CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements (Rocky Mountain Health Plans - CHP)

Lists services and codes that require prior authorization for UnitedHealthcare Colorado Rocky Mountain Health Plan CHP members and describes how providers request authorization; applies to participating and non‑participating providers when the plan is primary payor.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements (Rocky Mountain Health Plans - CHP)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests and supporting documentation via UHCprovider.com/priorauth or, for some services, via the eviCore portal or phone.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

dozensCPT/HCPCS codes referenced

multipleService categories listed

exceptionEmergency/urgent care

web & phoneAuthorization methods

J9000-J9999Chemotherapy J-codes range

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Coverage and Prior Authorization Criteria

Prior authorization coverage criteria (partial - from this document segment)

Prior authorization is required for the listed services and codes when UnitedHealthcare Colorado Rocky Mountain Health Plan CHP is the primary payor, except for emergency or urgent care and services not a benefit of the member's Evidence of Coverage.

ALL of the following

Service categories
- Arthroscopy services (Additional Information = Prior authorization required).
- Bariatric surgery and obesity-related services.
- Breast reconstruction (non-mastectomy reconstruction).
- Cardiology and cardiovascular procedures (e.g., specified CPT/HCPCS codes).
- Chemotherapy injectable drugs administered in outpatient settings (J9000–J9999 and listed J/Q/A codes).
- Cochlear implants and auditory implant-related codes.
- Congenital heart disease procedures and related surgical codes.
Exceptions: Prior authorization is not required for emergency or urgent care; services that are not a benefit of the member's Evidence of Coverage will not be authorized.

ALL of the following

Providers must submit prior authorization requests and supporting documentation via UHCprovider.com/priorauth for Rocky Mountain Health Plans providers.
Non‑participating providers may fax requests to 800-262-2567 or 970-255-5681.
For certain radiology and imaging requests providers submit via eviCore (www.evicore.com or 800-792-8750).
Behavioral health prior auth phone: 888-282-8801. Admitting facility notification phone: 800-416-2157 (option 4) or 970-248-5197.

Prior authorization requirement (partial)

Partial coverage notes from code listing

Prior authorization is required for codes where the Additional Information field states 'Prior authorization required'.

Prior authorization requirement by procedure category

Procedures described as 'Cosmetic and reconstructive', 'Cosmetic procedures that change or improve', 'physical appearance', 'improving or restoring', and 'Reconstructive procedures that treat a medical condition or improve or restore physiologic function' are identified with prior authorization requirements.

ALL of the following

Examples
- Cosmetic and reconstructive codes (examples: A4238/E2103 -> 11920; A4239 -> 11921/11922; E0784 -> 11960).
- Procedures improving or restoring physiologic function and reconstructive procedures (examples: 21145, 21146, 21740, 21742, 21743).
Submission for these procedures: submit requests online at www.evicore.com or call 800-792-8750 for notification/prior authorization.

Note: Some reconstructive HCPCS codes (e.g., Q2026) may be marked 'Not a benefit for Commercial or RMHP Prime' despite prior authorization routing; check benefit.

Prior authorization criteria for listed codes

The listed CPT/HCPCS codes require notification or prior authorization. Submission route is via eviCore online portal or phone.

Providers must submit prior authorization requests for listed CPT/HCPCS codes online at www.evicore.com or by calling 800-792-8750.

Prior authorization is required for diagnostic, therapeutic, reconstructive procedures and DME codes listed in the code tables and 'How to Obtain Prior Authorization' fields.

ALL of the following

Prosthetics are not DME — see Orthotics and prosthetics entries for L‑codes.
Some HCPCS codes (e.g., Q2026) are noted as not a benefit for Commercial or RMHP Prime despite appearing in the list.

Prior authorization requirement

Authorization requirement noted for enteral services and many DME-related codes.

Prior authorization required for enteral services and in‑home nutritional services for the HCPCS codes listed (examples include B4149, B4150, B4152, B4153, B4154).

Numerous DME (K/E) codes map to 'How to Obtain Prior Authorization' entries; follow the listed How to Obtain Prior Authorization code references for submission.

Partial authorization/coverage rules

Coverage/authorization stance for listed services (partial):

ALL of the following

Enteral services and in‑home nutritional services require prior authorization for the listed HCPCS codes (e.g., B4149, B4150, B4152, B4153, B4154, B4216, B5000, B5100, B5200, B9998, S9432‑S9435).

ALL of the following

Genetic tests and proprietary lab (U‑/T‑/M‑codes) have Additional Information = Prior authorization required; see code list for specifics (examples: 0001U, 0004M, 0005U, 0006M, etc.).

ALL of the following

Procedures labeled Experimental and investigational require prior authorization (examples: 64454, 64624, 64625, 91112, 91132, 91133).

ALL of the following

Prior authorization requirement for genetic tests/lab services

Prior authorization applies to genetic tests/lab services as indicated in the code listings.

ALL of the following

See listed CPT/HCPCS U‑/T‑/M‑codes (examples include 0001U, 0002U, 0003U, 0007U, 0008U, 0016U, 0017U, 0023U, 0035U, 0038U, etc.) for code‑specific submission instructions.

Submission: many genetic test entries indicate eviCore or other 'How to Obtain Prior Authorization' mapping — follow the code list entry for the specified submission route.

Prior authorization requirements (partial)

Services and codes in this excerpt that require prior authorization

Examples of codes requiring prior authorization

Selected lab/diagnostic codes (e.g., 83883, 83987, 84431) — Hearing/audio/vision codes (0100T, 66989, 66991, 67901–67903) are flagged Prior authorization required.
Home healthcare codes (e.g., G0176, G0248, G0249, G0250, S9340–S9343, S9355, S9364–S9368) — Additional Information = Prior authorization required.
Hyperbaric oxygen treatment (G0277) — Additional Information = Prior authorization required.

Prior authorization and coding criteria

Prior authorization requirements and code-specific notes

ALL of the following

Unclassified and temporary codes (e.g., C9399, J3490, J3590) require prior authorization only for specific products listed (examples: Amvuttra, Fylnetra, Lupaneta Pack, Nulibry, Recovi, Riabni, Skyrizi, white blood cell colony stimulating factors, Veopoz).
Effective Jan 1, 2024: Izervay should be billed using temporary codes J3490, J3590 and C9162; Daxxify should use C9160. Effective Aug 1, 2023: prior authorization required for J0174.

ALL of the following

Musculoskeletal and obstetrical procedures list many CPT codes with Additional Information = Prior authorization required (examples: 20957, 20972, 20973, 59897, 59898 and multiple L‑codes for orthotics/prosthetics).

Prior authorization required for listed CPT/HCPCS codes

Codes listed below require prior authorization as indicated in this document segment.

Radiation therapy and radiology codes: Prior authorization required for listed radiation therapy CPTs and many CT/MRI/MRA/PET radiology CPTs (examples include 70450, 70460, 70470, 70540, 70542, 70543, 70470–70498 series).

Orthotics/prosthetics and L‑codes: numerous L‑codes require prior authorization; consult the L‑code sections for How to Obtain Prior Authorization mappings (examples: L5321, L5610, L5673, L6694, L6910, L7185, L8690 series).

Pain management codes: pain management injection/nerve block CPT codes listed (e.g., 64451–64495 series) have How to Obtain Prior Authorization entries.

Prior Authorization Requirements (partial list)

Prior authorization required for listed procedures and codes; providers must submit requests via evicore online portal or phone prior to scheduling.

ALL of the following

Care providers ordering an Advanced Outpatient Imaging Procedure must notify/request prior authorization before scheduling via www.evicore.com or 800-792-8750.

General: Numerous CPT and HCPCS codes across radiology, nuclear medicine, surgery, spine, sleep, stimulators, skin substitutes and rhinoplasty are listed with How to Obtain Prior Authorization entries — these require prior authorization or notification per the code listing.

Prior authorization requirement statements

Statements indicating procedures requiring prior authorization.

Transplants: Prior authorization required for transplant‑related procedures listed (examples include CPT codes 32850–32856, 33930–33945, 38204–38215 and related codes).

Urinary system and vein procedures: Prior authorization required for listed urinary system and vein procedure CPT/HCPCS codes as noted in the code sections.

Code Lists (CPT / HCPCS / NDC / Temporary / Proprietary)

Arthroscopy (CPT)CPTCovered

29805	Arthroscopy, shoulder, diagnostic
29806	Arthroscopy, shoulder, surgical; debridement
29807	Arthroscopy, shoulder, surgical; capsulorrhaphy
29819	Arthroscopy, ankle, diagnostic
29820	Arthroscopy, ankle, surgical; synovectomy
29821	Arthroscopy, hip, diagnostic
29822	Arthroscopy, hip, surgical; trochanteric bursectomy
29823	Arthroscopy, hip, surgical; labral repair
29824	Arthroscopy, knee, diagnostic
29825	Arthroscopy, knee, surgical; meniscectomy

1–10 of 30

1/3

Bariatric & Upper GI (CPT)CPTCovered

43644	Gastric restrictive procedure with gastric bypass
43645	Laparoscopy, gastric restrictive procedure; with gastric bypass
43770	Laparoscopy, repair of gastric fistula
43771	Laparoscopy, complicated gastric procedure
43772	Gastrectomy, partial, distal
43773	Gastrectomy, total
43774	Excision, lesion of stomach
43775	Revision of gastric bypass
43842	Gastrectomy, sleeve, laparoscopic
43843	Gastric bypass, revision

1–10 of 17

1/2

Breast Reconstruction (CPT/HCPCS)mixedCovered

19300	Mastectomy, partial
19328	Removal of intact implant
19330	Immediate insertion of breast prosthesis following mastectomy
19340	Immediate reconstruction of breast with prosthesis
19355	Breast reconstruction with tissue expander
19357	Breast reconstruction with free flap
19361	Breast reconstruction with latissimus dorsi flap
19364	Breast reconstruction with other technique
19367	Breast reconstruction, delayed with implant
19368	Breast reconstruction with flap

1–10 of 18

1/2

Cardiology (CPT)CPTCovered

33206	Insertion of transvenous lead, pacemaker
33207	Change of pacemaker generator
33208	Revision or replacement of pacing system
33212	Insertion of leadless pacemaker
33213	Insertion of epicardial lead
33214	Removal of pacemaker lead
33221	Leadless intracardiac pacemaker implantation
33224	Conversion to biventricular pacing
33225	Insertion of ICD with transvenous lead
33227	Removal of ICD without replacement

1–10 of 34

1/4

Chemotherapy / Injectable Drugs (HCPCS J & related)HCPCSCovered

J9000-J9999	Chemotherapy injectable drugs range
J0640	Leucovorin, injectable
J0641	Levoleucovorin, injectable
J0642	Levoleucovorin, injectable (alternate)
J1950	Leuprolide acetate (Lupron Depot), injectable
J0885	Injection, oncology agent (specified)
J1449	Injection, antiemetic
J1932	Injection, chemotherapy agent
J1954	Injection, oncology biosimilar
A9607	Lutetium Lu 177, therapeutic radiopharmaceutical

1–10 of 14

1/2

Auditory Implants & Related (HCPCS/CPT/Q)mixedCovered

L8629	Cochlear implant device, internal
93593-93597	Cochlear/vestibular implant and mapping CPT range
93593	Cochlear implant; initial or revision mapping
93594	Cochlear implant; postoperative mapping
93595	Cochlear implant follow-up
93596	Cochlear implant programming
93597	Cochlear implant additional services
Q5111	Cochlear implant external processor
Q5120	Cochlear implant external accessory
Q5122	Hearing device accessory

1–10 of 11

1/2

Selected J-codes and HCPCS mappingsHCPCS

J0491	Injection code mapping (see internal mappings)
J0256	Injection code mapping
J0885	Therapeutic injectable (see list)
J1302	Dermatologic injectable
J0129	Biologic injectable
Q5125	Hearing device external part

How Providers Request Prior Authorization

Prior Authorization

How to request prior authorization

Rocky Mountain Health Plans providers must submit prior authorization requests and supporting documentation via UHCprovider.com/priorauth (Advance Notification and Plan Requirement Resources). Non‑participating providers may fax requests to 800-262-2567 or 970-255-5681. eviCore requests may be submitted via www.evicore.com or by calling 800-792-8750. Behavioral health requests use phone 888-282-8801. Prior authorization is not required for emergency or urgent care.

UHCprovider.com/priorauth > Advance Notification and Plan Requirement Resources
Fax (non‑participating): 800-262-2567 or 970-255-5681
eviCore web/phone: www.evicore.com / 800-792-8750
Behavioral health: 888-282-8801
Notification by admitting facility: 800-416-2157 (option 4) or 970-248-5197

Note

Scope and updates

Services that are not a benefit of the member's Evidence of Coverage will not be authorized. The list is updated periodically; providers should use UHCprovider.com/priorauth for the most current information.

Definitions and Notes

Prior authorization

DefinitionPrior authorization is the process where health care providers seek approval before rendering a service, as required by UnitedHealthcare policy.

Who must requestParticipating and non‑participating providers must request prior authorization when UnitedHealthcare is the primary payor (except emergency/urgent care).

PurposeEnsures prospective, concurrent, and retrospective review by UnitedHealthcare Health Services.

Advance notification

DefinitionAdvance notification is a requirement for care providers to give UnitedHealthcare timely communication of services so prospective, concurrent and retrospective care review can be performed.

When to notifyAdmitting facilities should notify via the facility phone contacts provided in the policy (see provider contacts).

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements (Rocky Mountain Health Plans - CHP)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests and supporting documentation via UHCprovider.com/priorauth or, for some services, via the eviCore portal or phone.

SourceLink

On This Page

Specific ENT, general surgery and gender dysphoria surgical codes are marked as prior authorization required; gender dysphoria treatments reference listed surgical codes paired with diagnoses (examples: 17380, 57291, 57292, 57296, 57335).

Services not in the Member's Evidence of Coverage will not be authorized
Most current list available at UHCprovider.com/priorauth > Advance Notification and Plan Requirement Resources

Prior Authorization

Services requiring prior authorization (examples and codes included)

The policy lists many specific service categories and CPT/HCPCS codes that require prior authorization (examples include arthroscopy, bariatric surgery, breast reconstruction, cardiology procedures, chemotherapy injectables, cochlear and auditory implants).

Arthroscopy services (e.g., 29805–29887 series)
Bariatric surgery (e.g., 43644, 43645, 43770–43775, 43842–43888)
Breast reconstruction (e.g., 19300–19396, S2066–S2068)
Cardiology/outpatient diagnostic catheterization and device implantation (e.g., 33206–33289, 93451–93461)
Injectable chemotherapy drugs (J9000–J9999 and specified J-codes)
Cochlear and other auditory implants (including L8629, 93593–93597)

Prior Authorization

Codes requiring prior authorization (partial)

Multiple CPT/HCPCS/NDC codes are listed in the document and several entries are explicitly marked 'Prior authorization required' or show effective dates indicating authorization status.

Examples in the list include 93596, 93593, 93597
Device and product codes such as L8629 and J2506 are listed and referenced as requiring authorization in related entries

Documentation Required

Authorization notes

Some code entries include an 'Additional Information' flag stating 'Prior authorization required' and several codes are noted as effective November 1, 2023; providers must check these notes when preparing requests.

Entries with Additional Information = Prior authorization required must be authorized prior to service
Certain codes are annotated as Effective November 1, 2023 — verify effective-date notes when applicable

Prior Authorization

Prior authorization submission instructions

For notification or prior authorization of many reconstructive and cosmetic procedures, providers must submit requests online at www.evicore.com or call 800-792-8750 as indicated in the code listings.

Use www.evicore.com or 800-792-8750 for notification/prior authorization for listed cosmetic and reconstructive procedures
Examples map HCPCS/HCPCS supplies (A4238, A4239, E0784, E2102, E2103) to CPT codes in the listing

Prior Authorization

How to obtain prior authorization

Many code lines include 'For notification/prior authorization, please submit requests online www.evicore.com or call 800-792-8750' — providers must use eviCore contact methods where shown.

Submit prior authorization requests via www.evicore.com or phone 800-792-8750 when the code line indicates eviCore
Follow the 'How to Obtain Prior Authorization' mapping in the code listing

Prior Authorization

Prior authorization requirement (DME/diagnostic/therapeutic)

Diagnostic, therapeutic and DME-related codes shown with Type = Prior authorization required must have prior authorization obtained before services are rendered.

When Additional Information or Type indicates 'Prior authorization required', obtain authorization prior to service
Some entries also note benefit exclusions (see specific code notes)

Note

Operational clarification

Operational clarification: prosthetics are not considered DME in this listing; providers should refer to the orthotics and prosthetics section for applicable prior authorization instructions.

Prosthetics are not DME — see Orthotics and prosthetics code listings for prior authorization instructions

Prior Authorization

How to Obtain Prior Authorization — code listings

The 'How to Obtain Prior Authorization' phrase appears alongside many HCPCS/CPT code lines — providers must follow the indicated prior authorization routing shown for each code in the list.

Follow the per-code 'How to Obtain Prior Authorization' mapping in the listing
Check each code line for the designated authorization route (e.g., eviCore, plan portal, specific phone/fax)

Prior Authorization

DME prior authorization mapping

Durable medical equipment (DME) code lines include 'How to Obtain Prior Authorization' mappings to many K- and E- series codes; providers should use those mappings to determine the authorization route.

DME codes (e.g., E2219, K0014, K0852) show explicit 'How to Obtain Prior Authorization' entries
Use the per-code mapping to identify whether eviCore or the plan portal should be used

Prior Authorization

Enteral services prior authorization

Enteral services and in-home nutritional services (examples include B4149, B4150, B4152–B4154 and additional B- and S-codes listed) are annotated 'Prior authorization required' and must be authorized prior to service.

Enteral codes: B4149, B4150, B4152, B4153
In-home nutritional code: B4154
Additional enteral/in-home nutrition codes are listed with prior authorization required

Prior Authorization

Prior authorization required for enteral and in-home nutritional services

Prior authorization is required for the broader set of enteral and in‑home nutritional HCPCS codes enumerated in the listing (including B4216, B5000, B5100, B5200, B9998, S9432–S9435); obtain authorization per the code instructions.

Examples: B4216, B5000, B5100, B5200, B9998, S9432–S9435
Follow the listed 'How to Obtain Prior Authorization' instructions for each code

Prior Authorization

Prior authorization required for experimental/investigational procedures

Procedures listed as 'Experimental and investigational' (examples include 64454, 64624, 64625, 91112, 91132, 91133) are annotated 'Prior authorization required' and require authorization before services are provided.

Experimental/investigational example CPTs: 64454, 64624, 64625, 91112, 91132, 91133
These entries include Additional Information = Prior authorization required

Prior Authorization

Prior authorization required for genetic tests/lab services

Genetic tests and laboratory/proprietary molecular tests are identified with 'Additional Information = Prior authorization required' — providers must obtain prior authorization for the many U-/M-/T- and CPT-level genetic/lab codes listed.

Examples include U-codes 0001U, 0004M, 0005U, 0006M and numerous others
Refer to the genetic tests/lab services code group for the full per-code authorization instructions

Prior Authorization

Prior authorization for surgical/ENT and gender dysphoria treatment codes

Various surgical and ENT procedures — and surgical codes associated with gender dysphoria treatment (when paired with the specified diagnosis codes) — are flagged 'Prior authorization required'; providers must obtain authorization per the code lines.

ENT/surgical examples include 68816 and a range of 697xx codes
Gender dysphoria surgical examples include 17380, 57291–57296, 57335 and related codes that require prior authorization

Prior Authorization

Prior authorization requirement

The document repeatedly annotates code lines with 'Prior authorization required' — providers must check each code entry and obtain authorization where the Additional Information indicates this requirement.

Genetic tests/lab services entries explicitly state Additional Information = Prior authorization required
Confirm per-code Additional Information notes before scheduling services

Prior Authorization

Prior authorization - hearing/audio/vision

Hearing, audio and vision services listed (including 0100T, 66989, 66991, 67901–67904 and multiple V-codes) show 'Additional Information = Prior authorization required' and must be authorized per the listing.

Examples: 0100T, 66989, 66991, 67901–67904
Several V-codes and device codes are also included — follow per-code instructions

Prior Authorization

Prior authorization - home healthcare

Home health services and related HCPCS codes (e.g., G0176, G0248–G0250, S9340–S9343, S9355, S9364–S9366) are marked 'Additional Information = Prior authorization required' — obtain authorization as shown.

Home healthcare examples: G0176, G0248, G0249, G0250
S-codes: S9340–S9343, S9355, S9364–S9366 — check listing for complete set

Prior Authorization

Prior authorization - hyperbaric oxygen

Hyperbaric oxygen treatment is annotated as requiring prior authorization; code G0277 is specifically listed with Additional Information = Prior authorization required.

Hyperbaric oxygen example: G0277 (Prior authorization required)

Prior Authorization

Prior authorization requirements for injectable medications

Many injectable medications and certain unclassified/temporary codes require prior authorization; for example, unclassified/temporary codes C9399, J3490, J3590 require authorization for specific drugs, and J0174 requires prior authorization effective Aug 1, 2023.

Unclassified/temporary codes C9399, J3490, J3590 require PA only for listed drugs (e.g., Amvuttra, Fylnetra, etc.)
J0174 prior authorization effective Aug 1, 2023
Effective Jan 1, 2024 mapping notes for Izervay (J3490, J3590, C9162) and Daxxify (C9160) — follow per-code PA instructions

Prior Authorization

Radiology prior authorization (eviCore involvement)

Radiology codes for certain CT/MRI/MRA/PET and other advanced outpatient imaging studies are annotated 'Prior authorization required'; participating physicians' requests for many of these studies are routed to eviCore per the listing.

Radiology examples: 70450, 70460, 70470, 70480–70498, 70540–70549
Participating physicians may have requests routed to eviCore — use www.evicore.com or 800-792-8750

Prior Authorization

Orthotics/Prosthetics and other L-code prior authorization

Numerous orthotics and prosthetics L-codes are listed with 'How to Obtain Prior Authorization' mapping; prior authorization is required for these L-code items and providers must follow the per-code authorization instructions.

Examples: L5321, L5610, L5673, L5790, L5930, L6020, L6400, L6694 and many additional L-codes
Follow the 'How to Obtain Prior Authorization' entry for each L-code

Prior Authorization

Pain management prior authorization

Pain management injection and nerve block CPT codes (for example 64451, 64461–64463, 64490–64495) are listed with 'How to Obtain Prior Authorization' and must be authorized prior to service.

Pain management examples: 64451, 64461–64463, 64490–64495
Obtain prior authorization per the code listing

Prior Authorization

How to Obtain Prior Authorization

Care providers ordering an Advanced Outpatient Imaging Procedure are responsible for providing notification or requesting prior authorization before scheduling; submit requests online at www.evicore.com or by calling 800-792-8750.

Providers must notify/request prior authorization before scheduling advanced outpatient imaging
Submit via www.evicore.com or call 800-792-8750

Prior Authorization

Prior authorization required for listed procedures

The document identifies numerous specific CPT/HCPCS procedures that require prior authorization (examples in the listing include CT, MRI, MRA, PET and other radiology codes) — providers must obtain authorization using the route listed for each procedure.

Examples: advanced outpatient imaging such as 70300 series, 75573, 76120, 76496, 77084, 78835
Check each code's 'How to Obtain Prior Authorization' instruction before proceeding

Prior Authorization

Transplants - prior authorization

Multiple transplant-related CPT codes are annotated 'Transplants, Additional Information = Prior authorization required'; providers must obtain prior authorization for the transplant procedures listed (e.g., 32850–32856, 33930–33945, 38204–38215 and related codes).

Transplant examples: 32850–32856, 33930–33945, 38204–38215
Obtain prior authorization as indicated in the transplant code listings

Prior Authorization

Urinary and vein procedures - prior authorization

Urinary system procedures and vein procedures are flagged 'Prior authorization required' in the listing; providers must obtain authorization per the code lines for the urinary and vein procedure groups.

Urinary system: entries indicate prior authorization required (see listing)
Vein procedures (treatment of venous disease/varicose veins) are marked prior authorization required

Prior Authorization

General prior authorization instructions

Numerous CPT/HCPCS codes across the document include the instruction 'How to Obtain Prior Authorization =' or similar language — providers must review each listed code and follow the specified authorization route (portal, eviCore, fax or phone) before performing the service.

Check per-code 'How to Obtain Prior Authorization' mapping for the correct submission method
Some codes route to eviCore (www.evicore.com / 800-792-8750), others to the plan portal or specified fax numbers

Relation to prior authAdvance notification supports prospective/concurrent review and does not replace required prior authorization where indicated.

Effective date note

Effective dateCodes marked with an asterisk in the list are effective November 1, 2023.

Scope of effectEffective date applies to the specific CPT/HCPCS entries annotated in the code listings.

Update noteThe prior authorization list is updated periodically; always confirm current codes at UHCprovider.com/priorauth.

Prior authorization note

Additional Information flagSome entries include an 'Additional Information' field that states 'Prior authorization required' — these codes require authorization before service.

Submission instructionWhen Additional Information indicates prior authorization is required, follow the 'How to Obtain Prior Authorization' instructions listed with the code (web/phone/fax as applicable).

ExceptionEmergency or urgent care is excluded from prior authorization requirements per policy.

Cochlear implants

Cochlear implants referencedSome code entries include 'Cochlear implants' in the Additional Information field and are flagged for prior authorization handling.

How to requestFollow the 'How to Obtain Prior Authorization' instructions shown with the cochlear implant code entries (submit per listed vendor/portal).

Confirm coverageServices not included in the member's Evidence of Coverage will not be authorized even if listed; verify benefit before authorization request.

Prior authorization (summary)

What it isPrior authorization is the required approval process providers must complete before rendering listed services to UnitedHealthcare members (unless emergency/urgent care).

How to submitSubmit requests and supporting documentation via UHCprovider.com/priorauth; non‑participating providers may fax to 800-262-2567 or 970-255-5681; some services use eviCore (www.evicore.com / 800-792-8750).

Where shownMany CPT/HCPCS/J and other codes in the document are annotated with 'How to Obtain Prior Authorization' indicating the prior authorization requirement applies to those codes.

Prosthetics vs DME

ClarificationProsthetics are explicitly stated as not being DME; see the Orthotics and prosthetics section for prosthetics-specific prior authorization instructions.

DME mappingDME entries are listed separately with 'How to Obtain Prior Authorization' mapping to many E/K/K0-series codes.

ImplicationDo not submit prosthetic requests under DME workflows; use the orthotics/prosthetics code entries and their authorization path.

DME

DefinitionDurable medical equipment (DME) entries are listed with specific HCPCS codes and 'How to Obtain Prior Authorization' instructions.

How to obtainFollow the 'How to Obtain Prior Authorization' mapping shown with each DME code (many map to E- and K-series authorization entries).

Example codesDME authorization mappings include entries such as E2219 and multiple E22xx codes referenced in the DME section.

Enteral services

DefinitionEnteral services = nutrition delivered enterally; specific HCPCS codes are listed and require prior authorization.

Example codesListed enteral/in‑home nutrition codes include B4149, B4150, B4152, B4153 and B4154 (in‑home nutritional).

How to obtainUse the 'How to Obtain Prior Authorization' instructions shown with these HCPCS entries when submitting requests.

Prior authorization required

StatementMultiple entries in the code list have 'Additional Information = Prior authorization required' indicating those services require prior authorization before provision.

Common categoriesCategories repeatedly flagged include enteral services, DME, certain surgical and diagnostic procedures, genetic tests, and injectable medications.

ExceptionEmergency or urgent care are excluded from the prior authorization requirement.

Experimental and investigational

DefinitionServices labeled 'Experimental and investigational' are treated distinctly and entries in this category require prior authorization.

Example codesExamples of investigational codes flagged for prior authorization include 64454, 64624, 64625, 91112, 91132, 91133.

SubmissionFollow the 'How to Obtain Prior Authorization' instructions listed with the investigational entries when requesting review.

Genetic tests/lab services (1)

ScopeGenetic tests and laboratory services (many proprietary U-/T-codes and CPT genetics codes) are included in the list and may require prior authorization.

How flaggedThe Genetic tests/lab services sections include 'Additional Information = Prior authorization required' for many entries; check the code list for specific codes and authorization path (often eviCore).

Example codesSample genetic/proprietary lab codes shown in the list include multiple T-/U-codes (e.g., 0663T–0683T series in the genetics section).

Genetic tests/lab services (2)

Authorization mappingMany genetic and proprietary lab codes list a specific 'How to Obtain Prior Authorization' code or note (examples: 0012U, 0036U, 0076U mappings to eviCore).

VendorSome genetic test prior authorizations are handled via eviCore (see entries that reference eviCore).

Action for providersWhen a genetic test code lists 'Prior authorization required', submit the request per the listed 'How to Obtain Prior Authorization' pathway and include required documentation.

Hyperbaric oxygen treatment

DefinitionHyperbaric oxygen treatment is listed and code G0277 is annotated 'Additional Information = Prior authorization required.'

How to obtainSubmit prior authorization requests using the 'How to Obtain Prior Authorization' instructions shown with the hyperbaric entry.

Related imaging noteCertain radiology vendor routing (eviCore) is noted elsewhere for imaging-related prior authorization steps that may be relevant to facility workflows.

Home healthcare

DefinitionHome healthcare services are included in the list and specific home health codes are marked 'Additional Information = Prior authorization required.'

Example codesHome healthcare entries include G0176, G0248, G0249, G0250 and multiple S93xx codes shown in the home health section.

SubmissionFollow the 'How to Obtain Prior Authorization' instructions shown with the home healthcare codes; contact details and eviCore info are provided in the policy.

Unclassified/temporary HCPCS codes and prior authorization

DefinitionUnclassified and temporary HCPCS codes (e.g., C9399, J3490, J3590) require prior authorization only when used for specified products or drugs listed in the policy.

Temporary code mappingEffective Jan 1, 2024 Izervay should be billed using temporary codes J3490, J3590 and C9162; Daxxify uses C9160. Prior authorization rules apply accordingly.

Specific drug PAPrior authorization required for select unclassified/temporary codes only for listed drugs (examples noted: Amvuttra, Fylnetra, Lupaneta Pack, Nulibry, Recovi, Riabni, Skyrizi, Veopoz).

Third-party radiology authorization vendor (eviCore)

VendoreviCore is the third-party vendor referenced for authorization of certain radiology requests; participating physicians' requests may be routed to eviCore.

ContacteviCore web: www.evicore.com; phone: 800-792-8750 — use these for notification/prior authorization of Advanced Outpatient Imaging Procedures and listed radiology CPTs.

Provider responsibilityCare providers ordering advanced outpatient imaging procedures are responsible for providing notification/requesting prior authorization before scheduling.

Advanced Outpatient Imaging Procedure

DefinitionAdvanced Outpatient Imaging Procedure = imaging procedures that require notification or prior authorization before scheduling.

Provider actionProviders ordering these procedures must request notification/prior authorization online at www.evicore.com or by calling 800-792-8750 prior to scheduling.

ExamplesCertain CT, MRI, MRA and PET scans and many listed radiology CPT codes are indicated as requiring prior authorization (see radiology section).

Prior authorization required (general)

ReminderNumerous CPT/HCPCS codes and service categories throughout the document are explicitly marked 'Prior authorization required' — follow the listed 'How to Obtain Prior Authorization' instructions for each code.

Submission pathsUse UHCprovider.com/priorauth for general requests; eviCore (www.evicore.com / 800-792-8750) for many radiology and imaging requests; behavioral health and other vendor contacts are provided in the policy.

ExceptionEmergency and urgent care are exempt from prior authorization requirements per the policy.