CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Virginia Cardinal Care

Lists services, CPT/HCPCS/ICD codes, and instructions for submitting prior authorization requests for participating UnitedHealthcare Community Plan of Virginia/Virginia Cardinal Care providers; affects in-network and out-of-network providers serving covered members in Virginia.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Virginia Cardinal Care

Policy CodePolicy N/A

Change TypeAdministrative update — no material coverage changes

Effective DateFebruary 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or call 844-284-0146.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2026-02-01Effective date

844-284-0146Phone

UHCprovider.comOnline

J9000-J9999Injectable chemotherapy

A4226/A9278CGM devices

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Orthotics/prosthetics threshold

Coverage and Prior Authorization Criteria

inv-01: Prior authorization criteria for injectable and bone-modifying agents

Prior authorization is required for the injectable colony‑stimulating factors, select bone‑modifying agents, injectable erythropoiesis‑stimulating agents, and outpatient injectable chemotherapy when administered under the listed indications.

Prior authorization is required as specified below.

Colony‑stimulating factors

Administered in an outpatient setting for a cancer diagnosis.
Agent is one of the listed J/Q codes: J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125, Q5148, J1449, J2820, J1447 (as applicable).

Erythropoiesis‑stimulating agent

Agent: J0885 (Procrit).
Prior authorization required when administered outpatient as indicated in document.

Bone‑modifying agent

Agent: Denosumab (Xgeva) J0897.
Prior authorization required when administered in outpatient setting for a cancer diagnosis as noted.

Injectable chemotherapy

Prior authorization required for injectable chemotherapy drugs administered in an outpatient setting (intravenous, intravesical, intrathecal) for a cancer diagnosis.
Includes chemotherapy HCPCS range J9000–J9999 and specified agents such as J0640, J0641, J0642, J1950, J1954 and other listed J‑codes; miscellaneous/unassigned chemotherapy billed under miscellaneous HCPCS also require prior authorization.
Submit requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) or call the number given in the document.

inv-02: Procedure prior authorization requirements

Prior authorization is required for the following procedures and services when billed with the listed CPT/HCPCS codes or otherwise indicated.

Surgical and specialty procedures

Bariatric surgery (e.g., CPT 43644, 43645, 43659, 43770, 43846) requires prior authorization.
Breast reconstruction (non‑mastectomy) procedures require prior authorization (examples: CPT 19316, 19330, 19357, 19368, 19318, 19340, 19361, 19369, 19325, 19342, 19364, 19370, 19328, 19350, 19367, 19371).
Bone growth stimulator (e.g., CPT 20975, 20979) requires prior authorization.

Brain injury services: Prior authorization required (example code S0281).

inv-03: Stated prior authorization requirements and notes

Selected prior authorization stances, special conditions, and notable exceptions.

Injectable chemotherapy administered in an outpatient setting (IV, intravesical, intrathecal) for a cancer diagnosis requires prior authorization.

Chemotherapy HCPCS range J9000–J9999 and specified J‑codes listed in the document require prior authorization; Q‑coded chemotherapy agents and miscellaneous/unassigned injectable drugs billed under miscellaneous HCPCS also require prior authorization.

Continuous glucose monitors listed (A4226, A9278, A4239, E0787, A9276, A9277) require prior authorization when used with a type 2 diabetes diagnosis as specified.

EEG monitoring note

CPT codes 95700–95726 referenced for EEG monitoring.

inv-04: Authorization and coverage annotations (partial)

Service‑level annotations and special coverage notes.

Durable Medical Equipment (DME)

DME HCPCS codes listed (examples include A9279, E0194) require prior authorization.
Certain DME items exceeding cost thresholds (see orthotics/prosthetics thresholds) may trigger additional review.

Enteral services (e.g., B9002, B9998) require prior authorization.

Experimental/Investigational services: Codes marked as experimental/investigational require prior authorization and may be subject to denial as investigational (examples provided in document).

Femoroacetabular impingement (FAI) and functional endoscopic procedures:

inv-05: Prior authorization examples (partial)

Representative examples of services and codes for which prior authorization is required.

Genetic and molecular testing

Genetic/molecular testing CPT codes such as 81162, 81229, 81403, 81407, 81412 and listed U‑codes require prior authorization.
Additional listed proprietary U‑codes appear in the genetic/molecular testing section and require authorization per the document.

Home health and hysterectomy examples

Home health care in outpatient settings (including the member's home) requires prior authorization for G0299, G0495, G0300, G0496, G0493, S9474 as listed.
Hysterectomy procedures require prior authorization for listed CPT codes (e.g., 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58290, 58542).

inv-06: Home health & hysterectomy authorization (partial)

Home health care and hysterectomy prior authorization specifics (excerpt).

Home health care prior authorization is required only in outpatient settings, including the member's home (examples: G0299, G0495, G0300, G0496, G0493, S9474).

Hysterectomy procedures listed in the document require prior authorization (examples include CPT 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58290, 58542).

inv-07: Authorization and submission criteria (excerpt)

Authorization and submission instructions and selected service‑level requirements.

White blood cell colony‑stimulating factor codes listed require prior authorization for both oncology and non‑oncology diagnoses as indicated; unclassified/temporary codes (C9399, J3490, J3590) require prior authorization when used for specific drugs per document guidance.

Therapy services

Occupational and physical therapy require prior authorization after the initial evaluation and before the initial therapy visit.
Prior authorization is required for ongoing therapy visits as noted in the policy.

Non‑emergent air ambulance transport requires prior authorization for the specified HCPCS codes (see document).

inv-08: Prior authorization criteria (partial)

Prior authorization criteria and code lists for therapy and orthotics/prosthetics (partial).

Occupational/Physical Therapy codes

Prior authorization required after the initial evaluation and before the initial therapy visit; required for all ongoing therapy visits.
Examples of therapy CPT codes referenced include 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, and therapy modality CPTs 97033–97036 which require prior authorization before initiation.

Orthotics and Prosthetics general rule

Prior authorization is required only for orthotic and prosthetic items listed in the policy (sample HCPCS: L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484).
Some orthotics/prosthetics are subject to purchase or cumulative rental cost thresholds (see orthotics/prosthetics criteria).

inv-09: Code listing / prior authorization

Code listing for orthotic and prosthetic HCPCS entries (excerpt) — enumeration of device codes for which prior authorization is referenced.

HCPCS prosthetic codes listed include L0464, L0480, L0482, L0484 and additional L‑codes; the policy notes that prior authorization applies only for orthotic and prosthetic items listed.

inv-10: Prior Authorization Requirement

Prior authorization requirement summary for orthotics and prosthetics (excerpt).

Prior authorization is required only for orthotic and prosthetic items listed in this section. Examples of HCPCS codes cited include L0464, L0170, L0456, L0462, L0480, L0482, L0484, and L0112.

inv-11: Orthotics and prosthetics prior authorization and code list (partial)

Partial listing and note that prior authorization applies to the orthotics/prosthetics codes shown.

The document lists multiple orthotic and prosthetic HCPCS codes (e.g., L0112, L0170, L0456, L0462, L0464, L0484) and CPT entries (e.g., 21255, 21296, 21299) and states prior authorization is required for the items listed.

Providers should refer to the full code listings in the policy for the complete set of HCPCS/CPT codes subject to prior authorization.

inv-12: Orthotics/Prosthetics Prior Authorization Criteria

Orthotics and prosthetics prior authorization criteria including cost threshold trigger.

Prior authorization is required for orthotic and prosthetic items when the retail purchase price or cumulative rental cost exceeds the stated dollar threshold (document references $500).

HCPCS L‑codes listed throughout the orthotics/prosthetics section are subject to this prior authorization requirement when the purchase/rental threshold condition is met.

inv-13: Radiation therapy criteria

Radiation therapy prior authorization rules (standard and stereotactic modalities).

Standard radiation therapy (2D/3D) CPTs (e.g., 77402, 77407, 77412) require prior authorization only when provided with diagnosis codes in the specified ranges (C34.00–C34.92; C50.011–C50.929; C61; C79.51–C79.52; C84.7A; D05.00–D05.92).

Stereotactic radiosurgery/SBRT and related CPTs (e.g., 77371–77373) are listed with prior authorization instructions; providers should submit per policy guidance.

inv-14: Speech therapy criteria

Speech therapy prior authorization requirements (excerpt).

Prior authorization is required after the initial evaluation and before the initial therapy visit, and is required for all ongoing therapy visits for speech therapy services for members aged 3 years and older.

Examples of speech therapy CPT codes listed include 92507 (initial evaluation), 92508, and 92526.

inv-15: Miscellaneous procedures

Miscellaneous procedures and services requiring prior authorization.

Private duty nursing (T1000, T1002, T1003) requires prior authorization.

Spinal surgery procedures (listed CPTs) require prior authorization as indicated in the spinal surgery section.

Stimulators, implantable neurostimulators and related device implantation (examples: E0747, E0748, E0749, E0760, L8680) require prior authorization.

inv-16: Prior authorization requirements

Additional categories and specific services that require prior authorization; contact and submission instructions where provided.

Transplant and CAR T‑cell therapy services require prior authorization; contact Optum Health Transplant Resource Services at 888‑805‑1802 or use the notification number on the member's ID card for submission.

Gene therapy and unclassified drug codes (J3490, J3590, C9399) require prior authorization; code 38232 requires prior authorization only for an oncology diagnosis as noted.

Ventricular assist devices (VAD) require prior authorization; call the notification number on the member's ID card then fax the form to Optum VAD Case Management at 855‑282‑8929 as instructed.

Vein procedures (e.g., CPT 36473, 36475, 36478, 37700) and wound VAC (E2402) require prior authorization as listed.

CPT / HCPCS / ICD-10 Codes

Injectable colony-stimulating factor drugs requiring prior authorizationHCPCSCovered

Q5101	Biosimilar (Zarxio)
J1442	Filgrastim (Neupogen)
Q5110	Filgrastim-aafi (Nivestym)
Q5125	Filgrastim-ayow (Releuko)
Q5122	Pegfilgrastim-apgf (Nyvepria)
J2506	Pegfilgrastim (Neulasta)
Q5120	Pegfilgrastim-bmez (Ziextenzo)
Q5111	Pegfilgrastim-cbqv (Udenyca)
Q5108	Pegfilgrastim-jmdb (Fulphila)
J2820	Sargramostim (Leukine)

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How to Submit Requests and Operational Steps

Prior Authorization

How to submit prior authorization requests

This list contains prior authorization requirements for participating UnitedHealthcare providers. Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call the phone numbers shown with specific services. Prior authorization is not required for emergency or urgent care. Out‑of‑network providers must request prior authorization for all procedures and services.

Online: Sign in at UHCprovider.com using One Healthcare ID → Prior Authorization and Notification tab
Phone general prior auth: 844-284-0146
Transplant/CAR T and select specialty services: call numbers listed with the service or Optum resources as noted

Prior Authorization

Prior authorization for specific surgical procedures

Prior authorization is required for many specific surgical procedures. Examples include (but are not limited to): bariatric surgery (43644, 43645, 43659, 43770, 43846); fistula/vein procedures (36473, 36475, 36478, 37700); spinal surgery (e.g., 63306–63308, 0098T); joint total hip and knee replacement procedures (see policy codes listed); hysterectomy (58150, 58152, 58180, 58260, 58542, 58262, 58263, 58267, 58270, 58542); prostate procedures (37243, 52441, 52442, 53850, 53852). For transplant and CAR T-cell therapy, contact Optum Health Transplant Resource Services at 888-805-1802 or the notification number on the member’s ID card.

Terms and Definitions

Prior authorization

DefinitionA requirement to obtain approval from the plan before performing specified procedures or services; not required for emergency or urgent care. Out-of-network providers must request prior authorization for all procedures.

How to submitOnline via UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID or by phone at 844-284-0146.

ScopeApplies to participating UnitedHealthcare Community Plan of Virginia/Virginia Cardinal Care providers for specified inpatient and outpatient services.

Colony-stimulating factor drugs

What they areInjectable agents that stimulate blood cell production (colony-stimulating factors) identified by J/Q HCPCS codes.

Examples of codes

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Virginia Cardinal Care

Policy CodePolicy N/A

Change TypeAdministrative update — no material coverage changes

Effective DateFebruary 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or call 844-284-0146.

SourceLink

On This Page

Gender dysphoria and related reconstructive procedures:

Prior authorization required for listed surgical CPT codes and the related diagnosis codes (see document).

Inpatient video EEG services may require prior authorization; outpatient hospital or ASC video EEG exceptions are noted in the document.

Providers should submit prior authorization requests via the UnitedHealthcare Provider Portal or by the phone numbers indicated in the policy for the specific service type.

Specific procedural codes for FAI and functional endoscopic sinus surgery require prior authorization as listed.

Gender dysphoria treatment: CPT codes for gender dysphoria‑related procedures require prior authorization (see listed CPT/ICD pairings).

Providers instructed to submit injectable medication requests via the UnitedHealthcare Provider Portal as noted in the injectable medications section.

Member age note present in document: only members 3 years of age and older are subject to certain therapy prior authorization entries as indicated.

Bariatric surgery: 43644, 43645, 43659, 43770, 43846
Hysterectomy: 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58542
Spinal surgery: 63306, 63307, 63308, 0098T
Joint replacement (hip/knee): see joint replacement codes in policy
Prostate procedures: 37243, 52441, 52442, 53850, 53852
Vein procedures for varicose disease: 36473, 36475, 36478, 37700

Prior Authorization

HCPCS codes and prior authorization note

Some HCPCS code families and unclassified/miscellaneous codes require prior authorization or special handling. Examples: unclassified drug codes J3490, J3590 and miscellaneous C9399 frequently require prior authorization for gene therapies and certain high‑cost drugs; therapeutic radiopharmaceuticals are billed with A9513, A9590, A9699, A9606/A9607, A9615 and require online prior authorization submission; non‑emergent air ambulance services use A0430–A0436 (prior authorization required). When a service is billed under a miscellaneous or ‘unclassified’ code, follow the policy guidance and submit supporting clinical documentation.

Unclassified drug codes: J3490, J3590, C9399 — may require prior authorization for gene therapy and other high‑cost drugs
Therapeutic radiopharmaceuticals: A9513, A9590, A9699, A9606, A9607, A9615 — submit via Provider Portal
Non‑emergent air ambulance: A0430, A0431, A0435, A0436 — prior authorization required

Prior Authorization

Prior authorization for orthotics and prosthetics

Prior authorization is required for orthotics and prosthetics in many instances — typically for higher‑cost or custom devices. Examples of HCPCS codes that commonly require prior authorization include L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484 and L8659. Submit requests through the UnitedHealthcare Provider Portal and include clinical documentation supporting medical necessity.

Examples of orthotics/prosthetics requiring prior authorization: L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L8659
Prior authorization required only for orthotic and prosthetic items as noted — include clinical justification and measurements when applicable
Submit online at UHCprovider.com or call the number on the member’s ID card

Prior Authorization

Code examples requiring prior authorization

Code examples across the policy that demonstrate where prior authorization is required (representative, not exhaustive). Use these examples to confirm when to route a request through the Provider Portal or specialty contact numbers.

Injectable chemotherapy and related J‑codes (J9000–J9999 and select J/Q codes such as J0640, J0641, J0642, J1950, J1954, J1932, J1299, J1323, J1326, J2277, J3055, J3263) — submit online or call 888‑397‑8129
Colony‑stimulating factors and biosimilars: J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125, Q5148 — prior authorization required (oncology and some non‑oncology diagnoses)
Erythropoiesis‑stimulating agent: J0885 (Procrit) — prior authorization required
Bone‑modifying agent (Xgeva): J0897 — prior authorization required
Cochlear implant and auditory implant codes: 69710, 69714, 69930 and related L‑codes (L8691, L8614, L8692, L8619, L8690) — prior authorization required except as noted when billed with specific Dx codes
Continuous glucose monitor supplies: A4226, A9278, A4239, E0787, A9276, A9277 — prior authorization required for type 2 diabetes in certain situations
Joint replacement and major orthopedic procedure examples: see joint replacement section codes (policy lists multiple CPT/HCPCS for total hip/knee)

Q5101, J1442, Q5110, Q5125, Q5122, J2506, Q5120, Q5111, J1449

When prior auth is requiredPrior authorization required when administered outpatient for oncology diagnoses; portal submission or specified oncology guidance applies.

Injectable chemotherapy

DefinitionInjectable chemotherapy: injectable chemotherapy drugs administered in an outpatient setting including intravenous, intravesical and intrathecal for a cancer diagnosis.

Code ranges / examplesHCPCS range J9000-J9999 and listed J-codes (see chemotherapy injectable list in source).

SubmissionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (or follow specified phone contact for chemotherapy authorizations).

Continuous glucose monitor (CGM)

DefinitionContinuous glucose monitor (CGM) devices and supplies identified by HCPCS codes (examples: A4226, A9278, A4239, E0787, A9276, A9277).

Prior authorization conditionPrior authorization required with a type 2 diabetes diagnosis for certain CGM devices (document notes 'Prior authorization required with type 2 diabetes diagnosis').

Examples of HCPCS codesA4226, A9278, A4239, E0787, A9276, A9277

Prior authorization

Submission methodsOnline via UHCprovider.com (Prior Authorization & Notification tool) or phone 844-284-0146.

Not requiredNot required for emergency or urgent care.

Out-of-network ruleOut-of-network physicians, facilities and other providers must request prior authorization for all procedures and services.

Experimental/investigational

DefinitionExperimental or investigational services and linked services identified in the list; these entries require prior authorization and may be subject to denial if investigational.

Examples of flagged codes33477, 36514, 64722, 65765, A4638, A6000, A9274, E0231, E1831

Provider actionSubmit prior authorization per the listed instructions; experimental/investigational items carry additional review/denial risk.

Home health care prior authorization

ScopeHome health care prior authorization required only in outpatient settings, including the member's home.

Example codesG0299, G0495, G0300, G0496, G0493, S9474

Related noteProviders should submit requests via the UnitedHealthcare Provider Portal as indicated in the document.

Gender dysphoria related prior authorization

ScopeSurgical codes associated with gender dysphoria treatment require prior authorization when billed; specified diagnosis codes include F64.0, F64.1, F64.2, F64.8 and Z87.890.

Provider guidancePrior authorization required for listed CPT codes related to gender dysphoria and reconstructive procedures (see surgical code lists in source).

Example CPT codesMultiple CPT codes listed in gender dysphoria section (see source for full enumeration).

Prior authorization / prior notification

DefinitionPrior authorization / prior notification: health care professionals ordering advanced outpatient imaging procedures are responsible for providing notification prior to scheduling; prior authorization required for certain advanced outpatient imaging (CT, MRI, MRA, PET, nuclear medicine).

How to submit radiology requestsSubmit online using the UnitedHealthcare Provider Portal or call 866-889-8054 for radiology-specific inquiries.

Examples of proceduresCertain CT, MRI, MRA, PET scans and nuclear cardiology procedures require prior authorization (see Radiology Prior Authorization and Notification for CPT lists).

Pre-determination / Review at Launch

Pre-determination recommendationPre-determination (Review at Launch) is highly recommended for drugs newly approved by the FDA and included on the Review at Launch Medication List.

ContextUse pre-determination to help ensure coverage and correct processing for newly approved medications.

SubmissionSubmit requests via the UnitedHealthcare Provider Portal as directed for drugs on the Review at Launch list.

Prior authorization (therapy)

Therapy prior authorization timingPrior authorization required after the initial evaluation and before the initial therapy visit; required for all ongoing therapy visits.

Examples of PT/OT CPT codes97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033-97036 (see source for full lists).

Provider actionSubmit prior authorization per portal guidance prior to initiating therapy beyond the initial evaluation.

Prior authorization (orthotics/prosthetics)

ScopePrior authorization is required only for orthotic and prosthetic items (selected HCPCS L-codes).

Example HCPCS codesL0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484

Submission noteProviders should submit prior authorization requests via the UnitedHealthcare Provider Portal per the document listing.

orthotic and prosthetics

DefinitionOrthotic and prosthetic device entries and code placeholders throughout the document; many prosthetic HCPCS codes are enumerated with prior authorization noted only for items listed.

Representative codesL0464, L0480, L0482, L0484, L0170, L0456, L0462, L0112

NoteFull device lists and codes appear across multiple sections; refer to the HCPCS listings in the source for details.

Orthotics and prosthetics

DefinitionOrthotics and prosthetics — devices and related HCPCS codes referenced in the document; prior authorization applies only to listed items.

ExamplesL0464, L0170, L0456, L0480, L0482, L0484

Provider guidanceSubmit prior authorization for listed orthotic/prosthetic items per portal instructions; many entries are repeated as placeholders in the list.

Prior authorization

Trigger for prior authPrior authorization required for orthotic/prosthetic items when retail purchase or cumulative rental cost exceeds $500.

Referenced HCPCS examplesL0486, L0624, L0629, L0631, L0632, L0634, L0636, L0637, L0638, L0640, L0700, L0710

ApplicabilityApplies to orthotic and prosthetic items listed in the document when cost threshold is met; providers must obtain prior authorization before purchase/rental exceeding threshold.

Prior authorization trigger

Trigger amount$500 retail purchase or cumulative rental cost (threshold mentioned in document).

Applies toOrthotic and prosthetic items subject to prior authorization when purchase or cumulative rental cost exceeds this amount.

Provider actionObtain prior authorization before completing purchase or cumulative rentals that exceed $500 for listed items.

Proton beam

DefinitionProton beam: focused radiation therapy that uses beams of protons; referenced in the radiation therapy section as a type of focused radiation therapy.

Related CPT examplesReferenced CPTs in radiation therapy section include 77520, 77522, 77523, 77525 and associated planning codes (see source).

Prior auth stanceRadiation therapy procedures require prior authorization per the radiation therapy section criteria and diagnosis ranges.

Advanced outpatient imaging

DefinitionAdvanced outpatient imaging includes certain CT, MRI, MRA, PET scans, nuclear medicine and nuclear cardiology procedures that require prior authorization.

Provider responsibilityHealth care professionals ordering these procedures must provide notification prior to scheduling.

How to submitSubmit requests online via UnitedHealthcare Provider Portal or call 866-889-8054 for details; see Radiology Prior Authorization and Notification for CPT lists.

Ventricular assist devices (VAD)

DefinitionVentricular assist device (VAD): a mechanical pump that takes over the function of the damaged ventricle and restores normal blood flow.

Prior auth processCall the notification number on the back of the member's health plan ID card, then fax the form provided by the nurse to Optum VAD Case Management at 855-282-8929.

ApplicabilityPrior authorization required for VAD implantation and related services per the transplants/VAD section.

Wound vac

DefinitionWound vac (negative pressure wound therapy) identified by HCPCS E2402 in the document.

Prior auth requirementPrior authorization required for wound vac services and supplies as noted in the transplants/related procedures section.

Example codeE2402