UnitedHealthcare Prior Auth Requirements — CO

Coverage Criteria and Prior Authorization Requirements

inv-01: Prior authorization requirements and submission instructions

Procedures and services listed require prior authorization from the plan or specified vendor prior to performance, except where noted.

Prior authorization is required for the inpatient and outpatient procedures and services listed in this document prior to performance, except as specifically noted (e.g., emergency/urgent care).

Submission methods

Submit requests online via the UnitedHealthcare Provider Portal (Prior Authorization and Notification tool) at UHCprovider.com; sign in with One Healthcare ID.
Non-participating providers may fax requests and documentation to 800-262-2567 or 970-255-5681.
For many cardiology/cardiovascular and advanced imaging services submit to eviCore (www.evicore.com or 800-792-8750).
Behavioral health services: call 888-282-8801. Notification by admitting facility: phone 800-416-2157, option 4 or 970-248-5197.

Exceptions

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.

Routing note: Some services (for example, specified cardiology/cardiovascular procedures and certain advanced imaging) must be submitted to eviCore; see eviCore contact for details.

inv-02: Coverage stance for listed services

Items and services that require prior authorization as listed in this section include:

Injectable chemotherapy drugs administered in an outpatient setting require prior authorization (including HCPCS range J9000-J9999 and specified J- and Q-codes, leucovorin J0640/J0641/J0642, Lupron Depot J1950, Lutetium A9607).

Cochlear implants and other auditory implants require prior authorization (examples: CPT 69930; device L8627).

Cosmetic/reconstructive surgeries

Selected cosmetic and reconstructive CPT procedures (examples listed in the document such as 11960, 14020, 21141-21246, etc.) — prior authorization required unless an exempting diagnosis is billed.

Providers must obtain prior authorization before outpatient administration or performance of the listed items and services.

inv-03: Prior authorization criteria (partial)

Rules in this excerpt:

When reconstructive procedures are billed with the listed diagnosis codes (examples: multiple C43.x and C44.x codes), prior authorization is not required for those reconstructive procedures.

Certain durable medical equipment (DME) and specific HCPCS codes listed require prior authorization; prosthetics are noted as distinct from DME and are handled separately in the listing.

inv-04: Partial coverage criteria sets

Services requiring prior authorization (partial excerpt):

Enteral services require prior authorization (examples: HCPCS B4149, B4150, B4152, B4153).

Genetic tests / lab services: Genetic tests and select laboratory services require prior authorization; multiple CPT/U codes listed (examples in document include 81439, 81443, 0417U and other PLA/U codes).

Experimental / investigational services: Experimental and investigational services require prior authorization; specific codes are listed in the document excerpt.

inv-05: Prior authorization by category

Prior authorization requirement by service category and specific CPT/HCPCS codes:

Hearing / Audio / Vision: Hearing/audio/vision procedures require prior authorization (examples: 67901, 67902, 67903, 67904 and related codes listed).

Home healthcare: Selected home healthcare codes require prior authorization (examples: G0176, G0248, G0249, G0250).

Injectable medications: Numerous injectable medication J-codes require prior authorization; consult the document mapping for specific J-code requirements and equivalents.

Medical and surgical supplies and related HCPCS codes require prior authorization (examples: C1821, Q4282, C9352, C9353 and many additional supply/Q-codes listed).

inv-06: Radiation and specialty procedure coverage criteria

Radiation therapy prior authorization criteria (diagnosis-limited condition noted)

Standard radiation therapy (2D/3D): Prior authorization is required for standard radiation therapy CPT codes (examples: 77401, 77402, 77407, 77412) only when billed with diagnosis codes in the specified ranges (e.g., C34.00-C34.92, C50.011-C50.929, C61, C79.51-C79.52, C84.7A, D05.00-D05.92).

Proton beam and related codes: Proton beam and related radiation therapy codes (examples: 77520, 77522, 77523, 77525, 77331, 77370, 77399, 77470) have prior authorization entries listed in the document.

Y90 microsphere procedure: Y90 implantable beta-emitting microsphere procedures (listed with 79445) require prior authorization.

inv-07: Pain management

Pain management prior authorization listing

Pain management injection codes: The following pain management CPT codes are listed in the prior authorization section: 64490, 64491, 64492, 64493, 64494, 64495.

inv-08: Orthotics/Prosthetics

Orthotics and prosthetics listing

Orthotics / Prosthetics L-codes: An extensive list of HCPCS L-codes for orthotics and prosthetics is included in the prior authorization listing; providers should refer to the L-code group in the document for specific codes (examples shown throughout the L-code series).

inv-09: Prior authorization criteria

Prior authorization and notification requirements for listed procedures and codes

Radiation therapy diagnostic limitation: Standard radiation therapy (2D/3D) requires prior authorization only when billed with diagnosis codes in specified ranges (e.g., C34.00-C34.92, C50.011-C50.929, C61, C79.51-C79.52, C84.7A, D05.00-D05.92).

Advanced outpatient imaging: Care providers ordering advanced outpatient imaging must provide notification prior to scheduling and submit requests online at www.evicore.com or call 800-792-8750; see Radiology Prior Authorization and Notification for full CPT lists.

Skin substitutes and selected procedures: Specific skin substitute HCPCS/CPT codes (examples: Q4117, Q4122, S8035, S8085) and selected CT/MRI/MRA/PET/nuclear procedures require prior authorization and should be submitted via the UnitedHealthcare Provider Portal or as directed in the document (phone 866-889-8054 for portal assistance).

Submission channels:

inv-10: Prior authorization requirements

Codes listed in this section require prior authorization for participating physicians/providers.

Prior authorization is required for the listed CPT/HCPCS codes in this section (examples include advanced outpatient imaging codes, spine surgery codes, stimulator/device codes and selected surgical CPT/HCPCS codes).

Requests for these codes must be submitted via the UnitedHealthcare Provider Portal (UHCprovider.com) or by calling 866-889-8054 unless a specific vendor (e.g., eviCore) is designated for certain services.

See Radiology Prior Authorization and Notification for additional details and the full list of CPT codes that require prior authorization.

inv-11: Prior authorization criteria (partial)

Prior authorization requirements and special routing instructions found in this section (partial list of codes).

Numerous surgical CPT/HCPCS codes listed in the document require prior authorization; providers should follow the submission instructions (portal or phone).

Transplant-related CPT/HCPCS codes require prior authorization; certain transplant drugs and unclassified J-codes require authorization routed through Optum Transplant.

Unclassified drug codes (e.g., J3490, J3590, C9399) for products such as Amtagvi, Aucatzyl and Lenmeldy require prior authorization through Optum Transplant. The document notes Aucatzyl requires prior authorization effective April 1, 2025.

Vein procedures and ventricular assist device entries are marked 'Prior authorization required.'

CPT, HCPCS and ICD-10 Code Listings

Procedures and CPT/HCPCS codes requiring prior authorization (partial list)CPT | HCPCS | ICD-10 | mixedCovered

29805	Arthroscopy service code listed as prior authorization required
29806	Arthroscopy service code listed as prior authorization required
29807	Arthroscopy service code listed as prior authorization required
29819	Arthroscopy service code listed as prior authorization required
29820	Arthroscopy service code listed as prior authorization required
29822	Arthroscopy service code listed as prior authorization required
29823	Arthroscopy service code listed as prior authorization required
29824	Arthroscopy service code listed as prior authorization required
29825	Arthroscopy service code listed as prior authorization required
29826	Arthroscopy service code listed as prior authorization required

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Diagnosis codes explicitly noted as not requiring prior authorization (partial list)ICD-10

E08.52	Diagnosis code listed as no prior authorization required
E09.52	Diagnosis code listed as no prior authorization required
E10.52	Diagnosis code listed as no prior authorization required
E11.52	Diagnosis code listed as no prior authorization required
E13.52	Diagnosis code listed as no prior authorization required
I70.221	Vascular diagnosis code listed as no prior authorization required

Examples of HCPCS/Q/ICD codes referencedmixedCovered

I73.81	Listed multiple times as CPT/HCPCS mapping for chemotherapy/oncology context
J0897	Bone modifying agent (example listed)
Q5108	Example Q-code listed
Q5110	Example Q-code listed
Q5120	Example Q-code listed
Q5122	Example Q-code listed

Cosmetic/reconstructive CPT examplesCPT

11960	Cosmetic/reconstructive CPT code listed
14020	Reconstructive CPT code listed
21141	Facial skeletal CPT code listed
21230	Craniofacial CPT code listed
21246	Craniofacial CPT code listed

ICD-10 diagnosis codes (partial list)ICD-10

C43.0	Malignant melanoma of skin of lip (example listed within C43 series)
C43.10	Malignant melanoma of unspecified eyelid, including canthus (example from C43 series)
C44.01	Basal cell carcinoma of skin of lip (example from C44 series)

HCPCS / DME codes (partial list)HCPCS

A9520	Durable medical equipment code listed (example)
E0194	DME code listed
E0265	DME/orthotics/prosthetics code listed

Enteral services (sample)HCPCSCovered

B4149	Enteral services
B4150	Enteral services
B4152	Enteral services
B4153	Enteral services

Genetic tests/lab services (sample)mixedCovered

81400	Genetic tests/lab services (example CPT/PLA codes)
81403	Genetic tests/lab services
0417U	Genetic test (example U-code)
0018U	Genetic test (example U-code)

Procedures (examples)CPT

19303	Breast surgery related CPT (example from list)
21121	Facial procedures (example from list)
53410	Urologic procedure (example from list)

Injectable medication J-codesHCPCS

J0202	Referenced with mapping to other J-codes in prior authorization instructions
J0224	Listed among injectable medication codes
J0491	Listed among injectable medication codes

Supplies and orthotics/prosthetics codesHCPCS

C1821	Medical and surgical supplies code listed
Q4282	Medical and surgical supplies code listed
L3649	Orthotics/prosthetics code listed

Radiation therapy / pain management / device codesCPT | HCPCSCovered

64490-64495	Pain management injection codes
77385-77386	IMRT planning/related radiation therapy codes
77387	IGRT
77520,77522-77525,77331,77370,77399,77470	Proton beam and related radiation therapy codes
Y90	Implantable beta-emitting microspheres for malignant tumors (paired with 79445)

Orthotics/prosthetics L-code groupHCPCSCovered

Many L-codes (examples: L5643, L5845, L5930, L6000, L6500, L7007, etc.)

Orthotics/prosthetics HCPCS L-codes listed for prior authorization

Radiation therapy CPT codesCPTCovered

77401	Radiation therapy management/standard radiation therapy
77402	Radiation therapy management/standard radiation therapy
77407	Radiation therapy management/standard radiation therapy
77412	Radiation therapy management/standard radiation therapy

Y90 microsphere procedureHCPCSCovered

Y90	Implantable Beta-Emitting Microspheres for treatment of malignant tumors (associated 79445)
79445	Radiation event/related reporting code referenced with Y90

Radiology, nuclear medicine, skin substitutes, sleep & other CPT/HCPCS codes requiring prior authorization (selected examples)mixedCovered

70450	CT head/brain without contrast
70460	CT head/brain with contrast
70470	CT head/brain without & with contrast
70540	MRI brain
70543	MRI brain with and without contrast
71250	CT thorax
71550	MRI chest
74150	CT abdomen/pelvis
78491	Myocardial imaging CPT example
78803	Nuclear medicine procedure example

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imaging/other codes excerptCPTCovered

96379

Therapeutic, prophylactic, or diagnostic injection; single or initial substance/drug

stimulator/device codes excerptCPTCovered

20975

Insertion or replacement of peripheral nerve stimulator

Selected surgical CPT codes (partial list)CPTCovered

23472	Shoulder procedure (code listed)
27130	Total hip arthroplasty (example code listed)
27446	Knee procedure (example code listed)

Selected J-/Q-codes and transplant drug codesHCPCSCovered

J3490	Unclassified drugs — Amtagvi/Aucatzyl/Lenmeldy noted
J3392	Specific injectable/transplant-related drug code listed

Submission Instructions and Provider Responsibilities

Prior Authorization

How to obtain prior authorization (UnitedHealthcare)

Prior authorization requests may be submitted through several UnitedHealthcare channels. Use the UnitedHealthcare Provider Portal (Prior Authorization and Notification tool) as the primary online method: go to UHCprovider.com, click Sign In (top-right), log in with your One Healthcare ID and password, then select the Prior Authorization and Notification tab. If you do not have a One Healthcare ID visit UHCprovider.com/access to register. You may also call UnitedHealthcare to request prior authorization at 866-889-8054.

Online: UnitedHealthcare Provider Portal — UHCprovider.com → Sign In → Prior Authorization and Notification tab (One Healthcare ID required).
Phone: 866-889-8054 for UnitedHealthcare prior authorization requests.
Non-participating providers: fax request and documentation to 800-262-2567 or 970-255-5681 (for non-participating providers).
Advanced outpatient imaging, nuclear cardiology and many radiology procedures: submit via eviCore at www.evicore.com or call 800-792-8750 (participating physicians may be directed to eviCore per code lists).
Behavioral health (mental health and substance use disorder services): call 888-282-8801.
Notification by admitting facility: phone 800-416-2157, option 4 or 970-248-5197.

Definitions and Key Terms

Prior authorization — Prior authorization

DefinitionPrior authorization = Requirement to obtain approval from the plan or specified vendor before performing listed outpatient or inpatient procedures and services.

ExceptionsNot required for emergency or urgent care; out-of-network providers must request prior authorization for all procedures and services.

Submission channelsSubmit via UnitedHealthcare Provider Portal (Prior Authorization and Notification tool), fax for non-participating providers (800-262-2567 or 970-255-5681), or to eviCore where directed.

inv-60: eviCore healthcare (external clinical review/prior authorization vendor) — eviCore

RoleeviCore healthcare is an external clinical review/prior authorization vendor used for specified services (notably advanced imaging and certain cardiology/cardiovascular requests).

Online portal

OpenPayer

Rocky Mountain Children's Health Plan — Prior Authorization Requirements

Coverage Criteria and Prior Authorization Requirements

CPT, HCPCS and ICD-10 Code Listings

Submission Instructions and Provider Responsibilities

Definitions and Key Terms