CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for UnitedHealthcare Community Plan Apple Health Expansion of Washington

A list of services that require prior authorization for providers participating with UnitedHealthcare Community Plan of Washington and Apple Health Expansion, and instructions for how to request prior authorization. Applies to participating health care professionals providing inpatient and outpatient services in the named plan.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan Apple Health Expansion of Washington

Policy CodePolicy N/A

Change TypeAdministrative — no material coverage changes

Effective DateApr 1, 2023

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com with One Healthcare ID) or by phone at 877-542-9231.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Online and phoneways to request prior authorization

Excludedemergency/urgent care

Multiple codesexamples of services

4distinct breast procedure codes

20+

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.

repeated code mappings

Services That Require Prior Authorization

Prior authorization requirements (partial list from this chunk)

The document lists services that require prior authorization and provides contact methods; emergency and urgent care do not require prior authorization.

Prior authorization is required for inpatient and outpatient bariatric surgery (examples: CPT 43644, 43645, 43659, 43770).

Prior authorization is required for bone growth stimulators (examples: CPT/HCPCS 20975, 20979).

Prior authorization is required for breast reconstruction services (example: CPT 19316 and other reconstruction-related CPT/HCPCS codes listed elsewhere in the document).

How to request prior authorization: submit online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com using One Healthcare ID) or by phone at 877-542-9231. Out-of-network requests must be made by a network care provider.

Authorization requirement — CPT codes

Procedure codes requiring prior authorization for non-mastectomy breast procedures are enumerated; the document maps repeated CPT codes to prior authorization instructions.

Non-mastectomy breast procedure CPT codes repeatedly shown with prior authorization mapping include: 19357, 19361, 19364, 19367.

Prior authorization stance and listed items

Prior authorization is required for the following categories and items; submission instructions vary by service (portal and phone numbers provided in document).

Outpatient-administered cancer supportive care drugs require prior authorization when used for a cancer diagnosis (examples: colony-stimulating factors and erythropoiesis-stimulating agents).

Breast reconstruction procedures require prior authorization; certain diagnosis codes are noted as not requiring prior authorization (see code-linked sections).

Cardiovascular outpatient procedures require prior authorization (examples of CPTs listed); some specific codes may be exempt in specified contexts tied to diagnosis codes.

Submission instructions: for cancer supportive care use the Provider Portal or call 888-397-8129; cardiology prior auth phone number listed as 866-889-8054; general portal access at UHCprovider.com.

Prior authorization requirements (partial list)

Coverage stance and prior authorization requirements for listed services and codes.

Inpatient video EEG (cerebral seizure monitoring) — prior authorization required for inpatient services (CPTs: 95700, 95711, 95712, 95713, 95714, 95715, 95716, 95718). Note: text contains a conflicting phrase 'Prior authorization is not required' in the same section.

Injectable chemotherapy drugs administered in an outpatient setting for a cancer diagnosis require prior authorization (examples: J9000-J9999 range, J0640, J0641, J0642, J1950, J1952, J1954, J1932).

Cochlear implants and other auditory implants require prior authorization (examples: CPT 69710, 69714, 69930; HCPCS L8690, L8691, L8692, L8614).

Continuous glucose monitors (CGMs) require prior authorization when billed with a Type 2 diabetes diagnosis; listed HCPCS examples include A4226, A9278, A4238, A4239, E0787, A9276, E2103, A9277, E2102 and numerous E11.* diagnosis codes.

Prior authorization criteria (excerpt)

Services and items in this excerpt require prior authorization as specified below.

Cochlear implants and other auditory implants — prior authorization required (CPT/HCPCS examples: 69710, 69714, 69930, L8690, L8691, L8692).

Continuous glucose monitors (CGMs) — prior authorization required when billed with Type 2 diabetes diagnosis codes (HCPCS examples: A4226, A9278, A4238, A4239, E0787, E2103).

Cosmetic and reconstructive procedures — prior authorization required; reconstructive procedures that treat medical conditions or restore physiologic function are included with supporting ICD-10 codes (example CPTs: 11960, 14020, 14021, 14041, 15820, Q2026 and many others).

Prior authorization criteria (listed services)

Prior authorization requirements for several service groups and examples of associated codes.

Durable medical equipment (DME) — prior authorization required only for the codes listed; many E-/K-/A-series HCPCS codes are enumerated (examples include A9279, A9280, A9900, E0118, E0194, E0265, E0266, etc.).

Enteral services / in-home nutritional therapy — prior authorization required (example HCPCS: B4034, B4102; additional CPT/HCPCS codes listed in document).

Functional endoscopic sinus surgery (FESS) — prior authorization required; example CPT/HCPCS and molecular/genetic codes listed (examples: 31240, 31256, 31257, 31267, 31276, 31287, 31288, 81228, 0048U, 81405).

General note: Multiple code groups for cancer supportive care (various HCPCS/CPT and diagnosis codes) are enumerated across the section for prior authorization tracking.

Prior authorization-required services

Services requiring prior authorization in this section:

Functional Endoscopic Sinus Surgery (FESS) — prior authorization required (example CPTs: 31240, 31256, 31276, 31257, 31287, 31288, 31267).

Genetic and molecular testing (including BRCA) — prior authorization required; many CPT/HCPCS molecular and genomic test codes are listed (examples: 81162, 81229, 81163, 81277, 81403, 81407, 81412, 81228, 0048U, 81405, and many others).

Prior authorization requirement

The document indicates that listed cancer supportive care codes require prior authorization; per-code clinical coverage criteria are not present in these chunks.

Prior authorization is required for the grouped cancer supportive care CPT/HCPCS/proprietary codes listed in these sections (examples include 81479, 81520, 0102U, 81521, 81518, 81522, 87505, 81519, 81546, 0006M, 0211U, 0242U, 0007M, 0213U, 87506, 0114U, 0233U).

Cancer supportive care PA code list

Codes requiring prior authorization for cancer supportive care (document lists U-codes and molecular CPTs with 'How to obtain prior authorization' references).

Document lists the following U- and molecular CPT codes with prior authorization instructions: 0378U, 0334U, 0379U, 0355U, 0409U, 0364U, 0417U, 0465U, 0471U, 0473U, 0474U, 0475U, and genomic CPTs 81427, 81441, 81449.

Cancer supportive care — codes for prior authorization

Section lists codes used to obtain prior authorization for cancer supportive care; the document repeatedly references an instruction code for prior authorization.

How to obtain prior authorization for many molecular/genomic codes references '0475U' as the administrative instruction; codes listed in this context include 81427, 81441, 81449.

Cancer supportive care code listing

Code listings indicate prior authorization requirements for cancer supportive care; explicit clinical coverage criteria are not provided in these chunks.

Codes repeatedly cited with prior authorization instructions include 0475U and molecular CPTs such as 81427, 81441, 81449; providers are directed to reference 0475U in prior authorization processing for these entries.

Cancer supportive care prior auth criteria mapping

Diagnosis-to-code mappings and prior authorization exceptions relevant to cancer supportive care and genetic/molecular testing.

Asterisked CPT/HCPCS codes shown in the genetic/molecular test lists do NOT require prior authorization when billed with the listed ICD-10 cancer diagnosis codes (see asterisk/exception note).

Genetic/molecular testing CPT codes requiring prior authorization are enumerated (examples shown in nearby sections include 81450, 81451, 81455, 81457, 81458, 81459, 81462, 81463, 81464, 81523, 81541, 81542, 81552, S3854).

Extensive ICD-10 diagnosis code ranges (C00–C34 and continuing through C50–C81 and related subcodes) are listed to map tests and supportive care services to cancer diagnoses for prior authorization linkage.

Code-linked prior authorization criterion (fragment)

ICD-10 code fragment associated with services that require prior authorization; providers should reference these diagnoses when requesting prior authorization.

ICD-10 diagnosis code block (example fragment shown: C31.x–C50.x) — use these diagnosis codes as reference when requesting prior authorization for genetic/molecular testing and cancer supportive care services; see full policy for documentation requirements.

Prior authorization mapping for cancer supportive care

This section maps diagnosis codes to prior authorization requirements and indicates associated CPT/HCPCS codes and instructions.

Diagnosis-to-authorization mapping: broad ICD-10 ranges for cancer (examples: C50.* through C81.* and many subcodes) are linked to prior authorization instructions for genetic/molecular testing and cancer supportive care; providers should reference the linked CPT/HCPCS codes and 'How to obtain prior authorization' entries (e.g., 0475U) when submitting requests.

CPT, HCPCS, and ICD-10 Codes Referenced

Sample CPT/HCPCS codes mentionedmixedCovered

43644	Bariatric surgery - CPT listed in document
43645	Bariatric surgery - CPT listed in document
43659	Bariatric surgery - CPT listed in document
43770	Bariatric surgery - CPT listed in document
20975	Bone growth stimulator - HCPCS/CPT listed in document
20979	Bone growth stimulator - HCPCS/CPT listed in document
19316	Breast reconstruction - CPT listed in document

Sample CPT/HCPCS codes mentioned - supporting sourcemixedCovered

No codes listed

Breast reconstruction CPT codes repeatedly listedCPTCovered

19318	Breast reconstruction - CPT listed
19325	Breast reconstruction - CPT listed
19342	Breast reconstruction - CPT listed
19328	Breast reconstruction (non-mastectomy) - CPT listed
19357	Breast reconstruction (non-mastectomy) - CPT listed multiple times
19361	Breast reconstruction (non-mastectomy) - CPT listed multiple times
19364	Breast reconstruction (non-mastectomy) - CPT listed multiple times
19367	Breast reconstruction (non-mastectomy) - CPT listed multiple times
19330	Breast reconstruction - CPT listed

Non-mastectomy breast procedure CPT codesCPTCovered

19357	Breast procedure code referenced as requiring prior authorization (non-mastectomy)
19361	Breast procedure code referenced as requiring prior authorization (non-mastectomy)
19364	Breast procedure code referenced as requiring prior authorization (non-mastectomy)
19367	Breast procedure code referenced as requiring prior authorization (non-mastectomy)

Cancer supportive care HCPCS/J-codesHCPCSCovered

Q5101	Zarxio (biosimilar filgrastim)
J1449	Eflapegrastim-xnst (Rolvedon)
J1442	Filgrastim (Neupogen)
Q5110	Filgrastim-aafi (Nivestym)
Q5125	Filgrastim-ayow (Releuko)
J2506	Pegfilgrastim (Neulasta)
Q5122	Pegfilgrastim-apgf (Nyvepria)
Q5120	Pegfilgrastim-bmez (Ziextenzo)
Q5108	Pegfilgrastim-jmdb (Fulphila)
Q5111	Pegfilgrastim-cbqv (UDENYCA)

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Breast reconstruction CPT/HCPCS codesmixedCovered

19368	Breast reconstruction CPT
19369	Breast reconstruction CPT
19370	Breast reconstruction CPT
19371	Breast reconstruction CPT
11971	Adjunct code listed
19380	Breast reconstruction CPT (non-mastectomy cont.)
19396	Breast reconstruction CPT (non-mastectomy cont.)
L8600	Breast prosthesis HCPCS

Cardiovascular CPT codesCPTCovered

37220	Transcatheter embolization or occlusion
37226	Transcatheter embolization or occlusion
37221	Transcatheter embolization or occlusion
37227	Transcatheter embolization or occlusion
37224	Transcatheter embolization or occlusion
37230	Transcatheter occlusion (no prior auth in specified contexts)
37231	Transcatheter occlusion (no prior auth in specified contexts)

Sample ICD-10 diagnosis codes referencedICD-10

E08.52	Diabetes mellitus with diabetic peripheral angiopathy with gangrene (listed as a diagnosis requiring prior auth context)
E09.52	Diabetes due to an underlying condition with peripheral angiopathy with gangrene
E10.52	Type 1 diabetes with peripheral angiopathy with gangrene
E11.52	Type 2 diabetes with peripheral angiopathy with gangrene
I70.221	Atherosclerosis of native arteries of the extremities with ulceration

Chemotherapy HCPCS/J-codesHCPCS

J9000-J9999	Chemotherapy injectable drugs range
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin

Continuous glucose monitor HCPCSHCPCS

A4226	CGM supplies
A9278	CGM supplies
A4238	CGM supplies

Examples of CPT/HCPCS requiring prior authorizationmixedCovered

L8690	Cochlear implant external/implantable component HCPCS
L8691	Cochlear implant HCPCS
L8692	Cochlear implant HCPCS
69710	Cochlear implant CPT
A4226	CGM supply HCPCS
A9278	CGM supply HCPCS

ICD-10 codes cited to support reconstructive/cosmetic procedure authorizationICD-10Covered

C43.10	Melanoma ICD-10 code listed in reconstructive coverage context
C44.01	Other skin cancer ICD-10 code listed
D04.10	In situ carcinoma ICD-10 code listed

Internal policy codesmixed

C4A.122	Internal listing referenced for how to obtain prior authorization
C4A.20	Internal listing referenced for how to obtain prior authorization
C4A.21	Internal listing referenced for how to obtain prior authorization
C4A.22	Internal listing referenced for how to obtain prior authorization

Enteral / endoscopic procedure codesCPT | HCPCSCovered

B4034	Enteral nutrition, home infusion related HCPCS
B4102	Enteral nutrition related HCPCS
31240	Nasal/sinus endoscopy CPT
31255	Endoscopic procedure CPT (listed)
31256	Endoscopic sinus surgery CPT
31267	Endoscopic sinus surgery CPT

FESS example codesCPTCovered

31240	FESS CPT example
31256	FESS CPT example
31276	FESS CPT example

Genetic/molecular testing example codesmixedCovered

81162	Genetic/molecular testing
81229	BRCA/testing
81431	Molecular testing family

Cancer supportive care code group (examples)mixed

0007M
0213U
87506
0114U
0233U

Cancer supportive care code group (examples) - sourcemixed

No codes listed

Later U-code groupmixed

0307U
0326U
0318U
0334U

Genomic/molecular test codesmixedCovered

0475U	HCPCS/CPT U-code referenced in document
81427	Molecular pathology CPT code referenced
81441	Molecular pathology CPT code referenced
81449	Molecular pathology CPT code referenced

Genomic/molecular test codes - sourcemixedCovered

No codes listed

Assorted U-codesHCPCSCovered

0378U	Proprietary U-code referenced
0379U	Proprietary U-code referenced
0355U	Proprietary U-code referenced
0409U	Proprietary U-code referenced
0417U	Proprietary U-code referenced
0465U	Proprietary U-code referenced
0471U	Proprietary U-code referenced
0473U	Proprietary U-code referenced
0474U	Proprietary U-code referenced

Cancer supportive care codesmixed

0475U	Prior authorization reference code as listed in document
81427	Genetic/CPT code listed
81441	Genetic/CPT code listed
81449	Genetic/CPT code listed

Referenced CPT/HCPCS and molecular codesmixed

0475U	Listed molecular/CPT/HCPCS code associated with prior authorization
81427	Molecular pathology / genomic code referenced
81441	Molecular pathology / genomic code referenced
81449	Molecular pathology / genomic code referenced

Cancer supportive care codesCPT | HCPCS | mixed

0475U	Unlisted molecular pathology code referenced as how to obtain prior authorization
81427	Targeted genomic sequence panel (example code listed)
81441	Oncologic molecular test (example code listed)
81449	Molecular pathology code (repeatedly listed)

genetic_molecular_testingCPTCovered

81450	Genetic testing
81451	Genetic testing
81455	Genetic testing
81457	Genetic testing
81458	Molecular testing
81459	Molecular testing
81462	Molecular testing
81463	Molecular testing
81464	Breast related panel
81523	Breast related panel

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other_codesmixed

81427	Targeted genomic sequence analysis
81441	Unlisted genetic analysis
81449	Unlisted genetic analysis
0475U	Proprietary/other code referenced as additional information

ICD-10 diagnosis codes referenced for cancer supportive care prior authorizationICD-10Covered

C31.1	Malignant neoplasm in C31 series (example shown in fragment)
C34.0	Malignant neoplasm of main bronchus / lung (example shown)
C44.0	Malignant neoplasm of skin (example shown)
C50.0	Malignant neoplasm of breast (example shown)

ICD-10-CM cancer diagnosis ranges referencedICD-10Covered

C50.* - C81.*

Multiple malignant neoplasm codes for breast and other cancers referenced for supportive care and genetic/molecular testing

ICD-10-CM cancer diagnosis ranges referenced - sourceICD-10Covered

No codes listed

How to Request Prior Authorization and Provider-Facing Notes

Prior Authorization

How to request prior authorization

This list contains prior authorization requirements for health care professionals participating with the UnitedHealthcare Community Plan of Washington and Apple Health Expansion providing inpatient and outpatient services. To request prior authorization, please submit your request in one of the following ways: - Online: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal. To access the portal, go to UHCprovider.com and click on Sign In in the top-right corner to sign in using your One Healthcare ID and password. - By phone: Call 877-542-9231 Prior authorization is not required for emergency or urgent care. Out-of-network requests must be made by network care provider.

Prior Authorization

Example codes requiring prior authorization

Example codes (CPT/HCPCS/NDC/ICD-10) that commonly require prior authorization are listed throughout this section by specialty — examples include bariatric surgery codes (43644, 43645, 43659, 43770), bone growth stimulator codes (20975, 20979), breast reconstruction and related CPT/HCPCS codes (19316, 19357, 19361, 19364, 19367, 19368–19371, L8600, 11971, 19380, 19396), and numerous oncology supportive drug codes (J- and Q-codes noted below). Always check the provider portal for the definitive current code list and submission instructions.

Bariatric surgery: 43644, 43645, 43659, 43770

Key Definitions and Terms

Prior authorization — definition

DefinitionPrior authorization is a required pre-approval process for non-emergency or non-urgent inpatient and outpatient services as described in this list.

When not requiredPrior authorization is not required for emergency or urgent care.

Requesting providerOut-of-network requests must be made by a network care provider.

How to obtain prior authorization

Online submissionUse the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) and sign in with One Healthcare ID.

Phone submissionCall 877-542-9231 (general prior authorization phone number); alternate numbers listed for some service groups (e.g., 888-397-8129 for cancer supportive care, 866-889-8054 for cardiology).

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan Apple Health Expansion of Washington

Policy CodePolicy N/A

Change TypeAdministrative — no material coverage changes

Effective DateApr 1, 2023

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com with One Healthcare ID) or by phone at 877-542-9231.

SourceLink

On This Page

Bone growth stimulator: 20975, 20979

Breast reconstruction (examples): 19316, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 19396, L8600, 11971

Oncology injectable drugs: J9000–J9999 series, specific J- and Q-codes listed in cancer supportive care

Prior Authorization

Prior authorization required CPT codes (non-mastectomy)

Prior authorization is required for specified breast reconstruction CPT/HCPCS codes when not related to mastectomy or when coverage criteria require review. Examples of non-mastectomy breast reconstruction codes that require prior authorization include: 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 19396, L8600, 11971. Note: some diagnosis codes listed in this section may exempt the requirement (see diagnosis-linked instructions).

Non-mastectomy breast reconstruction CPT/HCPCS examples: 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 19396, L8600, 11971
Prior auth NOT required when billed with specific diagnosis codes listed later in this section (see ICD-10 linkage)

Prior Authorization

How to obtain prior authorization / submission instructions

To obtain prior authorization or submit requests for services and drugs listed in this section, please use one of the following submission methods depending on the service type: - UnitedHealthcare Provider Portal: Go to UHCprovider.com and sign in with your One Healthcare ID. Use the Prior Authorization and Notification tool to submit clinical information and supporting documentation. - Phone: For general prior authorization assistance call 877-542-9231. For oncology supportive care drug prior authorization call 888-397-8129. For cardiology-related prior authorization call 866-889-8054. Include relevant CPT/HCPCS/NDC codes, diagnosis (ICD-10) codes, clinical notes, and attachments (operative reports, pathology, imaging, prior treatments) as applicable. Prior authorization is not required for emergency or urgent care; out-of-network requests must be made by a network provider.

Submit online via UHCprovider.com Prior Authorization and Notification tool
Call 877-542-9231 for general prior auth assistance
Oncology drug prior auth: 888-397-8129
Cardiology prior auth: 866-889-8054
Include CPT/HCPCS/NDC, ICD-10, clinical documentation and attachments

Prior Authorization

Breast reconstruction prior authorization requirements and codes

Breast reconstruction prior authorization is required for many reconstruction procedures. Submit procedure CPT/HCPCS codes, reason for reconstruction, related diagnosis (ICD-10), operative reports, and pathology when applicable. Examples of CPT/HCPCS codes requiring prior authorization include primary and revision reconstruction codes (19316, 19357, 19361, 19364, 19367, 19368–19371, 19380, 19396), implant and tissue-expander codes (L8600, 11971), and related modifiers or additional codes. Some breast cancer and reconstruction-related diagnosis codes listed in this section exempt prior authorization — review ICD-10 linkage below before submission.

Breast reconstruction examples: 19316, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 19396
Implant/device codes: L8600; adjunct codes: 11971
Include operative reports, pathology, and related diagnosis codes with request
Check ICD-10 linkage for codes that may NOT require prior authorization

Prior Authorization

Cancer supportive care drugs requiring prior authorization

Prior authorization is required for colony-stimulating factors, erythropoiesis-stimulating agents, bone-modifying agents and certain antiemetics administered in an outpatient setting for a cancer diagnosis. Submit oncology drug requests via the Provider Portal or by calling the oncology drug prior authorization number.

Colony-stimulating factor examples (require prior auth): Q5101 (Zarxio), J1449 (Eflapegrastim-xnst/Rolvedon), J1442 (Filgrastim/Neupogen), Q5110 (Filgrastim-aafi/Nivestym), Q5125 (Filgrastim-ayow/Releuko), J2506 (Pegfilgrastim/Neulasta), Q5122 (Pegfilgrastim-apgf/Nyvepria), Q5120 (Pegfilgrastim-bmez/Ziextenzo), Q5108 (Pegfilgrastim-jmdb/Fulphila), Q5111 (Pegfilgrastim-cbqv/UDENYCA)
Erythropoiesis-stimulating agent example: J0885 (Procrit)
Bone-modifying agent requiring prior auth: Denosumab
Antiemetic codes that require prior auth: J1456

Prior Authorization

Prior authorization required for listed cancer supportive care codes

The following cancer supportive care drug codes require prior authorization when administered in the outpatient setting for a cancer diagnosis. Submit requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) or call 888-397-8129 for assistance. Injectable colony-stimulating factor drugs that require prior authorization: Q5101 (Zarxio), J1449 (Eflapegrastim-xnst/Rolvedon), J1442 (Filgrastim/Neupogen), Q5110 (Filgrastim-aafi/Nivestym), Q5125 (Filgrastim-ayow/Releuko), J2506 (Pegfilgrastim/Neulasta), Q5122 (Pegfilgrastim-apgf/Nyvepria), Q5120 (Pegfilgrastim-bmez/Ziextenzo), Q5108 (Pegfilgrastim-jmdb/Fulphila), Q5111 (Pegfilgrastim-cbqv/UDENYCA).

Submit oncology drug prior auth via Provider Portal or call 888-397-8129
Colony-stimulating factors: Q5101, J1449, J1442, Q5110, Q5125, J2506, Q5122, Q5120, Q5108, Q5111

Prior Authorization

Prior authorization listing continued

Erythropoiesis-stimulating agent and bone-modifying agent prior authorization examples: - J0885 (Erythropoiesis-stimulating agent; Procrit) requires prior authorization when used for cancer-related indications per plan rules. - Denosumab (specific J- or HCPCS code as billed) requires prior authorization when used as a bone-modifying agent in cancer supportive care. For antiemetic injectable codes flagged for prior authorization, see J1456.

Erythropoiesis-stimulating agent: J0885 (Procrit)
Bone-modifying agent: Denosumab (code as billed)
Antiemetic prior auth example: J1456

Prior Authorization

Chemotherapy injectable drugs

Chemotherapy injectable drugs administered in outpatient settings require prior authorization. This includes the J9000–J9999 chemotherapy series and specific agents such as leucovorin (J0640), levoleucovorin (J0641, J0642), leuprolide formulations (J1950, J1952, J1954), lanreotide (J1932), and others. Some chemotherapy products have Q-codes or are new agents requiring review. Submit complete regimen details and supporting clinical documentation.

Chemotherapy injectable range: J9000–J9999
Examples: J0640 (Leucovorin), J0641/J0642 (Levoleucovorin), J1950/J1952/J1954 (Leuprolide variants), J1932 (Lanreotide)
Include regimen, indication (ICD-10 cancer diagnosis), prior treatments, and supportive labs

Prior Authorization

Cerebral seizure monitoring - inpatient video EEG

Cerebral seizure monitoring — inpatient video EEG prior authorization: Prior authorization is required for inpatient services for cerebral seizure monitoring (video EEG). Examples of CPT codes include 95700–95718 (monitoring series such as 95700, 95711–95716, 95713, 95714, 95715, 95718). Note: emergent inpatient care may not require prior authorization per emergency rules; verify with the portal for elective admissions.

Inpatient video EEG codes (examples): 95700, 95711, 95712, 95713, 95714, 95715, 95716, 95718
Prior authorization required for planned/elective inpatient video EEG monitoring

Prior Authorization

Prior authorization / codes referenced

Functional Endoscopic Sinus Surgery (FESS), cochlear implants, continuous glucose monitors, DME and many genetic/molecular tests likewise require prior authorization with specific CPT/HCPCS and ICD-10 diagnosis linkage. For genetic and molecular (including BRCA) testing, numerous specific CPT/HCPCS codes are listed in this section (examples: 81162, 81228, 81229, 81277, 81403*, 81407*, 81412, 81479*, 81520, 81427, 81441, 81449, 0475U, 0465U, etc.). Some codes marked with an asterisk (*) do NOT require prior authorization when billed with certain diagnosis codes listed below — see ICD-10 linkage.

FESS example CPTs: 31240, 31256, 31276, 31257, 31287, 31288
Cochlear implant/device example codes: 69710, 69714, 69930, L8690–L8692, L8614
Continuous glucose monitor examples: A4226, A9278, A4238, A4239, E0787, A9276, E2103, A9277, E2102
Genetic/molecular testing examples: 81162, 81228, 81229, 81277, 81403*, 81407*, 81412, 81427, 81441, 81449, 81479*
Note: * codes may be exempt from prior auth when billed with specific ICD-10 diagnosis codes listed below

Note

Prior authorization exception note

Prior authorization exception note: Some genetic/molecular procedure codes with an asterisk do NOT require prior authorization when billed with specified ICD-10 diagnosis codes. Always verify the specific CPT/HCPCS-to-ICD-10 linkage before submitting a request to determine whether prior authorization is required.

Codes with * (asterisk) may be exempt from prior auth if billed with listed ICD-10 diagnoses (see diagnosis codes below)
Verify on Provider Portal or include ICD-10 diagnosis to confirm requirement

Documentation Required

ICD-10 code-linked prior authorization instructions (fragment)

ICD-10 diagnosis codes are used to determine whether prior authorization is required or exempt for certain procedures and tests (notably breast reconstruction, genetic/molecular testing, and some reconstructive or cosmetic procedures). When submitting a prior authorization request, include the ICD-10 code(s) that correspond to the clinical indication. Examples of ICD-10 codes listed in this section that can affect prior authorization requirements include breast cancer and related site codes (C50.x series), D05.x, and multiple E11 (Type 2 diabetes) codes for continuous glucose monitor prior auth linkage.

Breast cancer/related diagnosis ICD-10 examples affecting breast reconstruction/genetic test auth: C50.011, C50.012, C50.019, C50.021, C50.022, C50.029, C50.111, C50.112, C50.119, C50.121, C50.122, C50.129, C50.211, C50.212, C50.219, C50.221, C50.222, C50.229
D05.219, D05.221
Continuous glucose monitor (Type 2 diabetes) diagnosis examples: E11.00, E11.01, E11.10, E11.11, E11.21, E11.22, E11.3212, E11.3213, E11.3541–E11.37X3 and related codes listed in this section

Documentation Required

Diagnosis codes and prior authorization linkage

Diagnosis codes and prior authorization linkage — operational notes: - Some breast reconstruction CPT/HCPCS codes are exempt from prior authorization when billed with specific breast cancer ICD-10 codes listed above. - Genetic and molecular testing codes (several 8xxx and 047x/01xx series) may be exempt when billed with the specified cancer diagnosis codes; codes with an asterisk in this document denote those exceptions. - Continuous glucose monitor prior authorization is required when billed with Type 2 diabetes ICD-10 codes unless otherwise noted. Always include the primary ICD-10 diagnosis with the prior authorization request to ensure correct determination.

Include primary ICD-10 diagnosis with all prior authorization submissions
Breast reconstruction and genetic testing: certain ICD-10 codes (C50.x, D05.x) may exempt prior auth for specific CPT/HCPCS codes
Continuous glucose monitor: prior auth required when billed with Type 2 diabetes codes (E11.x series) unless stated otherwise

Portal required for many requestsRequests should be submitted online via the Provider Portal where available; phone is an alternative when noted.

Cancer supportive care

ScopePrior authorization required for outpatient-administered cancer supportive drugs (e.g., colony-stimulating factors, erythropoiesis-stimulating agents) when used for a cancer diagnosis.

Example drug codesIncludes J1449, J1442, Q5101, J2506, Q5122, Q5120, Q5108, Q5111 and J0885 for listed supportive agents.

Administrative code guidanceMultiple molecular/genomic CPT/HCPCS and U-codes (e.g., 81427, 81441, 81449, 0475U) are referenced with 'How to obtain prior authorization' for cancer-supportive testing or panels.

implants

GeneralImplants defined as a medical device within the inner ear with an external portion that helps those with profound sensorineural deafness achieve conversational speech.

Prior authorization requirementPrior authorization required for cochlear and other auditory implants listed in the document.

Example CPT/HCPCSCodes shown for auditory implants include 69710, 69714, 69930 and HCPCS L8690, L8691, L8692.

Cochlear implants

DefinitionCochlear implants: a medical device within the inner ear and an external portion that helps those with profound sensorineural deafness achieve conversational speech.

Prior authorizationPrior authorization required for cochlear implants and other auditory implants.

Example codesDocument lists CPT codes 69710, 69714, 69930 and HCPCS codes L8690, L8691, L8692 for cochlear implants.

Continuous glucose monitor

DefinitionContinuous glucose monitor (CGM): devices/supplies listed by HCPCS/CPT that monitor glucose; prior authorization is required when billed with Type 2 diabetes diagnosis codes.

Example HCPCSListed CGM supply codes include A4226, A9278, A4238, A4239 and related E-/A-series codes.

Condition for PAPrior authorization required when CGM codes are billed with Type 2 diabetes (various E11.x ICD-10 codes are referenced).

Durable medical equipment (DME)

ScopeDurable medical equipment (DME) prior authorization applies only to the codes listed in the document; some items reference retail purchase or cumulative rental cost thresholds.

Example DME codesExamples include A9279, A9280, A9900 and numerous E- and K-series codes (E0118, E0194, E0265, etc.) listed for PA.

PA limitationPrior authorization required only for the specific DME codes enumerated; not a blanket PA for all DME.

Enteral services / in-home nutritional therapy

DefinitionEnteral services / in-home nutritional therapy (enteral) require prior authorization.

Example codesListed HCPCS/CPT examples include B4034, B4102 and multiple CPT codes for associated procedures.

SettingApplies to in-home enteral nutritional therapy when billed with the listed codes.

Functional endoscopic sinus surgery (FESS)

DefinitionFunctional endoscopic sinus surgery (FESS) — sinonasal endoscopic surgical procedures referenced in CPT coding lists.

Prior authorizationPrior authorization required for FESS procedures listed in the document.

Example CPT codesExample FESS CPT codes include 31240, 31256, 31257, 31267, 31276, 31287, 31288; associated test codes (81228, 0048U, 81405) also appear.

FESS

PA requirementFunctional Endoscopic Sinus Surgery (FESS) requires prior authorization; example CPT/HCPCS codes are provided in the list.

Representative codes31240, 31256, 31276, 31257, 31287, 31288, 31267 are cited as FESS examples.

Associated testingGenetic/molecular testing entries (e.g., 81162, 81229, 81403, 81405) are listed adjacent to FESS in the document for related testing that requires PA.

Genetic and molecular testing (BRCA)

DefinitionGenetic and molecular testing to include BRCA — genetic tests related to breast cancer risk and other molecular assays.

Prior authorizationPrior authorization required for listed genetic and molecular tests (including BRCA-related CPT/HCPCS codes).

Example codesDocument lists numerous codes including 81162, 81229, 81163, 81277, 81403, 81407, 81412, 81228, 0048U and many other genomic CPT/HCPCS codes.

How to obtain prior authorization

Primary submission methodSubmit requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID — this is the preferred method.

Phone alternativeCall 877-542-9231 for general prior authorization; service-specific phone numbers appear for select groups (e.g., 888-397-8129 for cancer supportive care).

Reference codesWhen requesting PA, reference the CPT/HCPCS or proprietary codes shown in the list (many entries include a 'How to obtain prior authorization' code such as 0475U for certain molecular tests).

Prior authorization instruction

Portal sign-inGo to UHCprovider.com and click Sign In to access the Prior Authorization and Notification tool with One Healthcare ID.

Phone supportCall 877-542-9231 for general PA requests; other phone numbers listed for specific service areas (see document entries).

Emergency careEmergency or urgent care do not require prior authorization.

0475U

0475U usage0475U is repeatedly listed as the 'How to obtain prior authorization' reference for multiple molecular/genomic test entries.

Associated genomic CPTs0475U entries are shown alongside CPT codes such as 81427, 81441 and 81449 in the document.

Provider actionWhen requesting PA for listed molecular tests, include the referenced code (e.g., 0475U) per the document's 'How to obtain prior authorization' guidance.

How to obtain prior authorization

Preferred channelUse the UnitedHealthcare Provider Portal (UHCprovider.com) Prior Authorization and Notification tool; sign in with One Healthcare ID.

Alternate phoneGeneral PA phone: 877-542-9231. Service-specific numbers are provided in the list for certain clinical areas.

Documentation tipWhen submitting a request, reference the exact CPT/HCPCS or proprietary code shown with the service in the policy (many entries include 'How to obtain prior authorization' codes).

0475U

0475U note0475U appears repeatedly as the 'How to obtain prior authorization' code for multiple molecular/genetic test listings in the document.

Related CPTs0475U references accompany genomic CPTs such as 81427, 81441 and 81449 in the policy entries.

Use in requestsInclude 0475U when indicated by the document entry for streamlined prior authorization processing of those tests.

Asterisked codes

Asterisk explanationAsterisked codes in the list do NOT require a prior authorization when billed with a diagnosis code listed below (per the document note).

Provider implicationVerify whether a specific code is asterisked and paired with an allowed DX to avoid unnecessary PA submission.

Where to find mappingThe document enumerates ICD-10 diagnosis codes (C00–C34 and beyond) that map to PA exceptions for asterisked codes.

BRCA / genetic and molecular testing

ScopeBRCA and other genetic/molecular testing entries require prior authorization when listed in the document.

Example BRCA-related codesDocument includes numerous genetic/molecular CPT/HCPCS codes (e.g., 81162, 81229, 81427, 81449, 81523, 81541, S3854) that are paired with PA instructions.

Diagnosis linkageExtensive ICD-10 cancer diagnosis ranges (C50–C81 and related codes) are listed to map genetic/molecular testing to prior authorization logic.

genetic/molecular testing

GeneralGenetic and molecular testing requires prior authorization when listed; entries include many CPT/HCPCS and proprietary U-codes.

Representative codesExamples in the document include 81162, 81229, 81427, 81441, 81449, 81520, 81521 and U-codes such as 0475U and 0465U.

How to submitWhen requesting authorization for these tests, reference the specific test CPT/HCPCS or the listed 'How to obtain prior authorization' code (e.g., 0475U) as shown in the policy.