CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements — UnitedHealthcare Community Plan of Wisconsin

Lists services, procedures and drugs that require prior authorization for participating UnitedHealthcare Community Plan of Wisconsin providers and explains submission methods and exceptions (emergency/urgent care and out-of-network requirements). Applies to participating providers in Wisconsin.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements — UnitedHealthcare Community Plan of Wisconsin

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone at 877-651-6677.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

phone + onlinesubmission methods

exemptemergency/urgent

many listedmany service categories

listed codescolony-stimulating factors

$500orthotics/prosthetics threshold

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.

Prior Authorization Coverage Criteria

Prior authorization requirements (listed services with contact instructions)

Prior authorization is required for many services and specific codes. Providers must submit requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or call the phone numbers shown below. Where noted, specialty teams (Transplant, VAD, Optum case management) must be contacted.

Please submit prior authorization requests online using the UnitedHealthcare Provider Portal at UHCprovider.com to sign in. If needed, call 888-397-8129 for injectable medications and chemotherapy authorizations. For advanced outpatient imaging, call 866-889-8054. For transplant and CAR T-Cell therapy services call the UnitedHealthcare Community and State Transplant Case Management team at 888-936-7246 or use the notification number on the member's ID card.

Bariatric surgery (inpatient and outpatient) — prior authorization required. Affected CPT/HCPCS codes include 43644, 43645, 43659, 43770, 43775, 43842, 43847.

Behavioral health services — prior authorization required for many plans; contact the number on the member's health plan ID card for specific codes and network referral instructions.

Birth to age 3 program and in-school therapies — prior authorization required for all therapies provided in lieu of or in addition to the program.

Cancer supportive care — prior authorization required for colony-stimulating factor drugs and bone-modifying agents administered in an outpatient setting for a cancer diagnosis. Specific J/Q codes (for example J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125, Q5148) require authorization; some also require authorization for non-oncology diagnoses (see injectable medications section).

Injectable chemotherapy drugs administered in an outpatient setting (intravenous, intravesical, intrathecal) require prior authorization for cancer diagnoses. Affected codes include chemotherapy range J9000–J9999 and specific agents such as J0640, J0641, J0642, J1950, J1954, J1932 and other listed J-codes and Q-codes; also includes drugs billed under Q-codes, miscellaneous HCPCS (unassigned codes billed as J3490/J3590/C9399/J9999) and products without an assigned HCPCS. For unclassified codes (C9399, J3490, J3590, J9999) prior authorization may be limited to specified agents (e.g., Abecma, Breyanzi, Amtagvi, Skysona, Zevaskyn) — see specialty guidance.

Injectable medications (non-oncology) — prior authorization required for many specialty and high-cost injectables. Submit via the Provider Portal or call 888-397-8129. Examples include Adakveo (J0791), Adzynma (J7171), Aldurazyme (J1931), Alhemo (J7173), Amvuttra (J0225) and others listed in the injectable medications inventory.

Enteral and in-home nutritional therapy — prior authorization required for enteral services and in-home nutrition delivered enterally or via gastrostomy. Examples of HCPCS/B codes: B4035, B4036, B4102, B4103, B4104, B9002.

Durable medical equipment (DME) — prior authorization required only for the DME codes listed or when a retail purchase or cumulative rental cost exceeds plan thresholds. Examples include A9900, E0194, E0265, E0266, E0277, E0328, E0329, E0445, E0457, E0465, E0466.

Orthotics and prosthetics — prior authorization required only for items with a retail purchase or cumulative rental cost above $500, and for listed L-codes (for example L0112, L0170, L0464, L0486, L0632, L0638, L1945, L1950, L1970, L2000, L2010, L2020, L2030, L2034, L2036, L2060, L2106, L2108, L2126, L2136, L2350, L2510, L2526, L2627, L2628, L3230, L3649, L3671, L3674, L3720, L3730, L3740).

Therapeutic radiopharmaceuticals and certain J-codes (including but not limited to agents such as Kebilidi, Lantidra, Ocrevus, Pavblu, Recovi, Rivfloza, Ryplazim, Starjemza, Viltepso, Zunovo) — prior authorization required. Note: for code J1954, cancer diagnoses may be excluded from prior authorization in specified circumstances — check coding-specific guidance.

Standard radiation therapy (2D/3D) — prior authorization required only when obtained with diagnosis codes in the following ranges: C34.00–C34.92, C50.011–C50.929, C61, C79.51–C79.52, C84.7A, D05.00–D05.92 for CPT 77402, 77407, 77412.

Rhinoplasty and septoplasty for treatment of nasal functional impairment — prior authorization required. Example CPT codes: 30400, 30410, 30435, 30450, 30465.

Transcranial Magnetic Stimulation (TMS) — prior authorization required for listed CPT/HCPCS codes such as 90867 and 90868 where applicable.

Transplants and CAR T-Cell therapy (including Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta) — prior authorization required. Call 888-936-7246 or the notification number on the member's ID card for transplant case management.

Ventricular assist devices (VAD) — prior authorization required. Call the notification number on the member's health plan ID card and then fax forms to the Optum VAD Case Management team at 855-282-8929.

Wound vac (negative pressure wound therapy) — prior authorization required. Example HCPCS: E2402.

Codes and Code Groups Requiring Prior Authorization

Bariatric surgery CPT codesCPTCovered

43644	Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)
43645	Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption (short limb)
43659	Unlisted laparoscopic procedure, stomach/intestine (used for certain bariatric approaches)
43770	Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device
43775	Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device
43842	Laparotomy, revision of gastric bypass; reconstruction of Roux-en-Y (revision)
43847	Revision, gastric bypass, with reconstruction of Roux-en-Y and creation of new gastroenterostomy

Breast reconstruction CPT codes requiring prior authorizationCPTCovered

11971	Adjunctive procedure for facial/neck soft tissue augmentation; implant-based — used here as listed in policy for certain reconstructive procedures
19316	Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy) — listed for reconstruction context
19318	Mastectomy, subcutaneous (e.g., nipple-sparing)
19325	Breast reconstruction with prosthesis, immediate or delayed
19328	Removal of tissue expander, immediate insertion of breast prosthesis
19330	Mastectomy, radical; complete
19340	Immediate insertion of breast prosthesis following mastopexy, partial mastectomy
19342	Delayed insertion of breast prosthesis
19350	Nipple/areola reconstruction
19357	Breast reconstruction with free flap

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Colony-stimulating factor and related HCPCS/J codes requiring prior authorizationHCPCSCovered

J1442	Filgrastim (Neupogen) — prior authorization required
J1447	Filgrastim, biosimilar — listed in policy
J1448	Pegfilgrastim biosimilar — listed
J1449	Eflapegrastim-xnst (Rolvedon) — requires prior auth
J2506	Pegfilgrastim (Neulasta) — prior authorization for cancer supportive care
J1449	(duplicate listed above)
Q5101	Filgrastim-aafi (Nivestym) — HCPCS Q-code biosimilar
Q5108	Pegfilgrastim-jmdb (Fulphila) — biosimilar Q-code
Q5110	Filgrastim-aafi (Nivestym) or related Q-code listing
Q5111	Pegfilgrastim-jmdb (Fulphila) — listed

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Radiation therapy / Special services CPT codesCPTCovered

77387	Portal imaging (treatment verification), 3D; per course of radiation therapy (image-guided radiation therapy)
77331	Special radiotherapy procedure, dosimetry, treatment devices (example listed elsewhere in policy)
77370	Special medical radiation physics consultation
77399	Unlisted procedural code for radiation physics
77470	Special radiation treatment procedures (example)
77371	SRS/SBRT treatment delivery
77372	SRS/SBRT treatment delivery (additional fractions)
77373	SRS/SBRT planning

Coding Quick Facts

Cancer diagnosis requirement for certain drugs

RequirementPrior authorization is required for colony-stimulating factor drugs and bone-modifying agents when administered in an outpatient setting for a cancer diagnosis.

Examples of affected codesJ1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125, Q5148 (colony-stimulating factors)

ScopeApplies to injectable supportive oncology drugs given outpatient (IV, intravesical, intrathecal) — PA required for oncology Dx; some listed agents also require PA for non-oncology diagnoses.

DME cost threshold

ThresholdPrior authorization required when cumulative rental cost or retail purchase of DME exceeds $500.

NotesOnly applies to the DME codes explicitly listed in the policy; prosthetics are noted separately and are not classified as DME.

What Providers Must Do / How to Obtain Prior Authorization

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (One Healthcare ID) or by phone at 877-651-6677. Prior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all procedures and services.

Online: UHCprovider.com -> Sign in with One Healthcare ID -> Prior Authorization and Notification tab
Phone: 877-651-6677

Prior Authorization

Examples of services requiring prior authorization

Many specific services and procedures require prior authorization, including inpatient and outpatient bariatric surgery, behavioral health services, birth-to-age-3 and school-based therapies, bone growth stimulators, breast reconstruction (non-mastectomy), and cancer supportive care (certain colony-stimulating factors and bone-modifying agents).

Bariatric surgery (inpatient and outpatient) — e.g., CPT 43644, 43775
Behavioral health services — call number on member ID card for specific codes

Definitions and Exceptions

Prior authorization (definition)

DefinitionPrior authorization: a required administrative approval before certain services, procedures or medications are provided or billed to UnitedHealthcare Community Plan of Wisconsin.

How to obtainSubmit requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone at 877-651-6677.

Emergency/Out-of-network notePrior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all procedures and services.

Emergency/urgent care exception

ExceptionEmergency or urgent care does not require prior authorization.

Provider actionFor non-emergent services, submit prior authorization via portal or phone as specified in the policy.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements — UnitedHealthcare Community Plan of Wisconsin

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone at 877-651-6677.

SourceLink

On This Page

How citedPolicy lists multiple E- and K- series DME codes and refers to the $500 cost threshold and cumulative rental cost language.

Orthotics/prosthetics PA threshold (duplicate reference)

ThresholdPrior authorization required only for orthotics and prosthetics with a retail purchase or cumulative rental cost of more than $500.

Examples of HCPCS L-codesL0112, L0464, L0486, L0632, L0638 (policy lists numerous L-series codes referencing PA)

Interaction with J3590Orthotics/prosthetics entries reference J3590 in sections listing specialty drugs billed under unlisted J-codes; PA rules apply as noted.

orthotics/prosthetics prior authorization dollar threshold

Dollar threshold$500 — retail purchase or cumulative rental cost triggers prior authorization for orthotics and prosthetics.

ScopeApplies to orthotics and prosthetics CPT/HCPCS codes and related billing when cost exceeds threshold.

Policy locationThreshold and examples are shown within the Therapeutic Radiopharmaceuticals / Orthotics and prosthetics sections listing L-series codes.

Birth-to-age-3 program and school-based therapies — PA required for these therapies

Prior Authorization

Injectable colony-stimulating factors: PA required

Certain injectable colony-stimulating factor drugs require prior authorization when administered in an outpatient setting for a cancer diagnosis; selected codes also require PA for non-oncology diagnoses.

Codes include J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125, Q5148
Examples listed: Zarxio (biosimilar), Rolvedon (J1449), Neupogen (J1442), Neulasta (J2506)

Prior Authorization

PA for outpatient injectable chemotherapy

Prior authorization is required for injectable chemotherapy drugs administered in an outpatient setting (IV, intravesical, intrathecal) for a cancer diagnosis; submit requests via the UnitedHealthcare Provider Portal or call 888-397-8129.

Includes chemotherapy injectable drugs (J9000–J9999) and specified HCPCS (e.g., J0640, J0641, J0642, J1950, J1954, J1932)
Also covers chemotherapy drugs with Q-codes or billed under miscellaneous HCPCS when unassigned

Note

Operational note: injectable chemo and related procedures require PA

Prior authorization is required for the listed injectable chemotherapy drugs and many listed CPT/HCPCS procedures; some cosmetic/reconstructive procedure codes are also shown with PA requirements.

PA applies to numerous injectable chemotherapy entries and related procedure codes (cosmetic/reconstructive examples such as 11960, 15820, 17106 are listed)
Review code-level entries for specific PA applicability

Note

PA exemption when billed with specified cancer Dx codes

Prior authorization is not required when certain CPT/HCPCS codes are billed with the specific ICD-10 diagnosis codes listed (e.g., C43.x, C44.x series); exemptions are explicitly shown in the document.

Examples: multiple C43.* diagnosis codes are listed as exemptions from PA for certain injectable chemotherapy entries
Check the listed Dx codes in the policy to determine exemption applicability

Prior Authorization

DME items and rental/purchase PA notes

Durable medical equipment (DME) items listed in the policy require prior authorization; some DME items have additional notes such as cumulative rental cost thresholds and retail purchase conditions.

Only the DME codes listed require PA (examples include E0194, E0471, E0328)
Some DME entries note PA when cumulative rental cost or retail purchase exceeds $500

Prior Authorization

Enteral and in‑home nutritional therapy require PA

Enteral services and in-home nutritional therapy (codes B4035, B4036, B4102, B4103, B4104, B9002) require prior authorization.

Enteral services: B4035, B4036, B4102, B4103
In‑home nutritional therapy/gastrostomy tube: B4104, B9002

Prior Authorization

How to obtain PA for injectable medications

Submit prior authorization requests for injectable medications online using the UnitedHealthcare Provider Portal or by calling 888-397-8129.

Online: UHCprovider.com sign-in
Phone: 888-397-8129

Note

Operational reminder: enteral & in‑home nutrition require PA

Enteral and in‑home nutritional therapy require prior authorization; providers should follow the 'Enteral services' and 'In‑home nutritional therapy' code listings in the policy when submitting requests.

Refer to listed HCPCS codes (B4035, B4036, B4102, B4103, B4104, B9002) when requesting PA
Submit via UHC Provider Portal as instructed in the policy

Prior Authorization

Joint replacement and J-code authorization notes

Prior authorization is required for certain drugs billed with J3590 and for specified joint replacement and musculoskeletal procedures; note that for code J1954 cancer diagnoses are excluded from prior authorization.

Unspecified J-code J3590 requires PA when used for multiple high-cost specialty drugs
J1954 is noted with a Cancer DX exclusion from PA in multiple entries

Prior Authorization

Orthotics/prosthetics PA threshold: $500

Orthotics and prosthetics require prior authorization only when the retail purchase or cumulative rental cost exceeds $500.

Threshold: retail purchase or cumulative rental cost > $500 triggers PA requirement
Prosthetics are noted separately from DME in the policy

Prior Authorization

PA required for listed therapeutic radiopharmaceuticals and unlisted J-codes

Prior authorization is required for specified therapeutic radiopharmaceuticals and for specialty drugs billed to unlisted J-codes (e.g., J3590); the policy lists named products (Amondys 45, Casgevy, Kebilidi, Lantidra, Ocrevus, Pavblu, Recovi, Rivfloza, Ryplazim, Starjemza, Viltepso, Zunovo) that require PA.

Named specialty drugs require PA when billed under J3590 or applicable codes
Review the therapeutic radiopharmaceuticals section for full product listing

Note

Orthotics/prosthetics PA threshold and J3590 note

Orthotics/prosthetics CPT/HCPCS codes and J3590 require prior authorization when the retail purchase or cumulative rental cost exceeds $500; several L-series HCPCS examples are listed (e.g., L0112, L0464, L0486, L0632, L0638).

Examples of L-codes shown: L0112, L0464, L0486, L0632, L0638
PA applies only when cost threshold ($500) is exceeded

Prior Authorization

PA notes for J1954 and J3590

For selected J-codes: J1954 has a Cancer DX exclusion from prior authorization, while J3590 requires prior authorization when used to bill certain specialty drugs.

J1954: Cancer diagnosis excluded from PA in multiple code groups
J3590: PA required for several listed specialty products

Prior Authorization

Orthotics/prosthetics listing and PA instructions (L-codes)

The policy lists numerous L-series HCPCS codes for orthotics and prosthetics with references to 'How to Obtain Prior Authorization'—providers must follow those instructions for listed L-codes when seeking PA.

Sample L-codes referenced include L2034, L2036, L2060, L2106, L2108, L2126, L2136, L2350, L2510
Follow the 'How to Obtain Prior Authorization' guidance linked for each L-code

Prior Authorization

How to obtain prior authorization — general contact

Please submit prior authorization requests online using the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-889-8054 for the services referenced in that section of the policy.

Online: UHCprovider.com sign-in
Phone: 866-889-8054

Prior Authorization

Transplant and CAR T‑Cell PA: contact Transplant Case Management

For transplant and CAR T‑Cell therapy services (including Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta), contact the UnitedHealthcare Community and State Transplant Case Management team at 888-936-7246 or use the notification number on the member's ID card.

Call UnitedHealthcare Community and State Transplant Case Management: 888-936-7246
Alternatively, use the notification number on the back of the member's health plan ID card

Documentation Required

Radiology notification responsibility before scheduling

Health care professionals ordering advanced outpatient imaging procedures are responsible for providing notification prior to scheduling the procedure; submit requests via the UnitedHealthcare Provider Portal or call 866-889-8054.

Applicable to certain CT, MRI, MRA, PET scans, nuclear medicine and nuclear cardiology procedures
Notification must be provided before scheduling

Prior Authorization

Selected services (prostate, radiation, TMS) require PA

Specific services such as prostate procedures, radiation therapy, Transcranial Magnetic Stimulation (TMS), and implantable stimulators are noted as 'Prior authorization required' in the policy; follow the listed code entries and PA submission instructions.

Prostate procedures examples: 52441, 55873, 52442, 53850, 53852
TMS example: 90867 (PA required)

Prior Authorization

Transplant/CAR T-Cell PA: brands and contact instructions

For transplant and CAR T‑Cell therapy services (including listed cellular therapies), call UnitedHealthcare Community and State Transplant Case Management at 888-936-7246 or use the notification number on the member's ID card to request prior authorization.

Therapies listed include Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta
Contact: 888-936-7246

Prior Authorization

PA required for saphenous vein removal/ablation

Vein procedures for removal and ablation of saphenous veins for treating venous disease require prior authorization; listed CPT codes include 36473, 36475, 36478, 37700.

CPT codes: 36473, 36475, 36478, 37700
PA required before performing these vein procedures

Prior Authorization

VAD prior authorization and notification process

Ventricular assist devices (VAD) require prior authorization; providers should call the notification number on the member's ID card and then fax the form provided by the nurse to the Optum VAD Case Management team at 855-282-8929.

Call notification number on member's ID card first
Fax completed form to Optum VAD Case Management: 855-282-8929

Prior Authorization

Wound vac devices require prior authorization

Wound vac devices require prior authorization; E2402 is listed as an example HCPCS code subject to PA.

Example HCPCS: E2402
PA required for wound vac supplies/devices

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

injectable chemotherapy (definition/reference)

DefinitionInjectable chemotherapy: chemotherapy drugs administered in an outpatient setting (including IV, intravesical and intrathecal) requiring prior authorization for a cancer diagnosis.

Code range citedChemotherapy injectable drugs range: J9000–J9999; specific agents (e.g., leucovorin J0640) are listed.

Submission instructionSubmit PA requests via UnitedHealthcare Provider Portal or call 888-397-8129 as noted in the injectable medications section.

cochlear implants / auditory implants definition/reference

DefinitionCochlear and other auditory implants: medical devices with internal and external components for persons with profound sensorineural deafness; listed CPT/HCPCS (e.g., L8614, L8619, L8690, L8691, L8692) require prior authorization.

Example codes69710, 69714, 69930, L8614, L8619, L8690, L8691, L8692 (policy lists these codes under cochlear implants).

ContextThese implant codes are included among services that require prior authorization per the policy's device and surgical sections.

Durable medical equipment (DME) notes and prosthetics distinction

DME noteDurable medical equipment (DME) items listed in the policy require prior authorization; certain E- and K-series HCPCS are cited (e.g., E0194, E0471, K0005).

Prosthetics distinctionPolicy states 'Prosthetics are not DME' — prosthetics are handled separately from listed DME items and may have different PA rules.

Cost threshold linkageSome DME items are subject to the $500 retail purchase or cumulative rental cost threshold for prior authorization as noted elsewhere in the policy.

Prior authorization exemption by diagnosis (ICD-10 cancer codes)

ExemptionPrior authorization is not required when certain CPT/HCPCS codes are billed with specific ICD-10 cancer diagnosis codes (examples include many C43.x, C44.x series codes).

Example Dx codesPolicy text references C43.0, C43.10, C43.111, C43.112 and many other C43*/C44* codes as exemptions when billed appropriately.

ScopeThese diagnosis-based exemptions are explicitly shown in the injectable chemotherapy / code-specific sections of the policy.

Injectable medications (definition/reference)

DefinitionInjectable medications: drugs administered by injection and billed with HCPCS/J-codes; many listed injectable medications require prior authorization.

Submission detailsProviders should submit PA requests online using the UnitedHealthcare Provider Portal or call 888-397-8129 for injectable medications as noted.

Examples of J-codesExamples listed include J0791 (Adakveo), J7171 (Adzynma), J1931 (Aldurazyme), J7173 (Alhemo), J0225 (Amvuttra).

J3590 (definition/reference)

DefinitionJ3590: an unclassified/miscellaneous J-code used for billing unspecified drugs; the policy requires prior authorization for specified high-cost specialty drugs when billed to J3590.

Affected drugsWhen J3590 is used to bill specialty drugs (e.g., Amondys 45 (casimersen), Casgevy, Kebilidi, Lantidra, Ocrevus, Pavblu, Recovi, Rivfloza, Ryplazim, Starjemza, Viltepso, Zunovo), prior authorization is required.

Cancer DX notePolicy also notes that for code J1954 cancer diagnoses are excluded from prior authorization in multiple listings — distinct from J3590 requirements.

J3590 (PA required note duplicate)

PA notePrior authorization is required for services billed with J3590 when used for specified specialty drugs listed in the policy.

Cross-referenceJ3590 entries appear in sections on joint replacement, orthotics/prosthetics and therapeutic radiopharmaceuticals indicating PA requirement when used for named products.

Provider actionProviders should follow 'How to Obtain Prior Authorization' instructions for J3590-billed drugs as shown in the policy listings.

Orthotics and prosthetics (PA dollar threshold)

Dollar thresholdOrthotics and prosthetics require prior authorization when retail purchase or cumulative rental cost exceeds $500.

Sample HCPCS L-codesPolicy lists many L-series codes (e.g., L0112, L0464, L0486, L0632, L0638, L1945, L2005, L1950, L2010) tied to PA guidance.

How to obtain PARefer to the policy's 'How to Obtain Prior Authorization' links or portal instructions for listed L-codes; many L-codes include 'How to Obtain Prior Authorization' references.

Cancer DX exclusion (definition/reference)

DefinitionCancer DX exclusion: the policy indicates that for certain codes (notably J1954) cancer diagnoses are excluded from prior authorization requirements in multiple listings.

ExampleText: 'For code J1954, Cancer DX is excluded from prior' appears repeatedly in related sections (therapeutic radiopharmaceuticals, orthotics/prosthetics listings).

ImplicationWhen J1954 is billed with qualifying cancer diagnosis codes listed in the policy, prior authorization may not be required per the exclusion language.

Advanced outpatient imaging (definition/reference)

DefinitionAdvanced outpatient imaging: certain CT, MRI, MRA, PET scans and select nuclear medicine/nuclear cardiology procedures that require notification or prior authorization before scheduling.

Provider responsibilityHealth care professionals ordering advanced outpatient imaging are responsible for providing notification prior to scheduling the procedure.

How to obtainSubmit requests online via the UnitedHealthcare Provider Portal or call 866-889-8054 as provided for radiology authorizations/notifications.

Proton Beam (definition/reference)

DefinitionProton Beam: focused radiation therapy using beams of protons (tiny positively charged particles).

Example CPT codes77520, 77522, 77523, 77525 are listed as proton beam therapy codes in the policy.

PA statusProton beam procedures are included among advanced radiation services that require prior authorization as shown in the policy section.

Ventricular assist device (VAD) definition

DefinitionVentricular assist device (VAD): a mechanical pump that takes over the function of the damaged ventricle; VADs require prior authorization.

Notification processProviders should call the notification number on the member's health plan ID card and then fax the form provided by the nurse to the Optum VAD Case Management team at 855-282-8929.

Example CPT/HCPCS codesPolicy references codes such as 33927, 33928, 33929, 33975 in the VAD section linked to PA requirements.

CAR T-Cell therapy (definition / listed brands)

DefinitionCAR T-Cell therapy: chimeric antigen receptor T-cell therapies that require transplant/case management contact prior to authorization (listed brand names included).

Listed brandsAbecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta are specified in the policy for which providers should contact UnitedHealthcare Community and State Transplant Case Management at 888-936-7246.

How to obtainFor transplant and CAR T-Cell services, call the UnitedHealthcare Community and State Transplant Case Management team at 888-936-7246 or the notification number on the member's ID card.