UnitedHealthcare Prior Auth Requirements (NM)

Extracted prior authorization criteria (partial)

Selected coverage/prior authorization rules and examples from the list:

ALL of the following

Abortion procedures (ONE of)
- Abortion procedure prior authorization required when billed using codes 59840, 59841, 59850, 59852, 59855, 59856, 59857.
Augmentative and alternative communication
- Prior authorization required for communication assessment and device codes (examples: 92607, 92608, 92609, A9901, E2500, E2502).
Cancer supportive care (outpatient)
- Prior authorization required for colony-stimulating factor and specified bone-modifying agents when administered in an outpatient setting (examples: Filgrastim J1442, Q5110, Q5125, Q5101; Pegfilgrastim J2506, Q5122, Q5120, Q5111, Q5108).
Breast reconstruction — exception
- Certain breast reconstruction CPT/diagnosis pairings note that prior authorization is NOT required for specified diagnoses (see document for detailed C50.x exemptions).

ALL of the following

Prior authorization is required for diagnostic catheterizations and related endovascular procedures (examples: 37220, 37221) and for specified cardiac procedures (see Cardiology Prior Authorization page for full CPT list).

Prior authorization coverage criteria (partial)

Prior authorization requirements identified for specific service categories and code lists.

Injectable chemotherapy — prior authorization required when administered in an outpatient setting (includes IV, intravesical, intrathecal) for a cancer diagnosis; applies to chemotherapy agents billed with Q-codes, the J9000–J9999 range, specified J-codes (e.g., J0640, J0641, J0642, J1950) and miscellaneous HCPCS-billed agents.setting = outpatient

EEG / video EEG — certain cerebral seizure monitoring video EEG and EEG services require prior authorization when performed in an outpatient hospital or ambulatory surgical center (examples: 95715, 95716, 95718, 95720, 95722, 95724, 95726).

Code-based prior authorization rules (partial)

Authorization criteria indicated by code lists and diagnosis mappings (partial).

Reconstructive vs cosmetic procedures — prior authorization required for listed reconstructive/cosmetic CPT codes unless billed with qualifying reconstructive ICD-10 diagnosis codes that exempt the service. Examples of CPT codes requiring prior authorization (partial): 21181, 21230, 21235, 21256, 21275, 67900, 67923, 67924, 67950, 67961, 67966. Prior authorization not required when billed with specified C43/C44/C50.* diagnosis codes as noted in the document.

Durable Medical Equipment (DME) — prior authorization required for enumerated HCPCS/E-codes when retail purchase or cumulative/rental thresholds are met; rental cost > $500 is noted as a trigger for authorization (examples: E0787, E0465, E0445, E0194, E0265).rental cost > $500

Prior authorization requirements (partial)

Prior authorization required for the following service categories and listed codes:

Enteral services — prior authorization required for the listed HCPCS codes (examples: B4034, B4035, B4036, B4101, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4155, B4158, B4159, B4160, B4161, B9002, B9998).

Genetic and molecular testing (including BRCA) — prior authorization/notification required; ordering provider must indicate the laboratory and test name and follow the notification process (example CPT codes: 81229, 81401, 81405, 81410, 81402, 81406, 81411, 81415, 81403, 81407, 81412, 81416, 81228, 81277, 81349).

Hearing services — prior authorization required for hearing evaluations and hearing aids (examples: 92590, 92591, 92592, 92593, 92594, 92595, V5010, V5011, V5014, V5030, V5040).

Prior authorization requirements (partial) — injectables & procedures

Prior authorization is required for the listed injectable medications and specified procedure codes.

Injectable medications — prior authorization required for enumerated J-/Q-codes (partial list shown). Providers may contact Optum Specialty Guidance Program (SGP) for online authorization support (phone provided in document). Examples include Actemra J3262, Acthar Gel J0801, Adakveo J0791, Alyglo J1552 and many others listed in the injectable medication sections.

Hysterectomy and selected home health services — prior authorization required for listed hysterectomy CPT codes and specified home health/service codes (examples: 58150, 58152, 58180, 58200, 58210, 58541 and various G/S codes for home health).

Authorization requirement by code

Codes listed below are subject to prior authorization per this policy; providers should reference the specific HCPCS/CPT code when requesting authorization.

Examples (ONE of)

Crysvita — J0584 (prior authorization required).
Selected injectable drugs — examples: J3060 (Elevidys), J1302 (Entyvio), J1745 (Remicade), J3060/J1413/J2508 as listed in document.
IVIG and related codes — examples: J1459 series and mapping to J1551/J1554/J1555 etc.; prior authorization required for IVIG products as enumerated in the IVIG section.

Authorization requirements (excerpt)

Services and codes requiring prior authorization or notification in this excerpt:

Inpatient admissions and post-acute services — notification and prior authorization of admission date required for acute care hospitals and acute inpatient rehabilitation; providers must notify per instructions in the document.

Joint replacement — prior authorization required for joint replacement procedures (multiple CPT codes listed, examples include total hip/knee codes).

Non-emergent air ambulance transport — prior authorization required for listed A-codes (examples: A0430, A0431, A0435, A0436).

Orthotics and prosthetics — prior authorization required for numerous L-codes enumerated in the document (examples: L0462, L0480, L0631 and many others).

Prior authorization-required services (excerpt)

Services requiring prior authorization or notification in this excerpt:

Outpatient therapy — prior authorization required for listed CPT/HCPCS codes (examples include 92507, 92508, 92526, 92630, 92633, 96105, 97012, 97014, 97016, 97022, 97026, 97028, 97033, 97034, 97039, 97110, 97112, 97113, 97116, 97124, 97140, 97535, 97799, G0281, G0283, 97530).

Pain injections and management — prior authorization required for specified CPT codes (examples include 64490, 64493).

Private duty nursing — prior authorization required for codes such as T1002 and T1003.

Radiation oncology / advanced radiation (IMRT, IGRT, SRS/SBRT, proton beam) — prior authorization required for numerous CPT/HCPCS/G-codes (examples: 77385, 77386, 77387, G6015, G6016, 77520, 77522, 77523, 77525, 77371, 77372, 77373, 77399, 77470, S2095, 79445).

Advanced outpatient imaging (CT, MRI, MRA, PET, nuclear medicine/cardiology) — prior authorization or notification required; providers must notify prior to scheduling and submit requests via the Provider Portal or call the number listed (866-889-8054).

Prior authorization requirements

Prior authorization is required for the listed procedures, implants, transplant/CAR‑T therapies, vein procedures, VADs and wound vacs; specific codes are enumerated in the lists.

General requirement — prior authorization must be obtained for the enumerated services; submit requests via the UnitedHealthcare Provider Portal or by calling the phone numbers listed in the document. Certain services require specialized routing (Transplant Case Management or Optum Transplant) and clinical documentation to establish medical necessity.

Specialty routing (ONE of)

Transplant and CAR T‑Cell therapies — prior authorization and clinical documentation required; providers should call UnitedHealthcare Transplant Case Management Team at 800-418-4994 or use the notification number on the member ID card (document lists specific CAR-T products).
Optum Transplant routing — unclassified J-codes (J3490, J3590) and C9399 for specified gene and cell therapies require prior authorization through Optum Transplant per instructions in the document.

Other specialized devices/procedures

Codes and Code Groups Requiring Prior Authorization

Colony-stimulating factor drugs (outpatient cancer supportive care)HCPCSCovered

J1442	Filgrastim (Neupogen)
Q5110	Filgrastim-aafi (Nivestym)
Q5125	Filgrastim-ayow (Releuko)
Q5101	Filgrastim-sndz (Zarxio)
J2506	Pegfilgrastim (Neulasta)
Q5122	Pegfilgrastim-apgf (Nyvepria)
Q5120	Pegfilgrastim-bmez (Ziextenzo)
Q5111	Pegfilgrastim-cbqv (Udenyca)
Q5108	Pegfilgrastim-jmdb (Fulphila)

Sample procedural and diagnostic codes noted as requiring prior authorizationmixedCovered

59840	Abortion procedure code listed as requiring prior authorization
59841	Abortion procedure code listed as requiring prior authorization
59850	Abortion procedure code listed as requiring prior authorization
92607	Augmentative and alternative communication assessment
92608	Augmentative and alternative communication assessment
92609	Augmentative and alternative communication
A9901	Augmentative/alternative communication HCPCS
81162	Genetic testing code listed
81163	Genetic testing code listed
19316	Breast reconstruction code

1–10 of 11

1/2

Breast reconstruction and related diagnosis codes (some diagnoses exempt from prior authorization)mixed

19330	Breast reconstruction code
19357	Breast reconstruction (non-mastectomy) prior auth code
C50.011	Breast cancer diagnosis listed as not requiring prior authorization
C50.012	Breast cancer diagnosis listed as not requiring prior authorization

Cardiovascular/cardiology codes and some exempt diagnosis codesmixed

37220	Endovascular procedure - requires prior authorization
37221	Endovascular procedure - requires prior authorization
93580	Cardiac catheterization code listed
E11.52	Diabetic complication diagnosis listed as no prior authorization required

Sample CPT/HCPCS codes referencedmixed

170.239
170.241
170.242
170.243
170.244
170.245
170.248
170.25

EEG / video EEG codesCPTCovered

95700	Cerebral seizure monitoring video EEG
95711	Cerebral seizure monitoring video EEG
95712	Cerebral seizure monitoring video EEG
95713	Cerebral seizure monitoring video EEG
95714	Cerebral seizure monitoring video EEG
95715	Cerebral seizure monitoring video EEG
95716	Cerebral seizure monitoring video EEG
95718	Cerebral seizure monitoring video EEG
95720	Electroencephalogram (EEG)
95722	Electroencephalogram (EEG)

1–10 of 12

1/2

Injectable chemotherapy / oncology drug HCPCS codesHCPCSCovered

J9000-J9999	Range indicating chemotherapy injectable drugs
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin (other)
J1950	Lupron Depot

CPT codes (reconstructive/cosmetic) — partial listCPTCovered

21181	CPT code listed under reconstructive/cosmetic procedures requiring prior authorization (partial context)
21280	CPT code listed under reconstructive/cosmetic procedures requiring prior authorization (partial context)
67900	CPT code listed under reconstructive/cosmetic procedures requiring prior authorization (partial context)

DME / HCPCS codesHCPCSCovered

E0787	DME HCPCS code requiring prior authorization
E0465	DME HCPCS code requiring prior authorization (rental cost threshold noted)
K0013	DME/orthotic HCPCS code listed for prior authorization

ICD-10 diagnosis codes (cosmetic/reconstructive context)ICD-10

C43.0	ICD-10 diagnosis codes referenced in relation to prior authorization (melanoma sites etc.)
C44.01	ICD-10 diagnosis code referenced for authorization guidance
D04.111	ICD-10 diagnosis code referenced for authorization guidance

K-code injectable/related suppliesHCPCSCovered

K0013	Listed K-codes requiring prior authorization (partial list)
K0821	Example K-code from list

Genetic and molecular testing codes (BRCA)CPTCovered

81401	BRCA/genetic testing CPT code (example)
81229	Genetic testing CPT code (example)

Hearing services codesCPT | HCPCSCovered

92590	Hearing evaluation
V5010	Hearing aid HCPCS/V code

Injectable HCPCS/J-codes requiring prior authorization (partial list)HCPCSCovered

J3262	Actemra
J0801	Acthar Gel
J0584	Crysvita (repeated many times in chunks)
J1743	Elaprase / Elelyso (referenced)

Procedure CPT codes requiring prior authorization (partial list)CPTCovered

58150	Hysterectomy
58548	Hysterectomy/related

Crysvita referencesHCPCSCovered

J0584

Crysvita (HCPCS code referenced repeatedly)

Selected injectable drug codesHCPCSCovered

J3060	Elevidys
J1302	Entyvio
J1745	Remicade

IVIG and biologicsHCPCS | mixedCovered

J1459	IVIG-related code group
J9038	Cancer/antineoplastic agents (example entry)

Selected injectable medication J/Q codesHCPCS

J3316	Truxima
Q5115	Tyenne'
Q5135	Tzield
J9381	Ultomiris
J1303	Unclassified codes (J3490, J3590, C9399 referenced)

Air ambulance transport codesHCPCS

A0430	Non-emergent air ambulance transport
A0431	Non-emergent air ambulance transport
A0435	Non-emergent air ambulance transport
A0436	Non-emergent air ambulance transport

Selected joint replacement CPT codes (examples)CPT

27130	Joint; total hip and knee replacement (example)
27447	Knee procedure (example listed among joint codes)

Orthotics/prosthetics L-codes (sample)HCPCS

L0462	Orthotic/prosthetic code listed
L0480	Orthotic/prosthetic code listed
L0631	Orthotic/prosthetic code listed

Radiation oncology and related codesCPTCovered

77385	IMRT planning/delivery
77386	IMRT additional unit
77520	Proton therapy delivery/planning
S2095	Implantable beta-emitting microspheres
79445	Injection for implantable microspheres (radiology)
G0340	Standard radiation therapy (2D/3D) - prior auth when certain diagnoses

Therapy, nursing and pain management codesCPTCovered

92507	Speech-language therapy assessment
97110	Therapeutic exercises
97535	Self-care/home management training
T1002	Private duty nursing - per hour
64490	Injection, diagnostic or therapeutic, nerve block (first level)

Orthotics/prosthetics L-codes (examples)HCPCSCovered

L5830	Orthotic/prosthetic L-code example from list
L5961	Orthotic/prosthetic L-code example from list

Rhinoplasty/septoplastyCPT

30400-30465, 30450-30462, 30435

Rhinoplasty and septoplasty CPT codes listed as requiring prior authorization

Orthopedic and spinal surgeryCPT

29805-29807, 29819-29828, 23470-23474, 22100-22899, 63001-63102, 63170-63272, 63286-63306

Shoulder, spinal and related surgical CPT codes enumerated as requiring prior authorization

Misc implants, transplant, vein, VAD, wound vac, gene therapy and CAR‑T codesmixed

E0747-E0749, L8680-L8688, 33927-33983, Q0507-Q0509, 36468-36478, 37700-37765, E2402, J3391-J3394, J3392, J3490, J3590, C9399, Q2041-Q2057, 38232, 38240-38242

Various HCPCS/CPT/J/Q/Codes for stimulators, implants, transplant/CAR-T billing, vein procedures, VADs, wound vacs and gene therapy codes requiring prior authorization

Injectable chemotherapy — outpatient setting requirement

RequirementPrior authorization is required for injectable chemotherapy drugs administered in an outpatient setting (intravenous, intravesical, intrathecal) for a cancer diagnosis.

Included codes/rangesChemotherapy injectable drugs with Q-codes; J9000–J9999 range; specified J-codes such as J0640, J0641, J0642, J1950; miscellaneous HCPCS-billed agents.

Submission methodSubmit prior authorization requests online via the UnitedHealthcare Provider Portal or call 888-397-8129 as noted for these drugs.

SettingApplies to outpatient administration (includes outpatient hospital, ambulatory surgical center, clinic/office-based infusions).

DME rental cost threshold

ThresholdDurable medical equipment (DME) items listed may require prior authorization when rental cost exceeds $500.

Example codesE0445, E0457, E0465, E0466 and other E-/K-/L- codes listed in the DME section require prior authorization per retail purchase or cumulative/rental thresholds.

ActionProviders must request prior authorization for DME meeting retail purchase or cumulative/rental thresholds as specified in the policy.

How to Submit Requests and Operational Routing

Prior Authorization

How to submit prior authorization requests (online, phone, fax)

This list contains prior authorization requirements for participating UnitedHealthcare providers. Submit prior authorization requests using one of the following methods: - Online: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal at UHCprovider.com (sign in with One Healthcare ID). - Phone: Call 888-702-2202 (for general prior auth) or program-specific numbers shown for certain services. - Fax: 866-968-7582. Fax forms are available at UnitedHealthcare Prior Authorization Forms.

Online: UHCprovider.com → Sign in → Prior Authorization and Notification tab
General phone: 888-702-2202
General fax: 866-968-7582

Prior Authorization

Cardiology prior authorization routing

Cardiology services (outpatient diagnostic catheterizations, electrophysiology implants and stress echocardiography) require prior authorization for participating physicians. Submit requests online via the UnitedHealthcare Provider Portal or call the Cardiology prior authorization line.

Portal: UHCprovider.com → Prior Authorization and Notification
Cardiology phone: 866-889-8054
See Cardiology Prior Authorization and Notification for full CPT/HCPCS code list

Prior Authorization

Cancer supportive care prior authorization

Colony-stimulating factors and certain bone-modifying agents used as cancer supportive care in the outpatient setting require prior authorization.

Filgrastim (Neupogen) — J1442
Filgrastim biosimilars — Q5110, Q5125, Q5101
Pegfilgrastim (Neulasta) — J2506 and biosimilars Q5122, Q5120, Q5111, J5108
Sargramostim (Leukine) — J2820
Trilaciclib (Cosela) — J1448
Denosumab (Xgeva) — J0897

Prior Authorization

How to submit prior authorization requests (alternate phone/portal reference)

For outpatient injectable chemotherapy (including intravenous, intravesical and intrathecal) prior authorization is required. This includes chemotherapy drugs billed with Q-codes, J9000–J9999, miscellaneous HCPCS (unlisted drug) codes, and certain supportive and adjunctive injectable drugs. Submit prior authorization requests online via the UnitedHealthcare Provider Portal or call the chemotherapy prior authorization line.

Includes: all chemotherapy injectable drugs with Q-codes and J9000–J9999 range
Includes: leucovorin J0640, levoleucovorin J0641–J0642, Lupron Depot J1950
Includes: injectable drugs billed under miscellaneous HCPCS (e.g., J3490, J3590, C9399) — see specialty routing for unclassified codes
Submit online: UHCprovider.com; Chemotherapy phone: 888-397-8129

Prior Authorization

EEG / video EEG prior authorization note

Electroencephalogram (EEG) and video EEG outpatient hospital/ambulatory surgical center services require prior authorization.

CPT/HCPCS examples: 95715, 95716, 95718, 95720, 95722, 95724, 95726
Submit requests online via the UnitedHealthcare Provider Portal

Prior Authorization

Injectable chemotherapy prior authorization requirement

Certain injectable chemotherapy and other specialty injectables require submission through designated online pathways or specialty programs. For many specialty injectables, Optum Specialty Guidance Program (SGP) handles authorizations.

For specialty injectable authorizations or questions, call Optum SGP: 877-881-7618
New-to-market medications: check Review at Launch policy and submit via the Provider Portal

Prior Authorization

Prior authorization required — CPT/HCPCS (partial list)

Prior authorization is required for a broad set of CPT/HCPCS codes (partial list provided elsewhere in this document). Always verify code-level prior authorization requirements before scheduling or administering services.

Refer to the policy's CPT/HCPCS code lists for Radiology, Radiation Oncology, Cardiology, Orthotics/Prosthetics, Transplant, and other service lines
Use the Provider Portal to confirm whether a specific code requires prior authorization

Prior Authorization

Prior authorization required — Durable Medical Equipment (DME) HCPCS

Durable Medical Equipment (DME) items listed below require prior authorization when furnished as a retail purchase or when cumulative/rental costs exceed applicable thresholds. Submit DME prior authorization requests via the Provider Portal.

E0787 — External ambulatory infusion pump, non-durable
E0194 — Special wheelchair accessory
E0265, E0266 — Pressure-reducing support surfaces
E0270 — Power wheelchair accessory
E0300 — Wheelchair component
E0445 — Enteral feeding equipment (may require authorization when retail purchase or cumulative cost exceeds threshold)
E0457 — Enteral feeding pump component
E0465, E0466 — Oxygen equipment
E0483, E0486 — Home oxygen system components
E0620 — External blood glucose monitor
E0636, E0638 — Respiratory equipment components
E0255, E0256, E0260, E0261, E0280, E0290, E0291–E0295, E0301, E0303, E0315, E0316, E0462 — other DME items listed in the DME code list
K-codes and L-codes (e.g., K0013, K0108, K0800–K0890, L0462, L0464, L0480–L0486, L0624–L0640, L0710, L0810–L0830, L5830–L6999) — many orthotics/prosthetics and complex DME items require prior authorization

Prior Authorization

Miscellaneous injectable chemotherapy/drug-related and other service codes requiring prior authorization

In addition to chemotherapy drugs, the following categories of miscellaneous injectable, drug-related, and other service codes require prior authorization. This list consolidates multiple code ranges and notable single-code examples found in the source.

Injectable specialty and biologic medications listed in the Injectable Medications section (examples include J3262, J0801, J0791, J7171, J1931, J1552 and many others — see injectable medication lists)
Intravenous immunoglobulin (IVIG) and related codes (e.g., J1459, J1551, J1554–J1559, J1561–J1569, J1572–J1599, J2782 series, 90283–90284)
High-cost/brand injectables and gene therapies (e.g., J3393, J3394, J3399, J9202, J2778, J0219) require prior authorization and may route to specialty programs
Unclassified/unlisted drug codes (J3490, J3590, C9399) — prior authorization required and may need Optum Transplant routing for certain gene therapies and transplant-related biologics
Supportive injectables and related supplies (e.g., pegfilgrastim/neulasta J2506, filgrastim J1442 and biosimilars Q-codes) — prior authorization required for outpatient cancer supportive care
Certain medications require authorization via Optum Specialty Guidance Program (SGP) or other designated routing (see Injectable medications and IVIG lists)
When a drug does not yet have an assigned HCPCS code and will be billed under miscellaneous/unclassified codes, obtain prior authorization before administration

Prior Authorization

Prior authorization required for listed injectables; contact for online authorization (Optum SGP)

For a comprehensive list of injectable medications that require prior authorization (by J-/Q- codes and product names), refer to the Injectable Medications sections elsewhere in this document. Call Optum SGP for online authorization questions.

Optum Specialty Guidance Program (SGP): 877-881-7618
Examples: Actemra J3262; Acthar Gel J0801; Enjaymo J1302; Entyvio J3380; Feraheme Q0138; Hemlibra J7170; Ilumya J3245; Injectafer J1439; many others listed in the injectable medication sections

Prior Authorization

Procedure prior authorization (hysterectomy, home health)

Certain procedures (e.g., hysterectomy) and services (e.g., home health) require prior authorization. Use the Provider Portal to submit requests and confirm required documentation.

Hysterectomy examples: 58150, 58152, 58180, 58200, 58210, 58240, 58260, 58262–58294, 58541–58548
Home health services and related G-/S-codes: G0151–G0300, S9123–S9131, S9129, S9128, etc.

Prior Authorization

Prior authorization required — additional codes and routing notes

A detailed code list for injectable medications, IVIG, genetic testing, orthotics/prosthetics, radiology, radiation oncology, transplant/CAR T-cell therapies, VADs, wound vac, and many other services is included in this policy. For unlisted codes or gene therapies billed with J3490/J3590/C9399, additional routing through Optum Transplant may be required.

Transplant/CAR T-cell routing: UnitedHealthcare Transplant Case Management Team 800-418-4994
Unclassified drug codes (J3490, J3590, C9399) related to transplant/gene therapy: prior authorization through Optum Transplant

Key Terms and Abbreviations

Prior authorization (definition)

TermPrior authorization

DefinitionA process requiring providers to obtain approval from UnitedHealthcare before performing certain services or billing specified CPT/HCPCS codes as listed in this document.

How to submitRequests may be submitted online via the UnitedHealthcare Provider Portal (Prior Authorization and Notification tool), by phone (888-702-2202) or by fax (866-968-7582).

RBHA

TermRBHA (Regional Behavioral Health Authority)

DefinitionThe Regional Behavioral Health Authority program is the channel for behavioral health services under the plan.

NoteProviders should follow RBHA procedures and routing for behavioral health prior authorization as applicable.

Injectable chemotherapy drugs — definition

TermInjectable chemotherapy drugs

DefinitionIncludes chemotherapy injectable drugs that have a Q-code, agents billed in the J9000–J9999 range, specified J-codes (e.g., J0640, J0641, J0642, J1950) and miscellaneous HCPCS-billed agents without assigned codes.

ScopeApplies to outpatient administration (IV, intravesical, intrathecal) for cancer diagnoses.

EEG / video EEG

TermEEG / video EEG

DefinitionCerebral seizure monitoring video EEG and standard EEG services (CPT codes such as 95700, 95711–95718, 95720, 95722, 95724, 95726) where certain outpatient hospital or ambulatory surgical center services require prior authorization.

Setting notePrior authorization required for some video EEG and EEG services when provided in outpatient hospital or ambulatory surgical center settings.

Reconstructive procedures

TermReconstructive procedures

DefinitionProcedures that treat a medical condition or improve or restore physiologic function (examples shown in CPT listings for reconstructive codes).

Authorization notePrior authorization is required for listed reconstructive procedure codes unless criteria/diagnosis exemptions apply.

Cosmetic procedures

TermCosmetic procedures

DefinitionProcedures that change or improve physical appearance without significantly improving or restoring physiological function.

Authorization noteMany cosmetic procedure codes are listed and require prior authorization when billed as cosmetic; reconstructive vs cosmetic distinctions affect authorization requirements.

Genetic testing — prior authorization/notification

TermGenetic testing prior authorization/notification

DefinitionPrior authorization/notification is required for genetic and molecular testing (including BRCA); the ordering provider must indicate the laboratory and test name as part of the process.

Example codesExamples include CPT codes 81229, 81401, 81405, 81410 and many U-/S-/Q- codes listed in the genetic testing section.

Optum SGP

TermOptum SGP (Optum Specialty Guidance Program)

DefinitionPhone-based support line for questions about the online authorization process for listed injectable medications; contact number provided for assistance.

ContactOptum Specialty Guidance Program (SGP) phone: 877-881-7618 for online authorization questions (per injectable medications section).

Injectable medications — definition

TermInjectable medications (term group)

DefinitionGroup term for a broad set of prescription injectable drugs and biologics enumerated in the policy (J-/Q- codes and named agents) that require prior authorization as listed.

IncludesBiologics, specialty injectables and other HCPCS/J-coded medications listed across the document (see injectable medications sections).

IVIG

TermIVIG

DefinitionIntravenous immunoglobulin (IVIG) — group of products and related HCPCS/J-codes enumerated for authorization (e.g., J1459, J1551, J1554, J1555, J1556 series, J2782 entries and related administration codes).

Authorization noteIVIG and related codes are included in the prior authorization lists and require submission per the policy's process.

Inpatient admission notification

TermInpatient admission notification

DefinitionNotification is required for inpatient admissions; prior authorization and notification of admission date are required for acute care hospitals and acute inpatient rehabilitation.

ActionProviders must notify UnitedHealthcare prior to inpatient scheduling per the admission and post-acute services guidance in the document.

Review at Launch — New to Market Medications

PolicyReview at Launch — New to Market Medications

DefinitionPolicy to consult for up-to-date guidance on newly FDA-approved drugs; providers are directed to check Review at Launch for New to Market Medications for determinations and submission instructions.

Submission noteRequests for new-to-market medications should be submitted online via the UnitedHealthcare Provider Portal as recommended.

Authorization submission methods

MethodsAuthorization submission may be done online via UHCprovider.com (Prior Authorization and Notification tool) or by phone; portal is primary method.

Phone numbersGeneral submission phone: 888-702-2202; alternative numbers in document for specific services (e.g., 866-889-8054 for cardiology/radiology routing; 888-397-8129 referenced for some injectable drugs).

FaxFax submissions accepted at 866-968-7582; prior authorization forms available on the Provider Portal.

Out-of-network prior authorization

TermOut-of-network prior authorization

DefinitionAll out-of-network services require prior authorization under this policy; providers must obtain authorization before providing out-of-network care.

ActionSubmit prior authorization requests via the Provider Portal or call the numbers provided for out-of-network service authorization.

UnitedHealthcare Transplant Case Management Team

TeamUnitedHealthcare Transplant Case Management Team

ContactFor transplant and CAR T‑Cell therapy services (e.g., Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta) call 800-418-4994 or use the notification number on the member's ID card.

RequirementTransplant and CAR T‑Cell services require clinical documentation and prior authorization routed to the Transplant Case Management Team.

Third‑party prior authorization routing (Optum Transplant)

RoutingThird‑party prior authorization routing (Optum Transplant) for certain unclassified drug codes

ScopeUnclassified J-codes (J3490, J3590) and C9399 for specified gene/cell therapies (e.g., Amtagvi, Casgevy, Lantidra, Lenmeldy, Ryoncil, Skysona) require prior authorization through Optum Transplant.

ActionProviders must route prior authorization requests for these unclassified codes to Optum Transplant per the document instructions.

OpenPayer

Prior authorization requirements for UnitedHealthcare Community Plan of New Mexico (Turquoise Care)

Services and Code-Based Prior Authorization Criteria

Codes and Code Groups Requiring Prior Authorization

How to Submit Requests and Operational Routing

Key Terms and Abbreviations