UnitedHealthcare LTSS Prior Auth Policy Update

Policy scope and summary

This document lists prior authorization requirements and associated procedure, HCPCS and ICD-10 codes for participating UnitedHealthcare Community Plan of Virginia Long‑Term Support Services (LTSS) providers for inpatient and outpatient services. It applies to submission workflows and specifies services, codes and contact methods for prior authorization.

This guidance applies to Virginia LTSS participating providers and is effective April 1, 2025.

Coverage stance: this document defines billing rules and prior authorization requirements (which services and codes require prior authorization and how to submit requests) for the plan.

Quick stats and contact information

Provider portal phone (standard prior auth)866-889-8054

General prior authorization phone844-284-0146

Injectable medications / cochlear prior auth phone888-397-8129

Transplant / CAR T-cell case management phone888-936-7246

Policy effective dateEffective April 1, 2025

Prior authorization applicability and thresholds

Scope summary: the list identifies which services and codes across many categories (for example, surgical procedures, radiology, DME, injectable medications and supportive cancer care) require prior authorization and outlines how to submit requests. Operational context: providers should use the UnitedHealthcare Provider Portal (One Healthcare ID sign‑on) or the phone numbers shown in the document to request prior authorization; prior authorization is not required for emergency or urgent care and out‑of‑network providers must request prior authorization for all procedures and services.

Thresholds and effective dates

DME cost threshold for prior authorizationPrior authorization required for DME items with cost of more than $500

Orthotics/prosthetics prior authorization thresholdPrior authorization required when retail purchase or cumulative rental cost exceeds $500

ICD-10 diagnosis ranges requiring prior auth for standard radiation therapyC34.00-C34.92; C50.011-C50.929; C61; C79.51-C79.52; C84.7A; D05.00-D05.92

Aucatzyl prior authorization effective dateEffective 2025-04-01 (Aucatzyl billed under J3490, J3590, C9301 requires prior auth for select services)

What providers must do

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID and the Prior Authorization and Notification tab, or by phone. For general prior authorization call 844-284-0146. Prior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all procedures and services.

Prior Authorization

Behavioral health prior authorization

For mental health and substance use services that require prior authorization, call the number on the member’s health plan ID card. For Applied Behavior Analysis (ABA) therapy, submit authorization requests via fax as directed in the behavioral health section.

Prior Authorization

Cancer chemotherapy and supportive drug prior authorization

Prior authorization is required for outpatient injectable chemotherapy and outpatient administration of colony‑stimulating factors, erythropoiesis‑stimulating agents and bone‑modifying agents for cancer diagnoses. Several J‑ and Q‑codes listed require prior authorization and certain biosimilar/pegfilgrastim/sargramostim codes will also require prior authorization even for non‑oncology diagnoses.

Codes grouped by status and category

Bariatric surgery (inpatient and outpatient)CPTCovered

43644
43645
43842
43659
43770
43846

Bone growth stimulator (electronic/ultrasound)CPT|HCPCSCovered

20975
20979
E0747	Bone growth stimulator, implanted
E0748	Bone growth stimulator, external
E0749	Bone growth stimulator, other
E0760	Electrical stimulator, other

Breast reconstruction (non-mastectomy)CPT|HCPCSCovered

19316
19318
19325
19328
19330
19340
19342
19350
19357
19361

1–10 of 19

1/2

Cancer supportive care - colony-stimulating factors / bone-modifying agents (outpatient)HCPCS|J-codes|Q-codes

J1449	Filgrastim (Neupogen)
J1442	Filgrastim-aafi (Nivestym) - requires prior auth also for non-oncology Dx
Q5110	Filgrastim-ayow (Releuko) - requires prior auth also for non-oncology Dx
Q5125	Pegfilgrastim-apgf (Nyvepria) - requires prior auth also for non-oncology Dx
Q5122	Pegfilgrastim (Neulasta) - requires prior auth also for non-oncology Dx
J2506	Pegfilgrastim-bmez (Ziextenzo)
Q5120	Pegfilgrastim-cbqv (Udenyca) - requires prior auth also for non-oncology Dx
Q5111	Pegfilgrastim-jmdb (Fulphila) - requires prior auth also for non-oncology Dx
Q5108	Pegfilgrastim-jmdb (alternate) - requires prior auth also for non-oncology Dx
J2820	Sargramostim (Leukine)

1–10 of 13

1/2

AntiemeticHCPCS

J1456

Antiemetic code listed as requiring prior auth

Cardiology procedure codes (outpatient/office-based diagnostic catheterizations, echocardiograms, EP implants, stress echoes)CPT

37220
37221
37224
37225
37226
37227
37228
37229
37230
37231

1–10 of 11

1/2

Vascular / peripheral angiogram-related diagnosis codes (ICD-10) requiring prior authICD-10

I70.221
I70.222
I70.223
I70.228
I70.229
I70.231
I70.232
I70.233
I70.238
I70.239

1–10 of 50

1/5

Additional ICD-10 and diagnosis codes referenced under cardiovascular sectionICD-10

T82.818A
T82.868A
S81.801A
S81.802A
S81.809A
S91.301A
S91.302A
S91.309A
M86.051
M86.052

1–10 of 36

1/4

Cerebral seizure monitoring - inpatient video EEGCPT

95700
95711
95712
95713
95714
95715
95716
95718
95720
95722

1–10 of 12

1/2

Cochlear and other auditory implantsCPT|HCPCS

69710
69714
69930
L8614
L8619
L8690
L8691
L8692

Continuous glucose monitor (CGM) - prior auth with type 2 diabetes diagnosisHCPCS

A4226
A4239
A9276
A9277
A9278
E0787
E2103
E2102

Continuous glucose monitor / related HCPCSHCPCS

A4226	Continuous glucose monitor (listed in document)
A4239	Continuous glucose monitor (listed in document)
A9276	Continuous glucose monitor (listed in document)
A9277	Continuous glucose monitor (listed in document)
A9278	Continuous glucose monitor (listed in document)

Other HCPCS / accessory codesHCPCS

E0787
E2103
E2102
A9279	DME - referenced
A9280	DME - referenced
A9900	DME - referenced
E0194	DME - referenced
E0265	DME codes referenced
E0266
E0270

1–10 of 43

1/5

Surgical / Reconstructive CPT codes (examples shown)CPT

11960	Cosmetic - listed
11971	Cosmetic - listed
14020	Cosmetic/reconstructive (note: PA rules changed effective 2023-05-01 for 14020, 14021, 14061 under certain Dx)
14021	Cosmetic/reconstructive (see note)
14040	Reconstructive
14041	Reconstructive
14060	Reconstructive
14061	Reconstructive (see note)
14301	Change or improve physical appearance
15820	Change or improve physical appearance

1–10 of 58

1/6

ICD-10 Diagnosis codes referenced (partial list)ICD-10

C43.0
C43.10
C43.111
C43.112
C43.121
C43.122
C43.20
C43.21
C43.22
C43.30

1–10 of 173

1/18

Durable medical equipment (DME) — HCPCS E/K/other seriesHCPCS

E0465
E0466
E0470
E0471
E0483
E0486
E0620
E0636
E0637
E0652

1–10 of 131

1/14

Enteral servicesHCPCS

B9002
B9004
B9006
B9998

In-home nutritional therapy / Home health careHCPCS/CPT

E0791	In-home nutritional therapy
G0299	Home health (outpatient prior auth required only in outpatient)
G0300
G0493
G0494
G0495
G0496
S9123
S9124
S9474

Experimental / Investigational — sample CPT codes listedCPTNot Covered

33477
36514
64722
65765
65767
66180
A4638
A6000
A9274
E0231

1–10 of 14

1/2

Femoroacetabular impingement (FAI)CPT

29914
29915
29916

Functional endoscopic sinus surgery (FESS)CPT

31240
31253
31254
31255
31256
31257
31259
31267
31276
31287

1–10 of 11

1/2

Gender dysphoria treatment — surgical codes and associated Dx codesCPT|ICD-10

55970
55980
11980
14000
14001
15757
15758
15775
15776
15777

1–10 of 49

1/5

Genetic and molecular testingCPT

81162
81163
81164
81228
81229
81400
81401
81402
81403
81404

1–10 of 49

1/5

HysterectomyCPT

58150
58152
58180
58260
58262
58263
58267
58270
58290
58291

1–10 of 20

1/2

Injectable medications (selected J/Q codes and others)HCPCS

J3262	Actemra
J0801	Acthar
J0791	Adakveo
J0172	Aduhelm
J7171	Adzynma
J1931	Aldurazyme
J1552	Alyglo
J1426	Amondys 45
J0225	Amvuttra
Q5121	Avsola

1–10 of 46

1/5

Therapeutic radiopharmaceuticals / A-series codesHCPCS

A9513
A9590
A9696
A9699

Selected miscellaneous HCPCS/CPT codes referencedmixed

90378	Synagis
90283	IVIG administration
90284	IVIG administration
J1555	IVIG
J1556
J1557
J1566
J1568
J1575
J1599

Injectable medications (selected examples shown)HCPCS|mixed

J2777
J9376	Viltepso
J1427	Viltepso / Vimizim (listed multiple times)
J1322	Vimizim (also listed)
J1823	Vabysmo
J3032	Vyjuvek

Joint replacement (shoulder and other joint procedures)CPT

24360
24361
24362
24363
27486
27487
29866
29867
29868
23470	Shoulder surgery (mapped in text)

1–10 of 13

1/2

Non-emergent air ambulanceHCPCS

A0430
A0431
A0435
A0436

Ambulance transport S-codesHCPCS

S9960
S9961

Orthognathic / maxillofacial surgeryCPT

21121
21123
21125
21127
21141
21142
21143
21145
21146
21147

1–10 of 38

1/4

Orthotics & Prosthetics (extensive HCPCS L-codes)HCPCS

L0112
L0170
L0456
L0462
L0464
L0480
L0482
L0484
L0486
L0624

1–10 of 236

1/24

Image-guided radiation therapy (IGRT)CPT|HCPCSCovered

77014	IGRT - portal imaging
77387	Stereoscopic or real time imaging for localization
G6001	IGRT HCPCS
G6002	IGRT HCPCS

Proton beamCPTCovered

77520	Proton beam treatment delivery, simple
77522	Proton beam treatment delivery, intermediate
77523	Proton beam treatment delivery, complex
77525	Proton beam dosimetry (treatment planning) or related

Intensity-modulated radiation therapy (IMRT)CPT|HCPCSCovered

77385	IMRT planning complex
77386	IMRT planning additional sessions
G6015	IMRT HCPCS
G6016	IMRT HCPCS

Special/associated radiation servicesCPTCovered

77331	Special radiation physics consultation
77370	Special teletherapy procedures
77399	Unlisted radiation procedure
77470	Special treatment procedures, pacemaker/mechanical

SRS/SBRTCPT|HCPCSCovered

77371	Stereotactic radiation treatment delivery single session
77372	Stereotactic radiation treatment delivery multiple sessions
77373	Stereotactic radiation treatment delivery, other
G0339	SRS/SBRT HCPCS
G0340	SRS/SBRT HCPCS

Standard radiation therapy (2D/3D)CPT|HCPCS|ICD-10Covered

77401	Radiation treatment delivery, simple (series includes 77402, 77407, 77412 mapping to G6003 etc.)
77402	Radiation treatment delivery
77407	Radiation treatment delivery (other)
77412	Radiation treatment delivery (complex)
G6003	HCPCS mapping for 77401 (1)
G6004	HCPCS mapping for 77401 (1) - variant
G6005	HCPCS mapping for 77401 (2)
G6006	HCPCS mapping for 77401 (3)
G6007	HCPCS mapping series
G6008	HCPCS mapping

1–10 of 16

1/2

Private duty nursingHCPCSCovered

T1000	Private duty nursing, per visit
T1002	Private duty nursing, RN
T1003	Private duty nursing, LPN
T1030	Private duty nursing, extended
S9125	Nursing service, private duty

Prostate proceduresCPTCovered

37243	Transcatheter embolization
52441	Open prostate procedure
52442	Open prostate procedure, with complications
53850	Prostatectomy
53852	Prostatectomy with reconstruction
55873	Prostate procedure (laser ablation etc.)
55874	Same family - related procedure

Radiation therapy (general)mixedCovered

Image-guided radiation therapy (IGRT)

See IGRT codes list

Stimulators and neurostimulationCPT|HCPCSCovered

E0747	Bone growth stimulator, implanted
E0748	Bone growth stimulator, external
E0749	Bone growth stimulator, other
E0760	Electrical stimulator, other
61863	Placement of spinal neurostimulation paddle lead
61864	Placement of spinal neurostimulation percutaneous lead
61867	Insertion of neurostimulator lead
61868	Insertion neurostimulator lead variant
61885	Insertion/placement additional
61886	Revision or removal of neurostimulator

1–10 of 24

1/3

Transplants and CAR T-cell therapymixedCovered

Q2042	CAR T-cell therapy related
Q2053	Gene/cellular therapy
Q2054	Gene/cellular therapy
Q2041	Gene/cellular therapy
Q2055	Gene therapy
Q2056	Gene/cellular therapy
Q2057	Gene/cellular therapy
C9301	CAR T-cell therapy high-cost code (also referenced for Aucatzyl changes)

Selected vein procedures (varicose/ablation)CPTCovered

36473	Injection procedure for sclerotherapy, single session
36475	Sclerotherapy, multiple
36478	Endovenous ablation therapy
37700	Ligation and stripping of varicose vein
37718	Ablation main trunks and named branches (saphenous)
37722	Ablation/removal related
37765	Vein procedure - other
37766	Vein procedure - other

Ventricular assist devices (VAD)mixedCovered

33927	Insertion of VAD (various codes listed)
33975	VAD related code
33976	VAD related code
33979	VAD related code

Wound VACHCPCSCovered

E2402

Negative pressure wound therapy, disposable canister

Selected surgical categories (shoulder, sinuplasty, rhinoplasty, spinal, sleep apnea procedures)CPTCovered

30400	Rhinoplasty
30410	Rhinoplasty with other procedure
30420	Rhinoplasty grafting
30430	Rhinoplasty complex
30435	Rhinoplasty revision
30450	Septoplasty
30460	Septoplasty with turbinate surgery
30462	Septoplasty with internal splint
31295	Sinuplasty
31296	Sinuplasty

1–10 of 22

1/3

Large list of abdominal, transplant and major surgical CPT codesCPTCovered

32850	Thoracic procedure
32851	Thoracic procedure
32852	Thoracic procedure
32853	Thoracic procedure
32854	Thoracic procedure
32855	Thoracic procedure
32856	Thoracic procedure
33930	Cardiac assist device procedure
33933	Ventricular assist device procedure
33935	Cardiac procedure

1–10 of 62

1/7

Defined terms

Key definitions

Prior authorizationApproval from UnitedHealthcare required before certain services, procedures or medications are provided to ensure coverage; not required for emergency or urgent care.

LTSSLong-Term Support Services

One Healthcare IDUnitedHealthcare single sign-on credential for provider portal access

DMEDurable medical equipment — referenced in the document; some DME codes require prior authorization, particularly when cost exceeds $500.

AucatzylReferenced drug/product for which prior authorization will be required (billing under J3490, J3590, C9301 effective 2025-04-01).

Policy updates

April 1, 2025Effective DateLatest

Policy effective; Aucatzyl prior authorization effective

OpenPayer

Prior authorization requirements for Virginia Cardinal Care LTSS

Policy scope and summary

Prior authorization applicability and thresholds

What providers must do

Codes grouped by status and category

Defined terms

Policy updates

Prior authorization requirements for Virginia Cardinal Care LTSS

Policy scope and summary

Prior authorization applicability and thresholds

What providers must do

Codes grouped by status and category

Defined terms

Related policies and operational notes

Policy updates