CurrentUnitedHealthcarePolicy N/A

Sureste plan notification and prior authorization requirements (partial)

Governance of notification and prior authorization processes for UnitedHealthcare participating providers serving Sureste and Surest Flex commercial plan members; describes which services require prior authorization or flexible coverage activation and how to submit requests.

Policy Summary

PayerUnitedHealthcare

PolicySureste plan notification and prior authorization requirements (partial)

Policy CodePolicy N/A

Change TypeNo material changes noted

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization or notification requests by phone (877-842-3210) or online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

UHCProvider.comOnline submission method

877-842-3210PA phone

3 business daysFlex activation lead time

888-397-8129Oncology support line

$1,000DME threshold

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Coverage and Prior Authorization Criteria

Coverage requirements (partial) - Arthroplasty and arthroscopy rules (partial)

Arthroplasty and arthroscopy rules (partial):

Arthroplasty: Prior authorization required for both Surest plan and Surest Flex plan members (multiple CPT codes listed).

Arthroscopy: Prior authorization required for Surest plan members; Surest Flex plan members require flexible coverage activation (must be activated at least 3 business days before service). Multiple arthroscopy CPT codes are listed.

Bone growth stimulator: Prior authorization required for both Surest and Surest Flex plan members (CPT codes 20974, 20975, 20979 listed).

Breast reconstruction: Prior authorization required for Surest plan members; Surest Flex members require flexible coverage activation for many breast reconstruction codes. Some diagnosis codes may exempt prior authorization.

Behavioral health: Outpatient ABA for Flex members does not require prior authorization; residential treatment center and partial hospitalization require notification/prior authorization.

Cancer supportive care (injectables): Prior authorization required when administered in an outpatient setting for a cancer diagnosis; some listed supportive care J-/Q-codes also require prior authorization when used for non-oncology diagnoses. Oncology prior authorization submissions should use the 'Oncology' prior authorization type in the Provider Portal or call 888-397-8129.

Prior authorization criteria (partial) - Prior authorization and flexible coverage activation requirements

Prior authorization and flexible coverage activation requirements

Outpatient oncology injectables administered for a cancer diagnosis: prior authorization required for both Surest and Surest Flex members (supporting codes include J1442, J1447, J1449, J2506, J1454, J1453, J1627, J0897 and others).

Selected cardiovascular and interventional procedure codes: prior authorization required for Surest plan members; flexible coverage activation required for Surest Flex plan members (examples: 33285, 33289, 37220, 93580). Some codes are not required with specified diagnoses.

Cartilage implants and related procedures (e.g., J7330, 27412, 29866): prior authorization required for both Surest and Surest Flex plan members.

Cerebral seizure monitoring / inpatient video EEG (e.g., 95700, 95711–95713): inpatient video EEG prior authorization required for both Surest and Surest Flex members; outpatient cerebral seizure monitoring is noted as not requiring prior authorization.

Prior authorization criteria and code exemptions (partial)

Prior authorization requirements and code-based exemptions where specified in the excerpt.

Injectable chemotherapy: prior authorization required for both Surest and Surest Flex members when administered outpatient for a cancer diagnosis (includes Q-codes; J9000–J9999; leucovorin J0640; levoleucovorin J0641/J0642; specified leuprolide codes).

Continuous glucose monitors and related supplies (examples: A4226, A4238, A4239, A9276, E0787, E2102, E2103): prior authorization required for both Surest and Surest Flex plan members.

Cosmetic and reconstructive procedures (multiple CPT examples listed, e.g., 11960, 14020, 21137, 21295): prior authorization required for both Surest and Surest Flex members; prior authorization is not required when billed with specific ICD-10 diagnosis codes (extensive C43/C44 skin neoplasm code list).

Exception: Cosmetic/reconstructive procedures billed with listed malignant skin/neoplasm ICD-10 codes (C43.x, C44.x series) are exempt from prior authorization per the listed Dx codes.

Authorization requirements (partial)

Prior authorization/notification requirements and specific code lists for several service categories (as presented in this excerpt).

Durable Medical Equipment (DME): For DME codes with a retail purchase or cumulative rental cost > $1,000, prior authorization is required; prosthetics are not considered DME but require prior authorization (see orthotics/prosthetics section).

ESRD dialysis: Notification for dialysis should be submitted via the Prior Authorization and Notification tool on the Provider Portal or by calling 877-842-3210; referral/enrollment options provided (Kidney Resource Service).

Foot surgery: prior authorization required for Surest plan members; flexible coverage activation required for Surest Flex members (examples: 28285, 28289, 28291, 28292 and others).

Functional Endoscopic Sinus Surgery (FESS): prior authorization required for Surest plan members; flexible coverage activation required for Surest Flex members (listed FESS CPT codes).

Genetic and molecular testing (including BRCA and other outpatient genetic tests: examples 81162, 81432, 81405): prior authorization required for genetic/molecular testing performed in outpatient settings for both Surest and Surest Flex members.

Procedure prior authorization rules (partial)

Prior authorization and flexible coverage activation rules for procedures

Hysterectomy and related infertility procedure codes: prior authorization required for Surest plan members; flexible coverage activation required for Surest Flex members. Multiple code mappings/equivalencies are noted (e.g., 58267 = 58150).

Procedure mapping note: Several codes are shown mapped or equated within the listing (e.g., 58267 = 58150; 58292 = 58544) — follow the listed mappings when determining authorization requirements.

Infertility prior authorization and Dx linkage (partial)

Infertility and diagnosis code linkage

Specified infertility CPT codes (examples: 52402, 54500, 55550, 58140, 58545, 58660, 58662, 58670, 58672, 58673, 58740, 58770, 89398) require prior authorization; associated ICD-10 diagnosis codes enumerated include N46.x, N97.x, N98.1, E23.0 and additional N46/N97 series codes.

Instruction: Submit specialty pharmacy prior authorization requests and injectable/specialty medication requests by logging into UHCProvider.com/Prior Authorization and selecting 'Specialty Pharmacy' as the prior authorization type.

Injectable medications authorization and site-of-service restrictions

Coverage stance and rules for injectable medications and select therapies

Injectable medications: Prior authorization is required for injectable medications for both Surest and Surest Flex plan members (drugs administered IV, subcutaneously, or IM).

Submission instruction: To submit a prior authorization for injectable/specialty medications, log into UHCProvider.com/Prior Authorization and Notification and select 'Specialty Pharmacy' as the prior authorization type.

Site‑of‑service restriction: Enzyme replacement therapy prior authorization applies only when administered at POS 19 and 22.

Authorization and coverage notes

Coverage/authorization notes for specific code groups and situations

Predetermination is highly recommended for drugs on the Review at Launch Medication List; example: code J0885 requires prior authorization for both oncology and non‑oncology diagnoses.

Unclassified/temporary codes (C9399, J3490, J3590): notification/prior authorization is required only for named products (e.g., Nulibry, Ocrevus Zunovo™, Revcovie, Rivfloza™); some members may not have coverage for these drugs.

Orthotics and prosthetics: prior authorization required when retail purchase or cumulative rental cost exceeds $1,000; applies to critical access hospitals, long‑term acute care hospitals, and skilled nursing facilities for Surest and Surest Flex plans.

Multiple sclerosis medications: site‑of‑service notes indicate certain MS J‑codes apply only at POS 19 and 22 (see listed MS J‑codes).

Acute/post‑acute inpatient admissions: prior authorization and notification of admission date required for both Surest and Surest Flex plan members (applies to acute inpatient rehabilitation and post‑acute services).

Authorization and coverage criteria excerpts

Coverage-related authorization rules and examples present in this excerpt:

Pain management procedures (specific CPT/Codes listed, e.g., 62320–62327, 64451, 64620, etc.): prior authorization required for both Surest and Surest Flex plan members.

Investigational/plan‑specific: Some investigational or linked services require prior authorization for Surest plan members (plan‑specific prior authorization noted).

Radiation therapy and associated services: prior authorization required; some services require authorization only with oncology diagnoses or specified diagnosis ranges (proton beam therapy and IMRT referenced).

Rhinoplasty and sinuplasty: rhinoplasty procedures require prior authorization for both Surest and Surest Flex members; sinuplasty prior authorization is required for Surest plan members. (Examples: 30400–30465; sinuplasty CPT 31295–31298).

Sleep disorder surgical procedures and sleep studies: listed CPT codes for sleep surgery and studies (examples: 21685, 41599, 42145, 95807–95811) with applicability notes by setting.

Prior authorization and coverage notes (excerpt)

Prior authorization requirements and notable coverage activation notes in this section

Sinuplasty: Prior authorization required for Surest plan members (CPT examples include 31295–31298).

Spinal cord stimulators: Prior authorization required for Surest plan members; flexible coverage activation may be required for Surest Flex members (examples include 63650, 63685 and device L‑codes).

Spine surgery: Multiple spine surgery CPT codes have notes indicating prior authorization is required for Surest and Surest Flex members (see listed spine CPTs and mapped equivalents).

Therapeutic radiopharmaceuticals: Submit outpatient therapeutic radiopharmaceutical prior authorization via UHCProvider.com/Prior Authorization and select 'Oncology'; prior authorization required for both Surest and Surest Flex members (examples: A9513, A9590, A9606, A9607, A9699).

Transplant, cellular and gene therapy services: prior authorization required for Surest and Surest Flex members; multiple related C/Q/J codes listed (see cellular/gene therapy code list).

Prior authorization requirements

Prior authorization requirements and contact instructions for specified services under Surest and Surest Flex plans.

Transportation services (HCPCS examples A0430, A0431, S9960, S9961, A0435, A0436): prior authorization required for both Surest and Surest Flex plan members.

Uterine fibroid MR‑guided focused ultrasound (OO71T, 0072T): prior authorization required for both Surest and Surest Flex plan members.

Vein procedures (removal/ablation of saphenous veins and branches; examples: 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479): prior authorization required for both Surest and Surest Flex plan members.

Ventricular assist devices (VADs; examples: 33927, 33928, 33929, 33975, 33976, 33979, 33981–33983): prior authorization required for both Surest and Surest Flex plan members. Instructions: call 888‑936‑7246, then fax the form provided by the nurse to the Optum VAD Case Management Team at 855‑282‑8929.

Codes and Billing Identifiers

How to Submit Requests and Provider Requirements

Prior Authorization

How to submit requests

Submit prior authorization or notification requests by phone at 877-842-3210 or online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal. Emergency and urgent care do not require notification/prior authorization.

Prior Authorization

Flexible coverage activation requirement

For Surest Flex members, services that require flexible coverage activation must be activated at least 3 business days before the service; services requiring activation do not require prior authorization.

Prior Authorization

Oncology prior authorization submission

Oncology prior authorization requests should be submitted via the Provider Portal by selecting 'Oncology' from the Prior Authorization and Notification tool or by calling 888-397-8129.

Definitions and Operational Notes

Flexible coverage activation definition

DefinitionFlexible coverage activation must be completed at least 3 business days before the service for Surest Flex plan members

Effect on prior authorizationServices that require flexible coverage activation do not require prior authorization for Surest Flex members

Example service categoryArthroscopy noted as requiring flexible coverage activation for Flex members while Surest members require prior authorization

Notification/prior authorization submission

Submission methodsSubmit prior authorization or notification requests by phone (877-842-3210) or online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal

ExclusionEmergency and urgent care do not require notification/prior authorization

Policy Summary

PayerUnitedHealthcare

PolicySureste plan notification and prior authorization requirements (partial)

Policy CodePolicy N/A

Change TypeNo material changes noted

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization or notification requests by phone (877-842-3210) or online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

SourceLink

On This Page

Gender dysphoria treatment and related reconstructive/cosmetic CPT codes: prior authorization required for both Surest and Surest Flex plan members.

Prior Authorization

Behavioral health notification/prior auth

Behavioral health: Flex members do not require prior authorization for outpatient behavioral health; inpatient cases require case creation for notification, and residential treatment center and partial hospitalization require notification/prior authorization (submit online or call 877-842-3210).

Prior Authorization

Oncology outpatient injectable medications - prior authorization

Prior authorization is required for the listed outpatient injectable oncology supportive care agents and colony-stimulating factors when administered for a cancer diagnosis; submit oncology injectable requests via the Provider Portal 'Oncology' prior authorization type or call 888-397-8129.

Examples of listed J/Q codes include J1442, J1447, J1449, J2506 and Q5101 (see code list in document).

Prior Authorization

Cardiovascular/procedure prior authorization

Prior authorization is required for the listed cardiovascular and related procedure codes for Surest plan members; Flexible coverage activation is required for Surest Flex members where noted.

Codes listed include 33285, 33289, 37220–37229 and 93580 (see document for full list).

Prior Authorization

Cartilage implants - prior authorization

Prior authorization is required for cartilage implants (J7330) and the listed related procedure codes for both Surest and Surest Flex plan members.

Related procedure codes referenced include 27412, 27415, 27416 and arthroscopic codes (see document).

Prior Authorization

Cerebral seizure monitoring - prior authorization rules

Prior authorization is required for inpatient cerebral seizure monitoring/inpatient video EEG codes for Surest and Surest Flex members; outpatient cerebral seizure monitoring is noted as not requiring prior authorization.

Inpatient video EEG codes include 95700, 95711, 95712 and 95713; outpatient EEG codes (e.g., 95714–95726) have separate notes.

Prior Authorization

Oncology prior authorization submission

Submit oncology prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (select 'Oncology') or call 888-397-8129.

Prior Authorization

Phone authorization and plan-specific requirements

For authorization of certain cardiovascular services (and other services noted), call 888-936-7246; prior authorization is required for Surest plan members and Flexible coverage activation is required for Surest Flex members where specified.

Age-specific rules noted: for patients ages 18 and older see cardiovascular section.

Prior Authorization

Services requiring prior authorization (codes listed)

Prior authorization is required for injectable chemotherapy drugs (Q-codes; J9000–J9999; leucovorin/levoleucovorin codes; certain leuprolide codes) when administered in an outpatient setting for a cancer diagnosis.

Includes chemotherapy drugs billed under Q-codes or J9000–J9999 and miscellaneous HCPCS codes for unassigned agents.

Prior Authorization

ESRD dialysis notification/authorization instructions

To provide notification for dialysis, submit the request using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 877-842-3210; refer or enroll members in ESRD Disease Management via the Kidney Resource Service at 866-561-7518.

Billing Rule

DME / prosthetics prior authorization and cost threshold

Prior authorization is required for prosthetics (not classified as DME) and for DME codes with a retail purchase or cumulative rental cost exceeding $1,000; some home health services may qualify under DME rules but are not subject to the $1,000 threshold.

Threshold: retail purchase or cumulative rental cost > $1,000 triggers prior authorization.

Prior Authorization

Foot surgery and FESS prior authorization

Prior authorization is required for foot surgery CPT codes for Surest plan members; Surest Flex members require flexible coverage activation. Functional endoscopic sinus surgery (FESS) also requires prior authorization for Surest members and flexible coverage activation for Surest Flex members.

Examples of foot surgery codes: 28285, 28289, 28291, 28292. FESS example codes: 31240, 31253, 31254 (see document for full lists).

Prior Authorization

Gender dysphoria treatment prior authorization

Prior authorization is required for gender dysphoria treatment for both Surest and Surest Flex plan members; specified reconstructive and related CPT codes are listed in the document.

Example codes include 14000, 15734, 19303 and additional reconstructive procedure codes (see list).

Prior Authorization

Genetic/molecular testing prior authorization

Prior authorization is required for genetic and molecular testing performed in outpatient settings, including BRCA testing (examples: 81162, 81163, 81164, 81432 and related CPT codes).

Submit prior authorization for outpatient genetic testing as noted in the portal.

Prior Authorization

Home health prior auth

Home health care requires prior authorization for both Surest and Surest Flex plan members (codes T1002, T1003).

Prior Authorization

Hysterectomy / Infertility prior auth

Hysterectomy and related gynecologic/infertility procedure codes require prior authorization for Surest plan members; Surest Flex members require flexible coverage activation for the same codes.

The document maps multiple codes (e.g., 58267 = 58150) and lists numerous related CPT codes subject to these rules.

Prior Authorization

Infertility prior auth and Dx linkage

Specified infertility-related CPT codes require prior authorization and must be linked to the enumerated ICD-10 diagnosis codes (examples include N46.x, N97.x, N98.1, E23.0).

Example infertility CPT codes: 52402, 54500, 55550, 58140, 58145, 58545; associated Dx codes are listed in the document.

Prior Authorization

Injectable medications prior auth / submission

Injectable medications require prior authorization for both Surest and Surest Flex plan members; specialty pharmacy prior authorization requests should be submitted via UHCProvider.com by selecting 'Specialty Pharmacy' from the prior authorization type.

Examples of injectable J-codes are listed in the document; follow specialty pharmacy submission instructions on the portal.

Prior Authorization

Submitting prior authorization for injectable/specialty medications

To submit a prior authorization for injectable or specialty medications, log into UHCProvider.com/Prior Authorization and Notification and select 'Specialty Pharmacy' as the prior authorization type.

For questions about the online authorization process call Optum Specialty Guidance Program (SGP) at 1-888-397-8129.

Note

Authorization support contact

For questions about the online authorization process, providers may call the Optum Specialty Guidance Program (SGP) at 1-888-397-8129.

Documentation Required

Prior authorization and predetermination notes

For certain oncology drugs (e.g., J0885), prior authorization is required for both oncology and non-oncology diagnoses; predetermination is highly recommended for drugs on the Review at Launch Medication List.

Unclassified/temporary codes (C9399, J3490, J3590) require notification/prior authorization only for specified products named in the document.

Billing Rule

Orthotics and prosthetics prior authorization threshold

Orthotics and prosthetics codes require prior authorization for critical access hospitals, long-term acute care hospitals, and skilled nursing facilities when the retail purchase or cumulative rental cost exceeds $1,000.

Examples of L-codes subject to this threshold are listed in the document.

Prior Authorization

Orthognathic surgery prior authorization

Orthognathic/maxillofacial surgery CPT codes require prior authorization for critical access hospitals, long-term acute care hospitals, and skilled nursing facilities for both Surest and Surest Flex plan members.

Example codes include 21050, 21060, 21121 and others listed in the document.

Prior Authorization

Prior authorization for pain management and other listed codes

Prior authorization is required for listed pain management codes and other specified services for both Surest and Surest Flex plan members; some codes may have plan-specific requirements.

Pain management example codes include 62320, 62322, 62324, 62325 and others shown in the document.

Prior Authorization

Prior authorization for investigational/linked services

Prior authorization is required for certain investigational or linked services for Surest plan members; some investigational services are plan-specific—refer to the listed codes in the document.

Prior Authorization

Prior authorization for radiation therapy and associated services

Prior authorization is required for many radiation therapy and associated services; some services require authorization only with an oncology diagnosis or specific diagnosis code ranges (proton beam therapy and IMRT referenced).

Example radiation codes include 77014, 77387, 77520, 77522 and associated G-codes.

Prior Authorization

Prior authorization for rhinoplasty, nasal procedures, and sinuplasty

Prior authorization is required for rhinoplasty-related procedures and sinuplasty for Surest plan members; rhinoplasty prior authorization is noted for both Surest and Surest Flex members.

Example codes include 30400, 30410, 30420 and sinuplasty code 31295.

Prior Authorization

Therapeutic Radiopharmaceuticals prior authorization

To submit a Therapeutic Radiopharmaceuticals prior authorization request for outpatient therapeutic radiopharmaceuticals, log on to UHCProvider.com/Prior Authorization and select 'Oncology' from the prior authorization type dropdown.

Prior authorization is required for both Surest and Surest Flex plan members for listed HCPCS A-codes.

Note

PA required for Surest / Surest Flex members

Multiple service categories in this document include explicit notes that prior authorization is required for Surest plan members and/or flexible coverage activation is required for Surest Flex members; confirm plan-specific requirements when submitting requests.

Examples include sinuplasty, spinal cord stimulators (63685), and multiple spine surgery CPT codes.

Prior Authorization

Transportation prior authorization

Prior authorization is required for the listed transportation HCPCS codes for both Surest and Surest Flex plan members.

Transportation codes include A0430, A0431, A0435, A0436, S9960 and S9961.

Prior Authorization

Uterine fibroid MR-guided focused ultrasound prior authorization

Prior authorization is required for uterine fibroid MR-guided focused ultrasound (codes OO71T and 0072T) for both Surest and Surest Flex plan members.

Prior Authorization

VAD prior authorization and case management process

Prior authorization is required for ventricular assist devices (VADs) for both Surest and Surest Flex plan members; providers must call 888-936-7246 and then fax the form provided by the nurse to the Optum VAD Case Management Team at 855-282-8929.

VAD-related CPT codes listed include 33927, 33928, 33929, 33975–33983 (see document).

Prior Authorization

Vein procedures prior authorization

Prior authorization is required for vein procedures (removal and ablation of saphenous veins and branches) for both Surest and Surest Flex plan members; multiple CPT codes are listed in the document.

Example codes include 36470, 36471, 36473, 36474, 36475, 36476, 37243 and 37700 (see full list).

Oncology-specific optionOncology requests can be submitted via the Provider Portal selecting 'Oncology' or by calling 888-397-8129

Oncology prior authorization submission (definition)

Submission type for oncologySubmit oncology prior authorization requests using the UnitedHealthcare Provider Portal Prior Authorization and Notification tool and select 'Oncology' as the prior authorization type

Phone optionAlternatively call 888-397-8129 for oncology prior authorization assistance

ScopeIncludes injectable oncology/supportive care agents and colony-stimulating factors administered outpatient for a cancer diagnosis

Flexible coverage activation

Definition and relation to Surest FlexFlexible coverage activation: a required activation step for certain services for Surest Flex members; must be completed at least 3 business days before service and replaces prior authorization for those Flex members

Plan distinctionSurest members generally require prior authorization for the same services listed; Flex members use flexible coverage activation where indicated

Per-code specificsActivation vs prior authorization is indicated per CPT/HCPCS code in the document (e.g., hysterectomy/infertility and arthroscopy listings)

chemotherapy injectables definition

DefinitionChemotherapy injectables: includes chemotherapy injectable drugs billed with Q-codes and J9000–J9999 series, plus related agents (e.g., leucovorin J0640, levoleucovorin J0641/J0642)

ScopeApplies when these agents are administered in an outpatient setting for a cancer diagnosis and require prior authorization

Uncoded productsIncludes chemotherapy drugs billed under miscellaneous HCPCS codes when no assigned code exists

Continuous glucose monitor (CGM)

DefinitionContinuous glucose monitor (CGM) and associated supplies (examples: A4226, A4238, A4239, A9276, E0787) require prior authorization for both Surest and Surest Flex plan members

Included itemsSensor, transmitter and supply HCPCS codes are listed in the CGM section of the document

Relation to DME/prostheticsCGM supplies are handled under prior authorization rules distinct from orthotics/prosthetics and DME thresholds

Prosthetics vs DME

Policy distinctionProsthetics are explicitly not considered DME for prior authorization purposes; prosthetics require prior authorization under prosthetics/orthotics rules

DME threshold contrastDME codes trigger prior authorization when retail purchase or cumulative rental cost > $1,000; this DME threshold does not classify prosthetics as DME

ReferenceSee separate orthotics/prosthetics prior authorization rules and HCPCS L-code listings

ESRD notification process

Notification processTo provide notification for dialysis, submit the request using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 877-842-3210

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

ScopeApplies to end-stage renal disease (ESRD) dialysis services including outpatient settings

Injectable medications

DefinitionInjectable medications: drugs capable of being administered intravenously (IV), subcutaneously (SC) or intramuscularly (IM); prior authorization is required for both Surest and Surest Flex plan members

Submission instructionSubmit prior authorization requests for specialty injectable medications via UHCProvider.com/Prior Authorization and select 'Specialty Pharmacy' as the prior authorization type

Site-of-service noteEnzyme replacement therapies have a site-of-service restriction: prior authorization applies only when administered at POS 19 and 22

Genetic testing/lab services definition

DefinitionGenetic testing and molecular lab services: outpatient genetic/molecular testing (including BRCA) that require prior authorization; multiple proprietary U-codes and CPT molecular codes are listed

ExamplesBRCA and panel codes (e.g., 81162, 81163, 81164, 81432) and numerous U-codes (e.g., 0018U, 0022U, 0306U) are referenced

SubmissionPrior authorization required for outpatient genetic/molecular testing per the listed CPT/HCPCS codes

Predetermination and unclassified code notes

Predetermination recommendationPredetermination is highly recommended for the drugs on the Review at Launch Medication List

Unclassified/temporary codesFor codes C9399, J3490 and J3590, notification/prior authorization is required only for specified products (e.g., Nulibry, Ocrevus Zunovo™, Revcovie, Rivfloza™)

Oncology drug exampleCode J0885 requires prior authorization for both oncology and non-oncology diagnoses

medical necessity / investigational determination

Medical necessity / investigational determinationA service is considered investigational when there is insufficient clinical evidence from well-conducted randomized controlled trials or cohort studies showing a beneficial effect on health outcomes

Plan-specific applicationSome services deemed investigational require prior authorization for Surest plan members (plan-specific determinations may apply)

Reference guidanceSee the document sections listing potentially unproven or investigational codes where PA is required

Plan-specific prior authorization

Plan-specific prior authorizationPrior authorization requirements differ by plan: certain codes require prior authorization for both Surest and Surest Flex members; others require prior authorization only for Surest members while Flex members require flexible coverage activation

ExamplesPain management, spine, and stimulator codes include plan-specific PA or flexible coverage activation notes in the listings

ActionCheck per-code listing in the document to determine whether PA or flexible coverage activation applies

Prior authorization required for Surest and Surest Flex plan members (definition)

PA required for Surest and/or Surest FlexMultiple service categories (e.g., sinuplasty, spinal cord stimulators, spine surgery) include explicit notes that prior authorization is required for Surest plan members and/or Surest Flex plan members

Flexible coverage activation possibilitySome codes within these categories indicate flexible coverage activation may be required instead of PA for Surest Flex members

Submission instructionSubmit prior authorization or activation per the per-code instructions via UHCProvider.com or the specified phone contacts

Cellular and gene therapy definition

Cellular and gene therapy definitionCellular and gene therapy (including autologous cellular products) are listed under therapeutic radiopharmaceuticals and cellular/gene therapy sections and require prior authorization

Codes referencedIncludes product and miscellaneous codes such as C9399, J3391–J3394, J3490/J3590 and Q2041–Q2058 as listed

Submission noteTherapies require prior authorization; follow the Therapeutic Radiopharmaceuticals/Cellular and Gene Therapy submission instructions in the document

VAD definition

VAD definitionVentricular assist devices (VAD): a mechanical pump that takes over the function of the damaged ventricle of the heart and restores normal blood flow

PA requirement and contact processPrior authorization required for both Surest and Surest Flex members; providers should call 888-936-7246 and fax the form to Optum VAD Case Management Team at 855-282-8929

Associated CPT codesExamples include CPT codes 33927, 33928 and others listed in the VAD section

Uterine fibroid MR-guided focused ultrasound definition

DefinitionUterine fibroid MR-guided focused ultrasound: MR-guided focused ultrasound procedure for uterine fibroids

PA requirementPrior authorization required for both Surest and Surest Flex plan members for codes OO71T and 0072T

CodesDocument lists OO71T and 0072T as the procedure codes for MR-guided focused ultrasound