CurrentUnitedHealthcarePolicy N/A

Rocky Mountain Children's Health Plan - Prior Authorization

This document lists prior authorization requirements, submission methods, and CPT/HCPCS codes for participating and non-participating providers delivering inpatient and outpatient services to members of UnitedHealthcare Community Plan of Colorado Rocky Mountain Children's Health Plan (CHP). It applies to providers requesting authorization for covered procedures and services.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization — Rocky Mountain Children's Health Plan (CHP)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal or to eviCore where indicated; phone and fax options are provided for specified services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~200+distinct code entries

online, phone, faxsubmission methods

excludedemergency exemption

J-codesinjectable drugs flagged

multipleeviCore-managed

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.

J3490/J3590/C9399Optum Transplant required

Coverage and Prior Authorization Criteria

Coverage criteria summary

Prior authorization is required for a wide range of outpatient and inpatient procedures and specific drugs; emergency/urgent care is exempt.

Providers must submit prior authorization requests through the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, by eviCore where indicated, by fax for non‑participating providers, or by phone for certain services; admitting facilities have a separate notification phone number.

Prior authorization is not required for emergency or urgent care services.

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

Listed CPT/HCPCS codes across specialties (including arthroscopy, bariatric surgery, breast/reconstruction, cardiology, injectable chemotherapy and supportive agents, cochlear/auditory implants, cosmetic/reconstructive procedures and others) require prior authorization as specified in the code lists.

Code-specific coverage notes

Selected codes have specific coverage/benefit constraints and prior authorization requirements.

Certain Q‑codes (for example Q2026, Q2028, Q2029) include benefit/coverage notes; Q2026 is noted as not a benefit for Commercial or RMHP Prime.

Some codes are limited to Medicare with specified diagnosis combinations (example: Medicare only with Dx B20 and E88.1 for lipodystrophy for listed codes).

Durable medical equipment entries (examples: G0429, K0891, A9520) have prior authorization and benefit constraints documented; obtain prior authorization as indicated.

Prior authorization coverage rules (partial)

Prior authorization requirement statements for listed service groups in this extract.

Enteral services and in‑home nutritional therapy require prior authorization for the listed B‑codes (examples include B4149, B4150, B4152, B4153, B4154, B4155, etc.).

Genetic tests and laboratory services identified in the list (multiple U/M/T/M proprietary codes such as 0001U, 0004M, 0016M, 0414U, 0417U, 0418U and many others) require prior authorization; some of these are routed to eviCore as noted.

Experimental and investigational procedures (examples: CPT codes 64454, 64624, 64625, 91112, 91132, 91133) require prior authorization.

Durable medical equipment (selected E/K series HCPCS codes shown in this section) require prior authorization for many listed items.

Prior authorization requirement (excerpt)

Prior authorization requirement for listed genetic and lab service codes

Numerous CPT/HCPCS and proprietary genetic test and molecular pathology codes listed in this section require prior authorization; specific codes are shown with 'How to Obtain Prior Authorization' and some entries are designated to eviCore for processing.

Prior authorization requirement for listed genetic tests/lab services

Services and codes requiring prior authorization and how to submit requests

Prior authorization is required for the genetic tests and laboratory service codes listed in this section; providers should submit requests online at evicore.com or call 800‑792‑8750 as indicated.

Prior authorization code criteria (partial)

Codes and mappings that require prior authorization:

Selected injectable medication codes and mapped equivalents are listed as requiring prior authorization (sample entries include J2350 mapped to J2353/J2354/J2356; J2502 mapped to J2506/J2507/J3247; J2786 mapped to J2802/J2840/J2998).

Unclassified and temporary HCPCS codes C9399, J3490, J3590 require prior authorization only for a specified set of products (examples listed: Amvuttra, Fylnetra, Lupaneta Pack, Nulibry, Recovi, Riabni, Rivfloza, Skyrizi, white blood cell colony stimulating factors, Veopoz); effective‑date notes for specific code requirements are provided in the list.

Prior authorization is indicated for multiple service categories including medicine services, musculoskeletal, obstetrical, orthotics and prosthetics and certain medical supplies when corresponding CPT/HCPCS codes are used.

Prior authorization coverage stance for listed codes

Prior authorization required for specified radiation and advanced imaging services; some standard radiation therapy prior authorization is conditioned on diagnosis code ranges.

Radiation therapy codes and services listed in this section require prior authorization; for standard radiation therapy (2D/3D) prior authorization is required only when obtained with diagnosis codes in specified ranges (example ranges include C34.00‑C34.92, C50.011‑ etc.).

Certain advanced outpatient imaging (CT, MRI, MRA, PET) are managed by eviCore and require prior authorization or notification as indicated (sample codes referenced include 70460, 70470, 70543 and other advanced imaging CPT/HCPCS codes).

Prior authorization and notification criteria (enumerated)

Procedures and services that require prior authorization or notification include:

Care providers ordering advanced outpatient imaging procedures are responsible for providing notification prior to scheduling; submit requests online at evicore.com or via the UnitedHealthcare Provider Portal, or call the listed phone numbers (evicore: 800‑792‑8750; UHC portal support: 866‑889‑8054).

Specific procedure groups are explicitly marked 'Prior authorization required', including rhinoplasty, skin substitutes (Q41xx series), sleep procedures (e.g., stimulators 64553/64568 series), spine surgery (examples include 22505, 22533), implantable stimulators (e.g., 63655) and other surgery groups listed with CPT codes.

Providers should consult the Radiology Prior Authorization and Notification details for the full CPT code list and submission instructions when scheduling advanced imaging procedures.

Prior authorization requirements

Prior authorization requirements as stated in this section:

Transplant procedures listed in the document require prior authorization.

Unclassified drug codes J3490, J3590 and C9399 require prior authorization through Optum Transplant for specified products (examples: Amtagvi, Lenmeldy, Tecelra).

Urinary system and vein procedures are annotated as 'Prior authorization required' (example vein procedure code listed: 36471 for removal/ablation of saphenous veins).

CPT / HCPCS / Other Code Listings

Arthroscopy (CPT)CPTCovered

29805	Arthroscopy, knee, diagnostic; with or without synovial biopsy
29806	Arthroscopy, knee, diagnostic, with meniscectomy (medial OR lateral)
29807	Arthroscopy, knee, diagnostic, with meniscus repair
29819	Arthroscopy, shoulder, diagnostic
29820	Arthroscopy, shoulder, diagnostic, surgical
29821	Arthroscopy, shoulder, surgical; with synovectomy
29822	Arthroscopy, shoulder, surgical; debridement
29823	Arthroscopy, shoulder, surgical; removal foreign body
29824	Arthroscopy, shoulder, surgical; distal claviculectomy
29825	Arthroscopy, shoulder, surgical; glenohumeral debridement

1–10 of 29

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Bariatric Surgery (CPT/HCPCS)mixedCovered

43644	Laparoscopy, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)
43645	Laparoscopy, gastric restrictive procedure; with gastric bypass and small bowel reconstruction to limit absorption
43770	Laparoscopy, revision of gastric restrictive procedure
43771	Laparoscopy, gastric bypass revision
43772	Laparoscopy, gastric restrictive procedure; sleeve gastrectomy
43773	Laparoscopy, conversion of prior bariatric procedure to sleeve gastrectomy
43774	Laparoscopy, revision of bariatric procedure
43775	Laparoscopy, gastric bypass for obesity, complex/revisional
43842	Gastric restrictive procedure; laparoscopic adjustable gastric banding
43843	Gastric restrictive procedure; removal of adjustable gastric band

1–10 of 18

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Breast and Reconstruction (CPT/HCPCS)CPTCovered

19300	Mastectomy for gynecomastia
19328	Removal of intact breast implant
19330	Removal of ruptured breast implant
19340	Immediate insertion of breast prosthesis following mastectomy
19355	Breast reconstruction with tissue expander
19357	Breast reconstruction with latissimus dorsi flap
19361	Acellular dermal matrix use in breast reconstruction
19364	Breast reconstruction with free flap, including microvascular anastomosis
19367	Breast reconstruction with deep inferior epigastric perforator (DIEP) flap
19368	Breast reconstruction with TRAM flap

1–10 of 18

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Chemotherapy & Supportive Agents (HCPCS/J-codes/Q-codes)HCPCSCovered

J9000-J9999	Chemotherapy injectable drugs (range)
J0640	Leucovorin, per 50 mg
J0641	Levoleucovorin, per 50 mg
J0642	Levoleucovorin, per 5 mg
J1950	Leuprolide acetate (Lupron depot), per 1 mg
J0885	Injection, pegfilgrastim, biosimilar (effective 11/1/2023)
J1449	Injection, rabies immune globulin
J1932	Injection, monoclonal antibody (example)
J1954	Injection, palonosetron, per dose
A9607	Lutetium Lu 177, therapeutic, radiopharmaceutical

1–10 of 19

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Auditory Implants (CPT/HCPCS)mixedCovered

69930	Implantation of auditory brainstem implant
L8619	Cochlear device, internal, unspecified
L8627	Cochlear device, internal component
L8629	Cochlear device, external component

Cosmetic / Reconstructive Surgery (CPT)CPTCovered

11920-11971	Repair of wounds; complex, extensive ranges
17106-17108	Destruction of premalignant lesions; chemical topical
17340	Interim repair of avulsed tissue
17360	Tissue grafting, skin
17380	Grafting procedures, complex
19105	Excision of breast lesion, open
20930-20931	Bone grafting; mandible and facial bones
21029	Osteotomy, facial bones
21031	Reconstruction mandible, complex
21076-21089	Facial trauma reconstruction series

1–10 of 15

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Cardiology (CPT)CPTCovered

33206-33289	Cardiac electrophysiology and device implantation range
33262-33274	Pacemaker and ICD related programming/management and implantation
33289	Removal of pacemaker/ICD lead
34839	Extracorporeal circulation
93451-93461	Right and left heart catheterization and coronary angiography series
93702	Comprehensive cardiopulmonary testing

Head/Face Reconstructive Examples (CPT)CPT

69930	(Also listed under Auditory Implants)
21100	Mandible reconstruction
21029	Osteotomy facial bones
21215	Facial reconstruction
21141	Maxillofacial procedures
21199	Unlisted craniofacial procedure

E21xx / Power Mobility (HCPCS) (excerpt)HCPCS

E2213	Power wheelchair component
E2214	Power wheelchair component
E2215	Power wheelchair component
E2216	Power wheelchair component

K-codes (DME) (partial)HCPCS

K0008	Walker, adjustable
K0009	Walker, other
K0010	Crutches, underarm

ENT / Facial Surgery Examples (CPT)CPT

68816	Stent placement, nasal
69705	Repair of nasal fracture
69706	Repair of nasal fracture complex
69719	Septoplasty
69726	Rhinoplasty

Genetic & Molecular Tests (CPT) (excerpt)CPTCovered

81164	CYP2D6 analysis
81165	CYP2C19 analysis
81166	Drug metabolism panel
81167	Gene sequencing, targeted
81173	BRCA1/2 analysis
81174	BRCA reflex testing

Selected Example Genetic Codes (CPT)CPTCovered

81407	Cancer panel, sequencing
81408	Cancer panel, full
81410	Targeted genomic sequence analysis

Genetic Tests / Lab Services (CPT)CPTCovered

83704	Drug screen enzymatic
83876	HLA typing
83883	Molecular pathology

Home Health & Hyperbaric Oxygen (HCPCS/CPT)mixedCovered

G0176	Home health; physician certification
G0248	Home health; skilled nursing
G0249	Home health; therapy
G0250	Home health; other
S9340	Home health aide
G0277	Hyperbaric oxygen, per session

Injectable Medications (HCPCS/J-codes)HCPCSCovered

J1302	Injection, example specialty drug
Q5125	Q-code biologic example
J0129	Injection, infliximab biosimilar
J0180	Injection, example
J0202	Injection, example
J0219	Injection, example
J0221	Injection, example
J0222	Injection, example
J0256	Injection, example
J0257	Injection, example

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Injectable Medication Mappings (sample)mixed

J2350	Infusion pump, mapping example
J2353	Mapping example 2
J2354	Mapping example 3

Orthotics / Prosthetics (HCPCS examples)HCPCS

L5642	Prosthetic component
L5643	Prosthetic component
L5644	Prosthetic component
L5645	Prosthetic component
L5647	Prosthetic component
L5649	Prosthetic component
L5650	Lower extremity prosthesis, initial
L5651	Lower extremity prosthesis, component
L5653	Prosthetic foot component
L5661	Prosthetic knee unit

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L-series HCPCS SamplesHCPCS

L6050	Prosthetic knee component
L6055	Prosthetic component
L6100	Prosthetic foot

Radiation Therapy (CPT/HCPCS)mixed

77401	Radiation therapy initial planning
77412	Radiation therapy complex planning
G6003	Radiation therapy code mapping

Advanced Imaging Examples (CPT)CPT

70460	CT head/brain w/wo contrast
70486	CT facial bones
70540	MRI brain without contrast

Advanced Imaging Example Codes (CPT)CPT

72148	MRI lumbar spine
72149	MRI lumbar spine with contrast
70542	MRI brain with contrast

Selected Surgery / Stimulator / Sleep CodesCPT

64568	Implantation of neurostimulator lead
64569	Revision or replacement of neurostimulator
64570	Removal of neurostimulator lead

Listed Procedural CPTs (partial)CPT

0095T	Unlisted procedure, example
0098T	Unlisted procedure, example

Vein Procedure (CPT)CPTCovered

36471

Venous ablation, main trunk and named branches of saphenous veins

Additional HCPCS/S Codes (partial)mixed

S2053	Transplant related code
S2054	Transplant related code
S2055	Transplant related code
S2060	Transplant related code
S2061	Transplant related code

Prior Authorization RequirementmixedCovered

Note	Prior authorization required for genetic tests/lab services and CPT/HCPCS codes listed in this section; submit requests via eviCore (www.evicore.com) or call 800-792-8750 as noted.

How Providers Obtain Prior Authorization / Submission Channels

Prior Authorization

How to submit prior authorization requests

Submit requests online via the UnitedHealthcare Provider Portal. To get started, go to UHCprovider.com and click Sign In at the top-right corner to log in using your One Healthcare ID and password. Then select the Prior Authorization and Notification tab on your dashboard. If you don't have a One Healthcare ID, visit UHCprovider.com/access. Non‑participating providers may fax request and documentation to 800-262-2567 or 970-255-5681. Prior authorization is not required for emergency or urgent care. Out‑of‑network physicians, facilities and other health care professionals must request prior authorization for all procedures and services.

Online: UnitedHealthcare Provider Portal (UHCprovider.com) — Prior Authorization and Notification tab (One Healthcare ID required).
Non‑participating providers: fax to 800-262-2567 or 970-255-5681.
Emergency/urgent care: no prior authorization required.

Prior Authorization

eviCore submission for specialty services

For certain cardiology and congenital heart disease procedures and selected cardiovascular services, submit requests online to eviCore. Use www.evicore.com to sign in or call eviCore at 800-792-8750.

Key Terms and Vendor Names

Definition of Prior Authorization

DefinitionPrior authorization is the requirement that participating and out-of-network providers request approval before performing specified procedures and services, except in emergency or urgent care situations.

Who must requestParticipating providers and out-of-network physicians, facilities and other health care professionals.

When not requiredEmergency or urgent care services are exempt from prior authorization.

Primary submission methodUnitedHealthcare Provider Portal (Prior Authorization and Notification tool) via UHCprovider.com using One Healthcare ID.

Chemotherapy injectable drugs list

Drug code rangeChemotherapy injectable drugs requiring prior authorization include J9000–J9999.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization — Rocky Mountain Children's Health Plan (CHP)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal or to eviCore where indicated; phone and fax options are provided for specified services.

SourceLink

On This Page

Cardiology and congenital heart disease procedures: prior authorization required; submit via eviCore (www.evicore.com or 800-792-8750).
eviCore-managed CPT examples include 93456–93461 and 93593–93597 where noted.

Prior Authorization

Prior authorization requirement note

Prior authorization is required for certain diagnostic and therapeutic procedures and for selected DME codes. Examples include diagnostic/therapeutic CPT/HCPCS such as 91065, 95012, 95060, 95065, 88375, 88749, 89240, and DME entries including K0891, A9520, K0898, A9999 and others listed in the DME section. Confirm the full code list before ordering and obtain authorization using the UnitedHealthcare Provider Portal or the contact noted for the service.

Diagnostic/therapeutic examples: 91065, 95012, 95060, 95065, 88375, 88749, 89240.
DME examples: K0891, A9520, K0898, A9999, C1840.

Note

Q-code benefit notes

Certain Q‑codes have plan‑specific benefit notes. For example, Q2026 is not a benefit for Commercial or RMHP Prime plans and is allowed only under specific circumstances (see plan details). Verify benefit applicability for the member's plan before requesting authorization.

Q2026: Not a benefit for Commercial or RMHP Prime (plan exceptions may apply).

Prior Authorization

Enteral/in-home nutrition prior authorization

Enteral and in‑home nutrition supplies require prior authorization. Submit requests via the UnitedHealthcare Provider Portal or as directed for DME/eviCore when indicated.

Enteral HCPCS examples requiring prior authorization: E2298, B4149, B4150, B4152, B4153, B4154.
In‑home nutritional supplies: B4154 and related B‑codes listed in the enteral services section.

Prior Authorization

DME prior authorization (selected E-codes)

Durable medical equipment (DME) items listed with K‑ and E‑codes require prior authorization. Providers should verify the specific HCPCS code and obtain authorization before delivery.

Selected DME HCPCS examples: K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885.
Contact UnitedHealthcare Provider Portal for submission or follow plan instructions.

Prior Authorization

Experimental/investigational prior authorization

Experimental and investigational procedures require prior authorization. Verify if the procedure/code is listed as investigational before scheduling.

Examples of investigational CPTs: 64454, 64624, 64625, 91112, 91132, 91133.
Submit authorization requests via the UnitedHealthcare Provider Portal or as directed.

Prior Authorization

Genetic tests/lab prior authorization

Many genetic tests and laboratory services require prior authorization and, in many cases, are managed by eviCore. Providers must submit requests online at evicore.com or call eviCore at 800-792-8750 for the listed genetic test CPT/HCPCS/proprietary codes.

Genetic test examples (PA required): 0001U, 0004M, 0005U, 0006M, 0007M, 0011M, 0012M, 0013M (eviCore), 0016M (eviCore), 0414U (eviCore), 0417U (eviCore), 0418U.
Additional CPT/HCPCS and lab codes requiring PA include many U‑codes and standard lab CPTs such as 83704, 83876, 83883, 83951, 83987, 84431, 86001, 86152, 86153, 86305, 86343 and others listed in the genetic/lab sections.
How to obtain authorization: submit online at www.evicore.com to sign in, or call 800-792-8750. For some services, eviCore is the required authorization vendor.

Prior Authorization

Advanced outpatient imaging prior authorization/notification

Care providers ordering advanced outpatient imaging (CT, MRI, PET and other advanced modalities) must provide notification prior to scheduling and, where required, obtain prior authorization. Radiology prior authorization for many advanced imaging CPT codes is managed by eviCore. Providers may submit authorizations online via the UnitedHealthcare Provider Portal or through eviCore as indicated.

Notification requirement: Providers must notify prior to scheduling advanced outpatient imaging procedures.
Submission options: For eviCore-managed radiology codes submit at www.evicore.com or call 800-792-8750. For UnitedHealthcare-managed radiology PA submit via the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-889-8054.
See Radiology Prior Authorization and Notification for the full CPT code list that requires PA.

Prior Authorization

Procedures explicitly marked as requiring prior authorization

UnitedHealthcare maintains additional prior authorization requirements for procedures such as rhinoplasty, skin substitutes, spine surgery, neurostimulators, transplants and others. Always verify the specific procedure code and follow the indicated submission channel (UnitedHealthcare Provider Portal or the vendor/phone number provided).

Examples: Rhinoplasty and skin substitutes (Q4xxx series), Spine surgery (22505, 22533, 22534, 22548, 22551–22554, 22558, 22585, 22590, 22595), Neurostimulator codes (64568–64595).
Transplants: prior authorization required; follow transplant vendor instructions where noted (Optum Transplant for certain unclassified drug codes).

Prior Authorization

PA for unclassified/temporary codes for specified drugs

For transplant‑related unclassified drug codes (J3490, J3590, C9399) for specific products, prior authorization is required through Optum Transplant. Check the Procedures and Services transplant notes for details.

Unclassified/temporary drug codes: PA required only for listed products (Amvuttra, Fylnetra, Lupaneta Pack, Nulibry, Recovi, Riabni, Rivfloza, Skyrizi, white blood cell colony stimulating factors, Veopoz, Izervay as noted).
Optum Transplant contact applies for Amtagvi, Lenmeldy and Tecelra via Optum Transplant PA process.

Prior Authorization

Vein procedure example

Removal and ablation procedures for saphenous veins (e.g., CPT 36471) are listed as requiring prior authorization. Verify vein procedure codes and obtain authorization before scheduling.

Example code: 36471 — Removal and ablation of main trunks and named branches of the saphenous veins.
Vein procedures: prior authorization required.

Selected supportive agentsExamples include Leucovorin (J0640), Levoleucovorin (J0641, J0642), Lupron Depot (J1950), and listed colony stimulating factors and bone‑modifying agents (e.g., J1442, J1447).

Q-code and miscellaneous billingChemotherapy agents billed under Q‑codes or miscellaneous HCPCS (unclassified) codes are included; some agents without assigned codes billed as miscellaneous HCPCS also require PA.

Prosthetics vs DME

ClarificationProsthetics are not considered durable medical equipment (DME).

Reference contextSee DME/orthotics and prosthetics entries where 'Prosthetics are not DME' is noted alongside HCPCS equipment codes (e.g., E0170, E0194).

ImplicationPrior authorization processes for prosthetics may differ from DME; review the specific prosthetics code entries for PA instructions.

Durable medical equipment (DME)

DME PA requirementDurable medical equipment (DME) entries (multiple HCPCS E- and K-series codes) require prior authorization for many listed items.

Example HCPCS codesSample referenced codes include K0890, E2301, E2310, E2311 and ranges E2321–E2331 and K0864–K0885 (see DME sections).

Submission guidanceEach DME entry includes a 'How to Obtain Prior Authorization' instruction — follow the channel specified for that HCPCS code (Provider Portal or vendor listed).

Genetic tests/lab services

PA for genetic tests/lab servicesNumerous genetic and laboratory test CPT/HCPCS/U codes (examples: 0001U, 0004M, 81283, 81432, 81441, 83704) are marked 'Prior authorization required.'

eviCore involvementMany genetic test entries are routed to eviCore for authorization processing or include eviCore notation (e.g., 0013M, 0414U, 0417U, 81296–81299).

Submission instructionsFor listed genetic tests/lab services, submit requests online at www.evicore.com or call 800-792-8750 where indicated; other entries reference the UnitedHealthcare Provider Portal as applicable.

Examples of proprietary codesProprietary and U-codes (e.g., 0355U, 0413U, 0002U) are included in the PA list — review code‑specific 'How to Obtain Prior Authorization' guidance.

Experimental and investigational

Experimental/investigational PAProcedures classified as experimental and investigational are noted as requiring prior authorization for the listed CPT codes (examples include 64454, 64624, 64625, 91112, 91132, 91133).

How flaggedEntries explicitly labeled 'Experimental and investigational' include 'Prior authorization required' and provide code‑level PA instructions.

Provider actionObtain prior authorization before scheduling or performing investigational procedures per the listed CPT codes.

eviCore

eviCore roleeviCore is the external utilization management vendor referenced for prior authorization of many specialty services and genetic tests/lab services.

Contact infoeviCore website www.evicore.com and phone 800-792-8750 are provided for submitting or obtaining PA when indicated by code entries.

ScopeeviCore handles advanced outpatient imaging and numerous genetic/molecular test prior authorization requests as noted in the code list entries.

'How to Obtain Prior Authorization' field indicator

Field meaning'How to Obtain Prior Authorization' indicates the specific process or vendor to obtain authorization for the listed code (e.g., Provider Portal, eviCore, phone number).

Per-code guidanceEach CPT/HCPCS/U code entry includes a 'How to Obtain Prior Authorization' entry specifying the submission channel and contact details for that code.

Action for providersFollow the 'How to Obtain Prior Authorization' instruction attached to the code when requesting authorization to ensure correct routing and processing.

How to Obtain Prior Authorization — Instructions

Online submission - eviCoreSubmit prior authorization requests for services routed to eviCore online at www.evicore.com (sign in) where the code entry indicates eviCore management.

Online submission - UnitedHealthcare PortalUse the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal at UHCprovider.com (sign in with One Healthcare ID) for portal‑routed requests.

Phone submissionFor eviCore‑managed requests call 800-792-8750; other UnitedHealthcare PA phone number referenced is 866-889-8054 for Provider Portal guidance.

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

Prior authorization — phone‑based process summary

PA definition (phone)Prior authorization: an approval obtained by calling the listed phone number prior to providing the listed procedures, services, genetic tests, hearing/vision services, home healthcare, hyperbaric oxygen, or injectable medications.

PA phone contactCall 800-792-8750 to obtain prior authorization for many listed CPT/HCPCS and J‑codes as specified in code entries.

Examples of services via phone PAMultiple genetic tests, advanced procedures and T‑code entries include 'you can call 800-792-8750' in their 'How to Obtain Prior Authorization' guidance.

Unclassified/temporary HCPCS PA rule

Unclassified/temp codes ruleUnclassified and temporary HCPCS codes C9399, J3490, J3590 require prior authorization only for a defined set of drugs listed in the policy (e.g., Amvuttra, Fylnetra, Lupaneta Pack, Nulibry, Recovi, Riabni, Rivfloza, Skyrizi, certain colony stimulating factors, Veopoz).

Special effective date notesPolicy includes effective‑date specific notes (e.g., Izervay Jan 1, 2024; J0174 Aug 1, 2023; Q5133/Q5135 Oct 1, 2024) affecting use of temporary codes and PA requirements.

Routing for transplant productsSome unclassified/temporary code PA requests may be routed to designated channels (see Optum Transplant notes for specific products).

Prior authorization requirement — medicine, musculoskeletal, obstetrical, orthotics/prosthetics and supplies

Service categories with PAPrior authorization is explicitly required for medicine services, musculoskeletal services, obstetrical services, orthotics and prosthetics, and certain medical supplies as indicated by listed CPT/HCPCS codes.

Example medicine codesExamples include vaccine/medicine codes such as 90587, 90626, 90627 listed under medicine services requiring PA.

Orthotics/prosthetics noteOrthotics and prosthetics entries include specific L‑series HCPCS codes and PA instructions listed in the document.

UnitedHealthcare Provider Portal

UnitedHealthcare Provider PortalSubmit requests online using the UnitedHealthcare Provider Portal at UHCprovider.com (sign in with One Healthcare ID) for portal‑routed prior authorization requests.

Portal phone supportFor Portal assistance the document references phone contact 866-889-8054 in Radiology/Provider Portal instructions.

Where usedProvider Portal is the channel specified for many CPT/HCPCS procedure PA requests and for non‑eviCore routed imaging entries in the document.

Radiology vendor (eviCore) referenced for advanced imaging

Radiology vendoreviCore is the radiology/utilization management vendor referenced for prior authorization of advanced outpatient imaging and many specialty imaging codes.

Radiology PA guidanceAdvanced outpatient imaging PA/notification instructions direct providers to submit requests online at www.evicore.com or call 800-792-8750; see Radiology Prior Authorization and Notification for full code lists.

Codes exampleRadiology examples in the policy include CT/MRI/PET codes (e.g., 70460, 70470, 70480, 73720–73722) with eviCore PA routing.

Prior authorization submission channels

Submission channels summaryAdvanced outpatient imaging requests: submit online at www.evicore.com or call 800-792-8750; other PA requests: submit via UnitedHealthcare Provider Portal (UHCprovider.com) or the channel listed per code.

Notification requirementCare providers ordering advanced outpatient imaging are responsible for providing notification prior to scheduling the procedure per radiology instructions.

Where to find code detailsFor complete CPT codes requiring PA and related instructions, see the Radiology Prior Authorization and Notification references within the policy.

Optum Transplant — designated PA channel for certain unclassified drug codes

Optum Transplant routingUnclassified codes J3490, J3590, and C9399 for specific transplant‑related products (Amtagvi, Lenmeldy, Tecelra) require prior authorization through Optum Transplant.

Where appliedThis routing applies when those unclassified codes are used for the listed products — follow Optum Transplant instructions for submission.

Provider actionSubmit PA requests for these products via the designated Optum Transplant channel as noted in the policy entry for those codes.