Prior authorization requirements for Virginia Cardinal Care LTSS
Lists prior authorization requirements and submission methods for UnitedHealthcare Community Plan of Virginia Long-Term Support Services (LTSS) participating providers for inpatient and outpatient services.
Policy Summary
PayerUnitedHealthcare
PolicyPrior authorization requirements for Virginia Cardinal Care LTSS
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateJul 1, 2024
Next Review DateN/A
Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone at 877-843-4366.
No material clinical or coverage changes in this revision.
Onlineaccepted submission method
877-843-4366phone number for prior authorization requests
Emergency/urgent careprior authorization not required for
Many codesexamples of services requiring PA
Inpatient video EEGspecific service requiring authorization
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Coverage and Authorization Criteria
Coverage criteria overview
Prior authorization applies to many listed inpatient and outpatient services and specific codes. Emergency and urgent care are exempt; out-of-network providers must request prior authorization for all procedures and services.
Submit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone at 877-843-4366.
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.
Cancer supportive care and related services prior authorization criteria (excerpt)
The following excerpts identify cancer supportive care injectables, certain device and monitoring services, and diagnosis-linked rules that require prior authorization.
Colony-stimulating factor and related oncology supportive injectables listed (e.g., J1449, J1442, Q5110, Q5125, Q5122, J2506, Q5120, Q5111, Q5108, J2820, J1447) require prior authorization for outpatient administration; select colony-stimulating factors also require prior authorization for non‑oncology diagnoses.
Inpatient video EEG cerebral seizure monitoring (CPT range 95700–95726) requires prior authorization; the service is not subject to prior authorization when performed in an outpatient hospital or ambulatory surgical center.
Injectable chemotherapy drugs billed in the J9000–J9999 range (and leucovorin J0640), including intrathecal when for a cancer diagnosis and miscellaneous HCPCS billed agents, require prior authorization for outpatient administration; miscellaneous/unassigned injectable agents should be submitted via the Provider Portal.
Cochlear and other auditory implants (procedure and device codes such as 69710, 69714, 69930 and device codes L8614, L8619, L8690–L8692) require prior authorization.
Continuous glucose monitor supplies and equipment (examples A4226, A4239, A9276, A9277, A9278, E0787, E2102, E2103) require prior authorization when billed with a type 2 diabetes diagnosis.
Effective May 1, 2023, CPT codes 14020, 14021 and 14061 do NOT require prior authorization when billed with the specified cancer diagnosis codes listed elsewhere in the policy.
Coverage stance and prior authorization requirements for selected service groups and equipment.
In‑home enteral nutritional therapy (enteral or via gastrostomy tube; e.g., B9002, B9004, B9006, B9998) requires prior authorization.
Services designated experimental and investigational in the document are subject to prior authorization (examples cited in the list include CPT/HCPCS codes such as 33477, 36514, 64722).
Durable medical equipment (selected HCPCS codes) requires prior authorization when retail purchase or cumulative rental/purchase cost thresholds are met (see DME cost threshold guidance).
Selected surgical procedures (for example FAI, FESS, and gender dysphoria surgeries) are listed as requiring prior authorization; associated CPT codes are provided in the sections referenced.
Prior authorization criteria (section excerpt)
Items in this section are subject to prior authorization as indicated below.
Enumerated injectable medications and biologics listed in the injectable medications sections (long J-/Q- code lists) require prior authorization; some entries note predetermination recommended or Optum Rx prior notification for specific products.
Genetic and molecular testing CPT codes listed (examples include 81162, 81163, 81164, 81228 and a wider series of 8xxx/00xU codes) require prior authorization.
Home health and outpatient home‑based services (example codes G0299, G0300, G0493–G0496, S9123, S9124, S9474) require prior authorization when provided in outpatient settings including the member's home.
Multiple surgical and procedure CPT codes in this section are associated with diagnosis code F64.9 indicating linkage to gender dysphoria diagnoses; prior authorization requirements are noted alongside those entries.
Authorization criteria (partial section)
Authorization rules for high‑cost medications, joint procedures, air ambulance, and orthotics/prosthetics thresholds.
Injectable medications and biologics listed (see the detailed J-/Q- code lists) generally require prior authorization or predetermination; certain products require prior notification through Optum Rx (e.g., Cimzia, Synagis) or have special handling for unclassified/temporary codes.
Joint replacement procedures (total hip and knee and related CPT codes) require prior authorization as listed in the joint replacement section.
Non‑emergent air ambulance transport (e.g., A0430, A0431, A0435, A0436) requires prior authorization.
Orthotics and prosthetics items require prior authorization only when retail purchase or cumulative rental cost exceeds $500; numerous L‑codes are listed where this threshold applies.> $500
Prior authorization requirements (section)
General prior authorization and notification rules for procedural, radiation, imaging, and supportive services.
Radiation therapy modalities (IGRT, IMRT, proton beam, stereotactic radiosurgery and related CPT/HCPCS codes) require prior authorization; standard radiation therapy (2D/3D: e.g., 77401, 77402, 77407, 77412) requires prior authorization only when billed with specified cancer diagnosis code ranges.
Advanced outpatient imaging (certain CT, MRI, MRA, PET, nuclear medicine/nuclear cardiology) requires prior authorization/notification; ordering providers must notify prior to scheduling and submit requests via the UnitedHealthcare Provider Portal Authorization and Notification tool.
Prostate or nasal procedures
Prostate procedures listed (examples in the document) require prior authorization.
Prior authorization requirements — special routing for transplant, CAR T, VAD, and other specialized services
Special routing and contact instructions apply for advanced therapies, device implants, and certain unclassified drug codes.
Advanced outpatient imaging procedures (certain CT, MRI, MRA, PET, nuclear medicine/nuclear cardiology) require prior authorization/notification via the UnitedHealthcare Prior Authorization and Notification tool; ordering providers are responsible for notification prior to scheduling.
Rhinoplasty/septoplasty and related ENT procedures listed require prior authorization (see CPT lists in the policy).
Shoulder and spinal surgeries listed in the document require prior authorization (see provided CPT ranges and codes).
Stimulator and neurostimulator implantation procedures and related device codes require prior authorization.
Transplant and CAR T‑cell therapy services require prior authorization; providers should contact the UnitedHealthcare Community Plan Transplant Case Management team at 888-936-7246 for authorization and coordination.
Codes and Billing Identifiers Requiring Authorization
Cancer supportive care injectables and related agentsHCPCSCovered
J1449
Filgrastim (Neupogen)
J1442
Filgrastim-aafi (Nivestym)
Q5110
Filgrastim-ayow (Releuko)
Q5125
Pegfilgrastim-apgf (Nyvepria)
Q5122
Pegfilgrastim (Neulasta)
J2506
Pegfilgrastim (Neulasta)
Q5120
Pegfilgrastim-bmez (Ziextenzo)
Q5111
Pegfilgrastim-cbqv (Udenyca)
Q5108
Pegfilgrastim-jmdb (Fulphila)
J2820
Sargramostim (Leukine)
1–10 of 13
1/2
Selected surgical and device codesCPT | HCPCSCovered
Threshold summaryCertain DME items require prior authorization when retail purchase or cumulative rental cost thresholds are met; some DME entries are noted as requiring authorization when rental or purchase cost is more than $500 or when marked for retail purchase/cumulative rental review.
How Providers Obtain Prior Authorization and Required Notifications
Prior Authorization
How to submit prior authorization requests
Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal to submit prior authorization requests. To get started, go to UHCprovider.com and click Sign In at the top‑right corner to log in using your One Healthcare ID and password. Then select the Prior Authorization and Notification tab on your dashboard. If you don't have a One Healthcare ID, visit UHCprovider.com/access. You may also call 877-843-4366. 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.
Prior Authorization
Examples of services and codes requiring prior authorization
This document lists examples of services and CPT/HCPCS codes that require prior authorization. The list is illustrative; for complete, up-to-date code lists and specialty-specific routing instructions (for example cardiology, radiology, oncology and transplant), use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or the specialty prior authorization web pages referenced in this policy.
Examples include (not limited to): bariatric surgery (e.g., 43644, 43645, 43659, 43770, 43842-43846), bone growth stimulators (20975, 20979), breast reconstruction (19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19367-19371, 19380, 19396, L8600), cochlear and auditory implants (69710, 69714, 69930), functional endoscopic sinus surgery (31240, 31253-31259, 31267, 31276, 31287, 31288), femoroacetabular impingement (29914-29916), gender dysphoria surgical codes (see listed CPTs and associated Dx codes), hysterectomy (58150, 58152, 58180, 58260-58270), joint replacement (numerous hip/knee CPTs and J7330, S2112), orthognathic and maxillofacial procedures (21121-21127, 21141-21149, 21193-21299), rhinoplasty/septoplasty (30400-30462, 30465, 31296), advanced outpatient imaging (certain CT/MRI/MRA/PET and nuclear studies) and many more listed in this policy.
Key Terms and Definitions
Prior authorization — definition
DefinitionPrior authorization: A review and approval process required before certain procedures, services or supplies are provided; requests must be submitted via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by phone at 877-843-4366.
When requiredPrior authorization is required for many listed outpatient and inpatient services and specific CPT/HCPCS codes as enumerated in this policy.
ExemptionsEmergency and urgent care do not require prior authorization (see Authorization applicability for details).
Authorization applicability
Applicability to out-of-network providersOut-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services.
Emergency and urgent care
Policy Summary
PayerUnitedHealthcare
PolicyPrior authorization requirements for Virginia Cardinal Care LTSS
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateJul 1, 2024
Next Review DateN/A
Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone at 877-843-4366.
Extensive orthotics/prosthetics L-code lists are provided; many entries include 'how to obtain prior authorization', indicating prior authorization applies where noted.
Certain unclassified/temporary drug codes (for example J3490, J3590, C9399) will require Optum Transplant prior authorization effective 7/1/24 for specified products as noted in the policy.
Ventricular assist devices (VAD) require prior authorization; providers should call the notification number on the member's ID card and fax the nurse‑provided form to the Optum VAD Case Management team at 855-282-8929.
E0470, E0445, E0328, E0329, E0300 are listed with retail purchase, rental, or cost threshold guidance indicating potential prior authorization requirements.
Cost-specific triggerSome DME items list 'cost of more than $500' as the trigger for prior authorization (e.g., entries referencing E0470 and related E0-series codes).
Threshold amountPrior authorization is required for orthotics and prosthetics when the retail purchase or cumulative rental cost is more than $500.
Relevant code examplesL0486, L0624, L0629, L0631–L0638 (many L-codes listed) are shown with cumulative rental/retail purchase notes.
Application noteThreshold applies to items listed under Orthotics and prosthetics where cumulative rental cost or retail purchase exceeds the $500 trigger.
Diagnosis‑limited prior authorization — standard radiation therapy (2D/3D)
ScopeStandard radiation therapy (2D/3D) requires prior authorization only when obtained with specific cancer diagnosis codes in the listed ranges.
Diagnosis rangesPrior authorization applies when billed with diagnoses in the ranges C34.00–C34.92, C50.011–C50.929, C61, and C79.51 (as listed in the policy).
Example CPT codesStandard radiation therapy codes referenced include 77401, 77402, 77407 and 77412 (these codes require authorization only with the specified diagnoses).
Injectable and high-cost biologic medications (see injectable medications section) and many oncology-supportive agents (e.g., colony-stimulating factors J1442/J1447/J2506/Q5101/Q5108/Q5110/Q5111/Q5120/Q5122/Q5125, J1449, J2820, J2506, J0885) require prior authorization.
Transplants, CAR T and many new-to-market specialty medications have separate routing and contact requirements; see Transplant/CAR T instructions in this policy.
Experimental, investigational or unproven services and linked codes (multiple CPT/HCPCS listed) require prior authorization.
Prior Authorization
Behavioral health and ABA prior authorization
Behavioral health services may be managed through a designated behavioral health network. For specific codes requiring prior authorization for mental health and substance use services, call the number on the member's health plan ID card. For applied behavior analysis (ABA) therapy, submit prior authorization requests via fax or through the Provider Portal as directed in the member-specific instructions.
Behavioral health prior authorization: call the number on the member's ID card for routing and code-specific requirements.
Applied Behavior Analysis (ABA): submit via fax or the Provider Portal per plan instructions.
Prior Authorization
Cardiology prior authorization routing
Prior authorization is required for participating physicians for many outpatient and office-based cardiology procedures, including diagnostic catheterizations, echocardiograms, electrophysiology implants and stress echocardiography prior to performance.
Submit cardiology prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 866-889-8054.
See the Cardiology Prior Authorization and Notification page for detailed CPT code lists and further instructions.
Prior Authorization
Durable Medical Equipment
Durable Medical Equipment (DME), orthotics and prosthetics require prior authorization when specific HCPCS/L-codes are listed or when thresholds are exceeded. Providers must obtain prior authorization for listed DME and for orthotics/prosthetics when the item is billed as a retail purchase or when cumulative rental costs exceed the specified threshold.
Prior authorization is specifically required when prosthetics are billed (prosthetics are not DME) and when orthotic/prosthetic retail purchase or cumulative rental cost exceeds $500.
How to obtain authorization: submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal. When instructed in the policy, follow specialty routing (for example, some VAD and transplant notifications route to Optum teams using specified fax numbers).
Note
Additional provider actions and routing
This policy contains many other service- and specialty-specific prior authorization requirements (for example, chemotherapy, radiation therapy, injectable medications, home health, genetic/molecular testing, private duty nursing, VADs, transplants and CAR T). Always consult the policy's detailed lists and, when applicable, the specialty prior authorization pages or phone/fax instructions listed in this document.
Prior authorization is not required for emergency or urgent care services.
Submission methodsRequests may be submitted online via the Prior Authorization and Notification tool on UHCprovider.com or by phone at 877-843-4366.
Prior authorization — related term
Definition (term)Prior authorization: See policy — requests for applicable services must be submitted and approved before services are rendered (portal submission is required for many items).
Chemotherapy noteInjectable chemotherapy and related miscellaneous HCPCS agents administered outpatient require prior authorization (see chemotherapy process for submission).
Portal instructionUse the Prior Authorization and Notification tool on UHCprovider.com to submit requests for services that require prior authorization.
Prior authorization process — chemotherapy (portal submission)
Process for chemotherapy injectablesUse the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) to request authorization for chemotherapy injectable drugs (J9000–J9999 and miscellaneous HCPCS billed agents).
Intrathecal/intravesicalPrior authorization also applies to intrathecal chemotherapy for a cancer diagnosis and other specified administration routes per policy.
Unassigned-code handlingChemo drugs not yet assigned a code billed under a miscellaneous HCPCS code also require prior authorization via the portal.
DME — definition and notes
DefinitionDurable medical equipment (DME): Medical equipment supplies and devices described by HCPCS codes that may require prior authorization when listed in this policy and when cost/rental thresholds apply.
DME examplesExamples include codes A9279, A9280, A9900, E0194, E0265, E0266 among others listed in the DME section.
Threshold and rental notesSome DME items are subject to retail purchase or cumulative rental review and may require authorization when rental or purchase cost exceeds specified thresholds (e.g., > $500 for some items).
Experimental and investigational — definition
DefinitionExperimental and investigational services: Services and procedures listed under the 'Experimental and investigational' heading in this policy; these services require prior authorization.
ExamplesExamples of codes listed as experimental/investigational include 33477, 36514, 64722 and others noted in that section.
Authorization requirementServices designated experimental and investigational must obtain prior authorization before provision per policy guidance.
Prior Authorization and Notification tool — portal definition
Tool namePrior Authorization and Notification tool: The online functionality on the UnitedHealthcare Provider Portal used to submit prior authorization and notification requests.
Access instructionsGo to UHCprovider.com, sign in with One Healthcare ID, then select the Prior Authorization and Notification tab on the dashboard to submit requests.
When to useUse this tool for the many services listed in this policy (including injectable medications, imaging, DME, radiation therapy and other prior authorization items).
Predetermination — definition
DefinitionPredetermination: A recommended review (predetermination) is highly recommended for certain newly approved or high-cost drugs; see the Review at Launch guidance for New to Market Medications.
ContextPredetermination is particularly recommended for drugs on the Review at Launch list and for new-to-market medications.
Relation to prior authorizationPredetermination complements prior authorization by encouraging advance review for costly or novel therapies.
Prior notification — Optum Rx prior notifications and contact
Definition and scopePrior notification: For select products (e.g., Cimzia and Synagis), prior notification must be obtained through Optum Rx prior notifications services at 800-310-6826.
Products requiring Optum Rx notificationCimzia and Synagis are explicitly called out as requiring prior notification via Optum Rx.
Alternate routing noteSome unclassified/temporary drug codes may also require Optum or transplant routing per the policy; follow specific product guidance.
Authorization and Notification tool — portal functionality
FunctionalityAuthorization and Notification tool: Portal functionality on UHCprovider.com used by providers to submit prior authorization and notification requests online.
Submission requirementProviders must use this tool to submit advanced outpatient imaging and many other prior authorization requests as indicated in the policy.
Access stepsSign in at UHCprovider.com using One Healthcare ID and select the Prior Authorization and Notification tab on the dashboard.
Standard radiation therapy (2D/3D) — definition and diagnosis‑limited prior authorization
Diagnosis‑limited authorizationThese standard radiation therapy codes require prior authorization only when billed with cancer diagnosis codes in the ranges C34.00–C34.92, C50.011–C50.929, C61, and C79.51 (policy-specified ranges).
Other radiation modalitiesAdvanced modalities (IMRT, IGRT, proton beam, stereotactic radiosurgery) are listed separately and generally require prior authorization regardless of these diagnosis ranges.
Ventricular assist device (VAD) — definition and context
DefinitionVentricular assist device (VAD): A mechanical pump that takes over the function of the damaged ventricle of the heart and restores normal blood flow.
Authorization requirementVADs require prior authorization per the policy; providers should call the notification number on the member's ID card and follow Optum VAD Case Management instructions.
Contact/faxAfter calling the notification number on the member's ID card, fax the form provided by the nurse to Optum VAD Case Management at 855-282-8929.
Stimulators / Neurostimulators — definition and examples
DefinitionStimulators / Neurostimulators: Implanted devices that send electrical impulses; examples include spinal cord stimulators and deep brain stimulators with related CPT/HCPCS and L-codes listed.
Example codesCodes referenced include device and implantation ranges such as E0747–E0760, L8680–L8688 and CPT procedure codes like 61864, 63650, 64553–64590.
Authorization statusStimulator and neurostimulator implantation procedures are noted as requiring prior authorization in the policy.