UnitedHealthcare Prior Auth Requirements (RMHP Prime)

Prior Authorization Coverage Criteria

Prior authorization coverage criteria (administrative)

Coverage stance and administrative requirements for prior authorization under RMHP Prime:

Services listed require prior authorization unless excluded from the member's Evidence of Coverage or are emergency/urgent care

Services not a benefit of the Member's Evidence of Coverage will not be authorized.

Providers must submit prior authorization requests and supporting documentation via the online portal (UHCprovider.com/priorauth), or by fax/phone as specified for non‑participating providers; certain authorizations are managed by eviCore; admitting facilities have a dedicated notification number

See eviCore (www.evicore.com, 800-792-8750); non‑participating fax numbers: 800-262-2567 or 970-255-5681; admitting facility: 800-416-2157 option 4 or 970-248-5197.

The document enumerates specific CPT/HCPCS/DME codes across specialties that require prior authorization (orthopedics, bariatric, breast reconstruction, cardiology, chemotherapy injectables, DME like CGMs, diagnostic, digestive, genetic tests, etc.)

Codes are listed throughout the prior authorization list and are subject to the requirements above.

Prior authorization requirement

Codes listed below are subject to prior authorization as indicated in the Additional Information field.

Prior authorization required for listed CPT/HCPCS and DME codes

See enumerated codes and Additional Information entries in the policy.

Prior authorization stance

Prior authorization required for listed services and codes in this section.

Enteral services (B‑codes) and in‑home nutritional therapy require prior authorization

Enteral services and in‑home nutritional therapy codes listed require prior authorization.

Procedures listed as experimental or investigational require prior authorization

Specific CPT/HCPCS codes denoted investigational/experimental are included in the list and require prior authorization.

Codes C9762, C9763 and S8080 require prior authorization through eviCore

Submit requests online at www.evicore.com or call 800-792-8750.

Surgical codes for gender dysphoria treatment require prior authorization when billed with the specified diagnosis codes

Gender dysphoria surgical CPT codes are linked to diagnosis codes (F64.x, Z87.890) and require prior authorization.

Prior authorization requirement list (partial)

Codes requiring prior authorization (surgical and genetic tests) as listed in this document segment.

Prior authorization required for the CPT/HCPCS surgical codes listed in this section (including gender dysphoria surgical codes)

See surgical code lists (e.g., 15769, series listed under Gender dysphoria).

Prior authorization required for genetic test and laboratory service codes enumerated in this section

Extensive lists of CPT/HCPCS/U genetic test codes are included and require prior authorization; some are identified as eviCore‑managed.

Management note: Some genetic test codes are identified as managed by eviCore

Entries annotated with (eviCore) indicate third‑party prior authorization management.

Certain surgical codes are linked to ICD‑10 diagnosis codes for gender dysphoria and history (F64.x, Z87.890)

When those diagnosis codes are billed with the listed surgical CPT codes, prior authorization is required.

Prior authorization requirement for listed codes

Genetic tests/lab services listed below require prior authorization.

Prior authorization required for genetic tests and laboratory services enumerated in the policy (CPT/HCPCS/U codes)

The policy includes mapping entries and grouping of many U/CPT genetic test codes that require prior authorization.

Prior authorization and temporary code mapping notes

Services and codes listed in this excerpt require prior authorization; specific temporary code assignments for certain drugs are noted with effective dates.

Prior authorization required for listed services such as hyperbaric treatment (G0277), hysterectomy (58578/58579), infusion/injection services and specified injectable medications

Examples of listed services and J/Q codes are shown in the Additional Information entries.

Temporary miscellaneous codes are assigned to specific products and must be used for prior authorization and claim submission per effective dates

Effective April 1, 2024: Pombiliti and Lyfgenia use J3490, J3590 and C9399. Effective January 1, 2024: Izervay uses J3490, J3590 and C9162; Daxxify uses C9160.

Prior authorization notes (partial)

Prior authorization requirement notes tied to listed codes

Selected medicine and vaccine codes (e.g., 90587, 90626, 90627, 90759) require prior authorization

Medicine services entries in the list are marked prior authorization required.

Multiple procedure and surgery CPT codes across musculoskeletal and other specialties are noted as requiring prior authorization

Examples include musculoskeletal and orthognathic surgery CPT codes (e.g., 99500, 20957, 21198, 21208).

Orthotics and prosthetics L‑series HCPCS codes require prior authorization

Numerous L‑codes are enumerated in the policy and prior authorization is required for orthotics and prosthetics.

Prior authorization/notification requirements

Provider action requirement for listed codes

Providers ordering listed CPT/HCPCS/L codes must obtain prior authorization or provide notification before scheduling (advanced outpatient imaging, orthotics/prosthetics, psych testing, etc.)

Care providers ordering Advanced Outpatient Imaging Procedures must notify/request prior authorization; orthotics/prosthetics L‑codes also require prior authorization.

When eviCore is referenced for a category (radiology, radiation therapy, procedure‑specific), submit notification/prior authorization via www.evicore.com or call 800‑792‑8750

Submission portal and phone number are provided in the policy for eviCore‑managed items.

Prior Authorization Requirements

Prior authorization/notification requirement

Participating providers must obtain notification or prior authorization via eviCore before scheduling Advanced Outpatient Imaging procedures and other listed services (radiation therapy, spine surgery, rhinoplasty, stimulators, etc.)

For notification/prior authorization submit requests online at www.evicore.com or call 800-792-8750.

Multiple CPT and HCPCS codes for advanced imaging, nuclear medicine and cardiology procedures are enumerated and are subject to prior authorization/notification

See the radiology and advanced imaging code lists in the policy (CT, MRI, MRA, PET and nuclear medicine).

Prior Authorization Criteria

Prior authorization requirement for listed procedures

Prior authorization is required for the listed CPT/HCPCS codes and categories including transplants, unlisted procedure codes, urological procedures, vein procedures, removal and ablation

Categories and example codes are provided; submit prior authorization requests online at www.evicore.com or by phone at 800-792-8750.

For notification/prior authorization of procedure categories and specific codes, submit requests online at www.evicore.com or call 800-792-8750

The policy repeatedly directs providers to the eviCore portal/phone for notification/prior authorization.

Examples: Example CPT ranges and codes requiring prior authorization include transplant codes (e.g., 32850–32856), unlisted codes (e.g., 77299, 77399), vein procedure series (36465–36483) and selected urological codes (e.g., 54400–54417)

These examples are illustrative of the listed categories in the policy.

How to Obtain Prior Authorization / Provider Responsibilities

Prior Authorization

How to request prior authorization

Submit prior authorization requests and supporting documentation via UHCprovider.com/priorauth (select Advance Notification and Plan Requirement Resources for the plan). Non‑participating providers may fax requests to 800‑262‑2567 or 970‑255‑5681. For services managed by eviCore submit requests at www.evicore.com or call 800‑792‑8750. Behavioral health services: call 888‑282‑8801. Admitting facility notifications: 800‑416‑2157, option 4 or 970‑248‑5197. Prior authorization is not required for emergency or urgent care.

Use the online portal UHCprovider.com/priorauth for RMHP Prime providers
Fax options for non‑participating providers: 800‑262‑2567 or 970‑255‑5681
eviCore: www.evicore.com / 800‑792‑8750
Behavioral health: 888‑282‑8801
Admitting facility notification: 800‑416‑2157, option 4 or 970‑248‑5197

Note

Authorization scope and updates

UnitedHealthcare will not authorize services that are not a benefit of the Member’s Evidence of Coverage. The prior authorization list is updated periodically; the online version at UHCprovider.com/priorauth is the authoritative source.

Prior Authorization

Obtain prior authorization for listed CPT/HCPCS codes

Obtain prior authorization for the CPT/HCPCS codes enumerated in the document (examples include 91065, 91112, 92512, 93702, 97610 and many surgical/diagnostic codes). These listed diagnostic, therapeutic, digestive and surgical codes require prior authorization as indicated.

Prior Authorization

Obtain prior authorization for listed DME/HCPCS E-codes

Durable medical equipment and HCPCS E‑series codes listed (for example A0110, A9520, E0170, E0250 and the extensive E‑code list) require prior authorization. Note: prosthetics are identified separately and are not classified as DME.

Refer to the E‑series HCPCS list in the policy for specific E‑codes requiring authorization
Prosthetics are not classified as DME per the list

Prior Authorization

EviCore prior authorization requirement

Codes C9762, C9763 and S8080 must be authorized through eviCore; submit requests online at www.evicore.com or by phone at 800‑792‑8750.

Prior Authorization

Enteral / in-home nutritional therapy

Enteral services and in‑home nutritional therapy (B‑series and related B codes such as B4149, B4150, B4152, B4153 and others) require prior authorization.

Prior Authorization

Gender dysphoria surgical codes

Surgical codes used for gender dysphoria treatment (examples include CPT 15769, 15771–15776, 15780–15793) require prior authorization when billed with the specified diagnosis codes.

Ensure claims include one of the listed ICD‑10 diagnoses: F64.0, F64.1, F64.2, F64.8, F64.9 or Z87.890
Obtain prior authorization before scheduling gender dysphoria‑related surgery

Prior Authorization

Experimental / investigational procedures

Codes listed as experimental or investigational (examples include CPT 53451–53454, 61736–61737, 62263–62264, 64454, 64624, 64625 and others marked investigational) require prior authorization.

Prior Authorization

Surgical procedures (gender dysphoria-related) prior authorization

Multiple surgical CPT codes associated with gender dysphoria treatment (see the listed CPT codes in the policy) require prior authorization prior to the procedure.

Prior Authorization

Genetic tests / laboratory services prior authorization

Extensive genetic test and laboratory service CPT/HCPCS/U codes enumerated in the policy (for example 0001U–81337 range and many specific 8xx/81xxx codes) require prior authorization; some genetic test codes are managed via eviCore as indicated next to individual codes.

Refer to the policy’s genetic test code list for the exact CPT/HCPCS/U codes requiring authorization
Note codes flagged “(eviCore)” must be submitted through www.evicore.com or 800‑792‑8750

Documentation Required

Associated diagnosis codes

ICD‑10 diagnosis codes associated with gender dysphoria (F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890) are the required diagnosis codes when submitting prior authorization requests for the listed gender dysphoria surgical procedures.

Prior Authorization

Prior authorization required for listed genetic tests/lab services

Prior authorization is required for the genetic test and laboratory CPT/HCPCS/U codes listed (see the code lists in the policy) and instructions for obtaining authorization are provided in the policy (online portal or eviCore where noted).

Prior Authorization

Prior authorization required for listed services

Obtain prior authorization for the listed services and J/C/Q codes (examples include G0277; hysterectomy codes 58578, 58579; infusion/injection service M0300; injectable examples 90291, Q5101 and multiple J/Q codes) prior to providing the service.

Billing Rule

Temporary (miscellaneous) code mappings for specific products

Temporary/miscellaneous code mappings are used for specific products: Pombiliti and Lyfgenia use temporary codes J3490, J3590 and C9399 effective April 1, 2024; Izervay and Daxxify have temporary code assignments noted in the policy—follow the effective‑date mapping when requesting authorization.

Pombiliti and Lyfgenia → J3490, J3590, C9399 (effective April 1, 2024)
Izervay → J3490, J3590, C9162; Daxxify → C9160 (effective January 1, 2024)

Billing Rule

Temporary HCPCS/CPT code usage for prior authorization

Effective January 1, 2024 use the temporary HCPCS/CPT code mappings specified in the policy for certain products (example: Izervay → J3490, J3590, C9162; Daxxify → C9160) when submitting prior authorization requests and claims.

Prior Authorization

Prior authorization required — selected medicine/procedure codes

Selected medicine and procedure codes (for example 90587, 90626, 90627, 90759) listed in the policy require prior authorization—follow the policy code list when submitting requests.

Prior Authorization

Prior authorization required — procedures and surgeries

Multiple procedure and surgery CPT codes across musculoskeletal, obstetrical, orthognathic and related categories (examples include 99500, 20957, 20972, 20973, 21198, 21206, 21208) require prior authorization as listed in the policy.

Prior Authorization

Orthotics and prosthetics prior authorization

Orthotics and prosthetics HCPCS L‑codes listed throughout the policy (examples include L1499, L5100, L5280, and many L‑series codes) require prior authorization prior to provision.

Prosthetics and orthotics L‑codes are subject to prior authorization per the L‑code lists in the policy

Prior Authorization

Prior authorization required for listed advanced outpatient imaging and other listed CPT/HCPCS codes

Advanced outpatient imaging CPT codes listed (CT, MRI, MRA, PET and other advanced imaging CPT codes in the 70000–79999 range shown) require provider notification/prior authorization before scheduling; submit requests online at www.evicore.com or call 800‑792‑8750.

Ordering providers are responsible for notification/prior authorization before scheduling advanced outpatient imaging
Use www.evicore.com or call 800‑792‑8750 to submit requests

Prior Authorization

Prior authorization for orthotics and prosthetics L‑codes

Orthotics and prosthetics L‑codes and prosthetics L‑codes listed (see L6704, L6706, L6712, L6721 and the L‑code list) require prior authorization; refer to the policy code list for exact L‑codes.

Prior Authorization

How to Obtain Prior Authorization

Care providers ordering Advanced Outpatient Imaging Procedures must provide notification or request prior authorization before scheduling; submit requests online at www.evicore.com or call 800‑792‑8750 as directed in the policy.

Prior Authorization

Procedure-specific prior authorization contact

For notification/prior authorization of procedure categories such as radiation therapy, rhinoplasty, stimulators and other listed procedures, submit requests online at www.evicore.com or call 800‑792‑8750 per the policy instructions.

Radiation therapy and many surgical/stimulator procedures require notification/prior authorization via eviCore
Submit via www.evicore.com or 800‑792‑8750

Prior Authorization

How to Obtain Prior Authorization

For notification or prior authorization for the listed procedures and categories, submit requests online at www.evicore.com or call 800‑792‑8750 as indicated in the policy.

Prior Authorization

Categories Requiring Prior Authorization

Certain categories—Transplants, Unlisted procedure codes, Urological procedures, Vein procedures, Removal and ablation and other listed categories—are explicitly identified as “Prior authorization required”; submit requests online at www.evicore.com or call 800‑792‑8750.

Transplant procedures require prior authorization
Unlisted procedure codes (e.g., 77299, 77399, 77499, 77799, 91299, 92499, 93799, 94799, 95199, 99199) require prior authorization
Use www.evicore.com or 800‑792‑8750 to submit requests

Definitions and Notes

Prior authorization / Advance notification

DefinitionPrior authorization is the process where health care providers seek approval before rendering a service; advance notification is a related requirement to provide timely communication for prospective, concurrent and retrospective review.

How to requestSubmit requests and supporting documentation via UHCprovider.com/priorauth for RMHP providers; non‑participating providers may fax to 800-262-2567 or 970-255-5681.

ExceptionsPrior authorization is not required for emergency or urgent care.

prosthetics / DME distinction

Policy distinctionProsthetics are explicitly noted as not classified as DME for the purposes of this list.

Citation contextListed when describing DME/HCPCS E-series codes; Additional Information states 'Prosthetics are not DME - see.'

ImplicationProsthetic items use prosthetics L‑codes and require separate prior authorization guidance rather than DME pathways.

EviCore prior authorization

EviCore-managed codesCertain codes (e.g., C9762, C9763, S8080) require prior authorization through eviCore; providers must submit requests online at www.evicore.com or call 800-792-8750.

Radiology vendor roleeviCore is referenced as the prior authorization manager for advanced outpatient imaging (radiology) procedures in the document.

Submission channelsFor eviCore-managed reviews submit requests online at www.evicore.com or by phone at 800-792-8750.

Enteral services

DefinitionEnteral services include enteral nutrition supplies and gastrostomy tube codes (B‑series) and in‑home nutritional therapy codes listed in the document.

Prior authorization requirementEnteral services and in‑home nutritional therapy codes require prior authorization.

Example codesB4149, B4150, B4152, B4153, B4154, B4155 (and related B‑codes listed).

Gender dysphoria treatment

DefinitionGender dysphoria treatment covers specified surgical CPT/HCPCS codes when billed with listed diagnosis codes (F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890).

Prior authorization requirementSurgical codes for gender dysphoria treatment require prior authorization when submitted with the specified diagnosis codes.

Associated diagnosis codesF64.0, F64.1, F64.2, F64.8, F64.9, Z87.890 (listed in the policy).

eviCore (third-party prior authorization manager)

RoleeviCore is the third‑party prior authorization manager referenced for specific codes and for advanced outpatient imaging procedures.

ContactSubmit requests online at www.evicore.com or call 800-792-8750 for eviCore‑managed reviews.

Codes exampleDocument identifies radiology and specific codes (e.g., C9762, C9763, S8080) as requiring eviCore authorization.

Genetic tests/lab services

Coverage stanceGenetic tests and laboratory services listed in the document require prior authorization.

ScopeExtensive lists of CPT/HCPCS/U codes (many U‑codes and CPT genetic test codes) are enumerated as requiring prior authorization.

eviCore noteSome genetic test codes are identified as managed by eviCore (indicated next to codes where applicable).

Prior authorization

General rulePrior authorization is required for listed CPT/HCPCS and DME codes as indicated throughout the document.

How to obtainProviders must submit requests via UHCprovider.com/priorauth for RMHP providers; other channels (eviCore, fax, phone) apply where specified.

Not covered/not authorizedServices not a benefit of the member's Evidence of Coverage will not be authorized.

Temporary code mappings

DefinitionTemporary code mappings are temporary/miscellaneous HCPCS/CPT/J codes used for certain drugs or products until permanent codes are available.

ExamplesJ3490, J3590, C9399, C9162, C9160 are used as temporary mappings for named products in the document.

Effective datesSome temporary assignments are effective January 1, 2024 or April 1, 2024 as noted per product in the policy.

temporary codes

DefinitionTemporary codes are HCPCS/CPT/J codes required for claim and prior‑authorization submission for named products beginning Jan 1, 2024 (where specified).

Products referencedIzervay (use J3490, J3590, C9162) and Daxxify (use C9160) are specifically called out for Jan 1, 2024 temporary code use.

Additional supply codesAssociated supply HCPCS codes (examples S0128, A2013, A4100, A4596, Q4135–Q4260) are listed alongside temporary mappings in the policy.

Temporary codes referenced for products (e.g., C9160 for Daxxify; J3490/J3590/C9162 for Izervay) effective Jan 1, 2024

Products and codesDaxxify → C9160; Izervay → J3490, J3590, C9162 (document specifies these temporary codes for Jan 1, 2024 effective use).

Other mappingsPombiliti and Lyfgenia use temporary codes J3490, J3590, C9399 effective April 1, 2024 (per Additional Information).

Submission noteUse the specified temporary codes for prior authorization and claims submission for the named products on/after the effective dates shown.

eviCore prior authorization vendor referenced for advanced outpatient imaging

Vendor referencedeviCore is the prior authorization vendor referenced for advanced outpatient imaging procedures; participating providers must notify/request prior authorization through eviCore.

ContactSubmit requests online at www.evicore.com or call 800-792-8750 for these imaging authorizations.

ScopeApplies to CT, MRI, MRA, PET and other advanced imaging CPT codes enumerated in the radiology sections.

Any advanced outpatient imaging study listed by CPT code in this section that requires provider notification/prior authorization before scheduling

DefinitionAn Advanced Outpatient Imaging Procedure is any CT, MRI, MRA, PET or other advanced imaging study listed by CPT code in this section that requires provider notification/prior authorization before scheduling.

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

ExamplesDocument lists numerous advanced imaging CPT codes (e.g., 70450, 70460, 72125, 73700, 74150, 75571) subject to prior authorization.

Advanced Outpatient Imaging Procedure

DefinitionAdvanced Outpatient Imaging Procedure — includes CT, MRI, MRA, PET and other advanced imaging procedures for which ordering providers must notify/request prior authorization before scheduling.

How to requestSubmit notification/prior authorization requests online at www.evicore.com or call 800-792-8750.

ApplicabilityApplies to participating physicians who request these advanced outpatient imaging procedures as listed by CPT code in the radiology sections.

Notification/prior authorization

Action requiredNotification or prior authorization must be submitted before scheduling selected procedures (submit online at www.evicore.com or call 800-792-8750).

Who must actOrdering care providers/participating physicians are responsible for initiating the notification/prior authorization.

When to contactFor radiation therapy, rhinoplasty, stimulators and other listed procedures follow the eviCore submission instructions in the document.

Unlisted codes

Policy noteUnlisted procedure codes (examples: 77299, 77399, 77499, 77799, 91299, 92499, 93799, 94799, 95199, 99199) are designated as requiring prior authorization.

Submission instructionFor unlisted procedures and other specified categories submit notification/prior authorization online at www.evicore.com or call 800-792-8750 as noted.

ExamplesSeveral unlisted and wildcard codes appear across the policy indicating prior authorization requirement for unlisted services.

Transplants

RequirementTransplant procedures identified in the transplant section require prior authorization.

Examples of codesTransplant-related CPT examples listed include 32850–32856 and a range of cellular therapy/transplant codes (e.g., 38205–38215, 33927–33945).

How to obtainFor transplant prior authorization follow document instructions to submit requests online at www.evicore.com or call 800-792-8750.

23206-23289	(range included in policy)
23472	Arthroplasty/related procedure
23473	Arthroplasty/related procedure
23474	Arthroplasty/related procedure
23929	Shoulder procedure
26556	Upper extremity procedure
26989	Hip/knee procedure
27130	Total hip arthroplasty
27132	Revision hip arthroplasty
27134	Hip procedure

43644	Bariatric surgery
43645	Bariatric surgery
43770	Bariatric surgery
43771	Bariatric surgery
43772	Bariatric surgery
43773	Bariatric surgery
43774	Bariatric surgery
43775	Bariatric surgery
43842	Bariatric - obesity related
43843	Bariatric - obesity related

93451-93461	Cardiac catheterization/angiography series
93451	Selective coronary
93461	Hemodynamic assessment
34839	Cardiovascular device implantation
J9000-J9999	Chemotherapy injectable drugs range requiring prior auth
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin
J1950	Leuprolide (Depot)
J0885	Injection (biosimilar/agent)

A4238	CGM transmitter/sensor
A4239	CGM supply
E0784	Continuous glucose monitor, external
E2102	Continuous glucose monitor, integrated
11920-11971	Cosmetic injection/related procedure range
11920	Cosmetic procedure example
11921	Cosmetic procedure example
11922	Cosmetic procedure example
11960	Cosmetic procedure
11970	Reconstructive procedure

91065	Diagnostic molecular pathology
91112	Digestive diagnostic
91132	Diagnostic procedure
91133	Diagnostic procedure
92512	Therapeutic procedure
93702	Therapeutic cardiology
96904	Therapeutic procedure
96920	Therapeutic procedure
96921	Therapeutic procedure
96922	Therapeutic procedure

OpenPayer

Prior authorization requirements (Colorado RMHP Prime)

Prior Authorization Coverage Criteria

Codes Requiring Prior Authorization (selected lists)

How to Obtain Prior Authorization / Provider Responsibilities

Definitions and Notes

A0110	DME (example)
A9520	DME (example)
A9999	DME (misc)
E0170	DME
E0193	DME
E0194	DME
E0196	DME
E0250	Scooter/wheelchair
E0255	Scooter/wheelchair
E0256	Scooter/wheelchair