CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Rocky Mountain Children's Health Plan

Lists prior authorization requirements and submission methods for participating and non‑participating providers serving UnitedHealthcare Community Plan of Colorado Rocky Mountain Children's Health Plan members; applies to inpatient and outpatient services.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Rocky Mountain Children's Health Plan

Policy CodePolicy N/A

Change TypeMinor revision — no material changes

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or use designated vendor phone numbers (eviCore, Optum Transplant) as instructed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Submission pathways

ExemptEmergency/urgent care

J9000‑J9999Chemotherapy J‑codes

~200+Listed codes (approx.)

eviCore/OptumExternal vendors

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

Coverage criteria for listed services

The document lists services and specific CPT/HCPCS/ICD-10 codes that require prior authorization for participating providers.

ALL of the following

CPT codes requiring prior authorization include: 29805, 29806, 29807, 29819, 29820, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29875, 29876, 29877, 29879, 29880, 29881, 29882, S2112.

ALL of the following

CPT/HCPCS codes include: 43644, 43645, 43770, 43775, 43842, 43845, 43846, 43847, 43848, 43860.

ALL of the following

CPT codes include: 19328, 19330, 19340, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 19396, L8600.

ALL of the following

Representative codes include: 33206, 33207, 33208, 33212, 33213, 33214, 33221, 33224, 33225, 33227, 33229, 33230, 33231, 33240, 33249, 33262, 33263, 33270, 93319, 93350, 93351, 93453, 93454, 93455, 93457, 93458, 93459, 93460, 93461, 0614T, 0571T.

Emergency or urgent care: prior authorization not required.

Out-of-network providers: must request prior authorization for all procedures and services.

Prior authorization criteria (summary)

Prior authorization is required for the following outpatient injectable chemotherapy drugs and selected injectable agents:

ALL of the following

Includes the J-code range J9000-J9999 and specific agents: J0640 (Leucovorin), J0641/J0642 (Levoleucovorin), J1950 (Lupron Depot), J0885, J1449, J1932, J1954, and Lutetium Lu (A9607).

ALL of the following

Chemotherapy items with Q-codes or billed under miscellaneous HCPCS are included per the chemotherapy listing.

ALL of the following

Examples include bone modifying agent J0897; additional injectable codes noted: J1442, J1447, Q5108, Q5110, Q5111, Q5120, Q5122, J2506 (some codes effective Nov. 1, 2023).

Reconstructive procedure exceptions

Reconstructive procedures

ALL of the following

The listing enumerates multiple ICD-10 codes (C43.*, C44.*, C4A.*, D03.*, D04.* etc.) under which reconstructive procedure prior authorization is not required when billed with those Dx codes.

When reconstructive procedures are performed to improve or restore physiological function and billed with the listed diagnosis codes, prior authorization is not required.

Implants and monitoring devices — device and implant coverage

Device and implant coverage

ALL of the following

Representative codes include CPT 69930 and HCPCS device/supply codes L8619, L8627, L8629, L8614.

ALL of the following

Representative supply/equipment codes include A4239, E0784, E2102, E2103.

DME prior authorization

Durable Medical Equipment

ALL of the following

Representative HCPCS codes include A9520, A9279, A9280, A9900 and equipment codes E0194, E0265, E0266; prior authorization is required for the DME entries shown.

Authorization requirements by service group

Service groups and their authorization expectations:

ALL of the following

Sample codes: A9520, A9279, A9280, A9900.

ALL of the following

Sample codes: B4149, B4150, B4152, B4153.

ALL of the following

Services flagged with B9002, B9998, S9434, S9435 require prior authorization as investigational items.

ALL of the following

Sample CPT codes shown include 14000, 14001, 14040; associated diagnosis mappings are listed (e.g., F64.1, F64.2).

Prior authorization coverage criteria (listed items)

Services and codes identified in this section require prior authorization before service or claim submission.

ALL of the following

Submission for many genetic tests is via eviCore (www.evicore.com, 800-792-8750) as noted in the genetic tests/lab services entries.

ALL of the following

Representative device/procedure codes include V5014, V5030 and multiple 679xx/697xx series codes listed under Hearing/audio/vision.

ALL of the following

Representative home health codes include G0176, G0248, G0249, G0250 and related S-codes; entries indicate prior authorization required.

ALL of the following

Prior authorization requirement by category

Categories and codes marked with 'Prior authorization required' in this section must obtain prior authorization before service or billing.

ALL of the following

Examples include C1821, Q4282, C9352, C9353 and numerous Q-series supply codes listed.

ALL of the following

Examples include therapy and medicine procedure codes such as 97533, 97605, 97606, 97750.

ALL of the following

Representative L-codes include L5816, L5826, L5848, L5850, L5845, L5856, L5857, L5858, L5930, L5950, L5960, L5961, L5962, L5964.

Musculoskeletal and obstetrical procedures identified in this section require prior authorization per the listed codes.

Effective-date notices (time-limited or new requirements)

Time-limited or newly required prior authorization entries:

ALL of the following

Notable effective-date items: Izervay use of temporary codes J3490/J3590 effective Jan 1, 2024; prior authorization required for J0174 effective Aug 1, 2023; prior authorization required for Q5133 and Q5135 effective Oct 1, 2024.

Radiation therapy prior auth criteria (excerpt)

Radiation therapy prior authorization condition based on diagnosis codes

ALL of the following

Applicable diagnosis code ranges include: C34.00 - C34.92; C50.011 - C50.929; C61; C79.51 - C79.52; C84.7A; D05.00 - D05.92.

When the service meets the diagnosis condition above, prior authorization is required for the radiation therapy codes listed (for example CPT 77401, 77402, 77407, 77412).

Pain management prior auth criteria (excerpt)

Pain management injections listed require prior authorization (codes provided).

ALL of the following

Specified CPT codes include: 64490, 64491, 64492, 64493, 64494, 64495.

Obtain prior authorization before performing or billing for the pain management injection procedures referenced.

Prior authorization criteria by procedure category

Prior authorization required for participating physicians for listed procedures and codes.

ALL of the following

Applicable codes include Q4117, Q4122, Q4123, Q4124, and associated codes such as S8035, S8085; submit via UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-889-8054.

ALL of the following

Examples include CPT codes: 64553, 64568, 64570, 64590, 95700, 95711, 95712; submit via UHCprovider.com or call 866-889-8054.

ALL of the following

Representative CPT codes include 22100–22102, 22110, and broader spine surgery/instrumentation series noted in the spine section; submit via UHCprovider.com or call 866-889-8054.

Prior authorization requirements and submission instructions (overview)

Prior authorization/notification is required for the listed procedures and codes; providers must submit via specified portals or phone numbers, and select services are managed by external vendors.

ALL of the following

Submit requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-889-8054; see Radiology Prior Authorization and Notification for the specific CPT codes.

ALL of the following

For eviCore-managed requests submit online at www.evicore.com or call 800-792-8750 as indicated in the document.

ALL of the following

For unclassified codes J3490, J3590, and C9399 (Amtagvi, Lenmeldy, Ryoncil) prior authorization is required through Optum Transplant.

ALL of the following

CPT / HCPCS / ICD-10 Codes Referenced

Covered HCPCS — Cochlear / Auditory Implant DevicesHCPCSCovered

L8619	Cochlear device, internal (implantable) (includes device only)
L8627	Ear prosthesis, cochlear, external (sound processor)
L8629	Ear prosthesis, cochlear, external, other
L8614	Cochlear device component (implantable), internal

Covered HCPCS — Other Hearing-related Device CodesHCPCSCovered

Q2029

Prosthetic device, external ear, auricular prosthesis; silicone, custom-fabricated

How to Submit Prior Authorization Requests and Provider Responsibilities

Prior Authorization

How to Submit Prior Authorization Requests

Submit prior authorization requests using one of the following: UnitedHealthcare Provider Portal (Prior Authorization & Notification tool at UHCprovider.com — sign in with One Healthcare ID), eviCore (www.evicore.com or 800-792-8750) for advanced imaging and many genetic/lab requests, Optum Transplant for select transplant/unclassified drug authorizations (see below), or by phone/fax where noted. Prior authorization is not required for emergency or urgent care. Out-of-network providers must request prior authorization for all procedures and services.

Portal: UHCprovider.com → Prior Authorization and Notification tab
eviCore: www.evicore.com or 800-792-8750 (see eviCore submission guidance for genetics/lab)
Optum Transplant: required for select unclassified drug codes (J3490, J3590, C9399)
Fax (non-participating providers): 800-262-2567 or 970-255-5681
Behavioral health: 888-282-8801
Notification by admitting facility: 800-416-2157 (option 4) or 970-248-5197

Prior Authorization

Bariatric surgery and breast reconstruction — provider action examples

Key Terms and Scope Notes

inv-70: Emergency/urgent care — prior authorization not required

DefinitionPrior authorization is not required for emergency or urgent care.

ScopeApplies to participating UnitedHealthcare Community Plan of Colorado Rocky Mountain CHP providers providing inpatient and outpatient services.

Provider noteNon-participating providers may fax requests to 800-262-2567 or 970-255-5681.

inv-71: Out-of-network providers — prior authorization requirement

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

ImplicationOut-of-network providers cannot rely on emergency/urgent care exemption and must submit prior authorization for planned services.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Rocky Mountain Children's Health Plan

Policy CodePolicy N/A

Change TypeMinor revision — no material changes

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or use designated vendor phone numbers (eviCore, Optum Transplant) as instructed.

SourceLink

On This Page

ALL of the following

Representative proprietary/genetic codes include 0417U and multiple 8xx/8xxx/Category II/III test codes routed to eviCore for authorization.

Representative injectable medication codes shown include J0175, Q5101 and other J-/Q-series codes per the injectable medications listing.

How to submit: for services routed to eviCore, submit requests online at www.evicore.com or call 800-792-8750; for other services follow the submission instructions shown (e.g., UHCprovider.com or listed phone numbers).

Providers should follow the listed submission channels and vendor instructions for these services.

Examples of bariatric surgery and breast reconstruction services that require prior authorization. Providers must submit a prior authorization request before scheduling and providing these procedures.

Bariatric surgery: 43644, 43645, 43770, 43775, 43842, 43845, 43846, 43847, 43848, 43860
Breast reconstruction (including non-mastectomy reconstruction and related reconstruction codes): 19328, 19330, 19340, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371

Prior Authorization

Cardiovascular procedures — provider action examples

Examples of cardiovascular procedures that require prior authorization for participating physicians (outpatient and many office-based diagnostic procedures). Submit authorization prior to performance.

Cardiac catheterization / diagnostic: examples include 93453–93461 series
Electrophysiology implants and stimulators: CPT examples include 33206, 33207, 33208, 33212, 33213, 33214, 33221, 33224, 33225, 33227, 33229–33231, 33240, 33249, 33262, 33263, 33270
Echocardiography/stress echoes: 93319, 93350, 93351 where applicable
Coronary angiography/interventional: 93453–93461 (see codes above)

Prior Authorization

Other injectable agents requiring prior authorization

Prior authorization is required for many outpatient injectable and specialty medications (including chemotherapy and other injectables). Providers should verify specific J-/Q-/A- codes, effective dates, and any temp/unclassified code routing before administration.

Outpatient injectable chemotherapy: J9000–J9999 series; leucovorin J0640; levoleucovorin J0641, J0642; Lupron depot J1950; lutetium Lu A9607; certain Q-codes and miscellaneous HCPCS-billed oncology drugs
Selected injectable non-chemotherapy agents requiring prior authorization (examples): J0897 (bone modifying agent), J1442, J1447, J2506 (effective Nov. 1, 2023), J0174 (PA effective Aug. 1, 2023)
Other injectable agents and specialty biologics (examples listed in source): Lupaneta Pack, Nulibry, Recovi, Riabni, Rivfloza, Skyrizi, Steqeyma IV, white blood cell colony stimulating factors, Veopoz, Yesintek IV
Temporary/unclassified billing notes: Izervay (effective Jan 1, 2024) may use J3490/J3590 — check operational guidance
Q-code PA changes effective Oct. 1, 2024: Q5133, Q5135 require prior authorization

Prior Authorization

Enteral services and DME — provider actions

Durable medical equipment, enteral nutrition and in-home nutritional therapy require prior authorization. Submit prior authorization for DME and enteral supplies before delivery.

Durable medical equipment (examples of HCPCS requiring PA): A9520, A9279, A9280, A9900, E0194, E0265, E0266, K0884–K0890, S1040, T1999, T5999
Enteral services (examples of HCPCS nutrition formula/products requiring PA): B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162
In-home nutritional therapy codes: B9002, B9998, S9434, S9435 — PA required when applicable

Prior Authorization

Genetic tests and lab services — provider actions (eviCore)

Genetic and laboratory tests often require prior authorization and many are managed through eviCore. Submit genetic test prior authorization requests online at www.evicore.com or by phone.

Genetic tests/lab services requiring PA (examples): CPT 81439, 81443, 81445, 81448, 81460, 81465, 81479, 81451, 81418, 81449, 81452 series and multiple proprietary/lab-specific CPT and CPT II/Temp codes (e.g., 0417U, 0411U, 0364U, 0379U)
Additional listed CPT/Temp examples: 0071T, 0207T, 0072T, 0208T, 0198T, 0210T, 0202T
How to obtain: Submit requests online at www.evicore.com (sign-in) or call 800-792-8750. Follow eviCore instructions for molecular/genetic panels and specialty lab services.

Prior Authorization

Service categories requiring prior authorization — provider actions

Service categories that require prior authorization are broad. Confirm PA requirements for the specific procedure code and diagnosis; when in doubt submit a PA request before service delivery.

Hearing/audio/vision services and devices (selected codes and V-codes) — PA required (examples: hearing device and prosthetic V-codes listed in hearing/audio/vision block)
Home health and home healthcare services — G0176, G0248–G0250 and related S-codes require PA
Injectable medications and biologics — see injectable medications blocks (J-, Q-, A- codes and select NDCs)
Medical and surgical supplies — selected HCPCS such as C1821, Q4282, C9352–C9364, Q2041–Q2043, Q4114–Q4165 require PA
Medicine services and procedures (select CPTs e.g., 97533, 97605–97606, 97750)
Musculoskeletal, obstetrical procedures, orthognathic surgery, reconstructive/cosmetic procedures, sleep studies, spine surgery, radiology/advanced imaging (eviCore) — PA required as listed in respective categories
Transplants, stimulators, vein procedures, ventricular assist devices (VADs) — PA required

Prior Authorization

Injectable medication codes and effective-date notes — provider actions

Selected injectable medication codes and mapping/replacement guidance — providers must check effective-date notes and code substitutions when submitting PA requests.

Broad chemotherapy range: J9000–J9999 (PA required for outpatient injectable chemotherapy)
Selected J/Q/A codes called out in source: J0897, J1442, J1447, J2506 (effective Nov. 1, 2023), J0174 (PA effective Aug. 1, 2023)
Mapping examples: some older Q-/J- code mappings shown in source (refer to source table when preparing PA)
Unclassified/temp codes: For J3490, J3590, and C9399 billing entries (Amtagvi, Lenmeldy, Ryoncil), prior authorization is required through Optum Transplant (see Optum Transplant entry)

Prior Authorization

Procedures, supplies and services requiring prior authorization — provider actions

Procedures, supplies and services across multiple categories require prior authorization. Providers should include the CPT/HCPCS code, relevant diagnosis, clinical documentation, and where applicable, device or product model details when submitting a request.

Medical/surgical supplies and implantable devices (selected HCPCS/C-codes/Q-codes listed in source)
Skin substitutes and advanced wound products (examples: Q4117, G0281, S8035, S8085, Q4122–Q4165) — PA required; submit via Provider Portal or call listed number
Radiology/advanced imaging (CT/MRI/MRA/PET/nuclear cardiology) — PA often managed by eviCore; see Radiology Prior Authorization and Notification guidance
Sleep procedures (CPT examples: 64553, 64568, 64570, 64590, 95700, 95711–95713) — PA required

Prior Authorization

Orthotics and prosthetics — prior authorization codes and provider submission instructions

Extensive lists of orthotics and prosthetics HCPCS (L-codes) require prior authorization. Providers must submit model/manufacturer and itemized component details with the PA request.

Orthotics and prosthetics examples requiring PA: L5816, L5826, L5848, L5850, L5845, L5856, L5857, L5858, L5930, L5950, L5960, L5961, L5962, L5964, L5966, L5968, L5973, L5979, L5980, L5981, L5982, L5987, L5990, L5999, L6000, L6010, L6020, L6050, L6055, L6100, L6110, L6120, L6130, L6200, L6205, L6250, L6300, L6310, L6320, L6350, L6360, L6370, L6380, L6382, L6384, L6400, L6450
Operational note: include manufacturer, model, measurements and medical necessity documentation with the PA submission.

Prior Authorization

Effective-date notes and code-change alerts — provider action

Effective-date and code-change alerts — providers must monitor effective dates for when prior authorization requirements apply to specific codes and for newly added Q-/J-/HCPCS codes.

J2506 — prior authorization effective Nov. 1, 2023
Izervay — effective Jan. 1, 2024 may be billed temporarily under J3490/J3590; confirm required PA routing
Q5133, Q5135 — prior authorization required effective Oct. 1, 2024
J0174 — prior authorization required effective Aug. 1, 2023
Always confirm the current PA effective date at submission time and include correct code versioning.

Prior Authorization

How to obtain prior authorization — additional codes and channels

Additional codes and submission channels: for many categories (skin substitutes, radiology, sleep, spine, surgical implants, stimulators, transplants, vein procedures, VADs) please submit via the UnitedHealthcare Provider Portal or the designated vendor (eviCore, Optum Transplant) as indicated in category guidance.

Skin substitutes and related codes: see Q4117, Q4122, Q4123, Q4124, Q4126, Q4161, Q4163–Q4165
Radiology/advanced imaging and spine imaging: managed by eviCore for participating physicians — submit via eviCore or Provider Portal as instructed
Sleep and spine procedural codes: submit via Provider Portal or call 866-889-8054 for assistance
Surgery, stimulators and VADs: submit PA prior to scheduling; examples and code ranges provided in the spine/stimulator/surgery blocks

Prior Authorization

Sleep procedures and spine surgery — provider actions

Sleep procedure and spine surgery prior authorization — providers must obtain PA before performing these services. For many radiology and sleep-related CPTs, the Radiology Prior Authorization and Notification guidance applies.

Sleep procedures — examples of CPT/HCPCS requiring PA: 64553, 64568, 64570, 64590, 95700, 95711–95713
Spine surgery — examples of CPTs requiring PA: 22100–22114 series, 22206–22214, 22220, 22224, 22510–22511, 22804, 22808, 22810, 22812, 22818–22819, 22830, 22849–22856, 22858, 22861, 22899, 63003, 63016, 63040, 63042, 63046, 63050, 63055
Submission: Use UnitedHealthcare Provider Portal or call 866-889-8054 for details; radiology components may route to eviCore

Prior Authorization

Spine instrumentation and neurosurgery — provider actions

Spine instrumentation, neurosurgery, stimulators and related implantable devices require prior authorization. Submit operative plans, device model numbers, and supporting clinical documentation.

Spine instrumentation and neurosurgery examples: CPTs/HCPCS in 228xx, 630xx, 632xx, 636xx series as listed in the spine blocks (e.g., 22804, 22808, 22810, 22812, 22818, 22830, 22849, 22852, 22855, 22856, 22858, 22861, 22899)
Stimulator codes and mapping examples: 20975, 20979, 63655, 63685, 64555, L8680, E0762, E0765 — PA required prior to implantation
Include device identifiers, implant supplier info, pre-op notes and supporting imaging with your PA request.

Prior Authorization

eviCore submissions — provider routing

eviCore submission reminder: certain advanced outpatient imaging, genetic/molecular testing and other vendor-managed services must be submitted online at www.evicore.com or by phone at 800-792-8750. Participating physicians should use eviCore for the categories it manages.

Advanced imaging (CT/MRI/MRA/PET/nuclear cardiology) — many CPTs route to eviCore (see radiology lists)
Genetic/molecular lab services — submit via eviCore portal or phone for authorization and clinical review
If a service is managed by eviCore, submit to eviCore rather than UnitedHealthcare portal to avoid delays.

Prior Authorization

Optum Transplant prior authorization for select unclassified drug codes

Optum Transplant — prior authorization required for select unclassified drug codes and transplant-related drugs billed to unclassified codes. For J3490, J3590, and C9399 entries representing Amtagvi, Lenmeldy, and Ryoncil, prior authorization must be obtained through Optum Transplant.

Unclassified codes requiring Optum Transplant PA: J3490, J3590, C9399 when used for Amtagvi, Lenmeldy, Ryoncil
Contact Optum Transplant per payer instructions for PA submission for these agents

Prior Authorization

Surgery, stimulators, transplants, vein procedures, VADs — provider actions

Surgery, stimulators, transplants, vein procedures and ventricular assist devices (VADs) require prior authorization. Submit complete clinical documentation, device details and proposed operative plan prior to scheduling.

Surgery examples: broad surgery code ranges listed in surgery blocks (e.g., major joint/orthopedic, spine, thoracic, abdominal CPTs) — PA required
Stimulators: see stimulator mapping and codes (20975, 20979, 63655, 63685, 64555, device HCPCS) — PA required
Transplants: listed transplant CPTs (e.g., 32850–32856, 33930) — PA required
Vein procedures: 37799 and related codes — PA required
Ventricular assist device (VAD) implants — prior authorization required; include device/product and clinical documentation

Submission guidanceOut-of-network providers should use authorized submission channels (portal, fax) as described in the policy.

inv-72: Injectable chemotherapy drugs definition (J9000-J9999)

HCPCS rangeInjectable chemotherapy drugs billed under HCPCS codes J9000–J9999 require prior authorization when administered in an outpatient setting for a cancer diagnosis.

Included examplesIndividual J-codes called out include J0640 (Leucovorin), J0641/J0642 (Levoleucovorin), J1950 (Lupron Depot).

Other agentsAlso includes listed agents such as J0885, J1449, J1932, J1954 and Lutetium Lu (A9607).

inv-73: Miscellaneous HCPCS/Q codes definition

DefinitionChemotherapy injectable drugs that have a Q code or that have not yet received an assigned code and will be billed under a miscellaneous HCPCS code require prior authorization.

Billing noteMiscellaneous items may be billed under an unassigned/miscellaneous HCPCS when an assigned code is not yet available.

Related codesPolicy references Q-coded chemotherapy items alongside J-code chemotherapy agents.

inv-74: Cochlear implants / auditory devices (definition/flag)

RequirementCochlear implants and other auditory prostheses require prior authorization.

Example procedure/codeCochlear implant procedure: CPT 69930; related supply codes include L8619, L8627, L8629, L8614.

Related device noteContinuous glucose monitor supplies (A4239, E0784, E2102, E2103) also specified elsewhere as requiring prior authorization when applicable.

inv-75: Durable medical equipment (DME) definition

DefinitionDurable medical equipment (DME) items listed in the policy (example HCPCS: A9520, A9279, A9280, A9900, E0194, E0265, E0266) require prior authorization.

ExamplesSample DME codes called out: A9520, A9279, A9280, A9900 and equipment codes E0194, E0265, E0266.

ActionObtain prior authorization before claim submission for listed DME items.

inv-76: Reconstructive procedures exception (definition)

ExceptionReconstructive procedures are not subject to prior authorization when billed with the enumerated diagnosis codes (multiple C43/C44 and related ICD‑10 codes).

ConditionApplies when the procedure is billed with the specific diagnosis codes listed in the policy indicating reconstructive intent to improve or restore physiological function.

ReferenceSee enumerated ICD‑10 diagnosis code list in the reconstructive procedures section for applicable codes (e.g., C43.* , C44.* ranges).

inv-77: Durable medical equipment (DME) — repeated definition

DefinitionDurable medical equipment (DME): HCPCS equipment codes listed in the policy (e.g., A9520, A9279, A9280, A9900) are subject to prior authorization.

Coding examplesPolicy provides example HCPCS equipment codes and notes prior authorization is required for these DME items.

Provider actionSubmit prior authorization prior to service or claim submission for listed DME codes.

inv-78: Enteral services definition

DefinitionEnteral services (enteral nutrition and associated supplies) require prior authorization.

Example HCPCS codesExamples include B4149, B4150, B4152, B4153 (and additional B41xx series codes listed in the policy).

ScopeApplies to in‑home enteral nutritional therapy and related billed supplies; obtain prior authorization before service.

inv-79: Experimental / Investigational definition

DefinitionExperimental and investigational services are those identified by investigational HCPCS/CPT mappings (e.g., B9002, B9998, S9434, S9435) and require prior authorization.

ExamplesPolicy maps investigational codes to a variety of CPT/HCPCS procedures (examples shown in the Experimental/Investigational section).

RequirementObtain prior authorization for services flagged as experimental/investigational before proceeding or billing.

inv-80: Gender dysphoria treatment definition

DefinitionGender dysphoria–related treatments and associated CPT/HCPCS codes (examples include CPT 14000, 14001, 14040) are identified in the policy and require prior authorization.

Diagnosis linkagePolicy references ICD‑10 codes F64.1, F64.2, F64.8, F64.9 and related codes alongside prior authorization requirements for gender dysphoria services.

ActionSubmit prior authorization for gender dysphoria treatment codes before service delivery.

inv-81: Third-party prior authorization vendor referenced for genetic tests/lab services (eviCore)

VendoreviCore is the third‑party prior authorization vendor referenced for many genetic tests and laboratory services.

ScopeSeveral proprietary U‑codes and other genetic CPT codes listed in the policy are routed to eviCore for prior authorization review.

Provider instructionWhen the policy lists (eviCore) next to genetic test codes, submit the request to eviCore as instructed.

inv-82: Online submission via www.evicore.com or by phone at 800-792-8750

Web submissionSubmit certain prior authorization requests online at www.evicore.com (sign in) — applicable to genetic tests and select procedures.

Phone submissionOr call eviCore at 800-792-8750 for prior authorization assistance.

ContextSome procedures and notifications also reference eviCore as the required submission pathway in the policy (see Radiology/Genetic sections).

inv-83: How to Obtain Prior Authorization (general reference)

Primary methodsHow to obtain prior authorization: submit requests via the UnitedHealthcare Provider Portal (UHCprovider.com) Prior Authorization & Notification tool, or follow vendor instructions (eviCore/Optum) as noted.

Alternate channelsNon-participating providers may fax requests to 800-262-2567 or 970-255-5681; specific phone numbers (e.g., 866-889-8054 for some radiology/skin substitute requests) are provided in the policy.

Behavioral healthBehavioral Health prior authorization inquiries use the dedicated line 888-282-8801.

inv-84: Standard radiation therapy prior authorization condition (definition)

ConditionStandard radiation therapy (2D/3D) requires prior authorization only when provided with specified cancer diagnosis code ranges (e.g., C34.00–C34.92; C50.011–C50.929; C61; C79.51–C79.52; C84.7A; D05.00–D05.92).

Applicable CPTsPolicy lists relevant radiation therapy CPTs (e.g., 77401, 77402, 77407, 77412) to which this condition applies.

ActionObtain prior authorization for standard radiation therapy when the service is linked to the specified diagnosis ranges.

inv-85: eviCore as external prior authorization vendor

RoleeviCore is identified as the external prior authorization vendor responsible for managing authorization of certain advanced outpatient imaging procedures.

ExamplesAdvanced imaging CPTs (e.g., 70486–70498 series, 70540–70546) are listed with (eviCore) indicating eviCore handles authorization.

Submission instructionWhen the policy lists (eviCore) next to CPT codes, submit those requests online at www.evicore.com or by calling 800-792-8750.

inv-86: Ordering provider (definition)

DefinitionOrdering provider: care providers who order or schedule advanced outpatient imaging procedures and are responsible for initiating prior authorization where required.

ContextOrdering providers should follow eviCore or UnitedHealthcare portal submission pathways as instructed for imaging prior authorization.

ActionEnsure prior authorization is obtained by the ordering provider before scheduling procedures requiring authorization.

inv-87: Prior authorization submission methods (portal, phone)

Online portalSubmit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) using the Prior Authorization and Notification tool.

Phone optionsSome authorizations may be obtained by phone (e.g., eviCore 800-792-8750; radiology/skin substitute line 866-889-8054; behavioral health 888-282-8801).

Fax for non-participating providersNon-participating providers may fax requests and documentation to 800-262-2567 or 970-255-5681.

inv-88: Unclassified J-/C-codes (J3490, J3590, C9399) — definition

Unclassified codesUnclassified J-/C-codes referenced: J3490, J3590, and C9399 are noted in the policy as unclassified codes used for certain products.

Specific use casePolicy notes that Amtagvi, Lenmeldy, and Ryoncil billed to unclassified codes (J3490/J3590/C9399) require prior authorization through Optum Transplant.

Prior authorization pathwayFor such unclassified drug codes, follow the Optum Transplant prior authorization instructions specified in the policy.

inv-89: evicore (definition / role)

RoleeviCore is an external clinical review vendor referenced for prior authorization of genetic tests, laboratory services and certain advanced imaging procedures.

FunctioneviCore processes online submissions (www.evicore.com) and phone authorizations (800-792-8750) for designated code groups noted in the policy.

IndicatorWhen the policy lists (eviCore) next to codes, submit to eviCore rather than the UnitedHealthcare portal.

inv-90: Optum Transplant (definition / role)

DefinitionOptum Transplant is the vendor designated to manage prior authorization for certain transplant‑related and unclassified drug codes.

Specific instructionFor unclassified codes J3490, J3590, and C9399 used for Amtagvi, Lenmeldy and Ryoncil, prior authorization is required through Optum Transplant.

ScopeOptum Transplant handles prior authorization routing for the specified transplant/unclassified drug scenarios noted in the policy.