This section consolidates Coverage Criteria and Authorization Rules across procedure-based and medication-based prior authorization requirements, exemptions, and program-specific submission instructions. Preserve listed codes and the prior authorization stance for outpatient injectable cancer supportive care, selected procedures, advanced imaging, radiology, musculoskeletal and other services.
Cancer supportive care: Prior authorization is required for colony-stimulating factor (CSF) drugs, injectable erythropoiesis-stimulating agents, and bone-modifying agents administered in an outpatient setting for a cancer diagnosis. Injectable colony-stimulating factor drugs that require prior authorization include: J1449 (Filgrastim - Neupogen), J1442 (Filgrastim-aafi - Nivestym)*, Q5110 (Filgrastim-ayow - Releuko)*, Q5125 (Pegfilgrastim-apgf - Nyvepria)*, Q5122 (Pegfilgrastim - Neulasta)*, J2506 (Pegfilgrastim-bmez - Ziextenzo), Q5120 (Pegfilgrastim-cbqv - Udenyca)*, Q5111 (Pegfilgrastim-jmdb - Fulphila)*, Q5108 (Pegfilgrastim-jmdb? / biosimilar) and J2820 (Sargramostim - Leukine), J1447 (Tbo-filgrastim - Granix)*. Note: Codes J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122 and Q5125 also require prior authorization when billed for a non-oncology diagnosis — see injectable medications section. Injectable erythropoiesis-stimulating agent requiring prior authorization: J0885 (Epoetin alfa - Procrit). Bone-modifying agent requiring prior authorization: J0897 (Denosumab - Xgeva).
Procedure-based prior authorization: Selected surgeries and cardiovascular procedures require prior authorization. Examples include cochlear implants (CPT 69710, 69714, 69930 — prior authorization required; submit via UnitedHealthcare Provider Portal or call 888-397-8129), joint replacement (total hip and knee — prior authorization required; example CPTs referenced), musculoskeletal/shoulder surgery (various shoulder and hip/knee CPTs listed throughout the musculoskeletal entries require prior authorization), orthognathic surgery (CPTs 21121, 21123, 21125, 21127 — prior authorization required), non-emergent air ambulance transport (HCPCS A0430, A0431, A0435, A0436 — prior authorization required), ventricular assist devices (VAD) — prior authorization/notification required (call notification number on member ID then fax to Optum VAD Case Management at 855-282-8929).
Advanced imaging and radiology: Prior authorization is required for participating physicians ordering advanced outpatient imaging procedures (certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology). Health care professionals ordering advanced outpatient imaging must provide notification prior to scheduling. Standard radiation therapy: prior authorization required only when obtained with certain cancer diagnosis code ranges (e.g., C34.00-C34.92, C50.011-C50.929, C61, C79.51-C79.52, C84.7A, D05.00-D05.92) for listed CPTs (e.g., 77401, 77402, 77407, 77412 and associated G6003-G6014 series). Submit requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-889-8054.
Durable medical equipment (DME), enteral services, home health, orthotics/prosthetics: Prior authorization is required for many DME codes (examples A9279, A9280, A9900, E0194, E0265, E0266, E0270, E0277, E0300) and enteral services for in-home nutritional therapy (B9002, B9004, B9006, B9998) — prior authorization required. Orthotics and prosthetics require prior authorization only when retail purchase or cumulative rental cost exceeds $500 (examples L0112, L0170, L0456, L8499, L8609, L8610, L8612, L8631, L8659).
Exemptions and effective-dated exceptions: Effective May 1, 2023 — CPT codes 14020, 14021 and 14061 do not require prior authorization when billed with specified diagnosis codes (see policy lists). Additionally, certain EEG inpatient video monitoring CPTs (95700, 95711-95718, 95720, 95722, 95724, 95726, etc.) include notes regarding inpatient vs outpatient prior authorization requirements — outpatient hospital or ambulatory surgical center EEG monitoring prior authorization not required per the excerpt.
Submission instructions and provider responsibilities: Many prior authorization requests must be submitted online via the UnitedHealthcare Provider Portal (UHCprovider.com) or by calling the numbers provided in each program area (e.g., oncology injectable medications line 888-397-8129; radiology/standard radiation therapy 866-889-8054). For VADs, follow member ID notification number then fax to Optum VAD Case Management at 855-282-8929. Providers ordering advanced outpatient imaging must notify prior to scheduling.
Investigational/experimental designations: Specific CPT/HCPCS codes are flagged as experimental or investigational and require prior authorization review where noted (examples listed in investigational fragment: 33477, 36514, 64722, 65765-65767, 66180, A4638, A6000, A9274, E0231, E1831, S1030, S1031, S2102). These items may be denied as experimental per policy.
Operational note: Codes listed across the musculoskeletal/shoulder surgery, injectable medications and other categories may appear repeatedly in source fragments; treat each listed CPT/HCPCS as requiring prior authorization unless an explicit exemption or alternative effective date applies.