CurrentUnitedHealthcarePolicy N/A

Rocky Mountain Children's Health Plan — Prior Authorization Requirements

Lists prior authorization requirements and submission methods for participating and non-participating providers delivering inpatient and outpatient services to members of UnitedHealthcare Community Plan of Colorado Rocky Mountain Children's Health Plan (CHP). Applies to providers who must obtain prior authorization for specified services and codes.

Policy Summary

PayerUnitedHealthcare

PolicyRocky Mountain Children's Health Plan — Prior Authorization Requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) Prior Authorization and Notification tool, fax (non-participating providers), or eviCore per instructions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3ways to submit prior authorization

EXCLUDEDemergency/urgent excluded

multipleservice categories listed

100+CPT/HCPCS codes referenced

eviCore

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Services That Require Prior Authorization

General prior authorization stance and submission requirements

Prior authorization is required for many inpatient and outpatient services listed below. Emergency and urgent care are excluded. Requests may be submitted via the UnitedHealthcare Provider Portal, eviCore, fax (non‑participating providers), or phone as noted.

ALL of the following

Submission methods
- Online: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) and sign in with One Healthcare ID.
- eviCore: Submit via www.evicore.com or call 800-792-8750 for services routed to eviCore (for example, many genetic/lab services and advanced outpatient imaging).
- Non-participating providers may fax requests and documentation to 800-262-2567 or 970-255-5681.
- For behavioral health services call 888-282-8801; admitting facility notification: 800-416-2157 (option 4) or 970-248-5197.
Prior authorization is not required for emergency or urgent care.
Out-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services.

Follow submission routes and contact numbers appropriate to the service (UnitedHealthcare Provider Portal, eviCore, fax or phone) as indicated in each service section.

Services Requiring Prior Authorization

Prior authorization is required for the following service categories and the associated CPT/HCPCS codes listed in the document.

Service categories requiring prior authorization (examples)

Durable medical equipment (DME) and related HCPCS codes (examples: A9520, A9279, A9280, A9900, E0194, E0265, E0266, E0270, E0277, E0300, E0328, E0329, E0445, E0446, E0457, E0460, E0465).
Enteral and in‑home nutrition services (specified K‑codes).
Orthotics and prosthetics (L‑codes and related HCPCS codes) — note: prosthetics are not considered DME; see orthotics and prosthetics section.
Genetic tests and laboratory services (numerous U‑codes and 8-series CPT/PLA codes) — many require prior authorization and some are managed via eviCore.

Prior authorization stance for listed services (partial)

The document specifies many service categories that require prior authorization and provides example codes and submission instructions; the following captures the stance for selected categories.

ANY of the following

Genetic tests/lab services: Prior authorization required; submit via eviCore (www.evicore.com / 800-792-8750) for those routed to eviCore.
Medical and surgical supplies: Category-level prior authorization applies (category 1 = prior authorization required) and numerous HCPCS supply codes are listed (examples: C1821, Q4282, C9352).
Musculoskeletal, obstetrical procedures, orthognathic surgery, orthotics and prosthetics, non-emergency transportation: category indications show prior authorization is required for category 1 items.
Home healthcare: Prior authorization required; example codes include G0176, G0248-G0250.

Temporary/unclassified code policy notes

Special rules apply for unclassified and temporary HCPCS/J‑codes; effective-date notes are included for select codes.

ALL of the following

Unclassified/temporary codes C9399, J3490, J3590: Prior authorization is required only when used for a defined set of drugs (examples listed: Amvuttra, Fylnetra, Lupaneta Pack, Nulibry, Recovi, Riabni, Rivfloza, Skyrizi, white blood cell colony stimulating factors, Veopoz).
Effective Jan. 1, 2024: Izervay should use temporary codes J3490, J3590 only.
Effective dates for other drug codes are noted where applicable (e.g., prior authorization required dates listed in the document).

For certain unclassified drug J‑codes (J3490, J3590, C9399) some agents require prior authorization through Optum Transplant — see Optum Transplant routing details in the document.

Prior authorization indicators and code lists (partial)

Categories, code examples, and header indicators showing which items require prior authorization.

ANY of the following

Medical and surgical supplies: Category 1 items require prior authorization (examples: C1821, Q4282, C9352).
Medicine services and procedures: Certain medicine/procedure CPT codes require prior authorization (examples: 97533, 97605, 97606, 97750).
Orthotics and prosthetics: Prior authorization required; examples include L1499, L3649, L4000, L4070.
Radiation therapy modalities (IGRT, IMRT, SRS/SBRT and related CPT/HCPCS codes) are included in header lists that require prior authorization or routing as indicated.

Header-level indicators in the document (e.g., 'Prior authorization required') apply to the code lists under each category; follow category-specific submission instructions.

Standard radiation therapy prior authorization by diagnosis

Prior authorization for standard (2D/3D) radiation therapy is required only when paired with specific diagnosis code ranges.

ALL of the following

Prior authorization required for standard radiation therapy (2D/3D) only when billed with diagnosis codes in the following ranges:
C34.00 - C34.92
C50.011 - C50.929
C61
C79.51 - C79.52

Advanced imaging prior authorization and notification

Advanced outpatient imaging and related procedures require notification or prior authorization; providers ordering these procedures must provide notification prior to scheduling.

ALL of the following

Care providers ordering advanced outpatient imaging are responsible for providing notification prior to scheduling the procedure.
Submit requests for advanced outpatient imaging via eviCore (www.evicore.com / 800-792-8750) as instructed in the Radiology section, or via the UnitedHealthcare Provider Portal where indicated.
For a full list of CPT codes requiring prior authorization, see the Radiology Prior Authorization and Notification reference noted in the document.

eviCore submission and phone number are provided for many advanced imaging items; UnitedHealthcare Provider Portal and phone (866-889-8054) are alternative submission routes where listed.

Skin substitute and sleep procedure prior authorization

Skin substitutes and sleep procedure codes listed in the document require prior authorization for participating physicians; follow UnitedHealthcare submission instructions.

ANY of the following

Skin substitutes: Prior authorization required for participating physicians who request these items; example HCPCS/CPT Q4117, Q4122, Q4123, S8035 (see section for full list).
Sleep procedures: Prior authorization required for participating physicians who request these procedures; example CPT codes include 64553, 64568, 64570, 64590 (see section for full list).

Submit skin substitute and sleep procedure prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-889-8054 as noted.

Prior Authorization Criteria (excerpt)

Excerpted prior authorization criteria and submission guidance for listed procedures and imaging codes.

ALL of the following

For advanced outpatient imaging, skin substitutes, and sleep procedures, participating physicians must request prior authorization; see the Radiology Prior Authorization and Notification for full CPT lists.
Submission options include the UnitedHealthcare Provider Portal (UHCprovider.com / call 866-889-8054) or eviCore (www.evicore.com / 800-792-8750) depending on the service routing specified in the document.
Example codes referenced in this excerpt include multiple Q/Q4/S HCPCS codes and CPT codes (e.g., Q4126, G0281, Q4127, S8035, Q4161, S8085, 96379, 64553, 64568, 64570, 64590, 95700–95724 series) — refer to the full lists for billing and authorization details.

Where the excerpt lists specific codes, those codes are subject to the header 'Prior authorization required' and must follow the indicated submission route.

Prior authorization coverage criteria (codes listed)

Prior authorization is required for multiple procedure categories and the specific CPT/HCPCS codes listed; certain unclassified J‑codes require routing through Optum Transplant.

ANY of the following

Radiology/advanced outpatient imaging: participating physicians must obtain prior authorization for many CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures (see Radiology Prior Authorization and Notification for full CPT lists).
Spine surgery, stimulators, transplant and other surgical procedures: Prior authorization required for numerous CPT/HCPCS codes listed in the document (example CPTs include many spine and neurosurgery codes and stimulator-related codes such as 20975, 20979, 63655, 63685).
Unclassified J‑codes (J3490, J3590, C9399) used for certain drugs (e.g., Amtagvi, Aucatzyl, Lenmeldy) will require prior authorization through Optum Transplant; Aucatzyl prior authorization effective April 1, 2025.

Follow the specified submission routes (UnitedHealthcare Provider Portal, eviCore, Optum Transplant) for the categories and codes indicated in the code lists.

CPT / HCPCS / Code Lists

Arthroscopy codes (partial)CPTCovered

29805	Arthroscopy procedure code listed as requiring prior authorization
29806	Arthroscopy procedure code listed as requiring prior authorization
29807	Arthroscopy procedure code listed as requiring prior authorization

Durable medical equipment codes (partial)HCPCSCovered

E0194	Durable medical equipment code listed for prior authorization
E0445	DME code listed for prior authorization

Selected DME/HCPCS examplesHCPCSCovered

A9520	DME-related HCPCS code listed for prior authorization
E0194	DME equipment HCPCS code listed for prior authorization

Genetic/Lab codesmixedCovered

0417U	Genetic test U-code requiring prior authorization
81406	Genetic test CPT/PLA code requiring prior authorization

Genetic testing CPT codes (partial)CPT

81402	Genetic test / laboratory service - code listed
81403	Genetic test / laboratory service - code listed
81404	Genetic test / laboratory service - code listed
81405	Genetic test / laboratory service - code listed

Additional genetic/test codes (partial)CPT

81518	Molecular/pathology related code
81431	Genetic test / laboratory service - code listed
81432	Genetic test / laboratory service - code listed
81435	Genetic test / laboratory service - code listed

Medical supplies and medicine services codes (partial)HCPCS | CPT

C1821	Medical and surgical supplies code listed
Q4282	Medical and surgical supplies code listed
C9352	Medical and surgical supplies code listed
97533	Medicine services and procedures code listed
97605	Medicine services and procedures code listed

Sample orthotics/prosthetics L-codesHCPCSCovered

L1499	Orthotics/prosthetics unspecified
L3649	Orthotics/prosthetics code listed
L4000	Orthotics/prosthetics code listed
L4070	Orthotics/prosthetics code listed

Pain management CPT codesCPTCovered

64490	Pain management injection/nerve block
64491	Pain management injection/nerve block

Radiation therapy codesCPTCovered

77385	IMRT related code
77520	Proton therapy code

Radiation/proton therapy codes requiring prior authorization (examples)CPTCovered

77520	Proton beam therapy
77522	Proton beam therapy
77523	Proton beam therapy
77525	Proton beam therapy
77331	Radiation therapy planning
77370	Special treatment delivery (radiation)
77470	Radiation treatment management

Advanced imaging CPT codes (examples) requiring prior authorizationCPTCovered

70450	CT head/brain without contrast
70460	CT head/brain with contrast
70540	MRI brain without contrast
70542	MRI brain with and without contrast
71250	CT thorax without contrast
71550	MRI chest without contrast

Skin substitute and related HCPCS/CPT codesmixedCovered

Q4117	Skin substitute code listed
G0281	Application of skin substitute or related
Q4122	Skin substitute code listed
S8035	Skin substitute code listed

Sleep procedures codesCPTCovered

64553	Sleep procedure / neurostimulation code listed
64568	Sleep procedure code listed

Sample HCPCS/Q codes in excerptHCPCSCovered

Q4126
G0281
Q4127
S8035
Q4161
S8085

Selected CPT codes in excerpt (non-exhaustive)CPTCovered

64553
64568
64570
64590
95700
95711
95712
95713
95714
95715

1–10 of 25

1/3

Spine/related CPT codes in excerptCPTCovered

22510
22511
22512
22513
22514
22515
22532
22533
22548
22551

1–10 of 37

1/4

Additional neurosurgery/spine CPT codesCPTCovered

63003
63016
63040
63042
63046
63050
63055
63064
63075
63077

1–10 of 20

1/2

Radiology codes requiring prior authorizationmixedCovered

63102	Example radiology/procedure code listed
G0281	Radiology-related HCPCS code listed

Spine and stimulator procedure codesCPTCovered

20975	Stimulator related code
63650	Spine/stimulator related code

inv-31: Temporary code usage restriction

Temporary code restrictionEffective Jan. 1, 2024 — Izervay should only be billed using temporary codes J3490 and J3590.

ScopeApplies to unclassified/temporary drug codes C9399, J3490, J3590 when used for specified drugs (see unclassified drug policy).

Related drugs examplePrior authorization for C9399/J3490/J3590 is required only for Amvuttra, Fylnetra, Lupaneta Pack, Nulibry, Recovi, Riabni, Rivfloza, Skyrizi, white blood cell colony stimulating factors, Veopoz.

How Providers Should Submit Requests and What to Expect

Prior Authorization

How to submit prior authorization requests and exceptions

Submit prior authorization requests using the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com, sign in with One Healthcare ID). Non-participating providers may fax requests and documentation to 800-262-2567 or 970-255-5681. Certain services (including advanced outpatient imaging and many genetic/laboratory services) are submitted via eviCore at www.evicore.com or by phone at 800-792-8750. Behavioral health requests: call 888-282-8801. Admitting facility notification: 800-416-2157 (option 4) or 970-248-5197. Prior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all procedures and services.

Online: UnitedHealthcare Provider Portal (UHCprovider.com) — use Prior Authorization and Notification (One Healthcare ID).
Fax (non-participating providers): 800-262-2567 or 970-255-5681.
eviCore: www.evicore.com or 800-792-8750 (for designated services including many genetic/lab and advanced imaging).
Behavioral health: call 888-282-8801; admitting facility notification: 800-416-2157 (option 4) or 970-248-5197.
Emergency/urgent care: prior authorization not required; out-of-network providers must request prior authorization for all services.

Key Terms and Portals

inv-61: Emergency/Urgent care

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

Notification for admitting facilityAdmitting facility notification phone: 800-416-2157 (option 4) or 970-248-5197.

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

inv-62: Prosthetics vs DME

DefinitionProsthetics are not considered durable medical equipment (DME); see orthotics and prosthetics for prior authorization requirements.

DME examplesDME items listed with HCPCS (e.g., A9520, E0194, E0445) require prior authorization when indicated.

Policy Summary

PayerUnitedHealthcare

PolicyRocky Mountain Children's Health Plan — Prior Authorization Requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2025

Next Review DateN/A

SourceLink

On This Page

Experimental and investigational procedures listed in the document require prior authorization.

Providers must obtain prior authorization for the specific CPT/HCPCS codes enumerated within each category in the full code lists.

Providers should follow the specific how-to-obtain instructions listed with each service (UnitedHealthcare Provider Portal or eviCore as indicated).

Other radiation therapy modalities (IMRT, IGRT, proton beam, SRS/SBRT) and their CPT/HCPCS codes are listed elsewhere and require prior authorization per their sections.

inv-32: Standard radiation therapy prior auth by diagnosis codes

When standard RT requires prior authStandard radiation therapy (2D/3D) requires prior authorization only when billed with diagnosis codes in these ranges: C34.00–C34.92, C50.011–C50.929, C61, C79.51–C79.52, C84.7A, D05.00–D05.92.

Related radiation modalitiesIMRT/IGRT and SRS/SBRT modalities are listed with CPT/HCPCS codes that require prior authorization (e.g., 77385, 77386, 77371–77373).

Proton beam referenceProton beam therapy CPT codes (77520, 77522, 77523, 77525) are listed under radiation/proton therapy requiring prior authorization.

inv-33: Effective date for Aucatzyl prior auth

Effective date for Aucatzyl prior authorizationEffective April 1, 2025 — Aucatzyl will require prior authorization when billed via unclassified J-codes.

How handledUnclassified codes J3490, J3590, and C9399 for Amtagvi, Aucatzyl, Lenmeldy require prior authorization through Optum Transplant.

Reference to Optum TransplantPrior authorization routing for these unclassified J-codes is via Optum Transplant (per section guidance).

Prior Authorization

Arthroscopy prior authorization (examples)

Arthroscopy CPT codes listed in the document (examples) require prior authorization before scheduling.

Examples of arthroscopy codes requiring prior authorization include: 29805, 29806, 29807, 29819, 29820, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29875, 29876, 29877, 29879, 29880, 29881, 29882, S2112.

Prior Authorization

Bariatric and breast reconstruction prior authorization (examples)

Bariatric surgery and non-mastectomy breast reconstruction procedures listed require prior authorization; specific CPT/HCPCS codes are provided in the policy.

Bariatric examples: 43644, 43645, 43770, 43775, 43842, 43845, 43846, 43847, 43848, 43860.
Breast reconstruction (non-mastectomy) examples: 19328, 19330, 19340, 19357, 19361, 19364, 19367–19371, 19380, 19396, L8600.

Prior Authorization

Cardiology prior authorization (examples)

Outpatient cardiology services, including office-based diagnostic catheterizations, echocardiograms, electrophysiology implants and stress studies, require prior authorization; numerous CPT/HCPCS codes are listed.

Sample cardiology codes requiring prior authorization include 33206, 33207, 33208, 33212, 33213, 33214, 33221, 33224, 33225, 33227, 33228, 33229, 33230, 33231, 33240, 33249, 33262–33264, 33270, 93350, 93351, 93452–93461, 0614T, 0571T, 93319.

Prior Authorization

Chemotherapy and implant prior authorization (examples)

Injectable outpatient chemotherapy drugs and selected implantable devices listed require prior authorization; selected HCPCS/CPT drug and implant codes are provided.

Examples include injectable chemotherapy drug HCPCS such as J1454, J0897, J1447 and implant/device codes such as 69930 and L8627; antiemetic and bone‑modifying agents are also listed.

Prior Authorization

DM monitoring and DME prior authorization (examples)

Continuous glucose monitors and certain durable medical equipment used for diabetes management require prior authorization; some monitors require authorization when the member has a Type 2 Diabetes diagnosis.

Continuous glucose monitor examples include CPT/HCPCS entries such as 11960 and 11971; certain monitors and related supplies (e.g., A4239, E0784) require prior authorization with Type 2 Diabetes as indicated.

Prior Authorization

Durable medical equipment prior authorization (examples)

Durable medical equipment (DME) items listed in the policy require prior authorization; prosthetics are not DME and have separate orthotics/prosthetics authorization requirements.

Examples of DME/HCPCS codes requiring prior authorization include A9520, A9279, A9280, A9900, E0194, E0265, E0266, E0270, E0277, E0300, E0328, E0329, E0445, E0446, E0457, E0460, E0465, E0466, E0470, E0471, E0483, E0485, E0625, E0636–E0710, E0745.
Note: 'Prosthetics are not DME - see Orthotics and prosthetics' as stated in the policy.

Prior Authorization

DME and Orthotics/Prosthetics Prior Authorization

Prior authorization is required for the DME, orthotics and prosthetics codes listed in the policy; orthotics/prosthetics codes and category entries are enumerated separately.

Orthotics/prosthetics examples include L1499, L3649, L4000, L4070 and many L‑codes shown under the Orthotics and prosthetics section.
Providers should follow the listed submission method for DME and orthotics/prosthetics.

Prior Authorization

K-codes and Enteral/In-home Nutrition Prior Authorization

Specified K‑codes and enteral/in‑home nutrition therapy codes require prior authorization; the policy lists the relevant K‑codes and mapped enteral HCPCS.

K‑code examples include mappings such as K0862/K0863/K0864/K0868 with corresponding replacement codes (e.g., K0862 = K0869, K0878, etc.) and enteral product codes B4149–B4162 and B9002/B9998 for gastrostomy tubes.

Prior Authorization

Experimental/Investigational Procedures

Procedures and services identified as experimental or investigational in the policy require prior authorization before provision; specific CPT and HCPCS examples are provided.

Examples listed as investigational include CPT codes 33477, 36514, 64722, 65765, 66180 and HCPCS such as A4638 and A9274.

Prior Authorization

Gender Dysphoria Treatment Prior Authorization

Gender dysphoria treatment surgical codes require prior authorization when billed with the specified diagnosis codes; surgical code lists and associated diagnosis requirements are indicated in the policy.

The policy states 'Gender dysphoria treatment — Prior authorization required' and notes 'These surgical codes with the following Dx codes' (see the gender dysphoria section for applicable CPTs and Dx pairings).

Prior Authorization

Genetic Tests / Laboratory Services Prior Authorization

Genetic tests and many laboratory services (including numerous U‑codes and PLA/814xx series CPT codes) require prior authorization; many of these are managed via eviCore as noted.

Examples include U‑codes and PLA codes such as 0417U, 0018U, 0022U, 0026U, 0047U, 0419U and CPT/PLA codes 81162–81164, 81228–81229, 81400–81408, 81410–81417, 81431–81465, 81518–81522, 81541, 81523, 81541 etc.
The policy instructs providers: 'Please submit requests online www.evicore.com to sign in. Or, you can call 800‑792‑8750' for genetic tests/lab services.

Prior Authorization

How to obtain prior authorization (eviCore submission and phone)

For eviCore‑managed services, submit prior authorization requests online at www.evicore.com or call 800‑792‑8750 as specified in the genetic and advanced imaging sections.

eviCore submission is required/used for many advanced outpatient imaging and genetic/lab services.
Phone: 800‑792‑8750; Web: www.evicore.com.

Prior Authorization

Genetic tests prior authorization requirement

Genetic tests and laboratory services listed in the policy require prior authorization; the document enumerates numerous U‑codes and 814xx/PLA codes that must be authorized.

See policy examples such as 0417U, 0018U, 0022U, 0026U, 0047U, 0419U, 81402–81408, 81410–81417, 81431–81465, 81518–81522, and many additional U‑codes and PLA entries requiring authorization.

Prior Authorization

Prior authorization for unclassified/temporary codes

Use Optum Transplant for prior authorization of specified unclassified/temporary J‑codes and C9399 when billed for the named drugs; the policy identifies the drugs and effective‑date change.

Unclassified/temporary codes C9399, J3490, J3590 require prior authorization only for specified drugs (Amtagvi, Aucatzyl, Lenmeldy, etc.).
Effective April 1, 2025: Aucatzyl will require prior authorization through Optum Transplant.
Note: the policy also lists other drugs subject to this rule (e.g., Amvuttra, Fylnetra, Lupaneta Pack, Nulibry, Recovi, Riabni, Rivfloza, Skyrizi, white blood cell colony stimulating factors, Veopoz).

Prior Authorization

Medical and surgical supplies prior authorization note

Medical and surgical supplies identified in the policy are subject to prior authorization; the policy enumerates Category 1 supply codes and other HCPCS entries that require authorization.

Examples of supply codes requiring prior authorization include C1821, Q4282, C9352, C9353, C9356, C9358, C9360, C9361, C9364 and numerous Q‑codes shown in the Medical and surgical supplies section.

Prior Authorization

Category-level prior authorization statement

Certain entire categories are flagged as requiring prior authorization (Category 1); these include musculoskeletal procedures, obstetrical procedures, orthognathic surgery, orthotics/prosthetics and non‑emergency transportation.

The policy states '...1 = Prior authorization required' for categories including Musculoskeletal, Obstetrical Procedures, Orthognathic Surgery, Orthotics and Prosthetics, and Non‑Emergency Transportation.

Prior Authorization

Pain management codes

Pain management injection and nerve‑block CPT codes listed require prior authorization; see the policy for the full list.

Pain management examples include CPT codes 64490–64495 (and related entries shown in the Pain management section).

Prior Authorization

Radiation therapy/proton beam codes

Radiation therapy and proton beam therapy codes require prior authorization; specific CPT/HCPCS codes for IMRT, IGRT, SRS/SBRT and proton beam examples are listed.

Examples include 77385, 77386, 77331, 77370, 77399, 77470 and proton beam codes 77520, 77522, 77523, 77525; submission via UnitedHealthcare Provider Portal or as directed.

Prior Authorization

Submission instructions (UnitedHealthcare)

Use the UnitedHealthcare Provider Portal (UHCprovider.com) to submit prior authorization requests or call 866‑889‑8054 when the policy directs UnitedHealthcare submission (for many radiology, skin substitute and other procedures).

Portal: UHCprovider.com (Sign In with One Healthcare ID) — Prior Authorization and Notification tab.
Phone for UnitedHealthcare submissions: 866‑889‑8054.

Prior Authorization

Submission instructions (eviCore) for advanced outpatient imaging

For advanced outpatient imaging, care providers must provide notification prior to scheduling and submit requests via eviCore online (www.evicore.com) or by calling 800‑792‑8750 as described.

Care providers ordering advanced outpatient imaging are responsible for notification before scheduling.
Submit via eviCore web portal or call 800‑792‑8750.

Prior Authorization

Prior authorization requirement summary

Participating physicians must obtain prior authorization for the advanced outpatient imaging, radiology, skin substitute and sleep procedures listed; follow the specified submission route (UHCprovider.com or eviCore) per the section.

Advanced imaging and radiology: see Radiology Prior Authorization and Notification for full CPT lists and submission instructions.
Skin substitutes and sleep procedures: prior authorization required for participating physicians; submit via UnitedHealthcare Provider Portal or call 866‑889‑8054 as directed.

Prior Authorization

How to Obtain Prior Authorization (UHCprovider.com / phone)

Submit prior authorization requests for the CPT/HCPCS codes identified for advanced outpatient imaging and other procedures via UnitedHealthcare Provider Portal (UHCprovider.com) or call 866‑889‑8054 when the policy indicates UnitedHealthcare submission.

Use UHCprovider.com or call 866‑889‑8054 for UnitedHealthcare‑managed prior authorization requests.
For the radiology CPT lists and details, see Radiology Prior Authorization and Notification referenced in the policy.

Prior Authorization

Radiology prior authorization

Radiology prior authorization is required for participating physicians requesting advanced outpatient CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures; submit via UnitedHealthcare Provider Portal or call 866‑889‑8054. For full CPT lists, consult Radiology Prior Authorization and Notification.

Example radiology CPTs referenced include 70450, 70460, 70470, 70480 and other CT/MRI entries; eviCore may manage some radiology requests as noted.

Prior Authorization

Surgery, spine, stimulators, transplants prior authorization

Multiple surgical, spine, neurostimulator and transplant procedure codes listed in the policy require prior authorization; providers should obtain authorization prior to scheduling.

Examples include stimulator and spine codes such as 20975, 20979, 63655, 63685, 95980–95982, 20975, 23473, 27130, 27446, 29868, 30465, 58541, 63001, 63190, 63191, 63650 and many spine surgery CPTs (see the Surgery/Spine/Stimulators/Transplants sections).
Transplants: prior authorization required (examples include 32850, 32851).

Prior Authorization

Unclassified drug codes prior authorization via Optum Transplant

Unclassified J‑codes (J3490, J3590) and C9399 used for the specified drugs require prior authorization through Optum Transplant; the policy lists Amvuttra, Aucatzyl, Lenmeldy and notes an effective date for Aucatzyl.

These unclassified/temporary codes require Optum Transplant prior authorization when billed for the named drugs.
Effective April 1, 2025, Aucatzyl requires prior authorization through Optum Transplant.

Prior Authorization

Vein procedures and ventricular assist device prior authorization

Vein procedures and ventricular assist device procedures listed require prior authorization; the policy provides CPT/HCPCS examples and notes prior authorization is required before performing these services.

Vein procedure example: 37799. Ventricular assist device (VAD) procedures are listed under the Prior Authorization section and require authorization.

Orthotics/prosthetics routingOrthotics and prosthetics have separate prior authorization entries and specific HCPCS L-codes listed in the prosthetics/orthotics section.

inv-63: eviCore

eviCore usageGenetic tests and certain lab services are managed via eviCore; providers should submit related prior authorization requests at www.evicore.com or call 800-792-8750.

Codes routed to eviCoreMultiple U-codes and PLA codes (examples in genetic test lists) are indicated as eviCore-managed in the genetic tests/lab services section.

Submission instructionProviders may sign in at evicore.com to submit requests or call the eviCore phone line for prior authorization handling.

inv-64: eviCore (portal and phone line)

eviCore portal and phoneSubmit genetic tests and eviCore-managed prior authorization requests online at www.evicore.com or call 800-792-8750.

Genetic test examplesNumerous U-codes and PLA codes (e.g., 0022U, 0026U, 0419U) in the genetic tests section are identified with eviCore routing.

Prior authorization requirementGenetic tests/lab services are designated as requiring prior authorization; see eviCore instructions for submission.

inv-65: Proton beam

Proton beam definitionProton beam — focused radiation therapy that uses beams of protons.

Prior authorization codesProton beam CPT codes listed include 77520, 77522, 77523, 77525 and require prior authorization.

Related radiation codesAssociated radiation planning and management codes (e.g., 77331, 77370, 77470) are listed alongside proton beam therapy.

inv-66: Proton beam

Proton beam therapy CPTsExamples of proton beam CPT codes requiring prior authorization include 77520, 77522, 77523, 77525.

Adjunct radiation codesPlanning and delivery codes listed in the radiation section (e.g., 77331, 77370, 77399, 77470) are associated with proton beam and other radiation modalities requiring prior authorization.

Modalities notedSRS/SBRT and IMRT/IGRT modalities and their CPTs are explicitly identified in the radiation therapy section.

inv-67: Radiation therapy modalities

Radiation therapy modalitiesIGRT, IMRT, SRS/SBRT and other radiation therapy modalities are listed with CPT/HCPCS codes that require prior authorization (e.g., 77385, 77386, 77371–77373).

Examples of modality codesModality and planning codes cited include 77385, 77386, G6015–G6017, and IGRT/IMRT-related entries.

Standard RT conditionStandard (2D/3D) radiation therapy has a separate rule: prior authorization required only with specific cancer diagnosis code ranges.

inv-68: Prior authorization (as used in this excerpt)

Prior authorization definition (excerpt)Prior authorization is required for participating physicians who request advanced outpatient imaging (certain CT, MRI, MRA, PET scans), nuclear medicine and nuclear cardiology procedures, and some specified procedures.

Submission portalSubmit requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-889-8054 for radiology and related prior authorizations.

Examples of covered imagingAdvanced outpatient imaging examples include certain CT, MRI, MRA and PET scans and associated CPT/HCPCS codes referenced in the Radiology Prior Authorization and Notification section.

inv-69: Optum Transplant

Optum Transplant routingUnclassified codes J3490, J3590 and C9399 for specific drugs (Amtagvi, Aucatzyl, Lenmeldy) require prior authorization through Optum Transplant.

Aucatzyl effective dateAucatzyl will require prior authorization effective April 1, 2025.

Provider actionProviders must follow Optum Transplant prior authorization procedures for those unclassified J-/C-codes as directed in the document.

inv-70: UnitedHealthcare Provider Portal

UnitedHealthcare Provider PortalPrimary online submission portal for prior authorization requests: UHCprovider.com (sign in with One Healthcare ID) — used for radiology and most prior authorization requests.

UnitedHealthcare phone supportProvider phone number for prior authorization: 866-889-8054 (radiology and portal support referenced across sections).

Alternate submission methodsNon-participating providers may fax to 800-262-2567 or 970-255-5681; eviCore and Optum Transplant are used for certain service categories.