CurrentUnitedHealthcarePolicy N/A

Prior Authorization Requirements for Texas STAR

Lists prior authorization requirements and how participating UnitedHealthcare Community Plan STAR providers in Texas must submit requests for inpatient and outpatient services.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Requirements for Texas STAR

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal, by phone 877-842-3210, or fax 877-940-1972.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

online/phone/faxsubmission methods

877-842-3210phone

877-940-1972fax

oncology DXoncology injectable rule

prior auth requiredchemotherapy injectables

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review at launch note

Coverage and Prior Authorization Criteria

Extracted coverage criteria (partial)

Prior authorization requirements tied to specific codes and diagnoses as listed below.

ALL of the following

Codes: J1449, J0885, J1456, Q5125, J1448, J2506 (and other listed cancer‑supportive codes).
Submit oncology requests via the UnitedHealthcare Provider Portal; prior authorization not required for these codes with non‑oncology diagnoses.

ALL of the following

Examples of chemotherapy/oncology J‑codes requiring prior authorization: J9345, J9072, J9255, J9286, J9324, J9052, J9172, J9258, J9321, etc.
Miscellaneous HCPCS‑billed chemotherapy agents (unassigned codes billed as miscellaneous) also require prior authorization.

ALL of the following

Examples: 37230, 37231, 93319, 33270, 33206, 33207, 93580 (see code listing).
Follow the Additional Information/How to Obtain Prior Authorization field for code‑specific submission instructions and effective dates.

Extracted prior authorization criteria (partial)

Selected coverage/prior authorization criteria and notes present in this extract:

Oncology injectable submission: For oncology diagnoses, submit prior authorization requests online using the UnitedHealthcare Provider Portal (select Prior Authorization and Notification).

ALL of the following

Examples of affected DME codes: E0637, E0465 (see DME listing).
Refer to DME Additional Information/How to Obtain Prior Authorization for submission details.

Enteral/nutritional therapy: Enteral services and in‑home nutritional therapy codes (e.g., B4034, B4036, B4103, B4104, B4150) require prior authorization effective May 1, 2019 for specified codes.

Experimental/Investigational codes: Procedure codes linked to Experimental & Investigational (e.g., codes associated with Gender Dysphoria Treatment DX) require prior authorization and are flagged as investigational/linked.

Genetic testing prior authorization criteria

Genetic and molecular tests (including BRCA) require prior authorization/notification when performed in an outpatient setting. The authorization/notification must include laboratory and test identification; payment is only for CPT codes registered with the program.

ALL of the following

Include laboratory and test name on the authorization/notification; notification/prior authorization is required for BRCA testing before DNA sequencing is performed.
Only CPT codes registered with the Genetic and Molecular Testing Prior Authorization/Notification program are payable.
Examples of affected codes: 81163, 81229, 81520, 87505, 87506, 87507.
Refer to the Genetic Testing section for effective dates and submission instructions.

Injectable and specialty medication prior authorization criteria

Multiple injectable and specialty medications listed require prior authorization; some entries specify effective dates and designated authorization channels.

ALL of the following

Follow specified authorization channels when noted (e.g., Optum SGP, OptumRx, UnitedHealthcare Provider Portal).
Some drugs include Prior Authorization Effective Dates (examples appear in the injectable listing).
Unclassified injectable drugs (e.g., J3490, J3590 and related C‑codes) require prior authorization and are subject to 'Review at Launch' guidance for new‑to‑market medications.
Pre‑determination is recommended for drugs on the list.
Examples of listed injectable codes: J0177, J2782, J1203, J1412, J2353, J1950, J9155, J9202, J3241, J1427, J9202, etc.
See the injectable medication code listings for full code set and effective dates.

Prior authorization listing and notes (partial)

Listed codes require prior authorization; some entries include effective dates and subcategory labels. New‑to‑market medications should be reviewed under the 'Review at Launch' policy and pre‑determination is recommended.

Examples

Unclassified injectable / new‑to‑market codes: J3490, J3590, C9167, C9166, C9168 — prior authorization required; consult Review at Launch for newly approved drugs.
Joint replacement codes (examples): 23470, 23472, 23473, 23474 — prior authorization entries present (effective dates vary).
Ambulance and Air/Ground codes: A0426, A0428, A0433, A0434, A0424, A0425 — prior authorization entries appear and some are labeled 'Ambulance TX MANDATE'.

Note: Medication list pre‑determination is highly recommended for drugs on the injectable/unclassified lists.

Codes requiring prior authorization (excerpt)

Codes listed below are associated with prior authorization entries in this excerpt for Texas.

Ambulance transport codes: A0420–A0428 range and related codes (e.g., A0398, A0433, A0434) are listed for prior authorization; several entries labeled 'MANDATE' reference Texas requirements.

Orthognathic and related surgical CPT codes listed with prior authorization (examples include multiple 21xxx series CPTs); some entries note effective dates.

Orthotics and prosthetics L‑series HCPCS codes (examples: L1832, L3763, L4631, L5647, L5700, L5986) require prior authorization; notes reference rental cost > $500 and retail/cumulative purchase thresholds.

Partial coverage criteria from excerpt

Stated coverage/authorization stances for specific service categories in this excerpt.

ALL of the following

Examples of therapy codes: 97024, 97035, 97139, 97164, 97535, 97542, 97760, etc.

Psychological testing codes (96131–96137 series): Prior authorization will not be required for dates of service on or after March 1, 2022 (authorization effective date noted Oct. 1, 2019).

Proton beam therapy codes (77520–77525): Prior authorization required; submit requests via the UnitedHealthcare Provider Portal.

Advanced outpatient imaging: Ordering providers are responsible for providing notification prior to scheduling; prior authorization submission via the Provider Portal as indicated for specified advanced imaging codes.

Listed procedures and site-of-service rules

Code lists and site‑of‑service notes extracted from the 'Submitting prior authorization requests' section.

Site‑of‑Service guidance: Prior authorization generally is not required if performed at a participating Ambulatory Surgery Center (ASC); prior authorization may be required when requesting service in an outpatient hospital setting.

Procedure‑specific notes: Certain procedures (e.g., rhinoplasty 30400/30410) include prior authorization effective dates when specified (example: Jan. 1, 2015).

Code listing rows in the submission template include fields for Code, Diagnosis Code, Prior Authorization Effective Date, and Additional Information/How to Obtain Prior Authorization (many entries are present with blank/placeholder fields in this excerpt).

SOS Outpatient Hospital prior authorization listing (partial)

Table‑style entries for Site of Service (SOS) Outpatient Hospital appear with placeholder fields in this excerpt.

SOS Outpatient Hospital rows shown with Code examples (e.g., 28124, 28292) while Diagnosis Code, Prior Authorization Effective Date, and Additional Information fields are blank in this fragment.

These entries indicate the service category (SOS Outpatient Hospital) requires prior authorization submission using the template fields where populated; refer to the complete policy for filled entries and instructions.

Prior authorization code entries (placeholders)

Procedure code lines with blank diagnosis and authorization fields — intended to indicate that prior authorization is required but details are not visible in this fragment.

Tonsillectomy & Adenoidectomy / Respiratory System: Codes listed (examples: 67312, 30802, 31525, 31536; associated code lines show blank diagnosis and authorization fields).

Respiratory system procedures: Codes listed (examples: 31536, 31624, 42820, 42825, 30930, 31535, 31541, 42821) with prior authorization fields blank in the excerpt.

PA applicability

Prior authorization applies to the listed urologic procedure codes.

Urologic procedure code groups are listed as requiring prior authorization; example codes shown in the urologic submissions include 50590, 52000, 52005, 52224, 52235, 52281, 52276, 52320, etc.

A prior authorization effective date is noted for listed urologic procedures (Jan. 1, 2015) where specified in the excerpt.

Sleep Apnea PA details

Sleep apnea prior authorization information.

ALL of the following

Examples of Sleep Apnea codes listed: 52356, 55700, 21685, 42145, 52224, 52235, 52281, 52332, 52352, 52260, 52310, 52353.
Additional submission instructions may be present in the full policy; this excerpt contains code group listings and the effective date.

Many Sleep Apnea table rows in the fragment are placeholders with fields left blank; check the complete policy for diagnosis‑specific guidance and how to obtain prior authorization.

Urologic Procedures PA listing

Urologic procedures listing.

Numerous urologic procedure CPT codes and subcategory entries are enumerated for prior authorization submission (examples across the fragments include 52000, 52005, 52204, 52224, 52234, 52235, 52260, 52276, 52281, 52310, 52320, 52332, 52352).

Where specified, prior authorization effective dates are provided in the full listing (example: Jan. 1, 2015 for some urologic procedure entries).

Codes and Code Groups (CPT/HCPCS) Requiring Prior Authorization

Examples of procedure codes requiring authorization in sections presentCPTCovered

43644	Bariatric surgery code listed as prior auth required
43645	Bariatric surgery code listed as prior auth required
43770	Inpatient bariatric-related code listed
43775	Outpatient bariatric-related code listed
43842	Outpatient bariatric-related code listed
19316	Breast reconstruction code noted
19318	Breast reconstruction code noted

Selected chemotherapy / injectable codes listedHCPCSCovered

J9324	Chemotherapy injectable HCPCS/J-code
J9052	Chemotherapy injectable HCPCS/J-code
J9331	Therapeutic injectable requiring prior auth
J9332	Therapeutic injectable requiring prior auth

Injectable/chemotherapy J-codesHCPCSCovered

J9165
J9151
J9178
J9160
J9171
J9176
J9181
J9190
J9201
J9185

1–10 of 14

1/2

Cosmetic/Reconstructive surgery CPT codesCPTCovered

14020	cosmetic/reconstructive code group
14021
14041
14061
21175
21182

DME and orthotics/prosthetics E-codesHCPCSCovered

E0639	DME pump or device code example
E0640
E0470	orthotics/prosthetics reference
E2325

Enteral nutrition codes (group 1)HCPCSCovered

B4034	enteral nutrition
B4035
B4036
B4103
B4104

Enteral nutrition codes (group 2)mixedCovered

B4034	Enteral nutrition supplies/therapy
B4036	Enteral nutrition supplies/therapy
B4103	Enteral nutrition supplies/therapy

Genetic and molecular testing codesCPT | HCPCS | mixedCovered

81163	BRCA testing / genetic testing
81229	Genetic testing code referenced
81520	Molecular pathology / genetic test
87505	Infectious agent detection (example grouped test codes)

Unclassified injectable medicationsHCPCSCovered

J3490	Unclassified injectable drug
J3590	Unclassified biologic
C9167	Temporary/placeholder C-code referenced with unclassified injectable

Ambulance / Ambulance TXHCPCSCovered

A0426	Ambulance service, advanced life support, non-emergency (example)
A0428	Ambulance, basic life support, non-emergency (example)
A0433	Ground ambulance (per section listing)

Ambulance HCPCS codesHCPCSCovered

A0420-A0428	Ambulance transport HCPCS range referenced across entries
A0398	Ambulance miscellaneous code referenced

Orthotics/Prosthetics HCPCS codesHCPCSCovered

L0000-L5999 (many specific L-codes)

Orthotics and prosthetics HCPCS L-series codes listed throughout the excerpt

Surgical/orthognathic CPT codesCPTCovered

21121-21299 (selected CPT)

Orthognathic CPT codes listed (e.g., 21121, 21123, 21125, etc.)

Radiology CT/MRI group (partial)CPT

71250	CT chest/abdomen/pelvis series (example grouped code)
71550	MRI body without contrast (example grouped code)

Outpatient therapy codes (partial)CPT

97024

Physical therapy service (listed among outpatient therapy codes)

Radiology CPT groups (partial)CPT

72193-72198	Lumbar/thoracic/cervical spine radiology codes (series listed across chunks)
73200-73225	Upper extremity/shoulder MR/CT radiology codes (series listed)

ENT / nasal proceduresCPT

30400, 30410, 30420, 30430, 30450, 30460, 30462, 30465	Rhinoplasty, septoplasty and nasal functional/impairment procedures
31295-31298	Sinuplasty codes

Digestive and ophthalmology groupsCPT

45378-45385, 45334-45335, 45381, 45390	Colonoscopy and related digestive procedure codes
66821, 66982, 66984	Cataract surgery codes

Musculoskeletal / reconstructiveCPT

20552-20553, 21012-21013, 21336, 21552-21556, 21930, 22902-22903, 23071-23075

Musculoskeletal and reconstructive procedure codes (multiple groups listed)

CPT codes mentionedCPT

23071
24071
27337
28035
28039
28060
28090
28110
20552
21012

1–10 of 11

1/2

Example procedure codes appearing in SOS Outpatient Hospital sectionCPT

28124
28292

Tonsillectomy & Adenoidectomy / Respiratory System (mixed)mixed

67312
30802
31525
31536
30930
31535
31541

Respiratory System (mixed)mixed

31536
31624
42820
42825
30930
31535
31541
42821

Listed proceduresCPT

42820
42825
42830
43235
42821
42826

Endoscopy — Urinary system codesCPT

43235	Procedure code listed in submission section
43249	Procedure code listed in submission section
52276	Procedure code listed in submission section
52320	Procedure code listed in submission section
52287	Procedure code listed in submission section
52000	Procedure code listed in submission section

Urologic/endoscopy CPT codes mentionedCPT

50590
52000
52005
52204
52224
52234
52235
52260
52276
52281

1–10 of 13

1/2

Sleep Apnea - subcategory examplesCPT

52356
55700
21685
42145

Sleep Apnea - codesCPT

52224
52235
52281
52332
52352
52260
52310
52353

Procedure codes appearing in table fragmentsCPT | HCPCS

55700
21685
42145
52224
52235
52281
52332
52260
52310
52353

DME rental/purchase cost threshold — Retail purchase or cumulative rental cost greater than $500 requires prior authorization

ThresholdRetail purchase or cumulative rental cost greater than $500 requires prior authorization for specified DME

How to Submit Prior Authorization Requests and Provider-Facing Rules

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) by selecting Prior Authorization and Notification on the provider portal dashboard; by phone at 877-842-3210; or by fax to 877-940-1972. Prior authorization is not required for emergency or urgent care. Out-of-network requests must be made by an in-network provider except for emergent/urgent care.

Online: UHCprovider.com → Sign In → Prior Authorization and Notification
Phone: 877-842-3210
Fax: 877-940-1972

Prior Authorization

Code-level prior authorization for cancer supportive agents

Cancer supportive care and colony-stimulating factor codes require prior authorization when billed with oncology diagnosis codes; prior authorization is not required for these codes with other diagnoses and providers should submit oncology-related requests via the UnitedHealthcare Provider Portal.

Examples: J1449, J0885, J1456, Q5125, J1448, J2506, J1442, J1447, Q5101 (see listing)

Definitions and Key Terms

Prior authorization

TermPrior authorization

Definition / actionApproval process required for certain services before they are provided; requests submitted via UnitedHealthcare Provider Portal, phone (877-842-3210) or fax (877-940-1972)

ExceptionNot required for emergency or urgent care

Emergency/urgent care — Emergency or urgent care does not require prior authorization

PolicyEmergency or urgent care does not require prior authorization

Submission implicationOut-of-network requests must be made by an in-network provider except for emergent/urgent care

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Requirements for Texas STAR

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal, by phone 877-842-3210, or fax 877-940-1972.

SourceLink

On This Page

Applies toDurable Medical Equipment (example codes: E0637, E0465) listed in the DME section

Effective date / notesDME prior authorization entries reference effective dates around May 2019 for some codes; see DME table for specific codes

Prior authorization required for BRCA/outpatient genetic testing — Authorization/notification must include laboratory/test name and registered CPT codes

RequirementGenetic and molecular testing (including BRCA) performed in an outpatient setting requires prior authorization/notification; include laboratory and test name in the authorization/notification

Payment conditionPayment is authorized only for CPT codes registered with the Genetic and Molecular Testing Prior Authorization/Notification program

Example test codesExamples listed include 81163, 81229, 81520 (see genetic testing section)

Rental cost threshold — Prior authorization noted for rental cost of more than $500

ThresholdRental cost of more than $500 for orthotics/related L-series items triggers prior authorization

Applies toOrthotics and prosthetics L-series codes included in the orthotics/prosthetics section (examples: L5647, L5673, L5683)

NotesSome orthotics/prosthetics entries reference rental-cost thresholds and prior authorization effective dates in 2019

Retail/cumulative purchase threshold — Prior authorization applies to orthotic/prosthetic retail purchase or cumulative amounts (threshold details partial)

ScopePrior authorization applies to orthotic/prosthetic retail purchases or cumulative purchase amounts when amounts exceed the DME threshold (retail purchase or cumulative rental > $500)

Relevant codesOrthotics and prosthetics L-series HCPCS codes are listed in the orthotics section (see L1832, L3763, L4631 and related entries)

Reference noteProsthetics are distinguished from DME in the DME section; see Additional Information/How to Obtain Prior Authorization for specific instructions

Submit oncology-related requests online via UHCprovider.com → Prior Authorization and Notification

Prior Authorization

Chemotherapy prior authorization

Injectable chemotherapy drugs administered in outpatient settings require prior authorization for oncology diagnoses; miscellaneous HCPCS-coded or unassigned injectable chemotherapy agents billed under miscellaneous codes also require prior authorization.

Examples of J-codes listed: J9345, J9072, J9255, J9286, J9324, J9052, J9172 (see listing)
Unassigned/new-to-market injectable chemotherapy billed under miscellaneous HCPCS require prior authorization

Prior Authorization

Cardiology and cardiovascular prior authorization

Certain cardiology and cardiovascular procedure codes require prior authorization for participating physicians; effective dates are specified per code in the listing.

Examples: 37230, 37231, 93319, 33270, 33206, 33207, 93580 (see listing)
Verify prior authorization effective date per code in the submission table

Prior Authorization

Oncology injectable prior authorization submission instructions

For oncology diagnoses submit prior authorization requests online using the UnitedHealthcare Provider Portal (UHCprovider.com) and select the Prior Authorization and Notification workflow on the provider dashboard.

Portal submission is the required channel for oncology injectable requests (select Prior Authorization and Notification)

Prior Authorization

DME prior authorization threshold

Prior authorization is required for specified DME codes; a retail purchase or cumulative rental cost greater than $500 triggers prior authorization.

Example DME codes: E0637, E0465 (see listing)
Retail purchase or cumulative rental cost > $500 requires prior authorization

Prior Authorization

Enteral services prior authorization

Enteral services and in-home nutritional therapy codes (e.g., B4034, B4036, B4103, B4104, B4150) have prior authorization requirements with an effective date of May 1, 2019 for listed codes.

Codes listed: B4034, B4036, B4103, B4104, B4150
Prior Authorization Effective Date indicated as May 1, 2019 for specified entries

Prior Authorization

Genetic testing prior authorization

Genetic and molecular testing, including BRCA testing (e.g., 81163, 81229, 81520 and related codes), performed in an outpatient setting requires prior authorization/notification; the authorization/notification must indicate the laboratory and test name.

Examples: 81163, 81229, 81520, 87505–87507 (see listing)
Include laboratory and test name in the authorization/notification; payment only for CPT codes registered with the program

Prior Authorization

Experimental/Investigational procedure prior authorization

Codes linked to the Experimental & Investigational category (for example, codes tied to Gender Dysphoria Treatment DX) require prior authorization and are noted as experimental/linked in the listing.

Examples shown: 31253, 31259, 31240, 31255, 31267, 31287, 55970
These codes are identified with Gender Dysphoria Treatment diagnosis codes and flagged as Experimental & Investigational

Prior Authorization

Enteral / In-home nutritional therapy

Enteral services and in‑home nutritional therapy codes are listed with prior authorization effective dates noted; providers should follow the portal submission guidance for these codes.

Codes include B4034, B4036, B4103, B4104, B4150
Prior Authorization Effective Date for some enteral entries is May 1, 2019

Documentation Required

Genetic and molecular testing (including BRCA)

Genetic and molecular testing, including BRCA testing, requires prior authorization/notification; providers must include laboratory/test identification and confirm CPT codes are registered with the Genetic and Molecular Testing Prior Authorization/Notification program.

Examples of codes: 81163, 81229, 81520, 87505–87507
Notification/authorization must include lab and test name; payment authorized only for registered CPT codes

Prior Authorization

Injectable and specialty medications

Numerous injectable and specialty medication HCPCS/J-codes require prior authorization; some entries direct providers to external authorization channels (e.g., Optum SGP, OptumRx) or the provider website and include effective dates where noted.

Examples include J0177, J2782, J1203, J1412, J3401, J0801, Q5128, J1449, J9155, J1950, J9202 (see listing)
Follow specified channels (Optum SGP, OptumRx or UHCprovider.com) when noted in the listing

Prior Authorization

Unclassified injectable medications / Review at Launch

Unclassified injectable medications billed under J3490/J3590 and related temporary C-codes require prior authorization; the policy references 'Review at Launch' for new-to-market medications and recommends pre-determination.

Codes: J3490, J3590, C9167, C9166, C9168 (see listing)
Check the Review at Launch for New to Market Medications and consider medication pre-determination

Prior Authorization

Joint replacement and ambulance (Ambulance TX) codes

Joint replacement procedure codes and multiple ambulance HCPCS codes are listed as requiring prior authorization; several ambulance entries are labeled 'MANDATE' indicating an authorization requirement specific to Texas.

Joint replacement examples: 23470, 23472, 23473, 23474 (see listing)
Ambulance examples: A0426, A0428, A0433, A0434; some Ambulance TX entries are marked 'MANDATE'

Prior Authorization

Specialty drug HCPCS codes

Specific specialty drug HCPCS/J-codes (biologics and other specialty drugs) are itemized and require prior authorization; some entries include prior authorization effective dates and additional instructions.

Examples: Inflectra (Q5103), Luxturna (J3398), Orencia (JO129), Zolgensma (J3399), Stelara (J3358) (see listing)
Follow any listed effective dates and channel instructions

Prior Authorization

Ambulance prior authorization entries

Ambulance codes A0426 and A0428 are explicitly listed among prior authorization submission entries.

Codes: A0426, A0428

Prior Authorization

Ground / Non-Emergent ambulance codes

Multiple ground/non-emergent ambulance HCPCS codes (e.g., A0420, A0422, A0424, A0425, A0398) are shown with prior authorization entries; providers should confirm requirements and effective dates in the listing.

Examples: A0420, A0422, A0424, A0425, A0398
Some entries include diagnosis-code or effective-date fields to verify

Prior Authorization

Orthotics and prosthetics prior authorization entries

Numerous orthotics and prosthetics L-series HCPCS codes require prior authorization; entries note prior authorization effective dates and reference retail purchase or cumulative rental cost thresholds (rental cost > $500).

Examples: L1832, L3763, L4631, L5647, L5700, L5986, L2136 (see listing)
Notes reference retail purchase or cumulative rental cost thresholds and rental cost > $500

Documentation Required

Additional prior authorization note

The listing contains an additional note fragment stating 'Prior authorization is required for' associated with orthotics entries; providers should refer to the full portal resources for the complete instruction.

Excerpt shows incomplete sentence 'Prior authorization is required for' tied to orthotics entries—refer to portal resources for details

Prior Authorization

Proton Beam — submission instruction

Prior authorization is required for proton beam procedure codes; submit requests online via the UnitedHealthcare Provider Portal.

Proton beam codes listed: 77520, 77523, 77522, 77525
Submit prior authorization via UHCprovider.com

Prior Authorization

Outpatient Therapy — authorization stance

For outpatient therapy, prior authorization is required for all re-evaluations and the therapy codes listed; initial evaluations do not require authorization.

Examples of therapy codes listed: 97024, 97035, 97139, 97164, 97535, 97542, 97760 (see listing)
Initial evaluations are not subject to prior authorization

Documentation Required

Radiology — advanced imaging notification/authorization

Ordering providers are responsible for providing notification prior to scheduling advanced outpatient imaging procedures; prior authorization submissions for advanced imaging should be made via the UnitedHealthcare Provider Portal as indicated.

Radiology examples: 70490–70496, 75580, 0697T, 0710T, 0712T (see listing)
Submit prior authorization via UHCprovider.com when required

Note

Psychological Testing — authorization change

Psychological testing codes listed (e.g., 96131–96137) will not require prior authorization for dates of service on or after March 1, 2022.

Codes: 96131, 96133, 96136, 96137; prior authorization not required for services on/after March 1, 2022

Prior Authorization

Site-of-Service prior authorization guidance

Site-of-service guidance: prior authorization is not required if a listed procedure is performed at a participating Ambulatory Surgery Center (ASC); prior authorization may be required when the same service is performed in an outpatient hospital setting.

If performed at a participating ASC, prior authorization is not required
If requesting the service in an outpatient hospital setting, prior authorization may be required

Documentation Required

Procedure-specific prior authorization notes

Certain procedures include procedure‑specific prior authorization effective dates in the listing (for example, rhinoplasty codes 30400/30410 with effective date Jan. 1, 2015; sinuplasty codes with effective dates July 1, 2018 and Aug. 3, 2015); providers should check the table for per-code effective dates.

Rhinoplasty: 30400 / 30410 — Prior Authorization Effective Date Jan. 1, 2015
Sinuplasty: 31295–31298 — Prior Authorization Effective Dates listed (e.g., July 1, 2018; Aug. 3, 2015)

Documentation Required

CPT code listings and subcategories

The document lists multiple CPT procedure codes grouped under submission categories for prior authorization; providers should reference the listed CPT code groupings when submitting requests.

Examples of grouped CPT codes: 23071, 24071, 27337, 28035, 20552, 21012, 21336 (see listings)
Use the submission table fields (Code, Diagnosis Code, Prior Authorization Effective Date, Additional Information) when submitting

Documentation Required

Additional CPT code listings

Additional CPT codes are listed under 'Submitting prior authorization requests' with Musculoskeletal and other subcategory labels; providers must include the appropriate submission fields per entry.

Examples: 20552, 21012, 21336, 27632, 28039, 21930, 22902, 23071 (see listings)

Documentation Required

Site of Service — Outpatient

Services designated 'Site of Service (SOS) Outpatient' in the listing indicate the outpatient site for which prior authorization submission entries apply; providers should use the portal submission workflow for these outpatient-designated CPTs.

Examples of SOS Outpatient entries: 28118, 28124, 28285, 28292 (see listing)

Documentation Required

Submitting prior authorization requests - SOS Outpatient

Submitting prior authorization requests for services designated 'Site of Service (SOS) Outpatient' should be completed using the submission fields in the table; repeated entries indicate a table of outpatient-service prior authorization items.

Submission template fields include Code, Diagnosis Code, Prior Authorization Effective Date, and Additional Information/How to Obtain Prior Authorization

Documentation Required

Submitting prior authorization requests - SOS Outpatient Hospital (continued)

Submitting prior authorization requests for services designated 'SOS Outpatient Hospital (cont.)' are listed with placeholders for Code, Diagnosis Code, Prior Authorization Effective Date, and Additional Information; providers must complete those fields when submitting.

Example entries in SOS Outpatient Hospital (cont.): 28124, 28292 (codes shown as examples)

Documentation Required

Submitting prior authorization requests — SOS Outpatient Hospital (continued)

The SOS Outpatient Hospital section enumerates outpatient hospital entries and indicates where CPT/HCPCS codes, diagnosis codes and prior authorization effective dates should be provided; many rows are placeholders — confirm details in the portal.

Tonsillectomy & Adenoidectomy example codes appear in this section and require completion of submission fields

Documentation Required

Tonsillectomy & Adenoidectomy codes

Tonsillectomy & Adenoidectomy and other respiratory system procedure code lines are shown in the submission table; providers should complete the diagnosis and prior authorization effective date fields when submitting requests.

Examples: 67312, 30802, 31525, 31536, 30930, 31535, 31541 (Tonsillectomy & Adenoidectomy / Respiratory System)
Submission fields in the table for each code must be completed

Documentation Required

Respiratory System codes

Respiratory system procedure codes are listed in the prior authorization submission table; providers must supply the diagnosis code and confirm any effective dates before submitting.

Examples: 31536, 31624, 42820, 42825, 30930, 31535, 31541, 42821 (see listing)

Documentation Required

Submitting prior authorization requests

The submission fragments list CPT codes (e.g., 42820, 42825, 42830, 43235, 42821, 42826) associated with upper gastrointestinal endoscopy/urinary system prior authorization entries; providers must complete the submission fields when requesting authorization.

Examples: 42820, 42825, 42830, 43235, 42821, 42826
Use the portal submission template fields when submitting

Documentation Required

Submitting prior authorization requests — Endoscopy (Urinary System)

Endoscopy (Urinary System) CPT codes are listed in the prior authorization submission section; the template includes fields for diagnosis code and prior authorization effective date that must be completed by the provider.

Examples: 43235, 43249, 52276, 52320, 52287, 52000
Complete Code, Diagnosis Code, and Prior Authorization Effective Date in the submission

Prior Authorization

Urologic Procedures — prior authorization codes

Urologic procedure CPT codes are listed for prior authorization submission and prior authorization applies to the listed codes; providers should complete the submission template fields for each entry.

Examples: 52000, 52204, 52234, 52260, 52310, 50590, 52005, 52224, 52235, 52281, 52276, 52320
Prior Authorization Effective Date is noted as Jan. 1, 2015 for many urologic procedure entries

Documentation Required

Prior authorization effective date

Submit prior authorization requests for the urologic procedure codes listed using the submission template; a prior authorization effective date of Jan. 1, 2015 is noted for the listed urologic procedures.

Ensure the submission includes Code, Diagnosis Code and Prior Authorization Effective Date (if applicable)

Documentation Required

Urologic Procedures - PA submission listing

The Urologic Procedures section repeats the 'Submitting prior authorization requests' heading and enumerates numerous urologic entries; providers should reference the table and complete required submission fields for each code.

Multiple urologic CPT codes are listed across the section—use the portal to submit authorization requests

Prior Authorization

Sleep Apnea - PA submission listing

Sleep apnea procedure groups and codes are included and have a prior authorization effective date noted as Jan. 1, 2015; providers should submit prior authorization for listed sleep apnea codes where required.

Sleep Apnea examples: 52356, 55700, 21685, 42145; codes 52224, 52235, 52281, 52332, 52352, 52260, 52310, 52353
Prior Authorization Effective Date indicated as Jan. 1, 2015

Documentation Required

Submitting prior authorization requests — Sleep Apnea (placeholder)

The Sleep Apnea section contains repeated 'Submitting prior authorization requests' headings as placeholders; no additional actionable submission contact details are present in those fragments—use the portal guidance and tables to complete requests.

Refer to the portal and the Sleep Apnea PA table entries to determine required submission fields

Documentation Required

Procedure code listings present in prior authorization table fragment

Procedure code listings are presented as fragments adjacent to prior authorization table headings; providers must complete code, diagnosis and effective-date fields in the portal when submitting requests.

Examples across fragments include 55700, 21685, 42145, 52224, 52235, 52281, 52332, 52260, 52310, 52353
Many rows are placeholders in the excerpt—confirm details in the portal before submission

For non-emergent prior authorization submit via UHCprovider.com, phone 877-842-3210, or fax 877-940-1972

Oncology injectable prior authorization — Oncology prior authorization submission reference

Submission instructionFor oncology diagnoses submit prior authorization requests online using the UnitedHealthcare Provider Portal (select Prior Authorization and Notification)

Applies toInjectable chemotherapy and oncology supportive agents when billed with oncology diagnosis codes

ExamplesListed oncology-related codes include J1950, J9155, J9202 (see oncology injectable section)

Experimental & Investigational — Procedures or codes considered experimental or linked to investigational diagnoses

DesignationExperimental & Investigational — procedures or codes considered experimental or linked to investigational diagnoses (example: codes linked to Gender Dysphoria Treatment DX Codes)

Authorization requirementThese codes require prior authorization and are noted as experimental/linked in the document

Effective date examplePrior authorization effective date cited as Dec. 1, 2022 for some experimental/linked entries

Genetic and Molecular Testing Prior Authorization/Notification — Prior authorization/notification process for genetic testing

RequirementGenetic and molecular testing (including BRCA) performed in an outpatient setting requires prior authorization/notification; include laboratory and test name when requesting authorization

Program conditionPayment is authorized only for CPT codes registered with the Genetic and Molecular Testing Prior Authorization/Notification program

Sample CPTsExamples shown: 81163, 81229, 81520

Authorization channels — Use specified channels (e.g., Optum SGP, OptumRx) or UHC provider website for prior authorization of certain specialty medications

ChannelsUse specified authorization channels where indicated (examples: Optum SGP, OptumRx) or submit via the UHC provider website for listed specialty medications

Example instructionSome injectable drugs list 'Prior authorization through Optum SGP' or Synagis notifications through OptumRx (800-310-6826)

Where to find detailsAdditional Information/How to Obtain Prior Authorization entries point to UHCprovider.com Community Plan Policies and Review at Launch guidance

Review at Launch — Review at Launch for New to Market Medications

ProcessReview at Launch — check the Review at Launch for New to Market Medications policy for up-to-date prior authorization guidance on newly approved drugs

RecommendationMedication list pre-determination is highly recommended for drugs identified in the Unclassified/Review at Launch entries

Example entryUnclassified injectable entries (e.g., J3490/J3590 with C9167/C9166/C9168) reference Review at Launch and pre-determination guidance

Ambulance TX MANDATE — Indicates an authorization requirement specific to Texas ambulance services listed in this section

MandateAmbulance TX MANDATE — certain ambulance HCPCS entries for Texas indicate an authorization requirement under the Texas mandate

Example codesAmbulance codes listed include A0426, A0428, A0433 and ground/non-emergent codes such as A0424, A0422, A0420, A0398

ContextAmbulance entries appear with multiple 'Ambulance TX' subcategory rows in the prior authorization listing

Prior authorization — short note reiterating PA requirement in orthotics/other entries

NotePrior authorization is required for many orthotics/prosthetics L-series entries and for DME when retail purchase or cumulative rental exceeds $500

ExamplesOrthotics/prosthetics examples include L1832, L3763, L4631 and related L-series codes; DME examples include E0637, E0465

InstructionSee Additional Information/How to Obtain Prior Authorization fields in the orthotics and DME tables for submission details

Prior authorization — general PA note (radiology/other)

General notePrior authorization is required for many radiology and advanced imaging procedures; ordering providers are responsible for notification prior to scheduling

SubmissionFor prior authorization submit requests online via the UnitedHealthcare Provider Portal (UHCprovider.com)

Effective datesSome radiology codes include effective dates (examples: entries reference Jan 1, 2019 and 2024 for various imaging codes)

Site of Service (SOS) guidance — SOS Outpatient Hospital: prior authorization may be required when requesting service in an outpatient hospital setting

SOS guidanceSite of Service (SOS) Outpatient Hospital: prior authorization may be required when requesting service in an outpatient hospital setting; prior authorization is not required if performed at a participating Ambulatory Surgery Center (ASC)

ExamplesSOS Outpatient and SOS Outpatient Hospital labels are used throughout to categorize services requiring PA submission (see codes in respective SOS sections)

ActionVerify site-of-service when submitting PA; ASC procedures may be exempt from PA in some cases

Procedure effective dates — Example dated entries (rhinoplasty, sinuplasty) included in procedure-level PA notes

ExamplesProcedure-level PA notes include dated entries (examples: Rhinoplasty CPT 30400/30410 with prior authorization effective Jan. 1, 2015; Sinuplasty codes with effective dates July 1, 2018 and Aug 3, 2015)

ImplicationSome procedure entries list explicit prior authorization effective dates — check the specific code row for date and instructions

Where listedProcedure effective dates are shown in the Submission table rows for respective CPT codes

Site of Service (SOS) Outpatient — designation repeated to indicate these procedures are associated with outpatient setting for PA submission

DesignationSite of Service (SOS) Outpatient — used repeatedly to indicate procedures associated with outpatient setting for PA submission

Typical codesExamples in SOS Outpatient rows include 28118, 28124, 28285, 28292 and many additional CPTs listed under the SOS Outpatient heading

InstructionRefer to the SOS Outpatient rows in the prior authorization table for code-specific PA requirements and any site-based exemptions

Site of Service (SOS) Outpatient — labeling used throughout this section to categorize services requiring prior authorization submission

UsageSite of Service (SOS) Outpatient — header used throughout the document to categorize services requiring prior authorization submission

Table formatSOS Outpatient entries are presented as table rows with fields for Code, Diagnosis Code, Prior Authorization Effective Date, and Additional Information/How to Obtain Prior Authorization

ActionCheck the corresponding SOS Outpatient table row for instructions and any site-specific PA rules

Site of Service (SOS) Outpatient Hospital (cont ) — continued entries of outpatient hospital services in the prior authorization listing

ContinuationSite of Service (SOS) Outpatient Hospital (cont.) — continued entries list additional outpatient hospital services in the PA listing

Fields presentRows include Code and Prior Authorization Effective Date and Additional Information/How to Obtain Prior Authorization (often blank in excerpt)

ExamplesExample codes in the continued SOS Outpatient Hospital rows include 28124 and 28292

SOS Outpatient Hospital — header repeated indicating location category for listed procedures

HeaderSOS Outpatient Hospital — section header repeated across the document indicating the location category for listed procedures requiring PA

ImplicationServices labeled SOS Outpatient Hospital may require PA when performed at an outpatient hospital versus ASC

ActionConfirm location and refer to the SOS Outpatient Hospital rows for PA submission details

Upper Gastrointestinal Endoscopy_ Urinary System — category term appears in excerpt

Category termUpper Gastrointestinal Endoscopy / Urinary System — used as a category label in the PA submission rows

Example codesExample CPTs listed under this category include 42820, 42825, 42830, 43235, 42821, 42826

Submission fieldsRows include fields for Diagnosis Code and Prior Authorization Effective Date (often blank in excerpt)

PA submission template fields — Fields include: Code, Diagnosis Code, Prior Authorization Effective Date, Additional Information/How to Obtain.

CategoryEndoscopy — Urinary System appears repeatedly as a submission category for prior authorization

Example codesCodes listed include 43235, 43249, 52276, 52320, 52287, 52000

Template fieldsSubmission template rows include Code, Diagnosis Code, Prior Authorization Effective Date, and Additional Information/How to Obtain Prior Authorization

Endoscopy_ Urinary System — referenced repeatedly as a category for PA submission

CategoryEndoscopy_ Urinary System — referenced repeatedly as a category for which prior authorization is submitted

CodesMultiple CPT/HCPCS codes are listed under this category across the submission rows

Submission noteRefer to the Endoscopy_ Urinary System rows for specific PA effective dates and instructions

Urologic Procedures — grouping of CPT codes and subcategories for PA

GroupingUrologic Procedures — grouping of CPT codes and subcategories for prior authorization

ExamplesUrologic codes listed include 52000, 52204, 52234, 52260, 52310, 50590, 52276

PA stancePrior authorization applies to the listed urologic procedure codes; check rows for effective dates and additional instructions

Submitting prior authorization requests — short header repeated in document

Submitting prior authorization requestsSubmitting prior authorization requests — header used throughout the section to introduce lists of codes and PA rows

UsageRepeated across Sleep Apnea, Urologic Procedures, SOS Outpatient Hospital and other categories

ActionUse the Provider Portal or listed contact methods to submit PA for codes under these headers