CurrentUnitedHealthcarePolicy N/A

Rocky Mountain Children's Health Plan – Prior Authorization Requirements

Lists services, CPT/HCPCS and ICD-10 codes that require prior authorization (or are excluded) for participating and out-of-network providers serving UnitedHealthcare Community Plan of Colorado Rocky Mountain Children's Health Plan members; includes submission methods and special routing (eviCore, behavioral health, admitting facility).

Policy Summary

PayerUnitedHealthcare

PolicyRocky Mountain Children's Health Plan – Prior Authorization Requirements

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (or route specific services to eviCore or the behavioral health line as specified).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

manyCodes listed

3Submission channels

J9000-J9999Injectable chemo class

yeseviCore referenced

CGMCGMs require PA

Services Requiring Prior Authorization

Service-level prior authorization requirements (partial)

Specific services and CPT/HCPCS codes require prior authorization as listed below.

ALL of the following

Arthroscopy services
- CPT codes: 29805, 29806, 29807, 29819, 29820, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29875, 29876, 29877, 29879, 29880, 29881, 29882, S2112
Bariatric and obesity-related services
- CPT codes: 43644, 43645, 43770, 43775, 43842, 43845, 43846, 43847
Breast reconstruction
- CPT codes: 19328, 19330, 19340, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380
Other listed services (examples)
- Diagnosis and procedure-related codes referenced: D05.80–D05.92, Z42.1, Z85.3, Z90.10–Z90.13 (see listing)

Prior authorization required for these listed services when billed as indicated; refer to the full CPT/HCPCS lists for additional codes and applicable diagnosis exceptions.

Oncology drug prior authorization

Covered when ALL of the following are met:

ALL of the following

Service: Outpatient administration (including intravenous, intravesical, intrathecal) of chemotherapy injectable drugs billed under J-codes (J9000–J9999) or specified HCPCS/Q codes/agents.
Codes: J9000-J9999; examples include J0640, J0641, J0642, J1950, J0885, J1449, J1932, J1954, A9607 as listed.
Indication: Administered for a cancer diagnosis (prior authorization required for outpatient setting).

Some colony stimulating factor codes and other oncology-related J-codes are separately listed; check the injectable medication section for specific named agents and unclassified-code exceptions.

Device prior authorization

Prior authorization is required for the following devices and implants when billed as indicated.

ANY of the following

Cochlear and auditory implants: codes 69930, L8614, L8619, L8627, L8629 (prior authorization required).
Continuous glucose monitors (CGMs): codes A4239, E0784, E2102, E2103 — prior authorization required when used with a Type 2 Diabetes diagnosis.

Refer to device/implant code listings for additional device-specific prior authorization requirements.

Surgical procedure prior authorization

Prior authorization required for listed cosmetic and reconstructive procedures.

ALL of the following

Cosmetic/reconstructive CPTs (examples)
- CPT codes include: 11960, 11971, 14020, 14021, 14060, 14061, 14061, 14301, 17106, 17107, 17108, 17999, 20930-20931, 21141-21151, 21154, 21155, 21159, 21160, 21180-21199, 21206, 21215, 21230-21249, 21255-21256, 21275, 21280-21295 (as enumerated).
Reconstructive procedures that treat a medical condition (specific CPTs listed) are included and require prior authorization.

See the full cosmetic/reconstructive CPT lists in the document for complete code coverage and submission instructions.

Authorization criteria (codes and exceptions)

Authorization requirements and listed exceptions:

ALL of the following

Durable medical equipment (DME) items listed require prior authorization (examples include HCPCS A9520, A9279, A9280, A9900; E-series and other E- and K-codes referenced).
Exception: Prior authorization is not required when billed with certain specified codes or when specific diagnosis codes apply (example ICD-10 C43.* series shown as Dx exceptions).

Refer to the DME and diagnosis code listings for specific applicability and billing combinations that alter prior authorization requirements.

Prior authorization criteria (excerpt)

Prior authorization is required for the following service categories and selected codes:

Some genetic and complex lab services are routed to eviCore for review per the listings; follow submission instructions shown in the radiology/genetic sections.

Radiation therapy diagnosis-linked prior authorization

Standard (2D/3D) radiation therapy requires prior authorization only under specified diagnosis ranges.

ALL of the following

Action: Prior authorization required for standard radiation therapy (2D/3D).
Diagnosis requirement: Only when billed with diagnosis codes within these ranges: C34.00–C34.92, C50.011–C50.929, C61, C79.51–C79.52, C84.7A, D05.00–D05.92.
Examples of associated CPT codes referenced in this section include: 77401, 77402 (radiation therapy planning/therapy codes).

Confirm diagnosis linkage on the claim; prior authorization applies only when one of the listed cancer-related diagnosis ranges is present.

Explicit prior authorization service list

Selected service categories explicitly require prior authorization as listed below.

ANY of the following

Pain management injections: prior authorization required (procedure codes 64490–64495).
Private duty nursing: prior authorization required (codes referenced elsewhere in document).
Prostate procedures: prior authorization required (codes referenced elsewhere in document).

See the applicable procedure sections for specific CPT codes and submission instructions.

Prior authorization criteria (radiology and procedures)

Advanced outpatient imaging and other procedure categories require notification and/or prior authorization.

ALL of the following

Advanced outpatient imaging: Prior authorization required for participating physicians who request these procedures; providers are responsible for providing notification prior to scheduling.
Submission: Providers must submit prior authorization requests online at www.evicore.com (or call 800-792-8750); UnitedHealthcare portal submissions may be used per instructions (UHCprovider.com or 866-889-8054).
Imaging examples
- Selected advanced imaging CPT examples listed: 0634T, 0636T, 0637T, 0638T, 0697T, 0698T, 0710T–0713T, 75573, 75580, 77021, 77084, and various nuclear medicine and PET codes (see radiology listing).
- Skin substitutes and rhinoplasty: skin substitutes (Q4117, Q4122, Q4123, Q4124) and rhinoplasty procedures are identified as prior authorization required.

Prior authorization requirements (selected)

Selected categories explicitly state prior authorization is required.

ALL of the following

Transplants: Prior authorization required for transplant-related CPT/HCPCS codes as listed (examples include 32850–32854 and other transplant procedure codes).
Vein procedures: Prior authorization required; unlisted vascular surgery code 37799 is noted as prior authorization required for vein procedures and ablation/removal of saphenous trunks/branches.
Ventricular assist device (VAD): Prior authorization required for ventricular assist device procedures.

Follow the listed procedure code groupings in the document for full code detail and submission routing.

Codes and Code Groups Requiring Prior Authorization

Bariatric and obesity-related CPT codesCPT

43644	Laparoscopy, gastric restrictive procedure
43645	Laparoscopy, proximal gastric bypass
43770	Laparoscopy, gastric restrictive procedure with partial gastrectomy
43775	Laparoscopy, gastric restrictive procedure with gastric bypass
43842	Gastric restrictive procedure with gastric bypass, laparoscopic
43845	Gastric restrictive procedure with intestinal bypass
43846	Gastric restrictive procedure with duodenal switch
43847	Revision of gastric restrictive procedure
43848	Removal of gastric restrictive device
43860	Laparoscopy, gastric revision

Breast reconstruction/implant and prosthesis codesCPT

19328	Mastectomy with reconstruction
19330	Immediate insertion of breast prosthesis
19340	Immediate reconstruction with tissue expander
19357	Nipple/areola reconstruction (non-mastectomy)
19361	Augmentation mammaplasty (non-mastectomy)
19364	Breast reconstruction with free flap (non-mastectomy)
19367	Breast reconstruction with latissimus dorsi flap
19368	Breast reconstruction with tissue expander
19369	Breast reconstruction with implant
19370	Revision of reconstructed breast

1–10 of 14

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Selected ICD-10 diagnosis codes referenced (breast reconstruction exemptions)ICD-10

C50.011	Malignant neoplasm of nipple and areola, right female
C50.012	... left
C50.019	... unspecified
Z42.1	Encounter for breast reconstruction following mastectomy
Z85.3	Personal history of malignant neoplasm of breast
Z90.10	Acquired absence of breast, unspecified

Injectable chemotherapy and oncology-related J-codesHCPCS

J0640	Leucovorin, including leucovorin calcium, per 50 mg
J0641	Levoleucovorin, per 25 mg
J0642	Levoleucovorin, per 100 mg
J1950	Leuprolide acetate (Lupron Depot), per 7.5 mg
J0885	Injection, pegfilgrastim-bmez, 6 mg (example colony stimulating factor)
J1449	Injection, filgrastim-sndz (colony stimulating factor)
J1932	Injection, trastuzumab, 10 mg
J1954	Injection, bevacizumab-awwb, 10 mg (note: cancer Dx excluded from prior auth for J1954)
A9607	Lutetium Lu 177 dotatate, per dosage unit

Cosmetic and reconstructive CPT codesCPT

11960	Repair of undermined skin flap
11971	Repair of eyelid, full-thickness
14020	Adjacent tissue transfer or rearrangement, forehead
14021	... scalp
14060	Adj tissue transfer, lips
14061	... nose
14301	Adj tissue transfer, complex
17106	Destruction of benign lesion, trunk/arm/leg, each
17107	Destruction of benign lesion, face/neck, multiple
17108	Destruction of benign lesion, hands/feet

1–10 of 52

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How to Obtain Prior Authorization and Provider Responsibilities

Prior Authorization

How to obtain prior authorization

Submit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com Sign In → Prior Authorization and Notification), or for non‑participating providers fax documentation to 800‑262‑2567 or 970‑255‑5681. Behavioral health prior authorizations: call 888‑282‑8801. Admitting facility notification: 800‑416‑2157 (option 4) or 970‑248‑5197. 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 → Prior Authorization and Notification
Fax (non‑participating providers): 800‑262‑2567 or 970‑255‑5681
eviCore (see related block): www.evicore.com, 800‑792‑8750
Behavioral health: 888‑282‑8801
Admitting facility notification: 800‑416‑2157 (option 4) or 970‑248‑5197

Key Terms and Definitions

Prior authorization submission channels, exclusions and summary

Submission channelsOnline via UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com); non-participating providers may fax to 800-262-2567 or 970-255-5681; admitting facility notification via 800-416-2157 (option 4) or 970-248-5197

eviCore routingUse eviCore (www.evicore.com; 800-792-8750) for certain specialty services as specified elsewhere in this list

Behavioral health prior authBehavioral health prior authorizations (mental health and substance use disorders) via 888-282-8801

Emergency/urgent carePrior authorization is not required for emergency or urgent care

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

Policy Summary

PayerUnitedHealthcare

PolicyRocky Mountain Children's Health Plan – Prior Authorization Requirements

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2025

Next Review DateN/A

SourceLink

On This Page

Refer to the Radiology Prior Authorization and Notification document for the complete CPT/HCPCS lists managed via eviCore.

Prior Authorization

eviCore routing for specified services

Certain specialty services (including many advanced outpatient imaging and specified cardiovascular services) must be submitted to eviCore; providers may submit online at www.evicore.com or call 800‑792‑8750 for eviCore‑managed reviews.

Submit eviCore requests online at www.evicore.com or call 800‑792‑8750
eviCore handles many advanced outpatient imaging and specified cardiovascular services

Note

General prior authorization listings

The document links many CPT/HCPCS and ICD‑10 codes to the general 'How to Obtain Prior Authorization' instructions; providers should consult the listed code entries to determine the appropriate submission method and PA requirement.

Many CPT/HCPCS and ICD‑10 codes in the list reference the 'How to Obtain Prior Authorization' instructions
Follow the referenced submission channel (UHC portal, eviCore, fax, behavioral health line) shown with each code

Prior Authorization

Injectable chemotherapy drugs

Prior authorization is required for outpatient injectable chemotherapy drugs (J9000–J9999) and specified named agents when administered via IV, intravesical, or intrathecal routes for a cancer diagnosis.

Includes chemotherapy J‑code range J9000–J9999 and listed agents such as J0640/J0641/J0642, J1950, J0885, J1449, J1932, J1954, A9607
Applies to outpatient administration (intravenous, intravesical, intrathecal) for cancer diagnoses

Prior Authorization

Devices requiring prior authorization

Prior authorization is required for specified devices and implants, including cochlear and other auditory implants (codes 69930, L8614, L8619, L8627, L8629) and continuous glucose monitors (A4239, E0784, E2102, E2103) when used with a Type 2 Diabetes diagnosis.

Cochlear and auditory implant codes: 69930, L8614, L8619, L8627, L8629
Continuous glucose monitor supply/device codes: A4239, E0784, E2102, E2103 (PA required with Type 2 Diabetes DX)

Prior Authorization

Cosmetic and reconstructive procedures

Cosmetic and reconstructive procedures require prior authorization; reconstructive procedures that treat a medical condition are included and numerous CPT codes are enumerated in the list.

Examples of listed cosmetic/reconstructive CPT codes include 11960, 11971, 14020, 14021, 14060, 14061, 14301, 17106, 17107, 17108, 17999, 20930–21282, 21295, 21280, 21282, 21295
Reconstructive procedures that treat medical conditions are explicitly included

Documentation Required

Prior authorization notes and example code

Some listed codes have exceptions or specific billing notes: prior authorization may not be required when billed with certain diagnosis codes (examples include melanoma codes C43.* shown in the list); providers must check the code entry for any 'Prior authorization not required when billed with' notes.

Example: entries state 'Prior authorization not required when billed with the following' and list Dx codes such as C43.0, C43.10, C43.111, C43.112, etc.
DME entries specifically list codes flagged as 'Prior authorization required' (e.g., A9520, A9279, A9280, A9900 and E‑series codes)

Prior Authorization

DME prior authorization requirement

Durable medical equipment (DME) items listed in the document require prior authorization; the list includes example HCPCS codes such as A9520, A9279, A9280, A9900 and E0194, E0265, E0266, E0270.

DME example codes flagged: A9520, A9279, A9280, A9900
Additional DME codes referenced: E0194, E0265, E0266, E0270

Prior Authorization

Authorization submission instructions

For many services managed by eviCore (including advanced outpatient imaging and certain genetic tests listed), submit authorization requests online at www.evicore.com or call 800‑792‑8750.

eviCore submission: www.evicore.com or 800‑792‑8750
Used for advanced outpatient imaging and many genetic test entries that reference eviCore

Prior Authorization

Enteral services prior authorization

Enteral services require prior authorization; listed HCPCS B‑codes (B4149, B4150, B4152, B4153, B4154, B4155, B4157–B4162, B9002, B9998 and S9434/S9435) are included in the entry.

Enteral service codes included: B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B9002, B9998, S9434, S9435

Prior Authorization

Genetic tests/lab prior authorization

Genetic tests and laboratory services require prior authorization; the list includes numerous U‑codes and PLA/CPT codes (examples: 0417U, 0018U, 0022U, 0026U, 0029U, 0047U, 0048U, 0050U, 0055U, 0419U, 0094U, 0101U, 0102U, 0103U, 0129U, 0171U, 0172U, 0173U).

Sample genetic/lab codes listed: 0417U, 0018U, 0022U, 0026U, 0029U, 0047U, 0048U, 0050U, 0055U, 0419U, 0094U, 0101U, 0102U, 0103U, 0129U, 0171U, 0172U, 0173U

Prior Authorization

Experimental/investigational prior authorization

Procedures and services identified as experimental or investigational in the list require prior authorization; the document flags multiple CPT/HCPCS codes as investigational and notes 'Prior authorization required.'

Examples of investigational entries include codes 33477, 36514, 64722, 65765, 66180, A4638, A9274
Eye/ear/nose/throat investigational codes and other flagged entries state prior authorization required

Prior Authorization

Hearing/vision prior authorization

Hearing, audio and vision procedures listed in the document require prior authorization; sample CPT codes include 67901–67911 and 69710–69716.

Hearing/audio/vision codes shown: 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911
ENT codes included such as 69710, 69711, 69714, 69716

Prior Authorization

Prior authorization required; specialty guidance available

Prior authorization is required for specified home health and injectable items; providers may contact the Optum Specialty Guidance Program (SGP) for online authorization assistance at 877‑881‑7618.

SGP contact for assistance: 877‑881‑7618
Examples of items include codes listed (G0176, G0248, G0249, G0250, S9340, S9341, S9342, S9343, S9355, S9364–S9368, J0175, 90283–90284, Q5101, A9513, A9590, A9606, A9699)

Prior Authorization

Prior authorization for supplies

Medical and surgical supplies listed in the document require prior authorization; example HCPCS/Q/Codes include C1821, Q4282, C9352–C9364, M0076, P9020, Q2041, Q2043, Q4114, Q4125, Q4130, and multiple Q‑codes.

Sample supply codes: C1821, Q4282, C9352, C9353, C9356, C9358, C9360, C9361, C9364, M0076, P9020, Q2041, Q2043, Q4114, Q4125, Q4130

Prior Authorization

Procedures requiring prior authorization

Selected medicine services, procedures, musculoskeletal and obstetrical procedure codes in the list require prior authorization; examples include 97533, 97605, 97606, 97750 and obstetrical HCPCS S2400–S2403.

Medicine/procedure examples: 97533, 97605, 97606, 97750
Obstetrical procedure examples: S2400, S2401, S2402, S2403

Prior Authorization

Injectable medications - L-codes

Numerous HCPCS 'L' codes for injectable medications require prior authorization; the document lists many L‑codes (e.g., L5600, L5610, L5613, L5614, L5616, L5639, L5640, L5642–L5661, L5673, L5682–L5683, L5700, L5702).

Examples: L5600, L5610, L5613, L5614, L5616, L5639, L5640, L5642, L5643, L5644, L5647, L5649, L5651, L5653, L5661, L5673, L5682, L5683, L5700, L5702

Prior Authorization

Orthotics and prosthetics - prior authorization

Orthotics and prosthetics codes listed require prior authorization; example L‑codes include L7499, L8514, L8682–L8694 and additional device/prosthesis codes noted in the entry.

Orthotics/prosthetics examples: L7499, L8514, L8682, L8683, L8685, L8686, L8687, L8688, L8691–L8694, L3330, L5986, L5988, L0112, L0170

Prior Authorization

Pain management injections

Pain management injection procedure codes 64490–64495 require prior authorization as listed in the document.

Pain management injection CPT codes: 64490, 64491, 64492, 64493, 64494, 64495

Prior Authorization

Private duty nursing and prostate procedures

Private duty nursing and prostate procedures are noted as requiring prior authorization; specific codes are not listed in this section and providers should reference the detailed entries for code-level guidance.

Entries state 'Private duty nursing — Prior authorization required' and 'Prostate procedures — Prior authorization required'
Providers should check the code-specific sections for submission instructions

Prior Authorization

Radiation therapy and associated services

Radiation therapy and associated planning/therapy codes require prior authorization; the list includes IGRT (77014), planning and intensity‑modulated codes (77385, 77386, G6015, G6016), proton beam and SRS/SBRT codes (77371–77373), and many radiation therapy planning/therapy CPT/HCPCS codes.

Examples: IGRT 77014; 77385, 77386; G6001–G6016; SRS/SBRT 77371–77373; planning/therapy codes 77401, 77402, 77407, 77412
Standard radiation therapy (2D/3D) requires prior authorization only when billed with specified cancer diagnosis ranges

Prior Authorization

Radiology imaging prior authorization

Certain advanced outpatient radiology CT/MRI/MRA/PET and nuclear medicine codes require prior authorization and may be managed via eviCore; sample CT/MRI codes listed include 70450–70498, 70496, 70498 and head/neck imaging codes 70540–70554.

Sample CT/MRI codes: 70450, 70460, 70470, 70480–70498; 70496; 70540–70554
Care providers ordering advanced outpatient imaging must provide notification prior to scheduling and submit requests to eviCore (www.evicore.com or 800‑792‑8750) or use the UnitedHealthcare portal per guidance

Prior Authorization

Prior authorization submission instructions

Care providers ordering advanced outpatient imaging must provide notification prior to scheduling and submit prior authorization requests online at www.evicore.com (or call 800‑792‑8750). UnitedHealthcare portal submissions: UHCprovider.com (or call 866‑889‑8054).

eviCore submission: www.evicore.com or 800‑792‑8750
UHC portal submission: UHCprovider.com or 866‑889‑8054

Prior Authorization

Procedure categories requiring prior authorization

The document groups many procedure categories that require prior authorization — examples include certain CT/MRI/MRA/PET scans, nuclear medicine and nuclear cardiology, sleep procedures, spine surgery, skin substitutes, rhinoplasty, stimulators and other listed procedures; see the CPT/HCPCS code listings in the radiology and procedure sections for details.

Procedure categories named: CT/MRI/MRA/PET, nuclear medicine/nuclear cardiology, sleep studies, spine surgery (e.g., 22100–22114, 22206), skin substitutes (Q4117, Q4122, Q4161), rhinoplasty, stimulators, spine surgery

Prior Authorization

Transplants prior authorization

Transplant procedures require prior authorization; the radiology/procedure section lists transplant CPT codes (for example, 32850–32854) and states 'Prior authorization required.'

Transplant example codes listed: 32850, 32851, 32852, 32853, 32854
Entry explicitly: 'Transplants — Prior authorization required'

Prior Authorization

Vein procedures prior authorization

Vein procedures require prior authorization; the unlisted vascular procedure code 37799 is shown with the note 'Prior authorization required.'

Unlisted vascular surgery code: 37799 — 'Prior authorization required'
Vein procedure descriptions reference removal/ablation of saphenous trunks and branches for venous disease

Prior Authorization

Ventricular assist device prior authorization

Ventricular assist device procedures require prior authorization; the document explicitly states 'Ventricular assist device — Prior authorization required.'

Ventricular assist device entries indicate prior authorization is required
Providers should reference the procedure entry for submission instructions

eviCore external vendor definition and contact

DefinitioneviCore healthcare is the external utilization management vendor for certain specialty prior authorization requests

Web and phoneSubmit online at www.evicore.com or call 800-792-8750

Radiology roleeviCore manages advanced outpatient imaging prior authorization and providers must notify prior to scheduling; see Radiology Prior Authorization and Notification for CPT details

Instruction repeatMultiple sections direct providers to submit specified service requests to eviCore (web or phone)

Injectable chemotherapy definition and scope (J9000-J9999)

Code rangeChemotherapy injectable drugs billed under HCPCS codes J9000 - J9999

Named HCPCS examplesLeucovorin (J0640), Levoleucovorin (J0641, J0642), Lupron Depot (J1950), J0885, J1449, J1932, J1954, Lutetium Lu (A9607)

Billing noteIncludes drugs with Q-codes and miscellaneous HCPCS codes when an assigned code is not yet available

Continuous glucose monitor (CGM) definition and PA condition

CGM codesA4239, E0784, E2102, E2103

PA conditionContinuous glucose monitors require prior authorization when used with a Type 2 Diabetes diagnosis

Related devices in sectionCochlear and other auditory implants are listed nearby and require prior authorization (69930, L8614, L8619, L8627, L8629)

Prosthetics vs DME

Key distinctionProsthetics are explicitly identified as not being durable medical equipment (DME)

ImplicationProsthetic items have separate coding/authorization pathways from DME, refer to prosthetics coding in the list

Reference examplesDocument links prosthetics to multiple HCPCS/E codes for related diagnosis mappings (see chunk for specific E-codes)

Enteral services

DefinitionEnteral services (enteral nutrition/supplies) are listed and require prior authorization

Example codesB4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B9002, B9998, S9434, S9435

Settings notedIncludes in-home nutritional therapy and enteral therapy administered through specified channels

Genetic tests/lab services

PA requirementGenetic tests and laboratory services require prior authorization

Example codesSelected U-codes and CPT/PLA codes listed include 0417U, 0018U, 0022U, 0026U, 0029U, 0047U, 0048U, 0050U, 0055U, 0419U, 0094U, 0101U, 0102U, 0103U, 0129U, 0171U, 0172U, 0173U

eviCore noteSome genetic test codes are noted with '(eviCore)' indicating routing to the vendor for authorization

Experimental/investigational

Policy stanceProcedures designated as experimental or investigational require prior authorization

Examples referencedDocument lists investigational codes and examples (e.g., 64722, 65765, 66180, A4638, A9274) and related procedural codes in the experimental/investigational sections

Associated areasGender dysphoria and certain eye/ear/nose/throat procedures are listed in proximity under experimental/investigational headings

SGP (Optum Specialty Guidance Program)

SGP nameOptum Specialty Guidance Program (SGP)

ContactSGP contact for assistance with authorization for specified home health and injectable items is provided in the document (SGP phone referenced in provider actions)

Use caseSGP is referenced as an option for online authorization assistance for specified items (home health, injectable) listed in the policy

Standard radiation therapy (2D/3D) prior auth condition

Condition for PAStandard radiation therapy (2D/3D) requires prior authorization only when billed with cancer diagnosis codes in specified ranges

Diagnosis rangesC34.00 - C34.92; C50.011 - C50.929; C61; C79.51 - C79.52; C84.7A; D05.00 - D05.92

Associated CPT examplesStandard radiation therapy codes in the section include 77401, 77402 and other radiation planning/therapy codes that require authorization when the diagnosis ranges apply

eviCore-managed imaging concept

ConceptCertain advanced outpatient imaging procedures are managed by eviCore (third-party utilization management) and require prior authorization

Provider responsibilityCare providers ordering advanced outpatient imaging must provide notification prior to scheduling the procedure and submit requests to eviCore

Submission instructionSubmit requests online at www.evicore.com or call 800-792-8750; UnitedHealthcare portal may also be used for other submissions

Advanced outpatient imaging procedures

ScopeAdvanced outpatient imaging procedures (selected CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology codes and specified procedural CPTs) require prior authorization

Examples of CPTsSample codes listed in the radiology section include 74183, 75559, 78431, 78814 and multiple Category III and other advanced imaging CPTs referenced in the radiology tables

Notification and submissionProviders must notify prior to scheduling and submit authorizations via eviCore (www.evicore.com; 800-792-8750)

eviCore vendor contact (radiology prior auth)

DefinitioneviCore is the vendor used for radiology prior authorization for participating physicians requesting advanced outpatient imaging

How to submitSubmit advanced outpatient imaging requests online at www.evicore.com to sign in, or call 800-792-8750; UnitedHealthcare portal submissions use UHCprovider.com or call 866-889-8054

Provider responsibilityCare providers ordering these procedures are responsible for prior notification before scheduling

Unlisted procedure vascular surgery note (37799)

Code37799

NoteUnlisted vascular surgery procedure code 37799 is shown with the note 'Prior authorization required' in the vein procedures section

ContextListed under vein procedures where prior authorization is explicitly required