CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Surest health plans

Lists notification and prior authorization review requirements and submission methods for UnitedHealthcare participating providers for members enrolled in Surest plans, including distinctions for Surest Flex plan features.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Surest health plans

Policy CodePolicy N/A

Change TypeMinor/No material change

Effective DateFeb 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone at 877-237-0006.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Online, Phonesubmission methods available for prior authorization requests

3 business daysminimum advance activation for flexible coverage

Optum Provider Expressportal referenced for ABA/Autism prior auth submissions

1,000DME cost-threshold requiring prior authorization

877-237-0006phone for general prior authorization/notification

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Services and Code-Based Prior Authorization / Flexible Coverage Rules

Coverage criteria by service

Services and codes listed with one of the following stances: prior authorization required for Surest plan members; flexible coverage activation required for Surest Flex members; some services require prior authorization for both plans.

Arthroplasty: Prior authorization required for both Surest and Surest Flex plan members; specific CPT/HCPCS codes listed in the Arthroplasty section (examples: 24365, 27120, 23470-23474, 24360-24363).

Bariatric surgery: Prior authorization required for Surest plan members; Surest Flex members require flexible coverage activation. Specific CPT codes include 43659, 43772, 43774, 43886-43888 and others listed.

Applied Behavioral Analysis (ABA): Prior authorization required for Surest plan members; not required for Surest Flex plan members. Submit via Optum Provider Express (providerexpress.com) using the Treatment Plan Request workflow.

Bone growth stimulator (electronic): CPT/HCPCS 20974, 20975, 20979 require prior authorization for both Surest and Surest Flex plan members.

Oncology supportive meds prior auth

Cancer supportive care injectable medications that require prior authorization when administered in an outpatient setting for a cancer diagnosis.

Antiemetic and supportive injectable drugs listed (examples: J1442, J1447, J1449, J2506, Q5101, Q5108, Q5110, Q5111) require prior authorization for both Surest and Surest Flex members when given outpatient for a cancer diagnosis.

Named agents and related Q-codes (for example: J1454 Akynzeo, J0185 Cinvanti, J1453/J1456 fosaprepitant, J1627 granisetron ER, J0897 denosumab, J1449 eflapegrastim) are included and require prior authorization as noted.

Certain Q5xxx codes (Q5120, Q5122, Q5125) require prior authorization for non-oncology diagnoses per the injectable medications section.

Cerebral seizure monitoring (video EEG) prior auth rules

Inpatient video EEG (cerebral seizure monitoring) prior authorization rules.

Inpatient video electroencephalogram (EEG) monitoring: Prior authorization is required for inpatient services for both Surest and Surest Flex plan members; prior authorization is not required for outpatient EEG services.

Example procedure codes associated with inpatient video EEG include 95700, 95712, 95713, 95714, 95716, 95718, 95720, 95722, 95726 (codes listed in the EEG section).

Cartilage implant prior auth

Cartilage implant prior authorization requirement.

HCPCS J7330 (cartilage implant): Prior authorization required for both Surest and Surest Flex plan members.

Prior authorization requirements (excerpt)

Services and codes listed require prior authorization or Flexible coverage activation as noted:

Cartilage implants: J7330 requires prior authorization for both Surest and Surest Flex members.

Selected surgical and monitoring codes (examples: 27412, 27415, 27416, 29867, 29868, S2112): Prior authorization required for Surest plan members; Flexible coverage activation required for Surest Flex plan members.

Inpatient video EEG (cerebral seizure monitoring): Prior authorization required for inpatient services; not required for outpatient services.

Chemotherapy services and injectable chemotherapy drugs (J9000-J9999, J0640-J0642, J1950/J1952/J1954, Q-code chemo, miscellaneous HCPCS billed chemotherapy): Prior authorization required for both Surest and Surest Flex members when administered outpatient for a cancer diagnosis; submit via UHCProvider.com Prior Authorization and Notification selecting 'Oncology'.

Clinical trial billing codes S9988, S9990, S9991: Prior authorization required for both Surest and Surest Flex members.

Authorization and notification criteria (partial)

Services and procedures that require prior authorization or notification for Surest and/or Surest Flex members as listed below.

Foot surgery (examples: 28285, 28289, 28291, 28292, 28296-28299): Prior authorization required for Surest plan members.

Functional endoscopic sinus surgery (FESS) (examples: 31240, 31253-31259, 31267, 31276, 31287, 31288): Prior authorization required for Surest plan members.

Gender dysphoria treatment (multiple listed codes including 55970, 55980, 14041, 15734, 15738, 15750, 15757-15758 and others): Prior authorization required for both Surest and Surest Flex plan members; notification or prior authorization may be required regardless of diagnosis for specified procedures.

Genetic and molecular testing (outpatient; BRCA and related codes such as 81228, 81163, 81164, 81432): Prior authorization required for both Surest and Surest Flex plan members when performed outpatient.

Durable medical equipment (DME): Prior authorization required for listed DME HCPCS when retail purchase or cumulative rental cost exceeds $1,000; prosthetics are not considered DME for this threshold.

Prior authorization criteria entries

Entries in this segment denote when prior authorization is required for specific services and codes.

Genetic/molecular testing performed in an outpatient setting: Prior authorization required for both Surest and Surest Flex plan members (BRCA and related codes listed).

Home health care (examples: T1000, T1002, T1003, S3870): Prior authorization required for both Surest and Surest Flex plan members for listed home health care codes.

Hysterectomy, infertility, and related outpatient procedure codes (many CPT entries listed): Prior authorization required for Surest plan members; some entries indicate prior authorization for both Surest and Surest Flex members as noted per code.

Injectable medications and specialty drugs (multiple J- and Q-codes listed): Prior authorization required for both Surest and Surest Flex members; submit via UHCProvider.com/Prior Authorization, selecting the Specialty Pharmacy/Notification workflow and contact Optum SGP for questions.

Authorization and coverage criteria for injectables and inpatient admissions

Coverage and authorization stance for listed injectables and inpatient admissions.

Injectable medications and specialty drugs billed with specific HCPCS/CPT codes (including unclassified/temporary codes) may require prior authorization for named products; providers should consult the Review at Launch Medication List and predetermination is highly recommended for new-to-market drugs.

Unclassified/temporary codes C9399, J3490, J3590: Notification/prior authorization is required only for specific named products (e.g., Nulibry, Ocrevus Zunovo, Revcovi, Rivfloza) and prior authorization rules vary by product and diagnosis; J0885 requires prior authorization for both oncology and non-oncology diagnoses.

Inpatient admissions (acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long-term acute care hospitals): Prior authorization and notification of admission date required for both Surest and Surest Flex plan members.

Prior authorization criteria summary

Services require prior authorization as specified below for Surest and Surest Flex plan members; some require flexible coverage activation for Surest Flex members or are limited to oncology diagnoses.

Inpatient admissions (acute and post-acute): Prior authorization and notification of admission date required for both Surest and Surest Flex plan members for listed facility types (acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long-term acute care hospitals).

Orthognathic surgery CPT codes listed (see orthognathic list): Prior authorization required for both Surest and Surest Flex plan members.

Orthotics and prosthetics L-codes listed: Prior authorization required for both Surest and Surest Flex plan members when retail purchase or cumulative rental cost exceeds $1,000.

Pain management CPT/HCPCS codes (numerous listed e.g., 62320-62361, 64451, 64484, 64520, 64620, 64640, E0782-E0786): Prior authorization required for both Surest and Surest Flex plan members.

Prior authorization criteria by code group

Prior authorization / Flexible coverage activation rules by code group.

Rhinoplasty codes 30400-30465: Prior authorization required for both Surest and Surest Flex plan members (functional and cosmetic entries indicate PA requirement).

Sinuplasty codes 31295-31298: Prior authorization required for Surest plan members (noted specifically).

Spinal cord stimulator implantation and related device codes (examples: 63650, 63688, 64553; HCPCS L8679-L8688 series): Prior authorization required for Surest plan members; Flexible coverage activation required for Surest Flex plan members as noted.

Extensive spine and neurosurgery CPT code groups (examples include ranges 20930-20939, 22101-22116, 22510-22595, 22610-22634, 22800-22862, 63001-63308 and others listed): Prior authorization required for both Surest and Surest Flex plan members as listed.

Radiation therapy/proton beam therapy planning and delivery codes (examples: 77385, 77386, 77520, 77401-77412, G6003-G6016): Prior authorization linkage applies when obtained with specified oncology diagnosis ranges.

Prior authorization required

Prior authorization requirement for listed services.

Therapeutic radiopharmaceuticals (examples: A9513, A9590, A9606, A9607, A9699): Prior authorization required for both Surest and Surest Flex plan members; submit via UHCProvider.com selecting 'Oncology' prior authorization type.

Transplant and transplant-related services (including pre-treatment/evaluation and bone marrow harvest; CPT/HCPCS examples: 38241, 38242, S2150): Prior authorization required for both Surest and Surest Flex plan members; providers should call 888-936-7246 for prior authorization.

Ventricular assist devices (VAD) (examples: 33927, 33928, 33975, 33976, 33982, 33983): Prior authorization required for both Surest and Surest Flex plan members; providers should call 888-936-7246 and fax the form to Optum VAD Case Management Team at 855-282-8929.

Transportation services (examples: A0430, A0431, A0435, A0436): Prior authorization required for both Surest and Surest Flex plan members.

Stimulators and implantable devices (various device codes including bone growth stimulators E0747-E0760 and neurostimulator codes): Prior authorization required for both Surest and Surest Flex plan members as listed.

CPT / HCPCS / ICD-10 Code Tables and Thresholds

Covered CPT codes - ArthroscopyCPTCovered

29824	Arthroscopy, shoulder, diagnostic
29825	Arthroscopy, shoulder, with decompression
29826	Arthroscopy, shoulder, repair
29827	Arthroscopy, shoulder, with meniscectomy
29828	Arthroscopy, with synovectomy
29830	Arthroscopy, elbow
29834	Arthroscopy, knee diagnostic
29835	Arthroscopy, knee, debridement
29836	Arthroscopy, knee, meniscectomy
29837	Arthroscopy, knee, meniscus repair

1–10 of 48

1/5

Covered CPT codes - Cartilage implantCPTCovered

29866

Arthroscopy, knee, cartilage implantation

Covered CPT codes - Bone growth stimulatorCPTCovered

20974	Electrical stimulation to aid bone healing
20975	Application of bone growth device, implanted
20979	Application of extracorporeal bone growth stimulator

Covered CPT codes - Breast reconstruction additional CPTCovered

19318	Mastectomy, subcutaneous
19300	Mastectomy, simple, complete

Covered CPT codes - Selected ranges (Arthroscopy robotic/advanced)CPTCovered

29824-29899	Arthroscopy and related arthroscopic procedures range (see individual codes)
29914-29916	Hip arthroscopy specific codes range

Covered HCPCS codes - Continuous glucose monitorHCPCSCovered

A4226	Sensor; invasive (e.g., subcutaneous), disposable
A4238	Transmitter
A4239	Transmitter
A9276	Continuous glucose monitor supply
A9277	CGM supply
A9278	CGM supply
E0787	CGM system
E2102	Glucose monitor
E2103	Glucose monitor

How Providers Submit Requests and What Actions are Required

Prior Authorization

How to submit prior authorization/notification

This list contains notification/prior authorization review requirements for participating UnitedHealthcare commercial plan health care professionals providing inpatient and outpatient services for members enrolled in Surest® plans. This list changes periodically. Updates are announced in UnitedHealthcare Network News. Please submit your request in one of the following ways: Online: use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCProvider.com) — sign in with One Healthcare ID and password and select Prior Authorization and Notification. Phone: Call 877-237-0006. Notification/prior authorization is not required for emergency or urgent care.

Prior Authorization

Flexible coverage activation requirement

Some members have the Surest Flex plan, which includes flexible coverage. Services listed as requiring flexible coverage activation must have flexible coverage activated at least 3 business days before the scheduled service. Note: Services that require flexible coverage activation do not also require prior authorization — activation is the required member action for Surest Flex members.

Flexible coverage activation must be completed at least 3 business days prior to service.

Key Terms and Thresholds

Flexible coverage activation — definition/note

DefinitionFlexible coverage activation is a Surest Flex plan feature that members must activate for listed services

TimingMember must activate flexible coverage at least 3 business days before receiving the service

EffectServices that require flexible coverage activation do not require prior authorization but do require activation

Notification/prior authorization — definition/quick reference

DefinitionNotification/prior authorization: provider submission of service review via the Prior Authorization and Notification tool or phone

Submission methodsOnline via UHCProvider.com Prior Authorization and Notification tool or by phone at 877-237-0006

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Surest health plans

Policy CodePolicy N/A

Change TypeMinor/No material change

Effective DateFeb 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone at 877-237-0006.

SourceLink

On This Page

Auditory implants and related CPT/HCPCS (examples: 69710, 69714, 69930, L8619, L8690, L8691, L8614, L8692): Prior authorization required for both Surest and Surest Flex members.

ESRD dialysis services: Providers must submit notification for dialysis via the Prior Authorization and Notification tool on UHCProvider.com or call 877-237-0006; Kidney Resource Service at 866-561-7518 for enrollment/referrals to ESRD Disease Management.

Investigational/Unproven services:

Potentially unproven or investigational services require prior authorization for Surest plan members; Surest Flex plan members require flexible coverage activation where noted.

Radiation therapy and prostate procedure codes: Prior authorization required; certain radiation therapy codes require prior authorization only when billed with oncology diagnosis codes in specified ICD-10 ranges (C34.00-C34.92, C50.011-C50.929, C61, C79.51-C79.52, C84.7A, D05.00-D05.92).

Vein procedures and uterine fibroid MRgFUS (examples: 0071T, 0072T, S9960, S9961, 37243, 37780): Prior authorization required for both Surest and Surest Flex plan members.

Flexible coverage activation applies to the specific services listed elsewhere in this section; check the individual procedure entry for Surest Flex activation guidance.

Prior Authorization

ABA / Autism prior authorization process

Applied behavior analysis (ABA) for autism: prior authorization is required for Surest plan members. ABA does not require prior authorization for Surest Flex members (flexible coverage activation applies where listed). To submit ABA/Autism prior authorization, providers should use Optum Provider Express (providerexpress.com) and follow the Autism/ABA submission instructions (Treatment Plan Request for UHSS/BIND/NTCA providers).

Prior authorization required for Surest plan members; not required for Surest Flex members (follow Surest Flex activation rules if applicable).
Submit ABA/Autism requests via Optum Provider Express per the Autism/ABA Corner instructions.

Prior Authorization

Oncology prior authorization submission instructions

For oncology prior authorization requests (including outpatient chemotherapy and cancer supportive care), submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal. From the Prior Authorization and Notification homepage select 'Oncology' as the prior authorization type.

Oncology PA submissions: UHCProvider.com → Prior Authorization and Notification → select 'Oncology'.
Antiemetic and supportive oncology injectable drugs listed in the Cancer supportive care section require PA when administered in outpatient settings for a cancer diagnosis.

Prior Authorization

Cancer supportive care drugs requiring prior authorization

Certain cancer supportive care drugs and injectable oncology/supportive agents require prior authorization when administered in an outpatient setting for a cancer diagnosis. Providers should follow the oncology submission routing on the Provider Portal for these agents.

Examples include specific J-codes and Q-codes listed in the Cancer supportive care section (e.g., J1454, J0185, J1453, J1456, J1627, J0897, J1449, etc.).
Some HCPCS Q-codes (e.g., Q5120, Q5122, Q5125) may require PA for non-oncology diagnoses — see the injectable medications section and oncology guidance.

Prior Authorization

Procedures requiring prior authorization / flexible coverage activation

Listed surgical and monitoring procedures require prior authorization for Surest plan members; for Surest Flex members some of the same procedures instead require flexible coverage activation (follow the Surest Flex guidance and timing). Examples include certain arthroplasty and selected CPT codes enumerated in this section.

Prior authorization required for Surest plan members for the listed surgical codes (see individual entries).
Surest Flex members: flexible coverage activation required for many of these procedures — activate at least 3 business days prior to service.

Prior Authorization

Cartilage implants (J7330)

Cartilage implants billed with J7330 require prior authorization for both Surest and Surest Flex plan members.

J7330 requires prior authorization for both plan types.

Prior Authorization

Selected surgical and spine/neurosurgery prior authorization

Certain surgical codes (including many spine and neurosurgery CPT codes) require prior authorization for both Surest and Surest Flex members. For Surest Flex members, some spine/neurosurgery procedures may instead require flexible coverage activation — check the individual code entries and follow the 3-business-day activation rule when specified.

Spine/neurosurgery codes listed throughout this section (e.g., 20930, 20931, 20939, 22101, 22103, 22110, 22112, 22114, 22116, 22206, 22208, many CPT 63xxx series and others) require prior authorization.
For Surest Flex members some spine procedures may be subject to flexible coverage activation instead of a PA; confirm per-code guidance.

Prior Authorization

Chemotherapy services (oncology) submission routing

For oncology chemotherapy services and related injectable drugs, submit PA requests via the Provider Portal Prior Authorization and Notification tool and select the appropriate oncology submission type. Prior authorization is required for outpatient administration for a cancer diagnosis for many chemotherapy injectable drugs (J9000–J9999 and related codes).

Chemotherapy injectables (J9000–J9999) and certain related J-codes require prior authorization when given outpatient for a cancer diagnosis.
Miscellaneous or new-to-market oncology agents billed under miscellaneous HCPCS codes also require PA; predetermination is recommended for new-to-market drugs (see Review at Launch guidance).

Prior Authorization

Clinical trials — PA required

Clinical trial procedure codes S9988, S9990 and S9991 require prior authorization for both Surest and Surest Flex plan members.

Prior authorization required for S9988, S9990, S9991 for both plan types.

Prior Authorization

Auditory implants — PA required

Auditory implant procedures require prior authorization for both Surest and Surest Flex plan members. Examples of related codes include CPT 69710, 69714, 69930 and HCPCS device codes L8619, L8690, L8691 — verify the exact codes on the patient claim and submit PA accordingly.

Prior authorization required for auditory implant CPT/HCPCS codes listed in this section (e.g., 69710 / L8619; 69714 / L8690; 69930 / L8691).

Prior Authorization

Cardiovascular / congenital heart prior authorization

Many cardiovascular and congenital heart services require prior authorization for Surest plan members and flexible coverage activation for Surest Flex members where noted. Some prior authorization requests for cardiology-related devices or procedures may require calling the provided specialty number (e.g., 888-936-7246) for preauthorization routing.

Certain cardiovascular CPT/HCPCS codes and device implantations listed in this section require PA for both plan types or PA for Surest and Flex activation for Surest Flex — check specific entries.
For some cardiology/device services call 888-936-7246 as directed in the cardiology/cardiac device entries.

Prior Authorization

Continuous glucose monitor — PA required

Continuous glucose monitoring (CGM) devices and associated CPT/HCPCS codes (examples listed in this section such as A4226, A4238, A4239, A9276–A9278, E0787, E2102–E2103) require prior authorization for both Surest and Surest Flex plan members.

CGM supplies and devices listed require PA for both plan types.
Confirm exact HCPCS/CPT code on the claim and submit PA via the Provider Portal.

Prior Authorization

Cosmetic and reconstructive procedures — prior authorization required

Cosmetic and reconstructive procedures listed in this section require prior authorization for both Surest and Surest Flex plan members. Examples of reconstructive codes that require prior authorization include 11960, 11970, 11971, 14020*, 14021*, 14061*, 14302, 15570, 15572, 15574, 15730, 15733, 15740, 15756, 15769, 15773, 15820–15823, 15830, 15847, 15877, 15878 and additional codes enumerated in this section.

Prior authorization required for cosmetic/reconstructive codes listed for both Surest and Surest Flex members.
Some codes marked with * may have additional documentation requirements — confirm during PA submission.

Note

ESRD dialysis notification / enrollment instructions

To notify or enroll dialysis (ESRD) patients: submit requests/notifications using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCProvider.com) or call 877-237-0006. To enroll or refer a member to the UnitedHealthcare ESRD Disease Management program contact the Kidney Resource Service at 866-561-7518.

Use UHCProvider.com Prior Authorization and Notification or call 877-237-0006 to provide dialysis notification.
Kidney Resource Service (ESRD Disease Management): call 866-561-7518 to enroll or refer members.

Prior Authorization

Procedure-specific prior authorization (hysterectomy, infertility, foot surgery, FESS, home health)

For certain procedures (e.g., foot surgery, FESS, hysterectomy, infertility-related procedures, home health entries and other outpatient procedures listed), prior authorization is required for Surest plan members. For Surest Flex members, flexible coverage activation may be required for some of these procedures — see the individual procedure entries and activate flexible coverage at least 3 business days before service when specified.

Examples: Foot surgery codes (28285, 28289, 28291–28299, 28296–28299) require PA for Surest members.
FESS codes (31240, 31253–31259, 31267, 31276, 31287, 31288) require PA for Surest members.
Hysterectomy and infertility-related CPT codes listed require PA for Surest members; infertility services require PA for both plan types when indicated.

Prior Authorization

Genetic / molecular testing prior authorization

Genetic and molecular testing performed in an outpatient setting requires prior authorization for both Surest and Surest Flex plan members. Confirm the specific test CPT/HCPCS code (examples included in the Genetic testing/lab services list) and submit PA via the Provider Portal.

Outpatient genetic/molecular testing codes listed require PA for both plan types.
Submit PA requests through UHCProvider.com Prior Authorization and Notification.

Prior Authorization

Home health care prior authorization

Home health care services (T1000, T1002, T1003 and listed home health codes) require prior authorization for both Surest and Surest Flex plan members when indicated — submit via the Provider Portal.

Home health CPT/HCPCS codes listed require PA for both plan types.
Check the individual home health code entries for any additional documentation requirements.

Prior Authorization

Injectable / specialty drug prior authorization and submission instructions

Injectable and specialty drugs billed with J- and Q-codes require prior authorization for both Surest and Surest Flex plan members. For injectable medications used in oncology, hematology, or specialty areas, follow the Prior Authorization and Notification tool routing (select the appropriate specialty e.g., Oncology, Pharmacy). New-to-market or unclassified codes (C9399, J3490, J3590) may require notification/PA for specific products and predetermination is recommended. Note: J0885 requires prior authorization for both oncology and non-oncology diagnoses.

Prior authorization required for J/Q coded injectables; follow specialty routing on the Provider Portal.
Unclassified/temporary codes C9399, J3490, J3590: notification/PA required for specific named products (see Review at Launch list).
J0885: PA required for both oncology and non-oncology diagnoses.

Prior Authorization

Unclassified/temporary codes and new-to-market drugs — PA/notification

For unclassified or temporary HCPCS codes and new-to-market medications billed under codes such as C9399, J3490, J3590, providers should check the Review at Launch and Review at Launch Medication List. Predeterminations are highly recommended for drugs on that list. Specific products billed under these unclassified codes (for example Nulibry®, Ocrevus Zunovo™, Revcovi®, Rivfloza™) require notification/prior authorization as noted.

Check the Review at Launch Medication List for newly approved drugs and follow predetermination guidance.
Notification/PA required for certain named products billed under C9399, J3490, J3590.

Prior Authorization

Inpatient admission prior authorization / notification

Inpatient acute and post-acute facility admissions require prior authorization and notification of the admission date for both Surest and Surest Flex plan members. This applies to acute care hospitals, acute inpatient rehabilitation, critical access hospitals and long-term acute care hospitals.

Prior authorization and admission date notification required for acute and post-acute inpatient admissions for both plan types.
Submit admissions notification via UHCProvider.com Prior Authorization and Notification or call 877-237-0006.

Prior Authorization

Orthognathic surgery prior authorization

Orthognathic surgery CPT codes listed in this section require prior authorization for both Surest and Surest Flex plan members — see the orthognathic surgery entries and submit PA as indicated.

Orthognathic CPT codes (e.g., 21199, 21206, 21208, 21209, 21210, 21215, 21240, 21242–21249, 21255, 21296, 21299) require PA for both plan types.

Prior Authorization

Orthotics and prosthetics — cost-threshold prior authorization

Orthotics and prosthetics (O&P) require prior authorization for both Surest and Surest Flex plan members when the retail purchase or cumulative rental cost exceeds $1,000. A large list of L-codes and related HCPCS codes are included in this section — confirm the exact code and cost threshold before submitting PA.

O&P codes listed (L0220, L0482, L0484, L0486, L0636, L0638, L1640, L1680, etc.) require PA when purchase/rental cost > $1,000.
Submit PA via UHCProvider.com Prior Authorization and Notification.

Prior Authorization

Pain management prior authorization

Pain management procedures and related CPT/HCPCS codes (examples include 62320–62361, 64451, 64484, 64520, 64620, 64640, E0782–E0786, G0260) require prior authorization for both Surest and Surest Flex plan members. Check individual code entries for details.

Pain management CPT codes listed require PA for both plan types.
Confirm additional documentation requirements during PA submission.

Prior Authorization

Investigational / potentially unproven services — prior authorization

Potentially investigational, unproven or not medically necessary services require prior authorization for Surest plan members; for Surest Flex members these services often require flexible coverage activation. Determinations are made when there is insufficient clinical evidence from well-conducted peer-reviewed literature. Examples of investigational/unproven codes are listed in this section (e.g., 26340, 36514, 64722, A9274 and others).

Prior authorization required for investigational/unproven services for Surest plan members.
Surest Flex members: flexible coverage activation required for investigational/unproven services where noted (activate at least 3 business days before service).
Coverage determinations are made based on published, peer-reviewed medical evidence.

Prior Authorization

Radiation therapy / prostate procedures — prior authorization

Radiation therapy and prostate procedure codes listed in this section require prior authorization for both Surest and Surest Flex plan members. Some radiation therapy codes require prior authorization only when billed with specific oncology diagnosis ranges (see code/diagnosis guidance).

Radiation therapy codes (e.g., 77331, 77370, 77387, 77470, 77371–77373, 77385–77386, G6015–G6017, etc.) require PA as indicated.
Prior authorization for certain radiation therapy services is required only when billed with oncology DX ranges (see C34.xx, C50.xx, C61, etc.).

Prior Authorization

Spinal cord stimulator / device implantation prior authorization

Spinal cord stimulators and related stimulator/device implantation procedures require prior authorization for Surest plan members. For Surest Flex members, many stimulator/device implantations require flexible coverage activation. Some neurostimulator and implant CPT/HCPCS codes listed require PA for both plan types (see the stimulator and spine surgery entries).

Stimulator implantation and related CPT/HCPCS codes require PA for Surest members; Surest Flex members may require flexible coverage activation.
Examples of related CPT codes include 61863–61868, 61885–61886, 64555, 64568, 64590, 64595, 64561, 64581 and others listed in the stimulators section.

Prior Authorization

Surgical prior authorization — spine/neurosurgery examples

Extensive lists of spine and neurosurgery CPT codes throughout this section require prior authorization for both Surest and Surest Flex plan members. Providers should verify the exact CPT code(s) and submit PA accordingly via the Provider Portal.

Many spine/neurosurgery CPT codes (see lists in the Spine surgery and Neurosurgery sections) require PA for both plan types.
For Surest Flex members, certain spine procedures may instead require flexible coverage activation — follow per-code guidance and the 3-business-day activation rule when applicable.

Prior Authorization

Therapeutic radiopharmaceuticals — prior authorization and submission routing

Therapeutic radiopharmaceuticals and related A-codes (A9513, A9590, A9606, A9607, A9699, etc.) require prior authorization for both Surest and Surest Flex plan members. To submit a Therapeutic Radiopharmaceuticals PA for outpatient services, log into UHCProvider.com Prior Authorization and Notification and select 'Oncology' from the 'Select prior authorization type for submission' dropdown.

Therapeutic radiopharmaceutical A-codes listed require PA for both plan types.
Submit outpatient therapeutic radiopharmaceutical prior authorizations via the Provider Portal and select Oncology routing.

Prior Authorization

Transplant and cellular/gene therapy prior authorization

Transplant, cellular and gene therapy services (including pre-treatment evaluations and transplant-related services) require prior authorization for both Surest and Surest Flex plan members. Examples include bone marrow harvest, organ transplant procedures, and named cellular/gene therapies (e.g., Abecma®, Carvykti™, Kymriah™, Lantidra™, etc.). For transplant prior authorization assistance please call 888-936-7246.

Prior authorization required for transplant and transplant-related CPT/HCPCS codes (e.g., 38241, 38242, S2150 and numerous organ transplant CPTs).
For transplant and cellular/gene therapy PA questions or to initiate review call 888-936-7246.

Prior Authorization

Ventricular assist device (VAD) prior authorization

Ventricular assist devices (VAD) require prior authorization for both Surest and Surest Flex plan members. Prior authorization routing: call 888-936-7246, then fax the form provided by the nurse to the Optum VAD Case Management Team at 855-282-8929.

VAD CPT codes listed (e.g., 33927, 33928, 33975, 33976, 33982, etc.) require PA for both plan types.
Contact 888-936-7246 and fax required forms to 855-282-8929 as instructed.

Prior Authorization

Transportation prior authorization

Transportation services billed with HCPCS codes A0430, A0431, A0435, A0436 require prior authorization for both Surest and Surest Flex plan members. Confirm the transport code and submit prior authorization via the Provider Portal.

A0430, A0431, A0435, A0436 require prior authorization for both plan types.
Submit transportation PA requests via UHCProvider.com Prior Authorization and Notification.

ExemptionNot required for emergency or urgent care

Prior authorization required for both Surest plan and Surest Flex plan members — definition

DefinitionPrior authorization required for both Surest and Surest Flex plan members for specified services and codes

ExamplesCartilage implants (J7330), therapeutic radiopharmaceuticals, many inpatient admissions and selected surgical/device codes

Provider noteFollow specific submission instructions per service (portal selection or phone as listed)

Flexible coverage activation required for Surest Flex plan members — definition

DefinitionFlexible coverage activation required for Surest Flex plan members for listed services instead of prior authorization

TimingActivation must occur at least 3 business days before the service

ExamplesSelected surgical and monitoring codes where Flex activation is specified (e.g., 27412, 29867)

Clinical trials — definition and applicability

DefinitionClinical trials: rigorously controlled studies of new drugs, devices, or treatments under institutional review oversight

PA requirementClinical trial–related services billed with S9988, S9990, S9991 require prior authorization for both Surest and Surest Flex members

Submission noteFollow the standard prior authorization submission process via the Provider Portal

Inpatient video EEG / cerebral seizure monitoring — definition about inpatient vs outpatient authorization

ClarificationInpatient video EEG (cerebral seizure monitoring) requires prior authorization when provided as an inpatient service; outpatient video EEG does not require prior authorization

Relevant codesExamples referenced include 95700, 95712, 95713, 95714, 95716, 95718, 95720, 95722, 95726

Plan applicabilityRequirement applies to both Surest and Surest Flex plan members when inpatient

DME threshold / prosthetics note — DME threshold and prosthetics note

DME thresholdDME items with retail purchase or cumulative rental cost greater than $1,000 require prior authorization

Prosthetics noteProsthetics are not classified as DME; orthotics/prosthetics have their own $1,000 threshold for PA

Provider actionSubmit prior authorization per listed DME codes when cost threshold is exceeded

ESRD notification/enrollment — dialysis notification instructions reference

Notification methodSubmit dialysis notification via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 877-237-0006

ESRD program enrollmentTo enroll or refer a member to the UnitedHealthcare ESRD Disease Management program contact Kidney Resource Service at 866-561-7518

Applies toEnd-stage renal disease (ESRD) dialysis services (outpatient dialysis)

Outpatient genetic/molecular testing prior authorization — definition of outpatient testing PA requirement

RequirementGenetic and molecular testing performed in an outpatient setting requires prior authorization for both Surest and Surest Flex members

ExamplesBRCA and related genetic testing codes (e.g., 81228, 81163, 81164, 81432, 81401) are included in the list

Submission noteFollow the Provider Portal prior authorization process for laboratory/genetic testing entries

Prior authorization submission process (injectables/specialty) — brief submission path note

Submission pathSubmit injectable/specialty drug prior authorization requests via UHCProvider.com/Prior Authorization selecting the 'Specialty Pharmacy' workflow

SupportProviders may contact Optum SGP for questions about the online authorization process

Codes includedVarious J- and Q-codes for injectable medications listed in the policy require PA

Inpatient admissions - post-acute services — facility-type admission PA definition

DefinitionPost-acute facility admissions (acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long-term acute care hospitals) require prior authorization and notification of admission date for both Surest and Surest Flex members

ActionProviders must submit PA and admission notification per the policy before planned admissions

Applies toBoth acute and post-acute inpatient facility types listed

Review at Launch Medication List — definition/reference for newly FDA-approved drugs

DefinitionReview at Launch Medication List: a referenced list of newly FDA-approved drugs; predetermination is highly recommended for drugs on this list

ActionCheck the Review at Launch policy and Medication List for new-to-market drugs before submitting requests

ContextApplies to unclassified/temporary codes and newly marketed products that may require predetermination

Drugs newly approved by the FDA that may require predetermination — Review at Launch list

ExamplesDrugs newly approved by the FDA included on the Review at Launch Medication List may require predetermination; predetermination is highly recommended

Unclassified codesFor C9399, J3490, J3590 notification/PA is required only for specific named products listed (see policy)

Provider actionUse Review at Launch policy to determine if predetermination is advised for a new drug

$1,000 orthotics/prosthetics prior authorization threshold — O&P threshold definition

Threshold$1,000 retail purchase or cumulative rental cost triggers prior authorization for orthotics/prosthetics

Applies toOrthotics and prosthetics HCPCS/L-codes listed in the policy

ActionSubmit prior authorization when the retail purchase or cumulative rental cost exceeds $1,000

Flexible coverage activation — definition cross-reference

Cross-referenceFlexible coverage activation: Surest Flex feature requiring member activation for listed services (activate at least 3 business days in advance)

UseRefer to flexible coverage activation table in the policy for services that require activation

EffectServices requiring activation do not require prior authorization but must be activated by the member

Prior authorization requirement — note about plan-specific applicability

Plan applicabilityPrior authorization requirements vary by plan type; some services require PA for Surest members and flexible coverage activation for Surest Flex members; others require PA for both plans

ExamplesCardiovascular procedures, cartilage implants (J7330), inpatient admissions, and many surgical/device codes are subject to PA rules

Provider instructionFollow the service- and code-specific submission instructions in the policy (portal selection or phone)

Ventricular assist device — VAD definition

DefinitionVentricular assist device (VAD): a mechanical pump that takes over the function of the damaged ventricle and restores blood flow

PA requirementPrior authorization required for both Surest and Surest Flex plan members

Submission instructionsCall 888-936-7246, then fax the form provided by the nurse to Optum VAD Case Management Team at 855-282-8929

Therapeutic radiopharmaceuticals — definition/reference for submission

DefinitionTherapeutic radiopharmaceuticals: outpatient therapeutic radiopharmaceuticals requiring prior authorization

PA codesExamples include A9513, A9590, A9606, A9607, A9699 which require prior authorization

Submission pathSubmit outpatient therapeutic radiopharmaceutical prior authorization via UHCProvider.com and select 'Oncology' prior authorization type