How to Request Prior Authorization

To request prior authorization, please submit your request online or by phone: - Online: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com). Click the UnitedHealthcare Provider Portal button (top right) and select the Prior Authorization and Notification tool on your Provider Portal dashboard. - Phone: 877-842-3210 Prior authorization is not required for emergency or urgent care. Out-of-network providers must request prior authorization for procedures and services (excluding emergent/urgent care). Site-of-service (SOS) review: For many procedures (for example select endoscopy/colonoscopy, arthroscopy, certain orthopedic and pain procedures) site of service will be reviewed as part of the prior authorization process; SOS exceptions apply in AK, MA, PR, TX, UT, VI and WI where noted.

• Submit requests online via the Prior Authorization and Notification tool on UHCprovider.com or call 877-842-3210.
• SOS (site-of-service) review is performed as part of prior authorization for many outpatient procedures; see specific code callouts below for SOS applicability.

Arthroscopy — Prior Authorization and Site‑of‑Service Review

Arthroscopy requires prior authorization in all states. In addition to medical necessity review, site-of-service will be reviewed as part of the prior authorization process.

• Common arthroscopy CPT examples requiring authorization: 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29827, 29828, 29830, 29834, 29835, 29836, 29845–29848, 29860–29863, 29870, 29873–29877, 29879–29887, 29888–29899, 29914–29916.

Behavioral Health — Network and Prior Authorization Instructions

Many UnitedHealthcare commercial benefit plans require behavioral health services to be obtained through a designated behavioral health network. Prior authorization or referral may be required depending on the plan and service.

• For specific behavioral health codes and prior authorization/referral instructions, call the number on the member's health plan ID card or the behavioral health phone number indicated on the plan.
• Behavioral health products may be administered by United Behavioral Health (UBH) or affiliates; follow the plan-specific network and authorization rules.

Selected Procedure and Implant Codes Requiring Prior Authorization

Selected procedures, implants and device codes require prior authorization. This includes certain cardiology/vascular procedures, cartilage and orthopedic implants, and inpatient-only services as listed below.

• Cardiology/vascular examples: 33285, 37220, 37221, 37224–37226, 93653, 93656.
• Cartilage and orthopedic implant examples: 27412, 27415, 27416, 29866–29868, J7330, S2112.
• Cerebral seizure monitoring (inpatient video): 95700, 95711–95715 (prior authorization required for inpatient).

Continuous Glucose Monitor and DME Codes (Partial)

Continuous glucose monitors (CGMs) and related durable medical equipment may require prior authorization depending on diabetes type and diagnosis codes. DME prior authorization is required when retail purchase or cumulative rental cost exceeds $1,000 for listed codes.

• CGM and related HCPCS/Codes: A4226, A4238, A4239, A9276, A9277, A9278; DME examples: E0787, E2102, E2103 and other E-codes listed.
• Prior authorization required for CGM with Type 2 and gestational diabetes when indicated by E11.xx diagnosis codes (specific E11.xxyy codes listed in policy).
• DME threshold: prior authorization required for DME codes with retail purchase or cumulative rental cost > $1,000 (examples: A7025, A7026, E0194, E0265, E0266, E0277, E0296–E0304, E0328–E0329, E0466, E0471, E0483, E0745, E0764, E0766).

Cosmetic and Reconstructive Procedure Codes (Partial)

Cosmetic and reconstructive procedures have separate prior authorization requirements. Cosmetic procedures intended solely to change or improve appearance require authorization; reconstructive procedures that treat a medical condition or restore function may also require authorization but have distinct coding considerations.

• Cosmetic examples (authorization required for all states): 11960, 11970, 11971, 14020, 14021, 14061, 14302, 15570, 15572, 15574, 15730, 15733, 15740, 15756, 15769, 15773, 15820–15823, 15830, 15847, 15877–15879, 17999.
• Reconstructive examples (authorization may apply): 21137–21139, 21172, 21175, 21179–21184, 21230, 21235, 21240–21249, 21255.
• Prior authorization not required when billed with certain diagnosis codes (see policy ICD lists); when in doubt, submit authorization request with supporting documentation.

Screening Colonoscopy Codes — SOS Note

Screening colonoscopy (G0105, G0121) — site‑of‑service (SOS) review applies. When the screening codes are used, the SOS-only note applies and prior authorization/SOS review may be required for other colonoscopy and endoscopy CPT codes as noted in the policy.

• Screening colonoscopy codes (SOS only applies): G0105, G0121.
• Many colonoscopy/EGD and related endoscopy CPT codes require prior authorization and SOS review except in AK, MA, PR, TX, UT, VI and WI; examples and full code lists are in the Gastroenterology/Endoscopy section of the policy.
• For prior authorization of endoscopy/colonoscopy services, submit via the Radiology/Cardiology/Oncology/Radiation Oncology/Gastroenterology Endoscopy tile on the Provider Portal or call 866-889-8054.

Unclassified/Temporary Codes and Review‑at‑Launch Medications

Unclassified or temporary HCPCS/CPT codes and 'Review at Launch' medications (new-to-market drugs) have special predetermination and prior authorization rules. Notification/authorization for certain miscellaneous or unclassified codes is required for specific products.

• Unclassified/temporary codes: C9162, C9399, J3490, J3590 — notification/prior authorization is required only for specified products (for example Izervay, Nulibry, Revcovi, Veopoz Q5120/Q5122/Q5125).
• Review at Launch: For drugs on the Review at Launch list, predetermination is highly recommended. See the Review at Launch for New to Market Medications policy at UHCprovider.com > Menu > Policies and Protocols > Commercial Policies > Medical & Drug Policies and Determination Guidelines.
• For non-oncology diagnoses involving Q-codes (e.g., Q5120/Q5122/Q5125) submit online at UHCProvider.com > Provider Portal > Specialty Pharmacy Transactions.

Coding Note for Prior Authorization Requests

Coding note — include appropriate CPT/HCPCS codes and relevant diagnosis codes when submitting prior authorization requests. Providing complete coding and clinical documentation expedites review and reduces risk of denial.

• Always include primary CPT/HCPCS code(s), any related modifier(s), and the pertinent ICD-10 diagnosis code(s) on the request.
• For drugs and biologics, include HCPCS J-/Q- codes, NDC (if applicable), and indication (oncology vs non‑oncology) to ensure correct routing (Specialty Pharmacy tile when required).
• For PT/OT authorizations through Optum Physical Health, include the initial evaluation and submit the Patient Summary Form (PSF) for subsequent visits as specified.