CurrentUnitedHealthcarePolicy N/A

Prior Authorization Requirements for Rhode Island Medicaid

List of prior authorization requirements and submission instructions for participating UnitedHealthcare Community Plan of Rhode Island health care professionals for inpatient and outpatient services.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Requirements for Rhode Island Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb. 1, 2025

Next Review Date

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID or call 855-766-0344.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Rhode Islandstate governed

Feb. 1, 2025effective date

UHCprovider.comsubmission method

855-766-0344phone

Multiple servicespriority examples

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Services Requiring Prior Authorization and Coverage Notes

inv-01: Prior authorization criteria — Services and codes that require prior authorization or are exempt

Services and codes that require prior authorization or are exempt:

ALL of the following

Requests must be submitted via the UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID and password; or by phone at 855-766-0344.
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.

ALL of the following

Prior authorization required for colony-stimulating factor drugs and bone‑modifying agents administered in an outpatient setting for a cancer diagnosis; specific HCPCS/J-codes listed in the document (examples: J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125, J0897).

ALL of the following

Prior authorization required for outpatient and office-based diagnostic catheterizations, echocardiograms, electrophysiology implants and stress echoes prior to performance.

ALL of the following

Adult day services: prior authorization required (example code S5102).
Bariatric surgery: prior authorization required (example CPTs: 43644, 43645, 43659, 43770).

ALL of the following

Routine outpatient behavioral health services through a designated behavioral provider may not require prior authorization; for other behavioral health services follow the member-specific prior authorization instructions and phone/portal submission methods.

ALL of the following

The document contains many additional code-specific entries and examples; providers should consult the full code listings for service-level prior authorization requirements.

inv-02: Coverage criteria and prior authorization requirements (partial)

Coverage-related notes and prior authorization expectations for specific services

ALL of the following

Prior authorization required for injectable chemotherapy drugs administered in an outpatient setting for a cancer diagnosis (includes HCPCS J9000-J9999 and listed examples such as J0640, J0641, J0642, J1950, J1954, J1932).

ALL of the following

Prior authorization required for cochlear and other auditory implants; example CPT/HCPCS codes include 69710, 69714, 69930 and L8614 (additional L86xx codes listed in document).

ALL of the following

Prior authorization required for inpatient services for cerebral seizure monitoring with listed monitoring CPT codes as shown in the document.

inv-03: Prior authorization for Continuous Glucose Monitors

Prior authorization condition stated in excerpt

ALL of the following

Prior authorization required for continuous glucose monitors when used for a Type 2 Diabetes diagnosis.
Example HCPCS codes listed in the document include A4226 and A4239 (additional A9276/A9277 marked entries present).

ALL of the following

Follow general submission methods (portal or phone) for prior authorization requests for CGMs as specified in the document.

inv-04: High-level coverage stance by procedure classification — reconstructive vs cosmetic

Classification guides coverage approach: reconstructive procedures (medical necessity) versus cosmetic procedures (cosmetic/non-covered).

Reconstructive (medical necessity): Procedures that treat a medical condition or improve or restore physiologic function are classified as reconstructive; associated CPT/HCPCS and ICD-10 codes are indicated in the document (see reconstructive code entries and ICD-10 references).

Cosmetic (non-reconstructive): Procedures that change or improve physical appearance without significantly improving or restoring physiologic function are labeled cosmetic; cosmetic code listings are provided separately.

ALL of the following

Use the ICD-10 diagnosis codes listed in the document to distinguish reconstructive versus cosmetic classification (examples appear in the reconstructive and cosmetic sections).

inv-05: Coverage-related distinctions (partial)

Fragment references coverage-relevant distinction between reconstructive and cosmetic procedures but provides no explicit coverage determinations in this section.

ALL of the following

The document repeats the distinction that reconstructive procedures improve or restore physiologic function while cosmetic procedures focus on appearance; many code entries in this fragment are placeholders or incomplete.

ALL of the following

Refer to full code and diagnosis listings elsewhere in the document for specific coverage determinations tied to reconstructive versus cosmetic classification.

inv-06: Codes and prior auth placeholders (listing fragment)

Code listing fragment — no coverage rules present in this part.

ALL of the following

This fragment contains numerous ICD-10 code entries and repeated placeholders; it does not define clinical coverage criteria by itself.

ALL of the following

Consult the complete code tables in the document for actionable prior authorization requirements tied to specific codes.

inv-07: Coverage notes (partial)

This excerpt enumerates diagnosis codes and DME HCPCS codes and notes when prior authorization is required; it does not include full coverage criteria in this fragment.

ALL of the following

Multiple ICD-10 codes are listed under 'Cosmetic and reconstructive' and related headings; separate DME HCPCS codes (examples: A9279, A9280, A9900, E0194, E0265, E0266, E0270, E0277, E0300, E0328) are shown with prior authorization notes.

ALL of the following

Durable medical equipment: prior authorization required only for DME codes listed with a retail cost more than $500 (document lists examples and indicates 'more than $500').

ALL of the following

For code-specific coverage and prior authorization instructions, follow the 'How to Obtain Prior Authorization' guidance and the individual code entries in the document.

inv-08: Prior authorization requirements (partial)

Partial list of services and associated codes that require prior authorization or notification as shown in this segment.

ALL of the following

Enteral services and specified in-home nutritional HCPCS codes require prior authorization (examples: B4034, B4035, B4036, B4100–B4161 series).

ALL of the following

Prior authorization required for listed surgical procedures including femoroacetabular impingement (FAI) surgery (example CPTs 29914–29916) and functional endoscopic procedures (example CPTs 31240, 31253, 31254).

ALL of the following

This segment contains additional listed codes that require prior authorization; consult the full document for complete code-level requirements.

inv-09: Authorization and listing criteria (section) — Prior authorization and listing criteria

Coverage stance and criteria noted in this section focus on authorization requirements rather than detailed clinical coverage criteria.

ALL of the following

Prior authorization required for genetic and molecular testing performed in an outpatient setting (examples include codes 81162, 81163, 81164, 81228, 81400–81408); ordering providers must indicate the laboratory and test when completing prior authorization/notification.

ALL of the following

Home health care: prior authorization required only in outpatient settings (listed G-codes); hospice: prior authorization required (examples: T2042–T2045).

ALL of the following

Submit injectable medication prior authorization requests online using the UnitedHealthcare Provider Portal or by calling 888-397-8129 as stated in the document.

ALL of the following

inv-10: Authorization and notification criteria (summary)

Prior authorization and notification requirements for listed services and codes.

ALL of the following

Notification with service detail (e.g., CPT/HCPCS code) and prior authorization of admission date is required for facilities providing post-acute inpatient services (acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long-term acute care hospitals, skilled nursing facilities).

ALL of the following

Prior authorization required for orthotics and prosthetic codes listed; rental cost or retail purchase cumulative cost over $500 requires prior authorization as stated in the document.

ALL of the following

For unclassified/temporary codes (C9399, J3490, J3590) prior authorization is required for specified therapies; Review at Launch and pre-determination guidance applies for newly approved drugs (examples and phone/portal submission methods provided).

inv-11: Prior authorization and site-of-service criteria

Prior authorization requirements and site-of-service rules for listed services and codes.

ALL of the following

Prior authorization required for certain advanced outpatient imaging procedures (CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology); care providers ordering these procedures must provide notification prior to scheduling and submit requests via the Provider Portal or by calling the specified radiology prior authorization number (866-889-8054).

ALL of the following

Private duty nursing (T1000) and certain potentially unproven services (examples include 33289, C2624) require prior authorization as listed in the document.

Site-of-service rule: Prior authorization is required only when requesting the service in an outpatient hospital setting; prior authorization is not required if the same service is performed at a participating Ambulatory Surgery Center (ASC).

inv-12: Code listings only — procedure code groupings

Procedure code groupings listed; no criteria described in this excerpt.

ALL of the following

The document lists procedure code groupings (examples: carpal tunnel 64721, various ophthalmologic and respiratory CPTs such as 65426, 65730, 30802, 30930, 31536).

ALL of the following

Use the full code tables elsewhere in the document to determine whether individual codes have associated prior authorization requirements.

inv-13: Prior authorization / notification requirements (partial)

Prior authorization / notification requirements (partial)

ALL of the following

Prior authorization required for sleep apnea procedures and surgeries; sleep studies (CPTs 95805, 95807, 95808, 95810) require prior authorization as listed.

ALL of the following

Spinal surgery codes listed in the document require prior authorization (examples include 22100 and other spinal CPT codes shown).

ALL of the following

Transplant and CAR T-Cell therapy services require contacting the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 for notification/prior authorization.

ALL of the following

inv-14: Authorization notes

Authorization and code-specific criteria notes present in this segment:

ALL of the following

For unclassified codes (J3490, J3590) and C9399 the document identifies specific new therapies that require prior authorization (examples: Amtagvi, Lenmeldy, Skysona, Tecelra); providers should follow the stated prior authorization requirements and submission methods.

ALL of the following

Vein procedures and related CPTs (examples: 36473, 36475, 36478, 37700, 37718, 37722, 37765, 37766) are listed and require prior authorization.

ALL of the following

Code 38232 will only require prior authorization for an oncology diagnosis as noted in the document.

ALL of the following

CPT, HCPCS and ICD-10 Code Listings

Injectable supportive and bone-modifying agentsHCPCSCovered

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

1–10 of 15

1/2

Cardiovascular procedural codes (examples)CPTCovered

37220-37231	Endovascular lower extremity angiography/embolization related CPT range referenced
93580	Related CPT code referenced in cardiology section

Example ICD-10 codesICD-10

E09.52	ICD-10 code listed in document
E10.52	ICD-10 code listed in document
E11.52	ICD-10 code listed in document

Chemotherapy HCPCS/J-codes and examplesHCPCSCovered

J9000-J9999	Range noted for chemotherapy injectable drugs (HCPCS J-codes)
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin (additional code listed)
J1950	Lupron Depot
J1954	Leuprolide Acetate
J1932	Lanreotide

Cochlear implant related HCPCS codes (partial)HCPCS

L8619	Medical device within the inner ear with an external portion to help persons with profound sensorineural deafness achieve conversational
L8690	Medical device within the inner ear with an external portion to help persons with profound sensorineural deafness achieve conversational
L8691	Medical device within the inner ear with an external portion to help persons with profound sensorineural deafness achieve conversational
L8692	Medical device within the inner ear with an external portion to help persons with profound sensorineural deafness achieve conversational

Continuous glucose monitor and cosmetic-related HCPCS codesHCPCSCovered

A4226	Continuous glucose monitor
A4239	Continuous glucose monitor
A9276	Continuous glucose monitor
A9277	Continuous glucose monitor
A9278	Cosmetic and reconstructive related HCPCS (marked with *)

Reconstructive / physiologic function CPT codes (partial)CPTCovered

21172	Improving or restoring physiological function (listed)
21280	Reconstructive procedures that treat a medical condition or improve or restore
21282	Reconstructive procedures that treat a medical condition or improve or restore
21295	Reconstructive procedures that treat a medical condition or improve or restore
21740	Reconstructive procedures that treat a medical condition or improve or restore
67902	Procedures that treat a medical condition or improve or restore (ocular/eyelid)
67903	Procedures that treat a medical condition or improve or restore (ocular/eyelid)
67904	Procedures that treat a medical condition or improve or restore (ocular/eyelid)
67906	Procedures that treat a medical condition or improve or restore (ocular/eyelid)
67908	Procedures that treat a medical condition or improve or restore (ocular/eyelid)

1–10 of 22

1/3

CPT/HCPCS referenced in sectionCPT

67916
67923
67917
67924
67921
67915
67922
67950
67961
67966

1–10 of 11

1/2

ICD-10 codes referencedICD-10

C43.112
C43.21
C43.60
C43.61
C43.62
C43.70
C43.71
C43.72
C43.8

ICD-10 codes cited in fragmentICD-10

C43.60	ICD-10 code referenced in reconstructive procedures section
C43.71	ICD-10 code referenced in reconstructive procedures section
C44.01	ICD-10 code repeatedly listed in code tables
C44.02	ICD-10 code repeatedly listed in code tables
C44.09	ICD-10 code repeatedly listed in code tables
C44.101	ICD-10 code repeatedly listed in code tables

ICD-10 codes referenced in this fragmentICD-10

C43.71
C43.9
C43.8
C44.01
C44.02
C44.09

ICD-10 codes referencedICD-10

C43.71	ICD-10 code mention in table fragment
C43.72	ICD-10 code mention in table fragment
C43.8	ICD-10 code mention in table fragment
C43.9	ICD-10 code mention in table fragment
C43.62	ICD-10 code mention in table fragment
C43.61	ICD-10 code mention in table fragment

Selected ICD-10 codes (partial)ICD-10

C44.1021	ICD-10 diagnostic code listed under Cosmetic and reconstructive
C44.1022	ICD-10 diagnostic code listed under Cosmetic and reconstructive
C44.1091	ICD-10 diagnostic code listed under Cosmetic and reconstructive
C44.1092	ICD-10 diagnostic code listed under Cosmetic and reconstructive
C43.71	ICD-10 code referenced multiple times in the excerpt

Selected DME HCPCS codesHCPCSCovered

A9279	DME HCPCS code listed as requiring prior authorization
A9280	DME HCPCS code listed as requiring prior authorization
A9900	DME HCPCS code listed as requiring prior authorization
E0194	DME HCPCS code listed as requiring prior authorization

ICD-10 and DME codes (partial)mixed

D04.0	ICD-10 lesion codes (partial list shown)
D04.10	ICD-10 lesion code (partial)
A9279	DME HCPCS example

Enteral and genetic testing codes (partial)mixed

B4034	Enteral services supply
81162	Genetic BRCA testing (example code listed)

Selected genetic/molecular test CPT codesCPTCovered

81162	BRCA/related genetic testing (example listed)
81163	BRCA/related genetic testing (example listed)
81164	BRCA/related genetic testing (example listed)
81228	Genetic testing code listed
81400	Genetic/molecular pathology code listed

Injectable medication J-/Q- codes (sample)HCPCSCovered

J0172	Aduhelm
J1306	Leqvio
J3380	Entyvio
J1459	IVIG (one of multiple IVIG codes listed)
J9312	Rituxan
J1439	Injectafer

Selected injectable HCPCS codes listedHCPCSCovered

J2502	Simponi Aria
J1602	Skyrizi
J2327
J7320	Sodium Hyaluronate
J1300	Soliris
J1930	Somatuline Depot
J1747	Spevigo
J2326	Spinraza
J3358	Stelara
J3316	Truxima

1–10 of 17

1/2

Orthotics and prosthetics L-codes (many listed)HCPCSCovered

L0112	Orthotics/prosthetics examples
L0456
L5639
L5980

Sample L-codes listedHCPCSCovered

L5718
L5722
L5724
L5726
L5728
L5780
L5790
L5795

Other procedure codes requiring prior authorizationmixedCovered

T1000	Private duty nursing
33289	Potentially unproven service (example listed)
C2624	Potentially unproven service (example listed)

Surgical codes requiring prior authorizationCPTCovered

30400	Septoplasty/rhinoplasty codes listed
64721	Carpal tunnel surgery
66821	Cataract surgery codes listed

Carpal tunnelCPT

64721

Carpal tunnel surgery

Cataract surgeryCPT

66821	Cataract surgery-related code
66982	Cataract surgery-related code
66984	Cataract surgery-related code
66987	Cataract surgery-related code
66988	Cataract surgery-related code

ColonoscopyCPT

45378	Colonoscopy
45380	Colonoscopy
45384	Colonoscopy
45385	Colonoscopy

Cosmetic and reconstructiveCPT

13101	Cosmetic and reconstructive procedure
13132	Cosmetic and reconstructive procedure
14040	Cosmetic and reconstructive procedure
14060	Cosmetic and reconstructive procedure
14301	Cosmetic and reconstructive procedure
21552	Cosmetic and reconstructive procedure
21931	Cosmetic and reconstructive procedure

Digestive System (partial list)CPT

42415
42440
43200
43236

ENT proceduresCPT

21320
30140
30520
69436
69631

Eye and Ocular Adnexa (partial list)CPT

65710
65820
66250
66710

Gynecologic procedures (partial list)CPT

57240
57250
57522

Hemic and Lymphatic SystemsCPT

38500
38510

Hernia repairCPT

49505	Hernia repair
49650	Hernia repair

Integumentary System (partial list)CPT

10121
11440
11770

Liver biopsyCPT

47000

Liver biopsy

Male Genital SystemCPT

54840

Male Genital System procedure

MiscellaneousCPT

20680

Miscellaneous

Musculoskeletal mappings/associationsCPT

20552	Musculoskeletal injection (with mapping notes)
21336	Musculoskeletal related mappings

Nervous SystemCPT

64561
64640

Ophthalmologic (partial list)CPT

65426
65730

Respiratory System (partial list)CPT

30802
30930
31536

Key coding thresholds and definitions

Prior authorization requirement for CGM (Type 2 Diabetes)

RequirementPrior authorization is required for Continuous Glucose Monitor (CGM) when the member has a Type 2 Diabetes diagnosis.

Relevant codes (examples)A4226, A4239, A9276, A9277 (HCPCS) — CGM-related codes appear in the CGM section.

How noted in policyEntry explicitly: 'Prior authorization required with Type 2 Diabetes Diagnosis.'

Reconstructive vs Cosmetic threshold — definition

Reconstructive definitionProcedures that treat a medical condition or improve or restore physiologic function are classified as reconstructive.

Cosmetic definitionProcedures that change or improve physical appearance without significantly improving or restoring physiologic function are classified as cosmetic.

How to Obtain Prior Authorization & Provider Responsibilities

Prior Authorization

How to Obtain Prior Authorization

This list contains prior authorization requirements for participating UnitedHealthcare providers. Submit requests by: Online — use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) and sign in with One Healthcare ID; Phone — call 855-766-0344. Prior authorization is not required for emergency or urgent care. Out‑of‑network providers must request prior authorization for all procedures and services.

Prior authorization required for continuous glucose monitors when billed for members with Type 2 Diabetes.
Prior authorization required for enteral services and in‑home nutritional therapy codes listed below.
Prior authorization required for select injectable medications; certain injectables require OptumRx prior notification.
Prior authorization required for sleep studies and many sleep apnea procedures.
Transplant and CAR T‑Cell therapy services require notification and prior authorization via the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246.
Prior authorization required for vein procedures.

Prior Authorization

Defined Terms and Reference Notes

Prior authorization (term entry)

DefinitionPrior authorization: a process by which providers must obtain approval prior to performing certain procedures or services; submission methods include the UnitedHealthcare Provider Portal (UHCprovider.com) or phone (855-766-0344).

ExceptionsPrior authorization is not required for emergency or urgent care.

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

Cochlear implant / auditory implant definition

DefinitionCochlear implant / auditory implant: a medical device implanted within the inner ear with an external portion to help persons with profound sensorineural deafness achieve conversational hearing; associated HCPCS examples include L8619, L8690–L8692.

Policy action

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Requirements for Rhode Island Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb. 1, 2025

Next Review Date

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID or call 855-766-0344.

SourceLink

On This Page

Numerous injectable J- and Q- codes are listed in the document and require prior authorization as indicated (examples include J0172, J1306, J3380, J1459, J9312, J1439 and others).

ALL of the following

Follow the provider submission instructions in the document (portal or designated phone numbers) when requesting prior authorization or notifications for these services.

Vein procedures require prior authorization (codes and examples provided in the document).

ALL of the following

Note: code 38232 will require prior authorization only for an oncology diagnosis; unclassified codes J3490, J3590, and C9399 require prior authorization for specific therapies identified in the document.

Follow portal or the phone numbers provided in the document when submitting prior authorization requests for these codes.

Ophthalmologic CPT codes (partial)CPT

65426	Ophthalmologic procedure code listed
65730	Ophthalmologic procedure code listed
66761	Ophthalmologic procedure code listed

Respiratory CPT codes (partial)CPT

30802	Respiratory/system code listed
30930	Respiratory/system code listed
31536	Respiratory/system code listed

Spine/neurosurgery CPT codes (partial)CPT

22100	Spinal surgery code listed
22514	Spinal surgery code listed (noted with asterisk in source)
22600	Spinal surgery code listed
63001	Cranial/spinal procedure code listed
63308	Neurosurgery code listed
0098T	Category III code listed

Listed CPT codes (excerpt)CPT

32850
32851
32852
32853

Additional CPT codes (excerpt)CPT

38232	will only require prior authorization for an oncology diagnosis
38240
44132

Unclassified codes with PA requirementHCPCSExperimental

J3490	Unclassified code — Amtagvi, Lenmeldy, Skysona, Tecelra will require prior authorization
J3590	Unclassified code — Amtagvi, Lenmeldy, Skysona, Tecelra will require prior authorization
C9399	Unclassified code — Amtagvi, Lenmeldy, Skysona, Tecelra will require prior authorization

Policy useICD-10/CPT/HCPCS entries are organized to reflect reconstructive versus cosmetic classification when determining coverage/authorization requirements.

Completeness — many code placeholders noted

Incomplete entries notedMultiple code entries in the document are placeholders or incomplete ('.' entries) indicating partial/incomplete code lists.

ImplicationReviewers should treat these sections as partial and consult other code table fragments in the document for full code lists.

Locations in sourcePlaceholders and repeated '.' appear across multiple CPT/HCPCS listing fragments (see chunks 72, 74, 90).

DME retail cost threshold for prior authorization

Retail cost thresholdDME items with a retail price more than $500 require prior authorization.

Examples of DME codes listedA9279, A9280, A9900, E0194, E0265, E0266, E0270, E0277, E0300, E0328 (HCPCS) are shown as examples in the DME section.

How expressed in policySource text: 'Durable medical equipment (DME)…Prior authorization required only for DME codes listed with a retail…more than $500.'

DME retail cost prior authorization threshold (duplicate entry)

Threshold statementDurable medical equipment (DME) codes listed with a retail more than $500 require prior authorization.

Document examplesSpecific HCPCS examples shown include A9279, A9280, A9900 and E-series codes (E0194, E0265, etc.).

ScopeApplies to DME entries flagged in the DME section of the policy; not all DME codes require authorization — only those meeting the retail > $500 criterion.

Prior authorization location threshold — outpatient setting

Site-of-service rulePrior authorization is required when requesting a service in an outpatient hospital; not required if performed at a participating Ambulatory Surgery Center (ASC).

Outpatient-specific requirementSeveral tests and services require prior authorization only when performed in outpatient settings (policy notes outpatient setting requirement).

Submission methodsProviders should submit requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or the phone numbers listed for specific service types.

Prior authorization threshold for orthotics/prosthetics

Orthotics/prosthetics thresholdPrior authorization required for orthotics/prosthetics when retail purchase or cumulative rental cost exceeds $500.

Example L-codesNumerous L-codes are listed throughout the orthotics/prosthetics and joint replacement sections (e.g., L0462, L0480, L7181, L8040, L8612).

Policy placementOrthotics/prosthetics authorizations are referenced in joint replacement and specialized device sections—see orthotics/prosthetics and joint replacement fragments.

Diagnosis code ranges referenced (examples)

Diagnosis code ranges (examples)Document references ranges such as C34.00–C34.92 and partial entries beginning with C50.011; other repeated ICD-10 codes include C44.01, C44.02, C44.09, C44.101.

Use in policyThese ICD-10 ranges and specific codes are used across code listings to inform reconstructive vs cosmetic determinations and prior authorization guidance.

Location in sourceSee Standard Radiation Therapy and code listing fragments where ranges and repeated ICD-10 codes appear (chunks 211, 90, 108, 136).

Musculoskeletal mapping note

Musculoskeletal mapping noteSeveral CPT codes have mapped equivalents or indexed associations (e.g., 20552→20553/21012/21013; 21336→21554/21555/21556), indicating mapped relationships in musculoskeletal mappings.

Practical useThese mappings link related CPT codes and may guide authorization reviewers to alternate or related procedure codes when evaluating requests.

Source fragmentMusculoskeletal mappings/associations are listed in the Musculoskeletal System section showing grouped code mappings (chunk 232).

Injectable medications requiring prior authorization

Certain colony‑stimulating factor and bone‑modifying agents administered outpatient for cancer (and for some codes, also non‑oncology diagnoses) require prior authorization.

Codes requiring prior authorization include J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5125, J1449, Q5110, Q5125, Q5101, J2506, Q5122, Q5120, Q5111, J5108, J2820, J1447, J1448, J0885, J0897.

Prior Authorization

Cardiology and cardiovascular procedures — PA requirements

Prior authorization is required for many outpatient cardiology and cardiovascular procedures prior to performance. This includes outpatient/office diagnostic catheterizations, echocardiograms, electrophysiology implants, stress echoes, and lower extremity angiograms.

Prior Authorization

Chemotherapy prior authorization for outpatient injectable chemo

Prior authorization required for outpatient administration of injectable chemotherapy agents. Submit prior authorization for outpatient injectable chemotherapy drugs prior to administration.

Injectable chemotherapy drugs administered in an outpatient setting require prior authorization.

Prior Authorization

Seizure monitoring prior authorization (inpatient)

Prior authorization required for inpatient seizure monitoring services. Submit authorization requests for inpatient continuous or extended EEG monitoring prior to admission.

CPT codes commonly associated with seizure monitoring: 95700, 95711, 95714, 95715, 95718, 95724, 95726 (inpatient monitoring — prior authorization required).

Prior Authorization

Cochlear and auditory implants prior authorization

Prior authorization required for cochlear and other auditory implant procedures. Include relevant CPT/HCPCS codes when requesting authorization.

Codes: 69710, 69714, 69930, L8614.

Prior Authorization

Continuous glucose monitor prior authorization (Type 2 Diabetes)

Continuous glucose monitors require prior authorization when the diagnosis is Type 2 Diabetes. Include the appropriate HCPCS when requesting authorization.

Continuous glucose monitor HCPCS: A4226, A4239, A9276*, A9277*. Prior authorization required with a Type 2 Diabetes diagnosis.

Documentation Required

CPT/HCPCS codes for reconstructive/cosmetic classification

CPT/HCPCS and ICD‑10 codes inform reconstructive versus cosmetic determinations. Reconstructive procedures are those that treat a medical condition or improve/restore physiologic function; cosmetic procedures are to change or improve appearance without significant physiological benefit. Q2026 is referenced for some reconstructive/cosmetic code mappings.

Reconstructive example HCPCS/CPT: Q2026 may be used in reconstructive contexts.
Cosmetic vs reconstructive determination relies on associated ICD‑10 diagnosis codes and supporting documentation demonstrating physiologic dysfunction or medical necessity.

Documentation Required

Diagnosis codes informing reconstructive vs cosmetic determination

Diagnosis codes are used to inform whether a procedure is classified as reconstructive (medically necessary) versus cosmetic (not medically necessary). When submitting prior authorization include the ICD‑10 codes that justify reconstructive intent or show medical necessity.

Examples of ICD‑10 codes used in reconstructive determinations include C43.112, C43.21 and extensive C44/C43 series codes listed throughout the policy — ensure the diagnosis supports improving/restoring physiologic function.
Cosmetic classification example ICD‑10 codes are provided where absence of physiologic impairment indicates cosmetic intent; include documentation if physiologic benefit exists.

Note

CPT/HCPCS and ICD-10 code listings (partial)

This policy includes numerous CPT/HCPCS and ICD‑10 code listings used for prior authorization processing. Provide the specific CPT/HCPCS and ICD‑10 codes on the authorization request and include requested clinical documentation.

Provide diagnosis (ICD‑10) and procedure (CPT/HCPCS) codes on all requests; many codes for skin, oncology, DME, enteral, genetic testing, and more are enumerated in the policy (see full code lists).
Unclassified/temporary drug codes (C9399, J3490, J3590) require prior authorization for specific therapies — submit with diagnosis and drug name.

Documentation Required

ICD-10 code entries with prior authorization guidance

The policy contains multiple ICD‑10 entries with prior authorization guidance across oncology, dermatology, and other body systems. When a listed ICD‑10 code is present, include it on the request to expedite determination.

Large series of C43/C44/C4A/Dxx codes are referenced — these are used for differentiating reconstructive versus cosmetic and determining prior authorization requirements for related procedures.
When codes indicate oncology or complex medical conditions, submit supporting pathology, imaging, or consult notes as applicable.

Prior Authorization

Enteral services prior authorization

Enteral services and in‑home nutritional therapy require prior authorization. Submit requests with the specific HCPCS codes and clinical justification for enteral feeding or gastrostomy feeding therapy.

Enteral HCPCS codes requiring prior authorization: B4034, B4035, B4036, B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4155, B4158, B4159, B4160, B4161.
In‑home nutritional therapy HCPCS: B4102, B4103, B4104, B4149. Include documentation of nutritional assessment and indication.

Prior Authorization

Surgical procedures prior authorization (FAI, FESS, gender dysphoria)

Select surgical procedures require prior authorization, including femoroacetabular impingement (FAI) procedures, functional endoscopic sinus surgery (FESS), and gender dysphoria treatments. Provide procedure codes and clinical documentation to support medical necessity.

FAI CPTs: 29914, 29915, 29916 (prior authorization required).
FESS CPTs: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288 (prior authorization required).
Gender dysphoria treatment CPTs: 55970, 55980 (prior authorization required).

Prior Authorization

OptumRx prior notification for specific injectables (Cimzia, Synagis)

For certain specialty injectables (for example, Cimzia and Synagis) OptumRx requires prior notification. Follow OptumRx procedures for these agents in addition to UnitedHealthcare authorization requirements.

OptumRx prior notification phone: 800-310-6826 — required for Cimzia and Synagis.
For other specialty injectables, submit requests online via the UnitedHealthcare Provider Portal or call 888-397-8129 as noted in the injectable medications section.

Prior Authorization

Sleep studies prior authorization

Sleep studies require prior authorization. Include the applicable CPT codes and clinical rationale for diagnostic polysomnography or home sleep testing when requesting authorization.

Sleep study CPTs: 95805, 95807, 95808, 95810 (prior authorization required).
Many sleep apnea procedures and devices (including maxillomandibular advancement and implantation procedures) also require prior authorization — include diagnostic sleep study results when applicable.

Prior Authorization

Transplant / CAR T-Cell notification requirement

Transplant and CAR T‑Cell therapy services require notification and prior authorization. Contact the UnitedHealthcare Community and State Transplant Case Management Team for all transplant and CAR T‑Cell therapy requests.

For transplant and CAR T‑Cell therapy services (including Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta), call the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246.
Also follow the notification process indicated in the policy and include procedure, diagnosis, and facility details when requesting authorization.

Prior Authorization

Transplant/CAR T-Cell prior authorization contact (888-936-7246)

For transplant and CAR T‑Cell therapy prior authorization and case management, contact the UnitedHealthcare Community and State Transplant Case Management Team.

Transplant/CAR T‑Cell prior authorization contact: UnitedHealthcare Community and State Transplant Case Management Team — 888-936-7246.

Prior Authorization

Vein procedures prior authorization

Vein procedures for treatment of venous disease require prior authorization. Include procedural CPT codes and clinical documentation for venous insufficiency or other indications.

Vein procedure CPTs: 36473, 36475, 36478, 37700, 37718, 37722, 37765, 37766 (prior authorization required).

Prior authorization is required for cochlear and other auditory implants (see cochlear implant section).

Source wordingSource describes the device as 'a medical device within the inner ear with an external portion to help persons with profound sensorineural deafness achieve conversational'.

Cochlear implant / inner ear device (descriptive)

Descriptive phraseInner ear device description: 'A medical device within the inner ear with an external portion to help persons with profound sensorineural deafness achieve conversational' (policy text fragment).

Associated codesHCPCS examples listed include L8619, L8690, L8691, L8692 in the cochlear implant fragment.

ContextUsed in the cochlear implant section to define the device type for prior authorization requirements.

CGM (definition)

DefinitionCGM: Continuous Glucose Monitor — device entries are listed under 'Continuous glucose monitor' with prior authorization rules tied to Type 2 Diabetes diagnosis.

Example HCPCS codesA4226, A4239, A9276, A9277 appear in the CGM section of the document.

Policy noteThe policy explicitly states: 'Prior authorization required with Type 2 Diabetes Diagnosis.' for CGM items.

Reconstructive vs Cosmetic definition

Reconstructive definitionReconstructive: procedures that treat a medical condition or improve or restore physiologic function.

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

ApplicationThis distinction is used to classify CPT/HCPCS and ICD-10 entries for coverage and prior authorization determinations.

Improve or restore physiologic function phrase

Phrase'Improve or restore physiologic function' — used repeatedly in the policy to indicate clinical intent tied to reconstructive procedure classification.

PurposeSignals procedures likely considered medically necessary when the primary intent is functional improvement or restoration.

Associated codesMultiple CPT/HCPCS/ICD-10 codes are tied to this phrase in reconstructive code groupings (see reconstructive code fragments).

reconstructive vs. cosmetic (duplicate definition fragment)

Distinction restatedReconstructive vs. cosmetic: distinction emphasized — reconstructive treats a medical condition or improves/restores physiologic function; cosmetic focuses on appearance without functional improvement.

Document fragmentsMultiple repeated fragments reiterate this policy distinction across code lists and examples.

Reviewer noteUsed consistently to inform coverage classification within the policy's code tables.

(empty/placeholder definition fragment)

Placeholder fragmentSection contains empty or placeholder definition fragments (no term provided).

ImplicationSome definition slots in the document are blank or incomplete and should not be treated as authoritative definitions.

LocationSee CPT/HCPCS code listing fragments with blank term/definition fields (chunk 90).

(empty/placeholder definition fragment)

Placeholder fragmentAdditional empty/placeholder definition fragment in code table region; no explicit definition text present.

Source noteAppears among CPT/HCPCS listing fragments with unfinished entries (chunk 108).

Reviewer actionTreat as incomplete — consult other sections for definitions and code intent.

DME prior authorization threshold (definition)

DefinitionDME prior authorization threshold: Prior authorization required only for DME codes listed with a retail more than $500.

ExamplesPolicy lists DME HCPCS examples such as A9279, A9280, A9900 and E-series codes (E0194, E0265, E0266, E0270, E0277, E0300, E0328).

How appliedApplies only to DME entries explicitly flagged in the DME section — not a blanket requirement for all DME.

Cosmetic and reconstructive category label note

Category label'Cosmetic and reconstructive' is used as a category heading in code listings to group procedures/diagnoses for review under the reconstructive vs cosmetic distinction.

Use in tablesThis label appears adjacent to ICD-10 entries and CPT/HCPCS groupings to indicate the classification context for those codes.

Reviewer noteCodes under this label should be evaluated using the reconstructive vs cosmetic definitions in the policy.

DME prior authorization threshold (duplicate)

Duplicate DME thresholdDurable medical equipment (DME) codes listed with a retail more than $500 require prior authorization (duplicate entry confirming threshold).

ExamplesSee HCPCS examples A9279, A9280 and E-series codes in the DME section.

ClarificationThis duplicate reinforces that the retail > $500 threshold is the deciding criterion for DME prior authorization within this policy.

Genetic/molecular testing prior auth definition

DefinitionGenetic/molecular testing prior auth: Genetic and molecular testing (including BRCA) performed in an outpatient setting requires prior authorization/notification and completion of laboratory/test information as part of the process.

Example codesExample CPT codes listed include 81162, 81163, 81164, 81228, 81229, 81349 and 81400–81410 series.

Provider responsibilityHealth care professionals requesting laboratory testing must complete the prior authorization/notification process and indicate the laboratory and test.

Prior authorization/notification process (term)

Process termPrior authorization/notification: the policy requires providers to submit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or designated phone numbers; specific services may require prior notification prior to scheduling.

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

Phone contactsPrimary phone for prior authorization: 855-766-0344; other sections list additional numbers for specific services (e.g., radiology, drugs).

Review at Launch for New to Market Medications policy (term: Pre-determination)

Pre-determination termReview at Launch for New to Market Medications policy term: 'Pre-determination' — recommended for drugs on the Review at Launch Medication List.

ActionPolicy advises pre-determination and references the Review at Launch Medication List for newly approved FDA drugs.

SubmissionRequests for new-to-market drugs should be submitted online via the UnitedHealthcare Provider Portal or via the phone number provided in the drug section (888-397-8129 noted for some drug submissions).

Orthotics and prosthetics (term entry)

TermOrthotics and prosthetics: items and codes listed under orthotics/prosthetics require prior authorization as noted; specific L-codes are enumerated in the orthotics/prosthetics sections.

ExamplesExample L-codes shown across sections include L7181, L7185, L7190, L8040, L8612 and many others in joint replacement fragments.

Threshold linkageOrthotics/prosthetics items may also be subject to the retail/rental > $500 prior authorization threshold.

Proton Beam (definition)

DefinitionProton Beam: focused radiation therapy that uses beams of protons (policy defines the modality and lists related CPT codes).

Associated codesPolicy lists related CPT codes (e.g., 77520→77522, 77523, 77525 and other associated planning/therapy codes) in the Proton Beam section.

ContextIncluded under radiation therapy procedure listings and prior authorization code groupings.

Site of service / Prior Authorization note (term)

Term noteSite of service / Prior Authorization: policy specifies site-of-service rules — prior authorization is required when service is performed in an outpatient hospital (SOS), and not required if performed at a participating ASC.

ApplicationThis rule is applied across multiple procedure groups when the site of service influences the authorization requirement.

Provider actionProviders ordering advanced outpatient imaging or other procedures must notify prior to scheduling and submit requests per the portal or phone instructions.

Transplants / CAR T-Cell therapy (term)

TermTransplants / CAR T-Cell therapy: transplant and CAR T-Cell therapy services require contacting the UnitedHealthcare Community and State Transplant Case Management Team for prior authorization/notification and coordination.

Contact infoCall the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 for transplant and CAR T-Cell therapy services.

ExamplesCAR T-Cell therapies listed in the policy include Abecma, Breyanzi, Carvykti, Kymriah, Tecartus and Yescarta among others referenced in the transplant/CAR T fragments.

CAR T-Cell Therapy (term entry)

CAR T-Cell Therapy termCAR T-Cell Therapy: policy groups CAR T-Cell therapy under transplant-related services and requires notification/prior authorization and case management contact.

Associated codes/labelsCAR T-Cell Therapy entries reference Q- and E-series codes and label 'CAR T-Cell Therapy' in related device/implant fragments.

Coordination requirementProviders must contact the Transplant Case Management Team (888-936-7246) to initiate authorization/coordination for CAR T therapies.