CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements — Rocky Mountain Health Plans Medicare Advantage and D‑SNP

Lists services and codes that require prior authorization or notification for UnitedHealthcare Rocky Mountain Health Plan Medicare Advantage and Dual‑Special‑Needs Plan members; applies to participating and non‑participating providers submitting requests to RMHP/eviCore.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements — Rocky Mountain Health Plans Medicare Advantage and D‑SNP

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJune 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (Prior Authorization and Notification tool), call 1-877-PRE-AUTH, or use eviCore as directed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

numerousPrior-auth codes enumerated in this section

exemptEmergency/urgent care

1-877-PRE-AUTHPhone contact

eviCoreeviCore-managed radiology

manyDME / K-codes requiring PA

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.

Services and Codes Requiring Prior Authorization

Prior authorization criteria (excerpt)

Services and codes requiring prior authorization or notification

Arthroplasty procedures listed require prior authorization (see enumerated CPT/HCPCS codes).

Arthroscopy procedures listed require prior authorization (see enumerated CPT codes).

Bariatric surgery codes listed require prior authorization (listed CPT/HCPCS codes include 43644, 43770, 43771, 43772–43775, 43843, 43845–43848, 43886–43888 and others).

Behavioral health services are managed through a designated behavioral health network; many benefit plans limit coverage and authorization/prior authorization is required through that network (codes include 90899, 97151–97157).

Breast reconstruction (non-mastectomy) procedures require prior authorization (see enumerated diagnosis and procedure codes).

Cardiology services (including device/EP codes) require notification/prior authorization and many cardiology items are managed by eviCore (examples: 33206, 33207, 33208, 33212, 33270, 33274, 33289, 93799, 94799).

Injectable chemotherapy and certain infusion medications require notification/prior authorization (examples: 96446, A9513, A9590, A9606, J0185 and other J-/A- codes listed).

Prior authorization request criteria/instructions

To request prior authorization for services listed:

Submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) and select the appropriate tool tile (e.g., Cardiology, Radiology).

1-877-PRE-AUTH
800-666-1353

For services managed by eviCore (e.g., many cardiology and radiology reviews) providers may submit requests via the eviCore website or app as directed.

Non-participating providers may use fax numbers or the methods specified by RMHP when indicated (see Provider Portal guidance).

Explicit prior authorization requirements (examples)

Services explicitly marked as requiring prior authorization in this section:

Chiropractic care — codes 98940, 98941, 98942, 98943 are listed with 'Prior authorization required.'

Device prior authorization requirements

Device and durable medical equipment entries marked as requiring prior authorization:

Cochlear implants and related device codes (e.g., 69711, 69714, 69716, 69717, 69799, E2103, A4238, A4239) are annotated 'Prior authorization required.'

Durable medical equipment (DME) HCPCS items (examples include A4265, A4556–A4558, A4595, A4633, A4640, A7020, A7025, E0170–E0194 and extensive E-/K- series) require prior authorization as listed.

Prior authorization code list (partial)

Codes listed below require prior authorization. Some entries include 'Additional information' or explicit notes stating 'Prior authorization required.'

Selected U-/temporary/proprietary codes (examples: 0143U, 0144U, 0145U, 0146U, 0147U, 0148U, 0150U, 0165U–0187U) are listed as requiring prior authorization.

Representative DME/E-code examples that require prior authorization include A4265 and E2218 (many additional E- and K- HCPCS codes are enumerated).

Note: code lists in this section are extensive; presence of 'Additional information = Prior authorization required' or similar indicates an authorization requirement for the code.

Prior authorization requirements (partial)

Services and codes that require prior authorization (partial list).

Multiple specialty services require prior authorization, including Endocrine procedures, Enteral services (e.g., B4149–B4164 series), Genetic Test/Lab services (e.g., 81162–81167, 81173–81174, 81185), and Gender dysphoria surgical codes (e.g., 15771–15793).

Genetic test and lab CPTs are explicitly flagged as requiring prior authorization in this segment. Examples include 81162, 81163, 81164, 81165 and others.

Where 'Additional information = Prior authorization required' appears next to a service category, an authorization step is required prior to provision of the service.

Prior authorization code list

Codes listed below require prior authorization as indicated in this section of the policy.

Selected molecular/genetic and temporary codes (examples include 81293–81364 range and many U-/M- codes such as 0282U–0334U, 0001U–0334U series) require prior authorization. Refer to the enumerated lists for exact codes.

Presence of a code in these grouped lists or an adjacent 'Prior authorization required' note denotes that prior authorization or notification is required before the service is rendered.

Prior authorization criteria (codes and service lists)

Prior authorization is required for the listed codes and services.

Hysterectomy procedures (examples: 58578, 58579, 58679) require prior authorization as noted in this section.

Injectable and infusion medications and related administration codes require prior authorization (examples include 96379 and numerous J-codes and proprietary drug listings; several specific drugs are named as prior authorization required).

Medical and surgical supplies (Q-codes such as Q4101–Q4134) are listed as 'Prior authorization required.'

Selected medicine and musculoskeletal CPTs (e.g., 97602, 97605–97607, 21029, 21031, 21076–21086) are annotated with prior authorization requirement.

Coverage stance for listed codes

This segment enumerates codes and flags where prior authorization is required or additional information is indicated. It does not include full clinical coverage criteria.

Selected CPT codes across medicine, musculoskeletal and obstetrical categories are marked with 'Prior authorization' (examples: 97602, 97605–97607, 21029, 21031, 59072, 59898).

Orthognathic/maxillofacial surgical codes (examples: 21100, 21141–21159 and related codes) are indicated as requiring prior authorization.

Large groups of orthotics/prosthetics L-series HCPCS codes (e.g., L1499, L3000, L3001, L3002, L3030–L3100 and many others) include 'how to obtain prior authorization' instructions and require prior authorization.

Authorization-flagged code groups

Codes listed below are annotated with prior authorization or notification requirements as indicated.

OT/PT/SLP/RT therapy codes (examples: 97533, 97597, 97598) are indicated as requiring prior authorization.

Pain management and related regional injection codes (examples: 64451, 64461–64463, 64490–64495, 64628–64636) require prior authorization.

Radiology services listed (examples: 70336, 70450, 70460, 70470, 70480) are managed by eviCore and require notification/prior authorization for participating and non-participating providers via eviCore.

Prior authorization requirement

Prior authorization/notification requirements and submission methods for listed services

Radiology services managed by eviCore require notification/prior authorization for participating and non-participating providers; submit via the Provider Portal Radiology tool tile or through eviCore (phone 1-877-PRE-AUTH as alternate).

For notification/prior authorization generally, submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 1-877-PRE-AUTH; eviCore may be used where indicated.

Prior authorization code-based criteria (fragment)

Categories and codes in this fragment with prior authorization notes

Stimulator procedures and related CPT codes (examples: 20974, 20975) are listed with 'Prior authorization' noted.

Transplant procedures (examples: 32850–32856, 33930, 33933, 33935, 33945, 38204–38210) require prior authorization.

Transportation HCPCS codes (A0430, A0431, A0435, A0436) are listed as requiring prior authorization.

Includes

Urological/Uterine procedures (e.g., 0499T, 58999) require prior authorization.
Vein and vascular procedures (examples: 36465, 36468, 36470–36476, 37700, 37718, 37735) are annotated as requiring prior authorization.

Representative Code Tables and Examples

Arthroplasty codes (sample)CPTCovered

0095T	Arthroplasty-related code listed requiring prior authorization
0098T	Arthroplasty-related code listed requiring prior authorization
0164T	Arthroplasty-related code listed requiring prior authorization
23472	Arthroplasty-related code listed requiring prior authorization

Arthroscopy codes (sample)CPTCovered

29805	Arthroscopy procedure — prior authorization required
29806	Arthroscopy procedure — prior authorization required

Bariatric surgery codes (sample)CPTCovered

43644	Bariatric surgery code — prior authorization required
43770	Bariatric surgery code — prior authorization required

Behavioral health and other miscellaneous codesmixedCovered

90899	Behavioral health code — many plans limit coverage; prior authorization required through designated network
97151	Behavioral health code — prior authorization/managed via designated network
20957	Bone growth stimulator — prior authorization required

Breast reconstruction, cardiology, chemotherapy codes (sample)mixedCovered

19316	Breast reconstruction (non-mastectomy) — prior authorization required
19330	Breast reconstruction (non-mastectomy) — prior authorization required
33206	Cardiology/electrophysiology device code — prior authorization managed by eviCore
93451	Cardiology diagnostic/therapeutic code — prior authorization managed by eviCore
J0185	Injectable chemotherapy drug — notification/prior authorization required

Sample HCPCS/J-codes (document contains many more)HCPCS | mixed

A9513	HCPCS code listed as requiring prior authorization
A9590	HCPCS code listed as requiring prior authorization
A9606	HCPCS code listed as requiring prior authorization
A9607	HCPCS code listed as requiring prior authorization
J9000	J-code listed as requiring prior authorization
J9214	J-code listed as requiring prior authorization
J9269	J-code listed as requiring prior authorization

Example J-codes (cardiology/infusion/medication codes)HCPCSCovered

J9247	Listed J-code included in prior authorization list
J9255	Listed J-code included in prior authorization list
J9258	Listed J-code included in prior authorization list
J9259	Listed J-code included in prior authorization list
J9260	Listed J-code included in prior authorization list
J9261	Listed J-code included in prior authorization list
J9262	Listed J-code included in prior authorization list

Example Q-codesHCPCSCovered

Q0166	Listed Q-code included in prior authorization list
Q2017	Listed Q-code included in prior authorization list
Q2043	Listed Q-code included in prior authorization list
Q2049	Listed Q-code included in prior authorization list
Q2050	Listed Q-code included in prior authorization list

Example Category I/II/III/U codesCPTCovered

0140U	Listed unlisted/proprietary CPT/other code requiring prior authorization
0143U	Listed code requiring prior authorization
0188U	Listed code requiring prior authorization
0218T	Listed CPT category II/III/T code requiring prior authorization

Selected U-codes (partial)HCPCSCovered

0143U
0144U

DME HCPCS/E-code groups (partial)HCPCSCovered

A4265	DME item — listed in document
E2218	DME E-code — listed in document

K-codes (wheelchair/assistive devices) (partial)HCPCSCovered

K0001	K-series DME code
K0802	K-series DME code

Examples — Enteral and Genetic Test/Lab codesHCPCS | CPT | mixedCovered

B4149	Enteral formula/device (example from list)
B4150	Enteral supplies (example from list)
81162	Genetic test/Lab service (example from list)
81163	Genetic test/Lab service (example from list)

Gender dysphoria treatment surgical codesCPTCovered

15771	Gender dysphoria treatment surgical code listed
15772	Gender dysphoria treatment surgical code listed

Examples from lab/genetic codesCPT | HCPCS | mixedCovered

82523	Referenced lab test requiring prior authorization
82542	Genetic test / lab code requiring prior authorization

Examples of codes requiring prior authorizationmixedCovered

0282U	Listed U-code requiring prior authorization
0538T	Procedure/service requiring prior authorization
Q4101	Medical/surgical supply Q-code requiring prior authorization
J0285	Injectable J-code requiring prior authorization

Selected CPT codes in this segmentCPT

97602	CPT — Debridement (as listed in chunk 126)
97605	CPT — Wound debridement (as listed in chunk 126)
97606	CPT — Wound debridement (as listed in chunk 126)
97607	CPT — Wound care/additional (as listed in chunk 126)
21029	CPT — Musculoskeletal procedure (as listed in chunk 126)
59072	CPT — Obstetrical procedure (as listed in chunk 127)

Sample L‑series HCPCS codesHCPCS

L1499	HCPCS L‑code (orthotic/prosthetic) listed in chunk 130
L3000	HCPCS L‑code (orthotic/prosthetic) listed in chunk 130
L5677	HCPCS L‑code (listed in chunk 136)
L5850	HCPCS L‑code (listed in chunk 139)
L6703	HCPCS L‑code (listed in chunk 144)

L-codes (orthotics/prosthetics)HCPCSCovered

L6650	Orthotic/prosthetic supply code listed
L6712	Example L-code present in list
L7186	Example L-code present in list

Mixed CPT and HCPCS codesmixed

90671	Vaccine CPT code listed
95803	Cardiac monitoring CPT code listed
C1761	HCPCS C-code listed

Selected miscellaneous/temporary and unlisted procedure codesCPT | HCPCSCovered

76499
76978
76979
78199
78299
78399
78499
78599
78699
78799

1–10 of 21

1/3

Radiology, spine, respiratory, rhinoplasty, sinuplasty, sleep disorder, stimulators, and other procedure codesCPT | HCPCSCovered

C8900
C8901
C8902
C8903
C8905
C8906
C8908
C8909
C8910
C8911

1–10 of 20

1/2

Radiology, spine, respiratory, rhinoplasty, sinuplasty, sleep disorder, stimulators, and other procedure codes (continued)CPT | HCPCSCovered

70481
70482
70486
70487
70488
70490
70491
70492
70496
70498

1–10 of 20

1/2

Representative codes (fragment)CPT | HCPCS | mixedCovered

20974	Stimulator implantation
20975	Stimulator revision
G0277	Wound care - debridement (example)
G0329	Wound care related

Emergency exemption — Prior authorization not required for emergency or urgent care

Emergency/urgent care exemptionPrior authorization is not required for emergency or urgent care (Out-of-network providers must still request authorizations for non-emergent services).

Where to submit for RMHP membersUse UHCprovider.com/priorauth > Prior Authorization and Notification tool to submit requests and supporting documentation.

How Providers Request Prior Authorization and Notifications

Prior Authorization

Prior Authorization Required — selected U‑codes

Prior authorization is required for the following selected U‑codes. Providers should submit prior authorization requests and supporting documentation via the UnitedHealthcare Provider Portal (UHCprovider.com > Prior Authorization and Notification tool) or call 1-877-PRE-AUTH. Non-participating providers may fax requests as noted by plan instructions.

0143U
0144U
0145U
0146U
0147U
0148U
0150U
0165U
0166U
0167U
0176U
0180U
0181U
0182U
0183U

Key Terms and Systems

Prior authorization — definition and role in policy

Prior authorization — definitionThe process where health care providers seek approval before rendering a service as required by UnitedHealthcare; required under direction of the UnitedHealthcare Health Services Department.

Role in policyPrior authorization is an essential part of managed care and is required for many listed CPT/HCPCS services and devices; providers must follow submission instructions in the policy.

ExemptionsEmergency and urgent care are explicitly exempt from prior authorization requirements.

Advance notification — definition and purpose

Advance notification — definitionA requirement for care providers to give UnitedHealthcare timely communication of services to enable prospective, concurrent and retrospective care review.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements — Rocky Mountain Health Plans Medicare Advantage and D‑SNP

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJune 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (Prior Authorization and Notification tool), call 1-877-PRE-AUTH, or use eviCore as directed.

SourceLink

On This Page

Wound care codes (e.g., G0277, G0329) are indicated as prior authorization required.

Non‑participating provider fax optionNon-participating providers may fax requests and documentation to 800-262-2567 or 970-255-5681.

eviCore contact for clinical reviewseviCore website: evicore.com; phone: 800-792-8750.

Behavioral health contactFor Behavioral Health Services call 888-282-8801.

eviCore-managed services — Specific cardiology and other services require authorization/notification via eviCore as listed

Scope of eviCore-managed servicesSpecific cardiology and radiology services are managed by eviCore; notification/prior authorization is required as listed in the policy.

How to submit cardiology/radiology requestsSubmit via the UnitedHealthcare Provider Portal (select the Cardiology or Radiology tool tile) or use eviCore as instructed; phone options provided (e.g., 1-877-PRE-AUTH).

Example cardiology codes managed by eviCoreExamples include device/EP codes such as 33206, 33207, 33208, 33212 and procedure codes like 33270, 33274, 33289 (see policy list).

Notification requirementNotification/prior authorization applies to both participating and non-participating providers for eviCore-managed services.

Prior authorization indicator — Some listed CPT/HCPCS codes are marked as 'Prior authorization' or 'Prior authorization required' in these chunks

Prior authorization indicator on code entriesMany CPT/HCPCS entries in the list include explicit notes such as 'Prior authorization' or 'Prior authorization required.'

Examples of code groups flaggedSelected U-codes (e.g., 0143U, 0144U), DME/E-codes (e.g., A4265, E2218) and Q-codes (e.g., Q4101–Q4124) are annotated with prior authorization requirements.

Drug-specific prior auth noteCertain drugs are listed with 'Prior authorization is required' (e.g., Amvuttra, Adzynma, Briumvi and others as enumerated).

Procedure code examplesMultiple CPT procedure codes in chunks (e.g., 97602, 21029) are marked with prior authorization annotations in the policy.

eviCore management — Notification/prior authorization required for participating and non-participating providers

eviCore notification/authorization applies to all providersNotification/prior authorization via eviCore is required for participating and non-participating providers for specified radiology and cardiology services.

Submission channelsUse UnitedHealthcare Provider Portal (Radiology/Cardiology tool tile), call 1-877-PRE-AUTH, or access eviCore website/app for prior authorization/notification.

Example radiology codes managed by eviCoreExamples include imaging CPTs such as 70336, 70450, 70460, 70470, 70480 as listed under eviCore-managed radiology.

Prior Authorization

Prior Authorization Required — E‑codes (selected)

Certain HCPCS E‑codes require prior authorization. Durable medical equipment and complex device codes listed below require prior authorization prior to service delivery. Use the Provider Portal or contact the plan for instructions.

E0441
E0442
E0443
E0444
E0447
E0465
E0466
E0467
E0470
E0471
E0472
E0482
E0500
E0550
E0555
E0560
E0636
E0651
E0657
E0667
E0672
E0692
E0849
E0860
E2218
E2219
E2220
E2221
E2222
E2224
E2225
E2226
E2227
E2228
E2231
E2310
E2311
E2312
E2313
E2321
E2322
E2323
E2324
E2325
E2326
E2327
E2328
E2329
E2330
E2340
E2341
E2342
E2343
E2351
E2359
E2360
E2361
E2362
E2363
E2364
E2365
E2366
E2367
E2368
E2369
E2370
E2371
E2373
E2374
E2375
E2376
E2377
E2378
E2381
E2382
E2383
E2384
E2385
E2386
E2387
E2388
E2389
E2390
E2391
E2392
E2394
E2395
E2396
E2397
E2398
E2402
E2500
E2502
E2504
E2506
E2508
E2510
E2601
E2602
E2603
E2604
E2605
E2606
E2607
E2608
E2611
E2612
E2613
E2614
E2615
E2616
E2619
E2620
E2621
E2622
E2623
E2624
E2625

Prior Authorization

Prior Authorization — additional K‑codes (partial)

Additional K‑codes listed in the source require prior authorization. Prior authorization must be obtained before furnishing orthotic/prosthetic items that map to these K codes.

K0001
K0002
K0003
K0004
K0005
K0006
K0007
K0009
K0010
K0011
K0012
K0015
K0017
K0018
K0019
K0020
K0037
K0038
K0039
K0040
K0041
K0042
K0043
K0044
K0045
K0046
K0047
K0050
K0051
K0052
K0053
K0056
K0069
K0070
K0071
K0072
K0073
K0077
K0098
K0105
K0195
K0606
K0607
K0608
K0609
K0738
K0739
K0800
K0801
K0802
K0806
K0807
K0808
K0813
K0814
K0815
K0816
K0820
K0821
K0822
K0823
K0824
K0825
K0826
K0827
K0828
K0829
K0830
K0835
K0836
K0837
K0838
K0839
K0840
K0841
K0842
K0843
K0848
K0849
K0850
K0851
K0852
K0853
K0854
K0855
K0856
K0861
K0862
K0863
K0864

Prior Authorization

Orthotics and Prosthetics HCPCS L‑codes — prior authorization process

Extensive lists of orthotics and prosthetics HCPCS L‑codes require prior authorization. Prior authorization is required for the prosthetic and orthotic codes shown; providers should use the Provider Portal tool tile for Orthotics/Prosthetics or contact Provider Services for submission instructions.

L1499
L3000
L3001
L3002
L3003
L3010
L3020
L3030
L3031
L3040
L3050
L3060
L3070
L3080
L3090
L3100
L3140
L3150
L3160
L3170
L3224
L3225
L3230
L3250
L3251
L3252
L3253
L3254
L3255
L3257
L3260
L3265
L3300
L3310
L3320
L3330
L3332
L3334
L3340
L3350
L3360
L3370
L3380
L3390
L3400
L3410
L3420
L3430
L3440
L3450
L3455
L3460
L3465
L3470
L3480
L3485
L3500
L3510
L3520
L3530
L3540
L3550
L3560
L3570
L3580
L3590
L3595
L3600
L3610
L3620
L3630
L3640
L3649
L4000
L4002
L4010
L4020
L4030
L4040
L4045
L4050
L4055
L4060
L4070
L4080
L4090
L4100
L4110
L4130
L4205
L4210
L5000
L5010
L5020
L5050
L5060
L5100
L5105
L5150
L5160
L5200
L5210
L5220
L5230
L5250
L5270
L5280
L5301
L5312
L5321
L5331
L5341
L5400
L5410
L5420
L5430
L5450
L5460
L5500
L5505
L5510
L5520
L5530
L5535
L8685
L8686
L8687
L8688
L8689
L8690
L8691
L8692
L8693

Prior Authorization

Potentially Unproven Codes — prior authorization

Some procedures and services are designated 'Potentially Unproven' in the source and require prior authorization before consideration. Submit clinical rationale and supporting documentation with the request.

0014M
0015M
0062U
0063U
0064U
0065U
0066U
0068U
0077U
0080U
0086U
0091U
0092U
0093U
0095U
0096U
0109U
0112U
0152U
0153U

Prior Authorization

Listed codes (partial) — prior authorization required

A broad set of additional listed CPT/HCPCS codes across multiple specialties require prior authorization per the source. Providers must request authorization before providing these services and should include relevant clinical documentation.

60659
60699
B4149
B4150
B4152
B4153
B4154
B4155
B4157
B4158
B4159
B4160
B4161
B4162
B4164
B4168
B4172
B4176
B4178
B4180
B4185
B4187
B4189
B4193
B4197
B4199
B4216
B5000
B5100
B5200
42699
42999
43206
43210
43252
43257
43284
43285
43289
43497
43499
43647
43648
43659
43881
43882
43999
44238
44799
44899
44979
45399
45499
45999
46707
46999
47379
47399
47579
47999
49329
49659
49999
50549
50949
51999
53855
53899
91112
91132
91133
91299
15771
15772
15773
15774
15776
15780
15781
15782
15783
15786
15787
15788
15789
15792
15793
15820
15821
15822
15823
15830
15832
15833
15834
15835
15836
15837
15838
15839
15847
15876
15877
15878
15879
21899
31599
42299
54400
54401
54405
54408
54410
54411
54416
54417
54699
55559
55706
55880
55899
56625
56800
56805
57106
57110
57291
57292
57295
57296
57335
57426
58661
58720
58940
64856
64892
64896
92507
92508
81162
81163
81164
81165
81166
81167
81173
81174
81185
81186
81189
81190
81201
81202
81203
81212
81215
81216
81217
81221
81222
81223
81225
81226
81227
81228
81229
81230
81231
81232
81234
81238
81239
81248
81249
81252
81253
81257
81258
81259
81269
81277
81283
81286
81289
81291
81292
81293
81294
81295
81296
81297
81298
81299
81300
81302
81303
81304
81306
81307
81308
81313
81317
81318
81319
81321
81322
81323
81325
81326
81327
81328
81335
81336
81337
81346
81349
81350
81351
81353
81355
81361
81362
81363
81364
81400
81401
81402
81403
81404
81405
81406
81407
81408
81410
81411
81412
81413
81414
81415
81416
81417
81419
81420
82542
82726
82777
83006
83698
83700
83704
83876
83883
83951
83987
84431
84999
86001
86152
86153
86305
86343
86849
88375
88749
89240
89398
91065

Prior Authorization

Transplant‑related Codes — prior authorization

Transplant procedures and related codes are subject to prior authorization. Authorization is required for the transplant surgical procedures, cellular therapy collection and transplant‑related inpatient services listed. Contact the plan’s transplant coordination resources when submitting requests.

32850
32851
32852
32853
32854
32855
32856
33930
33933
33935
33945
38204
38205
38206
38207
38208
38209
38210
38211
38212
38213
38214
38215
38230
38240
38241
38242
38243
47135
47140
47141
47142
47143
47144
47145
47146
47147
48551
48552
48554
48556
48999
50300
50320
50323
50325
50327
50328
50329
50340
50360
50365
50370
50380
50547

Used for prospective and concurrent review processes as described in submission instructions (Provider Portal, phone, eviCore).

Relation to prior authorizationAdvance notification complements prior authorization by ensuring UnitedHealthcare is informed for care review even when full prior authorization is not required (e.g., emergent exceptions).

Provider Portal — online tool referenced for submitting prior authorization requests

Provider Portal — purposeOnline tool (UnitedHealthcare Provider Portal) used to submit Prior Authorization and Notification requests via the Cardiology or Radiology tool tiles.

How to accessGo to UHCprovider.com and click the UnitedHealthcare Provider Portal button, then select the appropriate Prior Authorization/Notification tool tile.

Alternate contactPhone submission options (e.g., 1-877-PRE-AUTH or 800-666-1353) are provided in the policy for requests made outside the portal.

eviCore website — external portal referenced

eviCore website — roleExternal portal (evicore.com) used for clinical review and to submit prior authorization requests for specified cardiology and radiology services.

Contact detailseviCore website: evicore.com; phone: 800-792-8750; eviCore Prior Authorization and Notification App referenced for submissions.

When to use eviCoreProviders should use eviCore for services explicitly listed as managed by eviCore (cardiology, radiology) or when policy instructs to log onto the eviCore website.

Cochlear implants — short definition and context

Cochlear implants — short definitionA medical device within the inner ear with an external portion to help persons with profound sensorineural deafness achieve hearing; procedure and device codes listed.

Prior authorization statusCochlear implant procedure and device codes (e.g., 69711, 69714, 69716, 69717, 69799, E2103, A4238, A4239) are listed with 'Prior authorization required.'

Submission instructionFollow the policy's prior authorization submission methods (Provider Portal or other channels) when requesting authorization for cochlear implants.

Cosmetic vs Reconstructive procedures — definition note

Cosmetic vs Reconstructive — definition noteCosmetic procedures improve or change physical appearance; reconstructive procedures restore or improve physiologic function — the policy distinguishes these when listing codes.

Examples notedCosmetic CPTs (e.g., 17107, 17108, 17340, 17360) and reconstructive codes (e.g., 19300, 21120, 21125) are included in the policy's listings with context about intent and authorization needs.

DME — Durable medical equipment definition

DME — definitionDurable medical equipment (DME) items are listed by HCPCS codes and many entries indicate prior authorization is required.

Example DME codesExamples include A4265, A4556, A4557, A4558 and numerous E- and K-series codes requiring authorization as shown in the policy.

How to request authorizationFollow submission instructions in the policy (Provider Portal or other listed channels) when requesting prior authorization for DME items.

Prior authorization requirement — note that CPT/HCPCS codes listed require prior authorization

Prior authorization requirement — general noteCPT/HCPCS codes listed throughout the document require prior authorization; many entries include explicit 'Prior authorization required' annotations.

Code examples requiring prior authLists include U-codes (e.g., 0143U), genetic/lab CPTs (e.g., 82542), DME codes (e.g., A4265), and numerous specialty J/Q/L codes.

Submission expectationProviders must obtain prior authorization per the policy before rendering listed services except for emergency/urgent care.

Prior authorization — generic label

Prior authorization — labelPrior authorization

PurposeAuthorization process to approve services in advance according to UnitedHealthcare policy.

Where describedDefined and referenced across submission and code-list sections of the policy (see Provider Portal, eviCore guidance).

Relevant DX codes — diagnostic codes referenced for gender dysphoria treatment billing

Relevant DX codes for gender dysphoria billingDiagnostic codes F64.x and Z87.890 are referenced as relevant when billing surgical codes for gender dysphoria treatment.

Use in claims/authorizationWhen surgical codes are billed with one of the listed DX codes, prior authorization requirements and supporting documentation apply as noted in the policy.

Genetic Test/ Lab — definition

Genetic Test/Lab — definitionGenetic test and laboratory CPT codes are enumerated in the policy and many require prior authorization (examples: 82542, 82726, 82777, 83006).

Submission noteObtain prior authorization per the policy's submission instructions for listed genetic and lab tests.

U-/M- codes — temporary proprietary codes referenced

U-/M- codes — definitionTemporary and proprietary procedure codes (U-codes, M-codes) are included in the policy's lists and are treated as CPT/HCPCS identifiers that may require prior authorization.

ExamplesThe policy lists numerous U-codes (e.g., 0001U, 0002U, 0029U, 0282U) annotated as requiring prior authorization.

Prior authorization — label reaffirmation

Prior authorization — reaffirmationMultiple sections and code lists in the document consistently label covered items with 'Prior authorization' or 'Prior authorization required.'

Implication for providersProviders should assume listed codes require prior authorization and follow the policy's submission methods unless an emergency/urgent exemption applies.

Medical and surgical supplies (Q-codes) — definition/context

Medical and surgical supplies (Q-codes) — contextMedical and surgical supplies identified by Q-codes (e.g., Q4101–Q4134) are repeatedly noted as 'Prior authorization required.'

How listedThe policy groups Q-codes under 'Medical and surgical supplies' with explicit prior authorization annotations and code ranges.

prior authorization — label/context

Selected service categories requiring prior authNumerous categories (e.g., radiology via eviCore, OT/PT/ST/RT therapy, pain management, orthotics/prosthetics, transplants) are explicitly flagged as requiring prior authorization.

Example therapy/pain codesOT/PT/ST/RT examples include 97533, 97597, 97598; pain management includes 64451 and related codes.

Orthotics/prosthetics L-codesExtensive L-series HCPCS codes are listed with 'how to obtain prior authorization' instructions in the policy.

Prior authorization required for listed services — e.g., radiology via eviCore, specified therapy and pain management codes

Prior authorization required — summaryThe document lists numerous CPT/HCPCS/J/Q/U/M codes across specialties that require prior authorization; providers must follow submission methods (Provider Portal, phone, fax, eviCore) and note emergency exemptions.

Submission channels (summary)UnitedHealthcare Provider Portal (Prior Authorization and Notification tool), phone (1-877-PRE-AUTH or other numbers shown), eviCore website/app, and fax options for non-participating providers.

Code types includedIncludes temporary U/M codes, genetic/lab CPTs, DME E/K-codes, Q-codes, J-codes (injectables), L-codes (orthotics/prosthetics), and many CPT procedure codes across specialties.

eviCore-managed radiology — definition/context

eviCore-managed radiology — definitionRadiology services are managed by eviCore; notification/prior authorization is required for participating and non-participating providers through eviCore.

How to obtain authorization for radiologyUse the Radiology tool tile on the UnitedHealthcare Provider Portal, call 1-877-PRE-AUTH, or log onto the eviCore website/ app per the policy instructions.

Example radiology CPTsExamples listed include 70336, 70450, 70460, 70470, 70480 among other imaging CPTs managed by eviCore.

Prior authorization submission methods — Provider Portal, phone, eviCore website/app

Prior authorization submission methods — summarySubmit requests online using the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal; phone (1-877-PRE-AUTH or other numbers) and eviCore website/app are alternate methods.

Portal navigation guidanceAccess UHCprovider.com, click UnitedHealthcare Provider Portal, then select the appropriate tool tile (e.g., Cardiology, Radiology, Standard Prior Authorization/Notification Transactions).

Fax option for non-participating providersNon-participating providers may fax requests and documentation to 800-262-2567 or 970-255-5681 as noted in the policy.

Unclassified/Temporary codes — examples and note

Unclassified/Temporary codes — noteThe policy includes unclassified and temporary codes (examples: C9399, J3490 and many U-codes) which are treated as CPT/HCPCS identifiers and may require prior authorization.

Examples includedMultiple U-codes and other proprietary codes (0001U– etc.) are enumerated and annotated as requiring prior authorization in the document.

Prior authorization requirement — multiple procedure categories explicitly note 'Prior authorization required.'

Prior authorization — multiple categories flaggedNumerous procedure categories and individual codes are explicitly labeled 'Prior authorization required' across the policy (e.g., stimulators, transplants, wound care, DME, genetic tests, injectables).

Provider action requiredObtain prior authorization via the prescribed submission methods before performing or billing the listed services unless an emergency/urgent exemption applies.

Reference locationSee the policy code listings and the Provider Portal/eviCore instructions for specific code-level authorization requirements.