentially unproven, experimental or investigational services (including linked services and medications deemed ineffective or without beneficial health outcomes) require prior authorization. Provide supporting clinical evidence and intent if requesting coverage for such services.

Examples of potentially unproven CPTs listed: 26340, 33289, 33361, 0749T, 0773T, A9274
Clinical trials and investigational device/procedure entries (e.g., S9988, S9990) are subject to special review and PA

Prior Authorization

Out-of-network services prior authorization

Out-of-network services require prior authorization. Out-of-network providers, facilities and other health care professionals must request prior authorization for procedures and services in advance.

Out-of-network services: prior authorization required
Providers should follow the same submission channels (portal/chat/phone) and include justification for out-of-network care

Prior Authorization

Proton beam therapy prior authorization

Proton beam therapy requires prior authorization. When submitting, indicate whether the therapy is part of a clinical trial and include the appropriate CPT/HCPCS codes and clinical rationale.

Proton beam therapy CPT/HCPCS examples: 77522, 77523, 77525; device codes: L6975, L6970–L7009, L7181, L7191, L7185, L7499
Indicate if performed as part of a clinical trial
Provide complete clinical documentation supporting need for proton therapy

Prior Authorization

Transplant and CAR T‑cell therapies prior authorization

Organ and tissue transplants and CAR T-cell therapies require prior authorization before pre-treatment or evaluation. For CAR T-cell and certain gene therapies, contact Optum at 888-936-7246 or use the notification number on the member’s ID card for coordination.

Transplant-related CPT examples include 38241, 38242, 38213–38215, 38232* (see notes)
CAR T-cell / gene therapy codes and entries: 0537T–0540T, C9098, C9399, J3490, J3590; procedure/service examples include Abecma, Breyanzi, Carvykti, Kymriah, Skysona, Tecartus, Yescarta, elivaldogene autotemcel
Call Optum at 888-936-7246 for transplant and CAR T-cell therapy coordination

Note

Diagnosis code exceptions (incontinence) — informational

Certain combinations of procedure codes and incontinence diagnosis codes are exempt from prior authorization. Providers should confirm when these specific Dx-to-procedure combinations apply to avoid unnecessary PA submissions.

No prior authorization required when procedures are submitted with incontinence Dx codes such as: N32.81, N32.9, N39.3, N39.41, N39.42, N39.46, N39.490, N39.498
Additional incontinence and urinary-related Dx codes referenced: R30.x, R32, R33.x, R35.x, R39.x, R15.x
When in doubt, include the incontinence diagnosis on the prior authorization request to demonstrate the exception

Documentation Required

Prior authorization submission requirements — general reminder

For all prior authorization requests, include the applicable CPT/HCPCS codes, ICD-10 diagnosis codes, supporting clinical documentation, device details or DME cost (purchase vs rental), and indicate if the service is part of a clinical trial. Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call the listed specialty numbers (e.g., 866-889-8054 for cardiology; Optum 888-936-7246 for transplant/CAR T).

Always provide CPT/HCPCS and ICD-10 codes with clinical justification
Include device HCPCS and cost information for DME/prosthetics
Indicate clinical trial participation when applicable
Use portal/chat/phone submission channels as described at the top of this section

BRCA genetic testing requires prior authorization before DNA sequencing is performed; the ordering provider notifies the lab, which notifies UnitedHealthcare

Member notificationOnce UnitedHealthcare receives notification from the laboratory, the member is sent a letter explaining how to access the service

Clinical trials — definition

Clinical trials — definitionA rigorously controlled study of a new drug, medical device or other treatment on eligible human subjects that is subject to oversight by an Institutional Review Board

PA noteClinical trials entries indicate prior authorization is required for services tied to clinical trials in this document

Codes referencedClinical trial codes shown (examples: S9988, S9990) for authorization tracking

Cochlear and other auditory implants — definition

Cochlear & auditory implants — definitionA medical device within the inner ear with an external portion that helps persons with profound hearing loss

Authorization requirementCochlear and other auditory implants require prior authorization (document lists related CPT/HCPCS codes such as 69710, 69714, 69930, L8619, L8690, L8614)

Associated codesRefer to listed CPT/HCPCS implant codes when submitting PA requests

Prior authorization requirement — CGM and diabetes diagnosis codes

PA requirement for CGM with certain diagnosesPrior authorization is required for Continuous Glucose Monitor (CGM) when billed with listed type 2 and gestational diabetes diagnosis codes

ExemptionPrior authorization is not required for CGM when billed with type 1 diabetes diagnosis codes (per document)

Referenced diagnosis codesExamples of listed Dx codes include E11.00, E11.01, E11.10 and multiple O24.* and E11.* variants shown in the CGM section

CPT/HCPCS prior authorization reference

CPT/HCPCS PA reference — generalThe document references CPT and HCPCS codes and instructs providers to obtain prior authorization for listed cardiovascular procedures and mappings

ActionFollow CPT/HCPCS code listings in each section and submit PA via Provider Portal or specified phone numbers where noted

Example useSeveral cardiovascular mapping lines link ICD-10 diagnoses to prior authorization instructions for associated CPT/HCPCS codes

CPT/HCPCS prior authorization reference (cardiovascular)

CPT/HCPCS PA reference (cardiovascular)References to CPT ® or HCPCS codes and/or instructions on how to obtain prior authorization for cardiovascular diagnoses are present throughout the cardiovascular sections

Submission channelsUse UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call the number provided for cardiology when indicated

Example codesMultiple cardiovascular T-/HCPCS codes and mappings are shown; providers should reference the specific code lines in the cardiovascular section

Continuous glucose monitor — definition

Continuous glucose monitor — definitionContinuous glucose monitor (CGM) entries list relevant diagnosis codes (E11.* and O24.* variants) and associated PA instructions

Diagnostic codes listedExamples include E11.641, E11.649, E11.65, E11.69, E11.8, E11.9 and O24.111-O24.439 series referenced in the CGM section

PA instructionProviders should reference the CGM section codes when requesting prior authorization

Cosmetic procedures — definition

Cosmetic procedures — definitionProcedures that change or improve physical appearance without significantly improving or restoring physiologic function

PA stancePrior authorization is required for listed cosmetic procedure CPT codes in the document

Contrast to reconstructiveReconstructive procedures treat a medical condition or improve/restore physiologic function and are listed separately

Reconstructive procedures — definition

Reconstructive procedures — definitionProcedures that treat a medical condition or improve or restore physiologic function

PA noteReconstructive procedure codes are listed and may require prior authorization per the reconstructive procedure entries

Example codesExamples include 15878, 15879, 17106-17108, 17999, 21137-21139, 21172 etc., as listed in the reconstructive section

Injectable medications — definition

Injectable medications — definitionDrugs capable of being injected intravenously (infusion), subcutaneously or intramuscularly

PA requirementInjectable medications (including hemophilia products, immune globulin, HP Acthar and others) require prior authorization; many J-codes are listed

Program referenceFor drug-specific prior authorization requirements, refer to Clinical Pharmacy and Specialty Drugs Prior Authorization Programs

FESS — definition

FESS — definitionFunctional endoscopic sinus surgery (FESS): endoscopic surgical procedures of the sinuses identified by listed CPT codes

PA requirementFESS requires prior authorization for the listed CPT codes (examples: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31288)

Submission guidanceInclude the applicable CPT codes when requesting prior authorization

MRgFUS — definition and coverage conditions

MRgFUS — definition & conditionsMR-guided focused ultrasound (MRgFUS) is a procedure to treat uterine fibroids (CPT 0071T, 0072T) covered for certain plans subject to multiple conditions (in-network facility, member written consent acknowledging limited evidence, physician/facility demonstrated experience) and prior authorization

Coverage conditionsPhysician/facility must confirm member coverage; facility must be in-network; member must provide written consent and agree not to hold UnitedHealthcare responsible; physician/facility must demonstrate experience

Applicable CPT codes0071T, 0072T (MRgFUS uterine fibroid) as listed

Orthotics — definition and PA threshold

Orthotics — definitionOrthotics are durable medical equipment/devices; prior authorization is required when listed orthotics codes are used and retail purchase or cumulative rental cost exceeds $1,000

Examples of HCPCS/L-codesExamples include L1685, L1700, L1710, L1720, L1755, L1844, L1846, L2005, L2020, L2034, L2036, L2037

ActionSubmit PA for orthotics when cost threshold exceeded or when codes are among those listed

Prior authorization — generic PA note

Prior authorization — generic notePrior authorization is a required review before certain services; submit requests via chat, the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, or by phone where specified

PA required statementThe document repeatedly states 'Prior authorization required' for numerous categories and codes across sections

Provider responsibilitiesProviders ordering advanced outpatient imaging or other services are responsible for providing notification and obtaining PA as required

Proton beam therapy — definition

Proton beam therapy — definitionProton beam therapy (focused radiation therapy using beams of protons) requires prior authorization; indicate whether therapy is performed as part of a clinical trial

Codes referencedHCPCS/HCPCS examples include L7170, L7186, L8042 and CPT 77520, 77522-77525 (see proton beam section)

Clinical trial noteProviders should indicate if proton beam therapy is part of a clinical trial (see Clinical trials definition) when requesting PA

Surgical sleep apnea procedures — definition

Surgical sleep apnea procedures — scopeApplies only to surgical sleep apnea procedures (e.g., palatopharyngoplasty, oral pharyngeal tissue reduction); does not apply to sleep studies

PA requirementPrior authorization is required for listed surgical sleep apnea CPT codes (examples: 95805, 95811, 95807, 95808, 95810)

NoteThis definition clarifies the policy applies to surgeries only, not diagnostic sleep studies

Transplant/CAR T prior authorization — definition & contact

Transplant/CAR T prior authorizationOrgan/tissue transplant and CAR T‑cell therapy services require prior authorization before pre-treatment or evaluation; for certain CAR T and gene therapies providers should call Optum at 888-936-7246 or the notification number on the member ID

ExamplesCAR T and cellular therapy examples listed include Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta and others referenced in the transplant section

ActionContact Optum per the document for authorization of specified gene and cellular therapies

Ventricular assist device (VAD) — definition

Ventricular assist device (VAD) — definitionA ventricular assist device (VAD) is a mechanical pump that takes over the ventricle of the heart and restores normal blood flow

PA implicationVAD procedure codes are listed in the document and are included among services that require prior authorization

Example codesExamples of VAD procedure CPT codes referenced include 33975, 33976, 33979, 33981, 33982, 33983