CurrentUnitedHealthcarePolicy N/A

Prior Authorization Requirements for Rhode Island Medicaid

Lists prior authorization requirements and instructions for participating UnitedHealthcare Community Plan of Rhode Island providers for inpatient and outpatient services; includes methods to submit requests and examples of services and CPT/HCPCS codes that require prior authorization.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Requirements for Rhode Island Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone at 855-766-0344.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

UHCprovider.comonline portal

855-766-0344phone (PA)

J9000-J9999injectable chemo

Numerouscosmetic/reconstructive

ASCASC exemption

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C9399/J3490unclassified codes

Services and Codes Requiring Prior Authorization

COVERAGE CRITERIA: Coverage criteria and prior authorization requirements

The policy lists services and CPT/HCPCS/J/Q codes that require prior authorization for Rhode Island Medicaid participating providers; some diagnosis codes for lower extremity angiograms are exempt as noted.

Adult day services (S5102) — prior authorization required.

Bariatric surgery (43644, 43645, 43659, 43770) — prior authorization required.

Breast reconstruction (non-mastectomy) (19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19368-19371) — prior authorization required.

Injectable colony-stimulating factors and related agents (examples: J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125, J1449, J2820) — prior authorization required; some codes also require prior authorization for non‑oncology diagnoses (see injectable medications section).

Lower extremity angiogram and related CPTs (37221-37231 and related sequences) — prior authorization required except for specified diagnosis codes listed in the policy (no prior authorization required for listed diagnosis codes).

COVERAGE CRITERIA: Prior authorization criteria (selected)

Prior authorization criteria and routing for selected services, devices and drugs:

Inpatient video EEG: prior authorization required for inpatient services; not required for outpatient hospital or ambulatory surgical center.

Injectable chemotherapy drugs administered in an outpatient setting for a cancer diagnosis (including J9000-J9999 and related J/Q codes such as leucovorin and leuprolide entries) — prior authorization required; submit requests via UnitedHealthcare Provider Portal or by phone as directed.

Cochlear and other auditory implants (example L8614 and related L86xx codes and CPTs 69710, 69714, 69930) — prior authorization required.

Continuous glucose monitoring devices (examples: A4226, A9278, A4239, A9276, A9277, E2102, E0787) — prior authorization required when clinically indicated (Type 2 Diabetes diagnostic routing noted).

Operational instruction: Submit prior authorization requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) or call the phone number provided for the specific request type (injectable chemotherapy routing noted in policy).

COVERAGE CRITERIA: Prior authorization requirement

Codes and procedures in the lists are associated with a requirement for prior authorization.

Cosmetic and reconstructive procedures and associated diagnosis/CPT/HCPCS codes (examples in document: C43.59, C43.70, C43.9, C44.01, C44.02; CPT examples 14021, 15822, 15877) — prior authorization required for listed items.

COVERAGE CRITERIA: Prior authorization requirement (partial)

Prior authorization required for injectable chemotherapy drugs referenced by internal C44.* identifiers; CPT or HCPCS billing codes are referenced in the policy but not fully enumerated in this excerpt.

Injectable chemotherapy drugs identified by internal C44.* prior authorization codes (e.g., C44.1992, C44.201, C44.202, C44.209, C44.211, C44.212, C44.219, C44.221, C44.222) — prior authorization required; consult policy for associated billing code cross‑references and submission instructions.

COVERAGE CRITERIA: Prior authorization requirement

Injectable chemotherapy drugs listed by internal prior authorization code require prior authorization.

The internal authorization entries repeated in the policy (for example C44.1992, C44.201, C44.202, C44.209, C44.211, C44.1921, C44.1922, C44.219, C44.221) each denote injectable chemotherapy drugs that require prior authorization; map to CPT/HCPCS per the full policy.

COVERAGE CRITERIA: Prior authorization code list

List of internal authorization entries associated with injectable chemotherapy drugs that require prior authorization (excerpt shows repeated internal identifiers).

Internal prior authorization identifier C44.211 and related entries (C44.201, C44.202, C44.209, C44.212) are repeatedly referenced in the policy to indicate prior authorization is required for the associated injectable chemotherapy drugs.

COVERAGE CRITERIA: Prior authorization criteria (enumeration only)

Items and services enumerated in this section require prior authorization as indicated.

Durable medical equipment (DME) codes listed (examples: A9279, A9280, A9900, E-series and K-series entries) — prior authorization required; DME retail items with retail price more than $500 require prior authorization.

Enteral services and in‑home nutritional therapy (examples: B4034, B4035, B4036, B4100, B4102-B4161, B9002, B9998) — prior authorization required.

Specified surgical procedure groups (examples: femoroacetabular impingement codes 29914-29916; functional endoscopic sinus surgery 31240, 31253-31288; listed reconstructive/cosmetic procedure codes) — prior authorization required.

Gender dysphoria treatments and associated surgical codes (example: 55970 and linked diagnosis codes) — prior authorization required.

Note

COVERAGE CRITERIA: Prior authorization requirements

Prior authorization/notification requirements and submission instructions for injectable medications and genetic/molecular tests performed in outpatient settings:

Prior authorization required for many injectable medications; submit requests online using the UnitedHealthcare Provider Portal (UHCprovider.com) or by calling the designated phone number for injectable requests as noted in the policy.

Genetic and molecular testing (including BRCA testing) performed in an outpatient setting requires prior authorization/notification; ordering providers and laboratories must follow the notification and prior authorization process described in the policy.

COVERAGE CRITERIA: Partial coverage and authorization criteria for injectable medications

Prior authorization and notification criteria and rules (partial):

Post-acute inpatient services notification: Notification with service detail is required and prior authorization/notification of the 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).

Unclassified/temporary HCPCS codes: For drugs billed under unclassified/temporary codes C9399, J3490 and J3590, prior authorization is required for specified new‑to‑market medications (examples listed in policy).

ESRD exclusion: Prior authorization is not required for ESRD diagnosis as noted in the policy.

Colony-stimulating factors: White blood cell colony stimulating factor codes (J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122) require prior authorization for both oncology and non‑oncology diagnoses; oncology Dx handled under cancer supportive care section; for non‑oncology Dx submit online via UHCProvider.com or contact 24/7 per policy instructions.

COVERAGE CRITERIA: Authorization and Notification Criteria

Prior authorization requirements and site-of-service exceptions:

Orthotics/Prosthetics threshold: Prior authorization required for orthotics and prosthetic codes listed when retail purchase or cumulative rental cost exceeds $500 (examples: L0112, L0170, L0462, L0638, etc.).

Potentially unproven services listed in the policy (examples: CPT 33289, HCPCS C2624) require prior authorization.

Advanced outpatient imaging (certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology) requires prior authorization; care providers must notify prior to scheduling and submit requests via UnitedHealthcare Provider Portal or call the number provided (866-889-8054).

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

COVERAGE CRITERIA: Outpatient hospital prior authorization requirement

Procedures and CPT/HCPCS codes listed in the policy require prior authorization when performed in an outpatient hospital setting; procedures performed at a participating ASC do not require prior authorization.

Sleep apnea procedures and sleep studies (examples: 21685, 41599, 42145, 95805, 95807, 95808, 95810) — prior authorization required when performed in an outpatient hospital setting; ASC exemption applies when performed at a participating ASC.

Spinal surgery (extensive list of spinal CPT codes such as 22100-22633, 22800-22899) — prior authorization required when performed in outpatient hospital setting; ASC exemption applies when performed at a participating ASC.

Shoulder surgery and related musculoskeletal procedures (examples listed in policy) — prior authorization required when performed in an outpatient hospital setting; ASC exemption applies when performed at a participating ASC.

COVERAGE CRITERIA: Prior authorization notes

Assorted prior authorization requirement notes (partial):

Neurostimulator and related device implantations (examples: L8680-L8688, E0749, E0760; CPT examples in policy) — prior authorization required.

Transplants and CAR T‑Cell therapies (specific products listed) — prior authorization/notification required; contact UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or the number on the member ID card for these services.

Vein procedures and ablation/removal codes (examples: 36473, 36475, 36478, 37700-37780) — listed with prior authorization context in the policy.

CPT / HCPCS / ICD-10 Code Lists and Examples

Selected injectable HCPCS/J-codes (representative, prior authorization required)HCPCSCovered

J0257	Injection, aflibercept, 1 mg
J1411	Injection, insulin glargine and lixisenatide, per 1 unit (combination product)
J0638	Injection, zoster vaccine, recombinant, 0.5 mg
J3245	Injection, bivalirudin, 1 mg
Q5103	Biosimilar, pegfilgrastim-apgf (Nyvepria) — Q-code
J1439	Injection, ferric carboxymaltose, 1 mg
J1449	Eflapegrastim-xnst (Rolvedon)
J1442	Filgrastim (Neupogen)
J2506	Pegfilgrastim (Neulasta)
J0885	Erythropoiesis-stimulating agent (Procrit)

ICD-10 Cross-reference mappings (representative entries)ICD-10

C44.211	Squamous cell carcinoma of skin, nose
C44.212	Squamous cell carcinoma of skin, eyelid
C44.219	Squamous cell carcinoma of skin, unspecified site
E08.52	Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy
M86.051	Acute osteomyelitis of right shoulder

Chemotherapy and related HCPCS/J-codes (examples)HCPCSCovered

J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin, per unit
J1950	Leuprolide acetate (Lupron Depot)
J1932	Lanreotide

Cosmetic / Reconstructive CPT codes (representative)CPTNot Covered

11960	Subcutaneous injection, for cosmetic purposes (example)
14021	Adjacent tissue transfer, trunk, arms, legs; 30 sq cm or less
15822	Excision, excessive skin and subcutaneous tissue (example)
17106	Destruction of benign lesions (example)
21137	Reconstruction of maxillofacial area (example)

Representative CPT codes — examplesCPT

37226	Transcatheter therapy, peripheral
67903	Reconstruction, eyelid (example)
30410	Rhinoplasty, primary
22100	Spinal surgery, decompression
95805	Polysomnography; attended

Representative diagnosis / HCPCS codes (selected)mixed

C43.59	Melanoma of other part of face
C44.01	Basal cell carcinoma of skin of lip
C44.211	Squamous cell carcinoma of skin, nose
C44.222	Squamous cell carcinoma of skin, unspecified site

Internal prior authorization codes (partial list)mixed

PA-J1449	Prior authorization entry for J1449 (Rolvedon)
PA-J1411	Prior authorization entry for J1411
PA-Q5103	Prior authorization entry for Q5103 (biosimilar)

Frequently listed HCPCS / ICD codesmixed

J1442	Filgrastim (Neupogen) — commonly listed WBC colony stimulating factor
J2506	Pegfilgrastim (Neulasta) — commonly listed
C44.211	Frequently referenced diagnosis in cosmetic/reconstructive section

Selected specialty injectable medications (additional examples)HCPCSCovered

J0257	Injection, aflibercept, 1 mg
J1411	Injection, insulin glargine and lixisenatide, per 1 unit (combination product)
J0638	Injection, zoster vaccine, recombinant, 0.5 mg
J3245	Injection, bivalirudin, 1 mg
J1439	Injection, ferric carboxymaltose, 1 mg
Q5103	Biosimilar Q-code (pegfilgrastim biosimilar)

Sample CPT codes requiring review (digestive / ENT examples)CPT

43237	Esophagogastroduodenoscopy with biopsy, single or multiple
44361	Colonoscopy with extensive procedure
46221	Hemorrhoidectomy
45381	Colonoscopy, diagnostic

Additional sample codes (endoscopy / sleep / spine)CPT

95807	Sleep study, attended polysomnography
22101	Spinal surgery, revision or complex
63650	Placement of neurostimulator leads, spinal

How to Obtain Prior Authorization & Provider Instructions

Prior Authorization

How to Obtain Prior Authorization

Prior authorization is required for many services and must be obtained before performing non-emergent care. Submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal at UHCprovider.com (sign in with One Healthcare ID). If you need assistance by phone: call 855-766-0344 for general prior authorization requests. For certain injectable medication requests use the numbers shown in the specific medication callout guidance (e.g., 888-397-8129 or 866-889-8054 where noted). Prior authorization is not required for emergency or urgent care. Out-of-network providers must request prior authorization for all procedures and services.

Online: Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) — sign in with One Healthcare ID
Phone: Call 855-766-0344
Prior authorization not required for emergency or urgent care
Out-of-network providers must request prior authorization for all services

Prior Authorization

Examples of Services Requiring Prior Authorization

Examples of services that require prior authorization include (but are not limited to) the following categories. Providers should verify member-specific benefits and follow the submission instructions for each category.

Terms, Thresholds and Scope Notes

Emergency / urgent care

Emergency / Urgent carePrior authorization is not required for emergency or urgent care.

Where statedSee General Information submission instructions for portal and phone contact details.

Provider implicationDo not delay emergency or urgent treatment to obtain prior authorization.

Out-of-network providers

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

Submission channelsUse the Prior Authorization and Notification tool on UHCprovider.com or call the phone number(s) provided.

Document Revision Timeline

2025-04-01policy_effectiveLatest

Policy effective date for UnitedHealthcare Community Plan of Rhode Island prior authorization requirements.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Requirements for Rhode Island Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone at 855-766-0344.

SourceLink

On This Page

The document fragment lists numerous internal C44/C4A/D04/C79 series entries and many HCPCS/CPT codes; full mapping and coverage criteria are contained in other parts of the policy.

Adult day services (e.g., S5102) — prior authorization required
Bariatric surgery (e.g., 43644, 43645, 43659, 43770, 43775, 43842, 43845, 43846) — prior authorization required
Behavioral health: routine outpatient services generally do not require prior authorization; other behavioral health services may require authorization — call number on member ID card for specifics
Cardiology: outpatient/office-based diagnostic catheterizations, echocardiograms, electrophysiology implants and stress echoes — prior authorization required
Cerebral seizure monitoring: inpatient video EEG — prior authorization required for inpatient services (not required for outpatient or ASC)
Chemotherapy: injectable chemotherapy drugs administered in an outpatient setting (IV, intravesical, intrathecal) for cancer diagnosis — prior authorization required
Durable medical equipment (selected DME codes and items with retail or cumulative cost > $500) — prior authorization required
Enteral services and in-home nutritional therapy (selected B-codes) — prior authorization required
Femoroacetabular impingement (FAI) surgical procedures (e.g., 29914–29916) — prior authorization required
Gender dysphoria services — prior authorization required
Genetic and molecular testing (including BRCA) performed in outpatient settings — prior authorization/notification required
Home health care (outpatient) — prior authorization required in outpatient settings
Hospice — prior authorization required
Orthotics and prosthetics (selected L-codes) when retail purchase or cumulative rental cost > $500 — prior authorization required
Potentially unproven services (e.g., 33289, C2624) — prior authorization required
Private duty nursing (T1000) — prior authorization required
Prostate procedures (e.g., 37243, 52441, 52442, 53850) — prior authorization required
Radiology: advanced outpatient imaging (selected CT, MRI, MRA, PET and nuclear studies) — prior authorization/notification required
Radiation therapy (including proton beam, SRS/SBRT, IGRT, and certain standard RT codes) — prior authorization required (details and Dx-based exceptions noted below)
Spinal surgery (e.g., 22100–22110) — prior authorization required
Sleep studies and sleep apnea procedures (selected codes) — prior authorization required
Transplants and CAR T-cell therapies — prior authorization required (see transplant case management contact information)

Prior Authorization

Injectable Medications Prior Authorization

Certain injectable medications and supportive care agents require prior authorization. Submit these requests online via the UnitedHealthcare Provider Portal or by the phone numbers listed for specific drug groups. Note: white blood cell colony stimulating factors (listed below) require prior authorization for both oncology and non-oncology diagnoses; for oncology diagnoses see the cancer supportive care section.

Colony-stimulating factors (prior authorization required): Eflapegrastim-xnst (Rolvedon) J1449; Filgrastim (Neupogen) J1442; Filgrastim biosimilars Q5101, Q5110, Q5120, Q5122, Q5125; Pegfilgrastim J2506 and biosimilars Q5108, Q5111; Tbo-filgrastim J1447; Sargramostim J2820; Trilaciclib J1448. (For oncology Dx see cancer supportive care guidance.)
Injectable erythropoiesis-stimulating agents: J0885 (Procrit) — prior authorization required
Bone-modifying agent: Denosumab (Xgeva) J0897 — prior authorization required
Antiemetic agents requiring prior authorization: J0185, J1453, J1454, J1627, J1456
Some colony-stimulating factor codes (J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122) require prior authorization for non-oncology indications; oncology indications are handled under cancer supportive care
For submission options: use the UnitedHealthcare Provider Portal at UHCprovider.com or call the applicable phone lines (examples in medication-specific guidance: 888-397-8129; 866-889-8054)

Prior Authorization

Injectable Chemotherapy Prior Authorization

Selected chemotherapy injectable drugs require prior authorization when administered in outpatient settings. This includes miscellaneous, Q-coded, and J9000–J9999 range chemotherapeutic agents, as well as specific supportive oncology injectables. Submit requests via the UnitedHealthcare Provider Portal or by phone as directed.

Chemotherapy injectable drugs billed under J9000–J9999 — prior authorization required
Leucovorin (J0640), Levoleucovorin (J0641, J0642) — prior authorization required
Lupron Depot (J1950), Leuprolide acetate (J1954) — prior authorization required
Lanreotide (J1932) — prior authorization required
Chemotherapy injectable drugs with Q-codes and miscellaneous HCPCS (unassigned code billed under miscellaneous HCPCS) — prior authorization required
Submission: UnitedHealthcare Provider Portal (UHCprovider.com) or call 888-397-8129

Prior Authorization

Cosmetic and Reconstructive Procedures Requiring Prior Authorization

Many cosmetic and reconstructive procedures require prior authorization. Cosmetic procedures are those intended to change or improve physical appearance. Reconstructive procedures may also require authorization depending on diagnosis and procedure codes. Below are representative CPT/HCPCS and ICD-10 groups flagged for prior authorization — providers must confirm code-specific requirements prior to scheduling.

Breast reconstruction procedures (selected CPTs) — examples: 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19368–19371 — prior authorization required
Cosmetic and reconstructive CPTs (selected examples): 11960, 14020, 14021, 14061, 15820–15823, 15877–15879, 17106–17108, 21138–21299 (selected codes) — prior authorization required
Ophthalmic/eyelid and periocular codes (examples): 21740, 30620, 67903, 67909, 67950 — prior authorization required
Facial and soft-tissue reconstructive codes (examples): 21230, 21280, 21742, 67900, 67904, 67911, 67916, 67923, 67966 — prior authorization required
Many procedures tied to skin cancer or lesion excision have associated ICD-10 codes (C43.*, C44.*) that trigger prior authorization — confirm code-specific instructions

Prior Authorization

Additional Cosmetic / Reconstructive Codes

Additional cosmetic/reconstructive and diagnosis code groups flagged for prior authorization include numerous C43 (melanoma) and C44 (other skin cancer) series codes and specific ranges of cosmetic procedure codes. Authorization is required when procedures are billed with these diagnosis codes or the listed CPT/HCPCS codes.

C43-series examples referenced (selected): C43.10, C43.111, C43.122, C43.20, C43.30, C43.31, C43.39, C43.51, C43.52, C43.59, C43.61, C43.62, C43.70, C43.71, C43.72 — prior authorization required
C44-series examples referenced (selected): C44.01, C44.02, C44.09, C44.101, C44.1021, C44.1091, C44.1092, C44.111, C44.1121, C44.1191, C44.1192, C44.121, C44.1221, C44.1291, C44.1292, C44.131 — prior authorization required
When cosmetic procedures are performed that change or improve physical appearance without significant functional impairment (cosmetic-only indications), the C44.* diagnosis groupings called out should prompt prior authorization review

Prior Authorization

C44-Series Codes Requiring Prior Authorization

C44-series diagnosis codes (extensive ranges and individual codes) are repeatedly listed as triggers for prior authorization for associated procedures. Providers should confirm the specific C44 code used and obtain prior authorization when indicated.

Examples of frequently referenced C44 codes requiring prior authorization when associated with procedures: C44.101, C44.1021, C44.1091, C44.1092, C44.111, C44.1121, C44.1191, C44.1192, C44.121, C44.1221, C44.1291, C44.1292, C44.131, C44.1992, C44.201–C44.222 (selected subcodes) — prior authorization required
Many entries repeat C44.211, C44.212, C44.219, C44.221, C44.222 among other subcodes — verify exact code-level requirements prior to scheduling

Prior Authorization

Advanced C44-Series Authorization Codes

Later/advanced C44-series diagnosis code blocks are also specifically flagged across the source listing as requiring prior authorization for associated procedures. Confirm the precise subcode and follow the standard portal/phone submission process.

Advanced C44 entries cited repeatedly as prior authorization triggers: C44.201, C44.202, C44.209, C44.211, C44.212, C44.219, C44.221, C44.222 — prior authorization required
Multiple repeats of C44.211–C44.222 in the source indicate heightened need to verify authorization when these diagnosis codes are present

Prior Authorization

How to Obtain Prior Authorization (partial list)

Partial list: the policy source includes many specific CPT/HCPCS and ICD-10 codes throughout the cosmetic/reconstructive, injectable medication and chemotherapy sections that require prior authorization. Below are representative entries consolidated for operational use — always verify member-specific plan coverage and the final code billed.

Representative CPT/HCPCS codes requiring prior authorization in the cosmetic/reconstructive group: 11960, 14020, 14021, 14061, 15820–15823, 15877–15879, 17106–17108, 21138, 21230, 21280, 21740, 21742, 30620, 67900–67966 (selected codes) — prior authorization required
Representative ICD-10 diagnosis codes that trigger authorization review: C43.* and C44.* series codes (see detailed lists above)
Representative injectable medication/J-code groups: J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, J1449, J2820, J2506, J0885, J0897, J0185, J1453, J1454, J1627, J1456 — prior authorization required
Durable medical equipment and orthotics/prosthetics with specific HCPCS L-/E-/A- codes and cost thresholds (e.g., retail or cumulative rental > $500) — prior authorization required

Prior Authorization

Injectable Chemotherapy Drugs Requiring Prior Authorization & Other Selected Provider Actions

Private duty nursing and prostate procedures are among the non-pharmacy services specifically called out as requiring prior authorization. Radiation therapy services (including advanced modalities) require authorization with certain diagnosis-based exceptions.

Private Duty Nursing: T1000 — prior authorization required
Prostate Procedures: example CPTs 37243, 52441, 52442, 53850 — prior authorization required
Radiation Therapy: IGRT (77014, G6017), SRS/SBRT (77371, 77372, G0339), Proton beam therapy (77520, 77522, 77523, 77525), Special/Associated Services (77331, 77370, 77399, 77470) and Standard Radiation Therapy codes (77401, 77402, 77407, 77412) — prior authorization required. Note: standard RT prior authorization may be limited to services with specific cancer diagnosis ranges (e.g., C34.00–C34.92, C50.011– etc.) as indicated in the policy
Providers ordering advanced outpatient imaging or radiation therapy are responsible for notification/prior authorization prior to scheduling; submit via the Provider Portal or call 866-889-8054 for imaging requests

ApplicabilityRequirement applies to all procedures and services provided by out-of-network entities under this plan.

Chemotherapy injectable drugs (J9000-J9999)

Drug categoryInjectable chemotherapy drugs (J9000-J9999) require prior authorization.

Specific non-range codes listedLeucovorin (J0640), Levoleucovorin (J0641, J0642), Lupron Depot (J1950), Leuprolide Acetate (J1954), Lanreotide (J1932).

Submission instructionRequests for these chemotherapy injectables should be submitted via UHCprovider.com or by calling 888-397-8129.

Continuous glucose monitor prior authorization

Device requiring prior authorizationContinuous glucose monitors require prior authorization when used with a Type 2 Diabetes diagnosis.

Representative HCPCS/A/E codesA4226, A9278, A4239, A9276, A9277, E2102, E0787 (codes listed across the device entries).

ContextCGM entries in the document explicitly state 'Prior authorization required with Type 2 Diabetes Diagnosis.'

Cosmetic procedures (appearance-focused)

DefinitionCosmetic procedures: procedures that change or improve physical appearance; entries note prior authorization for appearance-focused services.

Internal referencesCosmetic entries are annotated with internal identifiers (e.g., C44.1091, C44.1092, C44.111) that tie to prior-authorization routing.

Provider implicationCosmetic/reconstructive codes listed require prior authorization per the document's entries.

C44.* (internal prior authorization code)

What C44.* meansC44.* codes are internal prior-authorization identifiers used throughout the document to indicate how to obtain prior authorization for listed injectable chemotherapy drugs and related entries.

ExamplesExamples include C44.1992, C44.201, C44.202, C44.209, C44.211, C44.221, C44.222 which are repeated as routing identifiers.

Use in documentMany chemotherapy and injectable medication entries reference a C44.xxxx 'How to Obtain Prior Authorization' identifier alongside CPT/HCPCS code references.

C44.xxxx internal prior authorization codes

Nature of codesC44.xxxx values are payer-specific internal prior authorization codes used to track and route requests; the document lists many C44 variants.

Common examplesC44.1921, C44.1992, C44.201, C44.202, C44.209, C44.211, C44.219, C44.221, C44.222.

How referencedC44.xxxx entries frequently accompany CPT/HCPCS or drug code listings and the phrase 'How to Obtain Prior Authorization.'

Injectable chemotherapy drugs that require prior authorization

ScopeInjectable chemotherapy drugs that require prior authorization are enumerated in the document and are associated with internal C44 identifiers.

Representative internal entriesC44.201, C44.202, C44.209, C44.211 are repeatedly referenced for injectable chemotherapy routing.

Submission instructionChemotherapy injectable requests should be submitted online via UHCprovider.com or by phone where specified in the chemotherapy section.

DME prior authorization threshold

DME prior authorization rulePrior authorization is required only for DME codes listed with a retail price of more than $500.

Representative DME codesExamples in the listing include A9279, A9280, A9900 and multiple E- and K-series codes.

Note on prostheticsThe document clarifies that prosthetics are not DME and references orthotics/prosthetics separately with their own threshold rules.

Service-level prior authorization

Service-level examplesEnteral services and certain surgical treatments (e.g., femoroacetabular impingement, FESS, gender dysphoria treatments) require prior authorization.

Representative codesEnteral: B4034, B4035, B4036, B4100 and related B4xx codes; FAI: 29914-29916; FESS: 31240, 31253-31288; Gender dysphoria: 55970 and related entries.

Notification/submissionSubmit prior authorization requests via the UnitedHealthcare Provider Portal or the phone numbers provided in the General Information section.

Genetic and molecular testing prior authorization/notification

Tests requiring prior authorization/notificationGenetic and molecular testing, including BRCA testing performed in outpatient settings, require prior authorization or notification.

Ordering provider responsibilityThe ordering provider must notify the laboratory conducting the test; the laboratory will notify UnitedHealthcare to complete the prior authorization/notification process.

Representative CPT codesExamples include 81162, 81163, 81164, 81228 and broader 81400-series codes listed in the section.

Outpatient / home health / hospice authorization scope

ScopePrior authorization is required in outpatient settings including home health care; hospice services also require prior authorization.

Representative codesHome health: G0299, G0300, G0493-G0496, S9122-S9124, S9474; Hospice: T2042-T2045.

ApplicabilityRequirement applies to outpatient/home health/hospice services per the document segment.

C9399, J3490, J3590 (temporary/unclassified codes) prior authorization

Unclassified / miscellaneous drug codesC9399, J3490, J3590 are used for temporary/unclassified or miscellaneous drugs and require prior authorization for specified products.

ExamplesProducts called out include Casgevy, Lantidra, Nulibry, Revcovi, Rivfloza, Xenpozyme; Tzield uses J3490/J3590 effective 2023-04-01 per the document.

Submission instructionRequests for these codes should be submitted via the UnitedHealthcare Provider Portal or by the chemotherapy-specialty phone number where noted.

Advanced outpatient imaging

DefinitionAdvanced outpatient imaging includes certain CT, MRI, MRA, PET scans and nuclear medicine/nuclear cardiology procedures that require prior authorization.

Provider responsibilityCare providers ordering advanced outpatient imaging must provide notification prior to scheduling and submit requests via the UnitedHealthcare Provider Portal or call 866-889-8054.

ExamplesThe document references CT, MRI, MRA, PET and specific CPT/HCPCS groupings for these modalities.

Proton Beam

DefinitionProton Beam: focused radiation therapy that uses beams of protons; listed CPT codes include 77520, 77522, 77523, 77525.

Authorization statusProton beam therapy and associated radiation therapy services require prior authorization.

Associated servicesSpecial/associated services and SRS/SBRT modalities are also listed and require prior authorization per the radiation therapy section.

SOS (Site of Service)

DefinitionSOS = Site of Service.

ImplicationPrior authorization requirements depend on site of service (e.g., outpatient hospital vs ASC).

Related ruleSee Outpatient Hospital vs ASC rule: prior authorization only required for outpatient hospital setting; not required at participating ASC.

ASC — Ambulatory Surgery Center exemption

ASC exemptionParticipating Ambulatory Surgery Centers (ASCs): procedures listed do not require prior authorization when performed at a participating ASC.

When authorization is requiredPrior authorization is required when the same procedures are requested in an outpatient hospital setting.

Provider actionConfirm site of service; if outpatient hospital, submit prior authorization via UHCprovider.com or the listed phone numbers.

Transplants / CAR T-Cell therapy

ScopeTransplants and CAR T-Cell therapy services require prior authorization/notification and specialized routing.

Contact for routingCall the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or use the notification number on the member's ID card.

Examples of CAR-T products listedMaraluecel, Carvykti, Kymriah, Tecartus, Yescarta (examples listed in the transplants section).