CurrentUnitedHealthcarePolicy N/A

Rocky Mountain Health Plan Prime — Prior Authorization Requirements

List of prior authorization requirements and instructions for participating UnitedHealthcare Colorado Rocky Mountain Health Plan Prime providers for inpatient and outpatient services; includes submission methods, contact numbers, and many CPT/ICD codes that require or do not require prior authorization.

Policy Summary

PayerUnitedHealthcare

PolicyRocky Mountain Health Plan Prime — Prior Authorization Requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateEffective November. 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (or follow alternate contact methods listed).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~200+codes listed

online, fax, phonesubmission methods

requires PAinjectable chemotherapy

800-792-8750eviCore contact

877-881-7618Optum SGP contact

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.

multipleprocedures flagged

Services and Codes Requiring Prior Authorization

Prior authorization is required as detailed below. Submit requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, www.evicore.com (call 800-792-8750) where indicated, or by fax to the numbers listed for non‑participating providers. Prior authorization is not required for emergency/urgent care. Out‑of‑network providers must request prior authorization for procedures and services.

ALL of the following

Prior authorization is required for the listed procedures, services and codes unless explicitly noted otherwise (see exempt diagnosis codes and specific exceptions).
Provider-action: submit prior authorization before scheduling elective services; exceptions below.
Services and code categories that require prior authorization
- Arthroplasty and arthroscopy procedures — listed CPT/HCPCS codes require prior authorization (examples include 23472–23474, 26989, 27130, 27132, 27134, 27137–27138, 27412, 27446–27487, 24786, etc.).
  See provider portal or contact eviCore for full CPT list.
- Advanced outpatient imaging procedures (see Radiology Prior Authorization and Notification) — care providers ordering advanced imaging must notify/prior authorize via eviCore (www.evicore.com or 800‑792‑8750).
  See Radiology Prior Authorization and Notification for full CPT code set.
- Outpatient injectable chemotherapy administered IV, intravesical or intrathecal for a cancer diagnosis — most J9000–J9999 range and specific J‑codes (including leucovorin J0640, levoleucovorin J0641/J0642, Lupron depot J1950, J0885, J1449, J1932, J1954, Lutetium Lu A9607) require prior authorization. Q‑coded chemotherapy and miscellaneous HCPCS billed drugs also require prior authorization.
  Exception: For code J1954, Cancer DX is excluded from prior authorization (chunk 73).
- Colony stimulating factors and specified injectable biologics — multiple J‑ and Q‑codes (examples include J1307, J1628, J2351, J7170, J7172, J1072, Q5133, Q5135, Q5147, Q5148, Q5099, Q9997–Q9999, Q5138, Q9999, J1809, J3590*, J3490*, C9399*) require prior authorization. For certain unclassified/temporary codes (C9399, J3490, J3590, Q5123) prior authorization is required only for specified products (see note).
  Operational: for unclassified/temporary codes see policy details; eviCore submission may be required.
- Durable medical equipment (DME) and enteral services — specified HCPCS/E‑codes (examples E0194, E0265, E0266, E0277, E0300, E0328, E0329, E0445, E0457, B4149–B4162, B4154–B4159, B9002, B9998) require prior authorization.
  Prosthetics are not DME — see policy specifics.
- Radiation therapy and radiation-related procedures — certain codes and standard radiation therapy require prior authorization when associated with specified cancer diagnosis code ranges (e.g., C34.*, C50.*, C61, C79.51–C79.52, C84.7A, D05.*).
  See section for IGRT and standard radiation therapy code lists.
- Transplants, implantable stimulators, neuromodulation, and many surgical/unlisted surgical procedures (examples include 17999, 20975, 20979, 61863–61886, 63251–63308, 50547, S2060–S2061, 44137, 44715–44721, 47133) require prior authorization. For transplant-related unclassified codes (J3490, J3590, C9399) certain products require Optum Transplant prior authorization.
  Contact Optum Transplant for transplant prior authorization where indicated.
- Unlisted or miscellaneous procedure codes (e.g., 77399, 29914–29916, 29845, 17999, 21299, 22899 and other unlisted surgery codes) require prior authorization.
  Submit clinical documentation to support medical necessity.
How to obtain prior authorization
- Online via UnitedHealthcare Provider Portal Prior Authorization and Notification tool — sign in with One Healthcare ID at UHCprovider.com; follow Prior Authorization and Notification tab.
  Providers without a One Healthcare ID: visit UHCprovider.com/access to register.
- For eviCore‑managed services (advanced imaging, specific musculoskeletal and radiation therapy services) submit online at www.evicore.com or call 800‑792‑8750.
  Care providers ordering advanced outpatient imaging are responsible for notification prior to scheduling.
- Non‑participating providers may fax requests and documentation to 800‑262‑2567 or 970‑255‑5681.
  Behavioral health services use 888‑282‑8801; admitting facility notifications use 800‑416‑2157 (option 4) or 970‑248‑5197.
Exempt diagnosis codes and specific exceptions
- No prior authorization is required for certain diagnosis codes listed in the policy (examples include E08.52, E09.52, E10.52, E11.52, E13.52, I70.221–I70.232 and others) — see policy diagnosis exempt list for full codes.
  These diagnosis‑based exceptions apply only where specified in the policy.
- Certain J‑codes and unclassified codes have product‑specific prior authorization rules: for example, for unclassified/temporary codes (C9399, J3490, J3590, Q5123) prior authorization is required only for specific named products (Amvuttra, Fylnetra, Lupaneta Pack, Ocrevus Zunovo, Recovi, Riabni, Skyrizi, Steqeyma IV, Syfovre, selected colony stimulating factors, Purified Cortrophine Gel, Yesintek IV).
  Also, for some J‑codes used in transplant or other specialized programs, submission must go through Optum Transplant.
Operational notes and provider responsibilities
- Prior authorization must be obtained before services are scheduled when required — failure to obtain prior authorization may result in denial of coverage or payment adjustments.
  Provider-impact: verify member eligibility and authorization requirements prior to service delivery.
- Where eviCore or Optum Transplant is referenced, follow those vendor processes for submission and documentation (online portal or phone).
  Contact numbers: eviCore 800‑792‑8750; Behavioral Health 888‑282‑8801; Optum Transplant per policy instructions.

CPT, HCPCS, and ICD-10 Codes (Examples and Groups)

Spine and Major Surgical CPT Codes Requiring Prior AuthorizationCPTCovered

20930	Autograft for spine surgery, morselized or structural
20931	Allograft for spine surgery
20975	Implantation of biologic (eg, BMP) — spine
20979	Packing of bone graft substitute, spine
22510	Arthrodesis, posterior or posterolateral technique, single level
22511
22512
22513
22514
22515

1–10 of 63

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How to Request Prior Authorization and Operational Notes

Prior Authorization

How to obtain prior authorization / contact methods

Submit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com — sign in with One Healthcare ID and select the Prior Authorization and Notification tab). Non-participating providers may fax requests and documentation to 800-262-2567 or 970-255-5681. For eviCore-managed services submit via www.evicore.com or call 800-792-8750. Behavioral Health Services: 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: UnitedHealthcare Provider Portal — UHCprovider.com (One Healthcare ID required)
Fax (non-participating providers): 800-262-2567 or 970-255-5681
eviCore: www.evicore.com or 800-792-8750
Behavioral Health: 888-282-8801
Admitting facility notification: 800-416-2157 (option 4) or 970-248-5197

Prior Authorization

eviCore submission instructions

Terms and Code-specific Notes

inv-54: prior authorization

DefinitionPrior authorization: Provider must obtain approval before performing or billing listed services; not required for emergency or urgent care.

Submission methodsOnline via UnitedHealthcare Provider Portal Prior Authorization and Notification tool; non-participating providers may fax to 800-262-2567 or 970-255-5681.

Vendor routingSome services use eviCore (www.evicore.com or 800-792-8750) or other referenced vendors; follow code-specific routing notes.

inv-55: Injectable chemotherapy drugs (outpatient, IV/intravesical/intrathecal) for cancer diagnosis

RequirementPrior authorization required for outpatient injectable chemotherapy drugs administered for a cancer diagnosis (includes J9000-J9999 and listed specific J/Q/A codes).

Included agents

Policy Summary

PayerUnitedHealthcare

PolicyRocky Mountain Health Plan Prime — Prior Authorization Requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateEffective November. 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (or follow alternate contact methods listed).

SourceLink

On This Page

For services managed by eviCore, submit prior authorization requests online at www.evicore.com to sign in. If needed, requests may also be initiated by phone at 800-792-8750.

Online portal: www.evicore.com — sign in to submit requests
Phone: 800-792-8750

Note

No prior authorization required — selected diagnosis codes

No prior authorization is required for the specific diagnosis codes listed in the document (examples include E08.52, E09.52, E10.52, E11.52, E13.52, I70.221–I70.235, I70.238).

Examples of exempt diagnosis codes shown in the policy: E08.52, E09.52, E10.52, E11.52, E13.52
Included vascular codes: I70.221, I70.222, I70.223, I70.228, I70.229, I70.231, I70.232, I70.233, I70.234, I70.235, I70.238

Prior Authorization

Prior authorization required — outpatient injectable chemotherapy

Prior authorization is required for injectable chemotherapy drugs administered in an outpatient setting for a cancer diagnosis, including chemotherapy J‑codes (J9000–J9999), leucovorin (J0640), levoleucovorin (J0641, J0642), Lupron Depot (J1950), and specified J/Q/A codes and miscellaneous HCPCS-coded agents.

Chemotherapy injectable drugs billed J9000–J9999 require prior authorization
Specific examples called out: J0640, J0641, J0642, J1950, J0885, J1449, J1932, J1954, A9607
Includes agents with Q‑codes and miscellaneous HCPCS codes when applicable

Documentation Required

Reconstructive/cosmetic procedures — condition-based PA exceptions

Many reconstructive and cosmetic CPT/HCPCS procedure codes include conditional notes on whether prior authorization is required depending on the billed diagnosis; prior authorization may not be required when the procedure is billed with specified condition codes per the procedure notes.

Check procedure-specific notes: some reconstructive/cosmetic codes are exempt from prior authorization when billed with listed condition/diagnosis codes.
Refer to the policy code entries for the exact diagnosis pairings that remove the prior authorization requirement.

Prior Authorization

Prior authorization required — Digestive procedures and DME

Prior authorization is required for listed Digestive procedures and for the durable medical equipment (DME) codes shown in the policy; providers must obtain authorization before services are provided.

Digestive CPT examples with prior authorization include: 42145, 43648, 43659, 43881, 43882, 49329
DME HCPCS codes listed (examples include E0194, E0265, E0266, E0277, E0300)

Prior Authorization

Prior authorization required — Enteral services

Prior authorization is required for enteral services and the enteral HCPCS codes listed (for example B4149, B4150, B4152–B4162, B9002, B9998); obtain authorization before providing enteral nutritional services.

Enteral service HCPCS examples: B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B9002, B9998
Prior authorization noted as required in the Enteral services section

Prior Authorization

Prior authorization required — Experimental & investigational procedures

Prior authorization is required for the procedures and codes listed as Experimental and Investigational; providers must obtain prior authorization for those codes before performing experimental or investigational services.

Policy examples of experimental/investigational CPT codes include 33477, 36514, 64722, 65765, 66180 and associated HCPCS such as A4638 and A9274
The policy marks these services as 'Prior authorization required' under Experimental and Investigational

Prior Authorization

Prior authorization required — Gender dysphoria treatment

Prior authorization is required for gender dysphoria treatment codes listed in the document (examples include CPT 14000, 14001, 14040, 15734, 15738, 15750, 15757); obtain authorization prior to treatment.

Gender dysphoria surgical examples: 14000, 14001, 14040, 15734, 15738, 15750, 15757
Section labels these services 'Prior authorization required' for Gender dysphoria treatment

Prior Authorization

eviCore prior authorization submission instructions

For eviCore-managed clinical areas, submit prior authorization requests online at www.evicore.com to sign in; phone assistance is available at 800-792-8750.

Online: www.evicore.com — sign in to submit
Phone: 800-792-8750

Documentation Required

Optum Specialty Guidance Program (SGP) contact

For questions about the eviCore online authorization process and specialty medication authorization routing, call the Optum Specialty Guidance Program (SGP) at 877-881-7618.

Optum Specialty Guidance Program (SGP): 877-881-7618 — for questions about online authorization process

Prior Authorization

Colony stimulating factors & related unclassified codes — PA required

Prior authorization is required for the listed unclassified/temporary and colony stimulating factor–related codes (examples include J3590, J1628, J1307, J7170, J7172, J1072, and J1809); follow the policy notes for specific product-based exceptions.

Examples of unclassified/temporary and CSF-related codes listed: J3590, J1628, Q5133, Q5135, J1307, J2351, Q5147, Q9997, Q9998, Q5138, Q9999, J7170, Q5099, Q5100, J7172, Q5148, J1072, J1809
Note: For unclassified/temporary codes C9399, J3490, J3590 and Q5123, prior authorization is required only for a specified product list (see policy); J1954 excludes Cancer DX from prior auth.

Prior Authorization

Advanced imaging prior authorization (eviCore)

Prior authorization is required for advanced outpatient imaging procedures requested by participating physicians; eviCore is the referenced reviewer—submit via www.evicore.com or call 800-792-8750.

Advanced imaging examples include multiple CT/MRI/MRA/PET CPT ranges (e.g., 70450–70555, 71250–71555, 72125–72130, 75580, etc.)
eviCore manages prior authorization review for these advanced outpatient imaging procedures

Prior Authorization

Radiology prior authorization / notification responsibility

Care providers ordering advanced outpatient imaging are responsible for notifying prior to scheduling and must submit authorization requests via www.evicore.com or by calling 800-792-8750.

Providers must provide notification before scheduling advanced outpatient imaging
Submit requests online at www.evicore.com or call 800-792-8750

Prior Authorization

UnitedHealthcare prior authorization submission instructions

For certain requests submit prior authorization via the UnitedHealthcare Provider Portal (UHCprovider.com). If needed, call UnitedHealthcare at 866-889-8054.

UnitedHealthcare Provider Portal: UHCprovider.com — sign in with One Healthcare ID
Phone: 866-889-8054

Prior Authorization

Radiation therapy prior authorization — diagnosis-limited requirement

Standard radiation therapy requires prior authorization only when billed with specified diagnosis code ranges (examples: C34.00–C34.92, C50.011–C50.929, C61, C79.51–C79.52, C84.7A, D05.00–D05.92).

Authorization required for standard RT only with listed malignancy diagnosis ranges (e.g., lung C34.xx; breast C50.xxx; prostate C61; metastatic codes C79.51–C79.52; select cutaneous lymphoma C84.7A; ductal carcinoma in situ D05.xx)

Prior Authorization

Device/stimulator prior authorization required

Prior authorization is required for implantable devices and stimulators listed in the policy (examples include CPT 20975, 20979, 61863–61868, 61885–61886); obtain authorization prior to device/stimulator procedures.

Stimulator/device examples: 20975, 20979, 61863, 61864, 61867, 61868, 61885, 61886
Additional device and implant codes listed throughout the surgery sections also require prior authorization

Prior Authorization

Stimulators — prior authorization required

Prior authorization is required for the stimulator CPT/HCPCS codes listed (examples: 20975, 20979, 61863, 61864, 61867, 61868, 61885, 61886); do not perform these procedures without authorization.

Listed stimulator codes requiring PA: 20975, 20979, 61863, 61864, 61867, 61868, 61885, 61886

Prior Authorization

Surgery and unlisted surgery — prior authorization required

Surgery and unlisted surgery codes (including unlisted procedure codes such as 17999, 21299, 22899 and device codes including L8680, 64590, 29914–29916) require prior authorization per the policy.

Unlisted surgery examples: 17999, 21299, 22899
Device/example codes referenced in surgery section: L8680, 64590, 29914, 29915, 29916

Prior Authorization

Unclassified J/C‑code transplant drugs — Optum Transplant PA required

Unclassified J/C-code drugs billed under J3490, J3590, or C9399 for specific transplant-related products (Amtagvi, Lenmeldy, Zevaskyn) require prior authorization through Optum Transplant.

For unclassified codes J3490, J3590, and C9399 when used for Amtagvi, Lenmeldy, and Zevaskyn — prior authorization must be obtained via Optum Transplant

Prior Authorization

Vein procedures — prior authorization required

Vein procedures and related removal/ablation codes listed in the policy require prior authorization; examples include 33975–33983, 36473, 36475, 36478, 37700, 37718, 37722, 37765–37780 and HCPCS Q0507–Q0509.

Vein procedure examples: 33975, 33976, 33979, 33981, 33982, 33983
Ablation/removal examples: 36473, 36475, 36478, 37700, 37718, 37722, 37765, 37766, 37780
HCPCS vein branch codes: Q0507, Q0508, Q0509

Prior Authorization

Transplants — prior authorization required

Prior authorization is required for transplant procedures and transplant-related CPT codes listed in the policy; providers must obtain authorization before performing transplant services.

Transplant procedure examples listed: 32850–32857, 33928–33935, 38232–38241, 47135–47147, 47140–47146, 50300–50370 and others shown in the Transplants section
Policy states 'Transplants — Prior authorization required'

Leucovorin (J0640), Levoleucovorin (J0641, J0642), Lupron Depot (J1950), plus listed J-codes (J0885, J1449, J1932, J1954) and Lutetium Lu (A9607).

Miscellaneous/Q-codesChemotherapy agents with Q-codes or those billed under miscellaneous HCPCS when no specific code exists are included and require prior authorization.

inv-56: Colony stimulating factors

CategoryColony stimulating factors — prior authorization applies to listed product uses and associated codes (see J-codes and clinical pairing notes).

Code examplesJ3590 is listed in the colony stimulating factor section; J1809 is specifically noted in the code list.

Clinical pairing/conditionsSome CSF entries include diagnosis/condition pairings and additional information guiding when prior authorization is required or not.

inv-57: Durable medical equipment (DME)

DefinitionDurable medical equipment (DME) — specified HCPCS E-codes require prior authorization.

Code examplesE0194, E0265, E0266, E0277, E0300, E0328, E0329, E0445, E0457, E0465, E0466, E0483, E0625, E0636, E0637, E0642, E0651, E0652, E0656, E0657, E0660, E0665, E0675, E0693, E0694 are listed.

ActionObtain prior authorization for listed DME codes before delivery to avoid claim denials.

inv-58: Enteral services

DefinitionEnteral services — enteral nutrition/home nutritional therapy codes require prior authorization.

Code examplesB4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B9002, B9998 are listed.

NoteEnteral services are listed with an explicit 'Prior authorization required' note in the Enteral services section.

inv-59: Special prior authorization note for unclassified/temporary codes

RuleUnclassified and temporary codes (C9399, J3490, J3590, Q5123): prior authorization is required only for a specified list of products and uses (see list in document).

Specified productsIncludes Amvuttra, Fylnetra, Lupaneta Pack, Ocrevus Zunovo, Recovi, Riabni, Skyrizi, Steqeyma IV, Syfovre, white blood cell colony stimulating factors, Purified Cortrophine Gel, Yesintek IV as examples.

Vendor routingFor certain unclassified drug uses (Amtagvi, Lenmeldy, Zevaskyn), prior authorization must be obtained through Optum Transplant as noted.

inv-60: Exception for J1954

ExceptionFor code J1954, cancer diagnoses are excluded from prior authorization (i.e., J1954 with Cancer DX is excluded from PA).

ContextJ1954 is listed among injectable chemotherapy-related codes but has an explicit exclusion for cancer diagnosis in the notes.

inv-61: Unclassified/temporary code PA rule

PolicyUnclassified/temporary code PA rule: C9399, J3490, J3590 and Q5123 require prior authorization only when used for the specified products listed in the document; otherwise typical unclassified coding rules apply.

Transplant drugsCertain drugs billed under J3490/J3590/C9399 (e.g., Amtagvi, Lenmeldy, Zevaskyn) require Optum Transplant prior authorization as specifically noted.

inv-62: eviCore

VendoreviCore is the referenced utilization management vendor for advanced outpatient imaging prior authorization and certain other services.

ContacteviCore web: www.evicore.com; phone: 800-792-8750.

ResponsibilityParticipating physicians ordering advanced outpatient imaging must obtain prior authorization/notification through eviCore per the radiology section.

inv-63: Proton beam

DefinitionProton beam: Focused radiation therapy using beams of protons; listed CPT codes include 77520, 77522, 77523, 77525.

AuthorizationProton beam therapy CPT codes are listed and require prior authorization per the radiation therapy sections.

inv-64: Unclassified drug codes (J3490/J3590/C9399)

PolicyUnclassified drug codes J3490, J3590, C9399: when used for specific named drugs (examples provided), prior authorization is required through Optum Transplant or as noted in the document.

ExamplesAmtagvi, Lenmeldy, Zevaskyn are called out as requiring Optum Transplant PA when billed under unclassified codes.

inv-65: Unlisted surgery codes

DefinitionUnlisted surgery codes (e.g., 17999, 21299, 22899, 29914-29916) are included in the surgery section and marked as requiring prior authorization.

ActionObtain prior authorization for unlisted surgery codes before performing the procedure to ensure coverage considerations are addressed.