ModifiedUnitedHealthcarePolicy N/A

Prior authorization requirements for Virginia Cardinal Care

This document lists prior authorization requirements and submission instructions for participating UnitedHealthcare Community Plan of Virginia / Virginia Cardinal Care providers for inpatient and outpatient services.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Virginia Cardinal Care

Policy CodePolicy N/A

Change TypeMaterial updates to injectable chemotherapy prior authorization (code-specific additions)

Effective DateFeb. 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or call 888-397-8129.

SourceLink

POLICY UPDATE CHANGES

Effective Jan 1, 2023: Prior authorization required.

Effective Jan. 1, 2023: Prior authorization required for J0897 for non-oncology diagnoses.

Effective Jan. 1, 2023: Prior authorization required for J0174.

Effective Oct. 1, 2024: Prior authorization required (reference to additional authorization requirement starting Oct. 1, 2024).

Prior authorization required for Q5133 and Q5135 effective Oct. 1, 2024.

2025-02-01policy effective date

No PA requiredemergency or urgent care

J0897, J0174, Q5133, Q5135notable J/Q codes added

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

888-397-8129PA assistance phone

Coverage Criteria and Prior Authorization Requirements

Prior authorization coverage stance

Prior authorization is required for many specified inpatient and outpatient services; emergency and urgent care are exempt.

ALL of the following

Services requiring prior authorization include
- Inpatient and outpatient bariatric surgery (examples: CPT 43644, 43645, 43659, 43770).
- Bone growth stimulators (CPT 20975, 20979).
- Brain injury case management (HCPCS S0280, S0281).
- Breast reconstruction and related CPT codes (examples: 19316, 19318, 19325, 19328).
- Cardiology outpatient and office-based diagnostic catheterizations, echocardiograms, electrophysiology implants and stress echoes (see Cardiology Prior Authorization and Notification for specific CPT codes).
- Experimental and investigational services and selected surgical procedures (examples in document: FAI, FESS, hysterectomy codes).
- Durable medical equipment (DME) listed in the policy when retail purchase or cumulative rental thresholds apply.
- Enteral in‑home nutritional therapy and home health services in outpatient/home settings.
- Image‑guided radiation therapy, standard radiation therapy (2D/3D) when indicated diagnoses present, IMRT, proton beam, SRS/SBRT, and other radiation therapy services listed in the policy.
- Transplants and CAR T‑cell therapy services.
Prior authorization is not required for emergency or urgent care.
Providers should submit requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone using the numbers provided in the policy; out‑of‑network providers must request prior authorization for all procedures and services.

Inpatient vs outpatient EEG authorization stance

Cerebral seizure monitoring (video EEG) — authorization differs by setting.

ALL of the following

Prior authorization is required for inpatient cerebral seizure monitoring (inpatient video EEG) and the listed inpatient EEG CPT/HCPCS codes (examples: 95700, 95711–95716, 95718, 95720, 95722, 95724, 95726).
Prior authorization is not required for outpatient hospital or ambulatory surgical center cerebral seizure monitoring services.

Follow the submission instructions in the policy (UnitedHealthcare Provider Portal or phone) for inpatient authorization requests.

Outpatient injectable chemotherapy

Injectable chemotherapy administered in outpatient settings requires prior authorization; submission pathways vary by diagnosis.

ALL of the following

Prior authorization is required for outpatient injectable chemotherapy drugs (chemotherapy injectable drugs J9000–J9999 and listed related codes such as J0640–J0642, J1950, J1954, J1932).
Submission for authorization
- For non‑oncology diagnoses: submit prior authorization requests online using the UnitedHealthcare Provider Portal (UHCprovider.com) or call the phone number provided (e.g., 888‑397‑8129 / numbers in policy).
- For oncology diagnoses: follow the Cancer supportive care section guidance (oncology pathway described in policy).

Some colony‑stimulating factors and other listed oncology supportive agents require authorization for both oncology and non‑oncology diagnoses (see specific code listings).

Cochlear implants and DME

Certain implanted devices and selected durable medical equipment require prior authorization.

ALL of the following

Prior authorization is required for cochlear and other auditory implants (examples: CPT 69710, 69714, 69930; HCPCS L8619, L8690, L8691, L8614, L8692).
Prior authorization is required only for listed DME codes when retail purchase or cumulative rental cost thresholds are met (examples in policy: A9279, A9280, E0194, E0265, E0266, E0270, E0277, E0300, E0328, E0329).

Orthotics and prosthetics require prior authorization only when retail purchase or cumulative rental cost exceeds $500 (see L‑code listings in policy).

Prior authorization requirements (excerpt)

Selected services and procedures shown in the policy excerpt require prior authorization.

ANY of the following

Experimental and investigational services require prior authorization (examples and codes listed in policy).
Femoroacetabular impingement (FAI) procedures require prior authorization (example CPTs 29914–29916).
Functional endoscopic sinus surgery (FESS) requires prior authorization (example CPTs 31240, 31253–31255, 31257, 31259, 31267).
Hysterectomy procedures listed require prior authorization (examples include CPTs 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58290–58292, 58542, 58552).
Enteral in‑home nutritional therapy and home health care in outpatient/home settings require prior authorization.

Authorization requirements for injectables

Prior authorization requirements and special submission instructions for injectable medications and related products.

ALL of the following

Submit prior authorization requests for injectable medications via the UnitedHealthcare Provider Portal (UHCprovider.com) or by the phone number shown in the policy (e.g., 888‑397‑8129 where specified).
Pre‑determination is highly recommended for drugs on the Review at Launch Medication List (new‑to‑market medications).
Certain products (e.g., Cimzia, Synagis) require prior notification through Optum Rx notifications at 800‑310‑6826.
Unclassified/temporary codes (C9399, J3490, J3590) require prior authorization only for specific drugs named in the policy (examples: Casgevy, Lantidra, Lupaneta Pack, Nulibry, Revcovi, Rivfloza).

Prior authorization criteria and submission instructions

Prior authorization is required for the injectable chemotherapy drugs and specified HCPCS/unclassified codes; submission pathways are provided.

ALL of the following

Prior authorization is required for listed injectable chemotherapy drugs and specified HCPCS/unclassified codes for both oncology and non‑oncology diagnoses (see code listings in policy).
How to submit
- For non‑oncology diagnoses: submit requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) or call 888‑397‑8129 as indicated.
- For oncology diagnoses: follow the Cancer supportive care section for authorization submission instructions.
Pre‑determination is recommended for new‑to‑market medications (Review at Launch list).

Coverage criteria — prior authorization and submission

Prior authorization requirement and submission pathway for injectable chemotherapy; specific code exceptions are noted.

ALL of the following

Effective Jan 1, 2023, prior authorization is required for the injectable chemotherapy drugs listed in the policy; submit requests via the UnitedHealthcare Provider Portal or call the phone number provided for assistance.
J0897 specifically requires prior authorization when used for non‑oncology diagnoses (effective Jan 1, 2023).
For oncology diagnoses consult the Cancer supportive care section for the appropriate authorization pathway.

Use the Provider Portal (UHCprovider.com) or the phone numbers in the policy (e.g., 888‑397‑8129) to submit prior authorization requests.

Prior authorization requirements for injectable chemotherapy

Prior authorization is required for specific injectable chemotherapy HCPCS codes; effective dates are provided where indicated.

ALL of the following

J0897 — prior authorization required when used for non‑oncology diagnosis (effective Jan 1, 2023).
J0174 — prior authorization required (effective Jan 1, 2023 as indicated in the policy).
Additional prior authorization requirements referenced with an effective date of Oct 1, 2024 (document cites Q5133 and Q5135 additions; details provided elsewhere in the policy).

Submit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or by calling the phone numbers listed in the policy.

Prior authorization criteria (partial)

Partial listing and references to effective dates for injectable chemotherapy prior authorization changes.

ALL of the following

Policy notes prior authorization required for J0174 (effective Jan 1, 2023).
Policy references an additional effective date of Oct 1, 2024 for added prior authorization requirements (document indicates Q5133 and Q5135 will require PA effective Oct 1, 2024).

Details for the Oct 1, 2024 additions are present elsewhere in the document; follow the code lists and effective dates in the policy when submitting requests.

Prior authorization requirements (excerpt)

Prior authorization requirement for additional injectable chemotherapy codes noted in the excerpt.

ANY of the following

Q5133 — prior authorization required effective Oct 1, 2024.
Q5135 — prior authorization required effective Oct 1, 2024.
J0174 — prior authorization required (effective 2023 as stated).

Follow the submission instructions in the policy (Provider Portal or phone) when requesting authorization for these codes.

Prior authorization requirements (excerpt)

Prior authorization requirement for Q‑codes and J‑codes as stated in the document excerpt.

ALL of the following

Q5133 — prior authorization required effective Oct 1, 2024.
Q5135 — prior authorization required effective Oct 1, 2024.

These Q‑codes are explicitly listed with the Oct 1, 2024 effective date; confirm submission method via the Provider Portal or phone per the policy.

Prior authorization list

Codes requiring prior authorization are listed in the policy; refer to the code lists for specifics.

ALL of the following

The policy lists multiple HCPCS/J/Q and CPT codes that require prior authorization; consult the policy code listings for the full set and effective dates (examples include J0174, J0897, Q5133, Q5135).

Use the Provider Portal or the phone numbers in the policy to submit authorization requests for codes on the list.

Prior authorization coverage stance

Prior authorization is required for the following injectable chemotherapy codes as of the effective dates noted.

ANY of the following

J0174 — prior authorization required (effective Jan 1, 2023 per policy notes).
J0897 — prior authorization required when used for non‑oncology diagnoses (effective Jan 1, 2023).
Q5133 — prior authorization required effective Oct 1, 2024.
Q5135 — prior authorization required effective Oct 1, 2024.

Submit requests via UnitedHealthcare Provider Portal or by phone using the numbers provided in the policy.

Prior authorization criteria

Prior authorization is required for specified injectable chemotherapy HCPCS/J/Q codes; follow the portal or phone submission process.

ALL of the following

J0897 — prior authorization required for non‑oncology diagnosis (effective Jan 1, 2023).
J0174 — prior authorization required (effective Jan 1, 2023 as indicated).
Q5133 and Q5135 — prior authorization required effective Oct 1, 2024.
Submission process: submit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or call 888‑397‑8129 as listed in the policy.

For oncology diagnoses, follow the Cancer supportive care authorization guidance in the policy.

Prior authorization requirements (excerpt)

Prior authorization is required for listed injectable chemotherapy J‑codes and selected procedure/supply codes; submission instructions are provided.

ALL of the following

Listed injectable chemotherapy J‑codes require prior authorization (document names J0897 and J0174 among others; effective dates provided in the policy).
Selected CPT/HCPCS and L‑codes for procedures, joint replacement, orthotics/prosthetics and other services require prior authorization (see code listings such as joint replacement CPTs and L‑codes in the policy).
Submission: Use the UnitedHealthcare Provider Portal or call the phone numbers in the policy to obtain prior authorization.

Orthotics/prosthetics prior authorization applies when retail purchase or cumulative rental cost exceeds $500 per policy guidance.

Prior authorization code list (excerpt)

The policy includes extensive code lists and service categories that require prior authorization; examples are provided below.

ANY of the following

Orthotics and prosthetics: numerous L‑codes require prior authorization; PA required when retail purchase or cumulative rental cost exceeds $500 (examples: L0112, L0464, L0486, L0631, L0637, L0710, L0859, L1005, L1499, L3976, L3977, L3999, L4010, L4020, etc.).
Joint replacement and related CPT codes require prior authorization (examples: 24360–24363, 27120, 27125, 27130, 27132, 27134, 27412, 27446, 27447, etc.).
Potentially unproven services and private duty nursing require prior authorization (examples: 33289, C2624, T1000–T1003).
Prostate procedures listed in the policy require prior authorization (examples: 37243, 52441, 52442, 53850, 53852, 55873, 55874).

Prior authorization required

Prior authorization is required for radiation therapy, transplants and certain device/procedure categories; diagnosis‑based rules apply for some radiation services.

ALL of the following

Radiation therapy (standard 2D/3D, IGRT, IMRT, proton beam, SRS/SBRT) requires prior authorization when listed in the policy; for standard 2D/3D radiation therapy PA is required only when obtained with specified cancer diagnosis code ranges (examples: C34.*, C50.*, C61, relevant C79.* and others).
Transplants require prior authorization per the policy; for transplant and CAR T‑cell therapy services contact Optum Health Transplant Resource Services as directed in the policy.
Certain implantable devices and neurostimulators and related E/L/HCPCS codes require prior authorization (examples are listed in the policy excerpts).

Submit radiation and transplant authorization requests via the UnitedHealthcare Provider Portal or the contact numbers provided in the policy (e.g., 866‑889‑8054 for some radiation submissions; transplant contacts listed in the document).

Codes and Code Groups Mentioned

Sample CPT/HCPCS codes requiring prior authorizationmixed

43644	Bariatric surgery
43645	Bariatric surgery
43659	Bariatric surgery
43770	Bariatric surgery
20975	Bone growth stimulator
20979	Bone growth stimulator
S0280	Brain injury case management
S0281	Brain injury case management
19316	Breast reconstruction
19318	Breast reconstruction

1–10 of 14

1/2

ICD-10 diagnosis codes listedICD-10

M86.559	Osteomyelitis code (example from listing)
M86.8X0	Other osteomyelitis codes (example from listing)

Cosmetic and reconstructive procedure codesCPT

11960	Cosmetic/reconstructive CPT example listed
14020	Cosmetic/reconstructive CPT example listed

Sample DME/HCPCS codesHCPCSCovered

A9279	DME HCPCS code listed for prior authorization
A9280	DME HCPCS code listed for prior authorization
E0194	DME HCPCS code listed for prior authorization

Genetic/molecular testing codesCPTCovered

81162	Genetic/molecular testing CPT code requiring prior authorization
81479	Genetic/molecular testing CPT code requiring prior authorization
81518	Genetic/molecular testing CPT code requiring prior authorization

Sample injectable medication HCPCS/J-codesHCPCSCovered

J3262	Actemra (injectable medication)
J0801	Acthar (injectable medication)
Q5128	Cimerli (injectable)

sample listed HCPCS/J-codes/Q-codes/A-codesmixedCovered

J3262	Actemra
J0801	Acthar
Q5138	Fylnetra (example Q-code listed)
A9513	Therapeutic radiopharmaceutical (example A-code listed)
J3399	Unclassified/temporary J-code (example listed)

HCPCS / temporary / unclassified codes requiring authorizationHCPCS | mixedCovered

J1442
J1447
J1448
J2506
Q5101
Q5108
Q5110
Q5111
Q5120
Q5122

1–10 of 14

1/2

Highlighted HCPCS codeHCPCSCovered

J0897

Specific injectable chemotherapy code noted as requiring prior authorization for non-oncology diagnoses

HCPCS chemotherapy codes requiring prior authorizationHCPCSCovered

J0897	Injectable chemotherapy code requiring prior authorization for non-oncology diagnosis
J0174	Injectable chemotherapy code noted as requiring prior authorization

Injectable chemotherapy HCPCS/Q codes requiring prior authorization (partial list)HCPCSCovered

J0897	HCPCS code cited as requiring prior authorization for non-oncology diagnoses
J0174	HCPCS code cited as requiring prior authorization
Q5133	HCPCS/Q-code cited as requiring prior authorization (effective Oct 1, 2024)
Q5135	HCPCS/Q-code cited as requiring prior authorization (effective Oct 1, 2024)

HCPCS/Q and J-codes with PA requirement in excerptHCPCS | mixedCovered

J0174	Injectable chemotherapy drug (code listed as requiring prior authorization)
Q5133	Injectable chemotherapy drug (PA required effective Oct 1, 2024)
Q5135	Injectable chemotherapy drug (PA required effective Oct 1, 2024)

HCPCS/CPT injectable chemotherapy codesHCPCSCovered

Q5133	Injectable chemotherapy code listed as requiring prior authorization
Q5135	Injectable chemotherapy code listed as requiring prior authorization
J0174	Injectable chemotherapy code listed as requiring prior authorization

HCPCS/CPT codes requiring prior authorizationHCPCSCovered

Q5133	HCPCS code listed as requiring prior authorization
Q5135	HCPCS code listed as requiring prior authorization
J0174	Injectable chemotherapy code requiring prior authorization (effective Jan 1, 2023)
J0897	Injectable chemotherapy code requiring prior authorization for non-oncology diagnoses (effective Jan 1, 2023)

HCPCS/J/Q codes requiring prior authorizationHCPCSCovered

J0897	Injectable chemotherapy drug — prior auth required for non-oncology diagnosis
J0174	Injectable chemotherapy drug — prior auth required (effective Jan 1, 2023)
Q5133	Injectable chemotherapy drug — prior auth required (effective Oct 1, 2024)
Q5135	Injectable chemotherapy drug — prior auth required (effective Oct 1, 2024)

Chemotherapy J-codes with new prior authorization requirementsHCPCSCovered

J0897	Injectable chemotherapy drug — prior authorization required for non-oncology diagnoses effective Jan 1, 2023
J0174	Injectable chemotherapy drug — prior authorization required effective Jan 1, 2023

Examples of other CPT/HCPCS/L-codes requiring prior authorizationmixedCovered

A0430	Non-emergent air ambulance transport
L0112	Example orthotic/prosthetic HCPCS L-code listed

Select L-codes (examples from chunk 234)HCPCSCovered

L0112
L0464
L0486

IGRT codesCPT | HCPCSCovered

77014	Image-guided procedure code
77387	Qualification for IGRT
G6002	IGRT related HCPCS

IGRT codesCPT | HCPCSCovered

77014	Image-guided radiation therapy (IGRT)
77387	IGRT
G6002	IGRT

IMRT codesCPTCovered

77385	Intensity-modulated radiation therapy (IMRT)
77386	IMRT
G6015	IMRT
G6016	IMRT

Proton beam codesCPTCovered

77520	Proton beam therapy
77522	Proton beam therapy
77523	Proton beam therapy
77525	Proton beam therapy

SRS/SBRT codesCPTCovered

77371	Stereotactic radiosurgery / SBRT
77372	Stereotactic radiosurgery / SBRT
77373	Stereotactic radiosurgery / SBRT
G0340	SRS/SBRT

CAR T-cell therapy Q-codesHCPCSCovered

Q2041	CAR T-cell therapy
Q2042	CAR T-cell therapy
Q2053	CAR T-cell therapy
Q2054	CAR T-cell therapy

inv-43: DME retail purchase / cumulative rental threshold

Threshold triggerAuthorization required when retail purchase or cumulative rental cost for listed DME codes meets the policy's specified threshold (see DME code entries).

Applies toDurable medical equipment (listed HCPCS codes such as A9279, A9280, E0194, E0265 and others).

What Providers Must Do / Submission Instructions

Prior Authorization

How to obtain prior authorization

Submit prior authorization requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) using your One Healthcare ID and password and select the Prior Authorization and Notification tab. If you do not have a One Healthcare ID, follow the portal registration prompts at UHCprovider.com. You may also call the listed phone numbers for assistance. Prior authorization is not required for emergency or urgent care. Out‑of‑network providers must request prior authorization for all procedures and services.

Online: UHCprovider.com — Sign in with One Healthcare ID → Prior Authorization and Notification tab
Phone: 844-284-0146 (general requests)
Phone for injectable medications and many pharmacy-related prior auths: 888-397-8129
Cardiology prior auth phone/portal: 866-889-8054
Transplant and CAR T-cell notifications: Optum Health Transplant Resource Services 888-805-1802

Prior Authorization

Examples of CPT/HCPCS codes requiring prior authorization

Key Definitions and Terms

inv-81: Definition — Prior authorization

DefinitionPrior authorization is the requirement to obtain approval from UnitedHealthcare before performing certain non-emergency services; not required for emergency or urgent care.

Who must requestOut-of-network physicians, facilities and other health care providers must request prior authorization for all procedures and services.

How to submitUse the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call the phone number provided in the policy.

inv-82: Chemotherapy injectable drugs

ScopeChemotherapy injectable drugs (including J9000-J9999 and specified related injectable drug J‑codes such as leucovorin J0640, levoleucovorin J0641/J0642, Lupron Depot J1950, leuprolide J1954, lanreotide J1932).

Includes

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Virginia Cardinal Care

Policy CodePolicy N/A

Change TypeMaterial updates to injectable chemotherapy prior authorization (code-specific additions)

Effective DateFeb. 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or call 888-397-8129.

SourceLink

On This Page

Providers must follow the submission instructions in the policy (UnitedHealthcare Provider Portal or designated phone numbers) to request authorization for these services.

White blood cell colony‑stimulating factors (codes like J1442, Q5101, Q5110, Q5111, Q5120, Q5122, etc.) will require authorization for both oncology and non‑oncology diagnoses per policy guidance.

Specific colony‑stimulating factor codes and Q‑codes are noted in the policy to require authorization for both oncology and non‑oncology uses; consult the code list in the document.

Image‑guided radiation therapy (IGRT) codes listed (77014, 77387, G6002) require prior authorization per the listing.

Consult the full policy code lists and submission instructions (Provider Portal or listed phone numbers) when requesting authorizations for these codes/services.

SubmissionSubmit prior authorization requests via UnitedHealthcare Provider Portal (UHCprovider.com) or phone per portal instructions in policy.

inv-44: Orthotic/prosthetic prior authorization threshold

Threshold amountPrior authorization required when retail purchase or cumulative rental cost of orthotic or prosthetic item exceeds $500.

Applies toOrthotic and prosthetic L‑series HCPCS codes listed (e.g., L0112, L0464, L0486, L0631, L0637, L0710, L0859, etc.).

ExceptionProsthetics are not classified as DME; see orthotics and prosthetics section for code-specific rules.

inv-45: Orthotics/prosthetics retail purchase/rental cost threshold

Prior authorization rulePrior authorization is required only for orthotics and prosthetics with a retail purchase or a cumulative rental cost of more than $500.

Relevant codesExamples include L0112, L0464, L0486, L0631, L0637, L0710, L0859 and many additional L‑codes listed in the orthotics and prosthetics section.

How to requestSubmit requests via the UnitedHealthcare Provider Portal or by the phone numbers listed in the policy.

Examples of services and CPT/HCPCS codes that require prior authorization. This list is illustrative — follow the portal prompts or specialty prior authorization pages for complete code lists.

Bariatric surgery: 43644, 43645, 43659, 43770
Bone growth stimulators: 20975, 20979
Brain injury case management: S0280, S0281
Breast reconstruction (non‑mastectomy): 19316, 19318, 19325, 19328
Cardiology and cardiovascular procedures: see Cardiology Prior Authorization and Notification (example CPTs: 37220, 37224)
Cerebral seizure monitoring (inpatient video EEG): 95700–95726 (inpatient only)
Cochlear and auditory implants: 69710, 69714, 69930 and related L‑codes (L8619, L8690, L8691, L8614, L8692)
Continuous glucose monitors (type 2 diabetes diagnosis): A4226, A4239, A9276, A9277, A9278, E0787, E2103, E2102
Durable medical equipment (DME): A9279, A9280, E0194, E0265–E0277, E0300, E0328–E0329, E0445, E0457, E0465–E0470 (prior auth required only for listed codes when retail purchase or cumulative rental threshold exceeded)
Enteral in‑home nutritional therapy: B9998 and related enteral codes (prior authorization required)
Joint replacement and related CPTs: 24360–24363, 27120–27138, 27412, 27446–27487
Musculoskeletal/shoulder surgery example: 23470, 23473–23474
Orthognathic/maxillofacial surgery examples: 21121–21127, 21141–21160, 21188, 21193–21199, 21206, 21208, 21209, 21210, 21215, 21240–21245
Potentially unproven services and private duty nursing: 33289, C2624, T1000–T1003
Prostate procedures: 37243, 52441, 52442, 53850, 53852, 55873, 55874

Prior Authorization

Service‑specific prior authorization notes

Service‑specific notes and timing for prior authorization. Where noted, effective dates apply and oncology vs non‑oncology routing differs — follow portal prompts or specialty pages for correct routing.

Bariatric surgery: prior authorization required for inpatient and outpatient bariatric procedures (codes listed above)
Cancer supportive care / colony‑stimulating factors: Codes J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122 (white blood cell colony‑stimulating factors) require authorization for both oncology and non‑oncology diagnoses. For oncology diagnoses see the Cancer Supportive Care section; for non‑oncology diagnoses submit via the Provider Portal.
Injectable chemotherapy and other injectable medications: Prior authorization required for many J‑ and Q‑codes (including J0174, J0897, Q5133, Q5135 and a range of J9000–J9999, Q‑codes and unclassified/temporary codes).
Effective dates: Prior authorization required for J0897 for non‑oncology diagnoses effective Jan 1, 2023; J0174 effective Jan 1, 2023; Q5133 and Q5135 effective Oct 1, 2024.
Review at Launch: New‑to‑market medications are listed on the Review at Launch Medication List — pre‑determination is highly recommended.
Unclassified/temporary codes (C9399, J3490, J3590): prior authorization is required only for certain products (for example Casgevy, Lantidra, Lupaneta Pack, Nulibry, Revcovi, Rivfloza).
Optum Rx notifications: Prior notification (not full prior auth) is required for certain products (example: Cimzia and Synagis) through Optum Rx at 800-310-6826.

Prior Authorization

Prior authorization submission instructions

Submission instructions and routing guidance — use the portal first; phone numbers available for specific programs or when portal access is not possible.

Primary submission method: UnitedHealthcare Provider Portal — UHCprovider.com (sign in with One Healthcare ID → Prior Authorization and Notification)
If portal unavailable or for assistance, call 888-397-8129 for many injectable medication prior authorizations and general prior auth support
Cardiology outpatient and office‑based diagnostic catheterizations, echocardiograms, electrophysiology implants and stress echoes: submit via portal or call 866-889-8054 and consult the Cardiology Prior Authorization and Notification page for codes
Transplant and CAR T‑cell services (notifications/authorizations): call Optum Health Transplant Resource Services 888-805-1802 or use the notification number on the back of the member’s ID card
For behavioral health and substance use services or specific behavioral health network questions: call the number on the member’s health plan ID card; for Applied Behavior Analysis (ABA) follow the ABA submission instructions (fax or Provider Express)

Prior Authorization

Prior authorization — general listing and orthotics/prosthetics note

General listing notes, orthotics/prosthetics and prosthetic purchase thresholds.

Orthotics and prosthetics: prior authorization is required only for orthotic and prosthetic items listed and when obtained via retail purchase or when cumulative rental cost exceeds $500 (examples of L‑codes requiring prior auth are listed above)
Durable medical equipment (DME): prior authorization required only for the specific DME codes listed and when retail purchase or cumulative rental thresholds are met
When in doubt, submit the request via the Provider Portal with supporting clinical documentation to determine whether prior authorization is required

Prior Authorization

Prostate procedures — prior authorization

Prostate procedures require prior authorization. Submit requests via the Provider Portal or call the prior authorization number when portal submission is not possible.

Prostate procedure CPT examples requiring prior authorization: 37243, 52441, 52442, 53850, 53852, 55873, 55874

Chemotherapy injectable drugs that have Q‑codes or that are billed under temporary/unassigned codes until a permanent code is assigned.

SubmissionSubmit PA requests online via the UnitedHealthcare Provider Portal or call 888-397-8129 per policy instructions for injectables.

inv-83: Cerebral seizure monitoring definition

DefinitionCerebral seizure monitoring refers to inpatient video electroencephalogram (video EEG) services (CPT codes 95700, 95711–95716, 95718, 95720, 95722, 95724, 95726, etc.).

Authorization stancePrior authorization is required for inpatient cerebral seizure monitoring; prior authorization is not required for outpatient hospital or ambulatory surgical center services.

Relevant codesExamples: CPT 95700, 95711–95716, 95718, 95720, 95722, 95724, 95726, 95713 listed in inpatient EEG section.

inv-84: Prosthetics vs DME

DistinctionProsthetics are not considered durable medical equipment (DME); see the orthotics and prosthetics section for code‑specific authorization rules.

ImplicationOrthotics and prosthetics have their own prior authorization threshold and listing separate from DME rules.

ReferenceSee orthotics and prosthetics L‑code listings and related prior authorization notes in the policy.

inv-85: Home health prior authorization scope

ScopePrior authorization for home health care is required only in outpatient settings, including services provided in the member's home (per home health outpatient rules).

Overlap with DMESome home health services may qualify for DME rules; check DME and orthotics/prosthetics sections for code‑specific guidance.

How to submitSubmit prior authorization requests via UnitedHealthcare Provider Portal or phone as directed in the policy.

inv-86: Prior notification for certain drugs

Prior notificationPrior notification for certain drugs (for example, Cimzia and Synagis) must be obtained through Optum Rx notifications services at 800-310-6826.

Unclassified codesFor unclassified/temporary codes (C9399, J3490, J3590), prior authorization is required only for specific drugs named (e.g., Casgevy, Lantidra, Lupaneta Pack, Nulibry, Revcovi, Rivfloza).

Review at LaunchNew‑to‑market medications are included on the Review at Launch Medication List — pre-determination is highly recommended.

inv-87: Review at Launch list referenced

DefinitionReview at Launch Medication List: a referenced list of new-to-market medications for which pre-determination (prior review) is highly recommended.

RecommendationPre-determination is highly recommended for drugs on this list to ensure timely authorization decisions.

Where to checkSee the policy's Review at Launch guidance for the most up-to-date information on newly approved drugs.

inv-88: Review at Launch Medication List

List nameReview at Launch Medication List (new‑to‑market medications).

ActionPre-determination is highly recommended for items on this list.

SupportPolicy directs providers to check the Review at Launch policy for FDA‑new drugs included on the list.

inv-89: Prior authorization required for listed injectable chemotherapy drugs and specific codes (see J0897 for non-oncology Dx)

RequirementPrior authorization is required for the listed injectable chemotherapy drugs and specified HCPCS/J/Q codes; J0897 is specifically required for non‑oncology diagnoses (effective Jan 1, 2023).

Effective datesEffective Jan. 1, 2023: PA required for J0897 (non‑oncology Dx) and J0174; Effective Oct. 1, 2024: PA required for Q5133 and Q5135 (as listed).

SubmissionSubmit PA requests via UnitedHealthcare Provider Portal (UHCprovider.com) or call 888-397-8129 as provided in the policy.

inv-90: UnitedHealthcare Provider Portal

PortalUnitedHealthcare Provider Portal (UHCprovider.com) is the online channel for submitting prior authorization requests; sign in using One Healthcare ID and select the Prior Authorization and Notification tab.

Phone alternativePhone submission options are also provided in the policy (numbers vary by section), but the portal is the preferred online route.

AvailabilityPortal access instructions and One Healthcare ID setup are detailed in the policy's submission instructions.

inv-91: UnitedHealthcare Provider Portal or phone (888-397-8129)

Submission routesSubmit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone (e.g., 888-397-8129 or the portal phone numbers shown in the policy).

Portal sign-inAccess the Prior Authorization and Notification tool by signing in at UHCprovider.com with a One Healthcare ID.

Phone numbersPolicy lists phone contact numbers for assistance (examples include 844-284-0146 for general PA and 888-397-8129 for injectable chemotherapy sections).

inv-92: Prior authorization — requirement that certain injectable chemotherapy codes obtain approval before service

RequirementPrior authorization required for certain injectable chemotherapy codes prior to service; providers must obtain approval before administration for the listed drugs.

Codes notedPolicy explicitly names codes such as J0897 and J0174 among those requiring prior authorization (see code lists and effective dates in policy).

How to requestUse the UnitedHealthcare Provider Portal or call the phone numbers listed in the policy for submission and assistance.

inv-93: Prior authorization — Prior authorization required (as stated) for the listed HCPCS/Q/J codes on the effective dates provided

PA requirement summaryPrior authorization required for the HCPCS/Q/J codes listed on the effective dates provided in the policy (examples include J0174, Q5133, Q5135).

Effective datesJ0174: effective Jan. 1, 2023; Q5133 and Q5135: effective Oct. 1, 2024 per policy excerpts.

Action for providersVerify code-specific effective dates in the policy and submit PA requests via the Provider Portal or phone.

inv-94: Prior authorization

DefinitionPrior authorization: requirement to obtain approval before providing listed injectable chemotherapy drugs (per policy listing).

Non‑oncology noteSome codes (e.g., J0897) are specifically called out as requiring PA for non‑oncology diagnoses effective Jan 1, 2023.

Provider instructionFollow submission instructions in the policy (portal or phone) when requesting authorization for these drugs.

inv-95: non-oncology Dx

TermNon‑oncology Dx — used in the policy to indicate diagnoses that are not cancer-related; certain codes (e.g., J0897) require prior authorization when billed for non-oncology diagnoses.

ImplicationProviders must submit PA requests for specific J‑codes when used for non‑oncology indications as specified by the policy.

SubmissionUse the Provider Portal or listed phone numbers for non‑oncology PA submissions per policy guidance.

inv-96: Prior authorization — requirement to obtain approval before providing the listed injectable chemotherapy drugs

DefinitionPrior authorization — requirement to obtain approval before providing the listed injectable chemotherapy drugs; effective dates and code specifics are detailed in the policy.

Provider channelsSubmit requests via UnitedHealthcare Provider Portal (UHCprovider.com) or call 888-397-8129 as indicated in the policy sections for injectables.

Check effective datesConfirm code-level effective dates in the policy (e.g., Jan 1, 2023 and Oct 1, 2024) when preparing PA requests.

inv-97: Orthotic/prosthetic prior authorization threshold

Orthotic/prosthetic PA thresholdPrior authorization is required only for orthotic and prosthetic items with a retail purchase or a cumulative rental cost of more than $500.

Policy locationSee the orthotics and prosthetics L‑code listings and associated notes in the orthotics/prosthetics section for code‑level details (policy lists many L‑codes).

Submission guidanceSubmit authorization requests through the UnitedHealthcare Provider Portal or by phone as specified in the policy.

inv-98: Orthotics and prosthetics

ScopeOrthotics and prosthetics: numerous L‑series HCPCS codes are listed; prior authorization notes and thresholds appear associated with these entries.

Example codesExamples include L3976, L3977, L3999, L4010, L4020, L4631, L5010, L5105, L5150, L5160, L5210, L5220, L5230, L8044, L8045, L8046, L8047, L8499, L8612, etc.

Threshold reminderAuthorization is required when retail purchase or cumulative rental cost exceeds $500 (see orthotics/prosthetics notes).

inv-99: Private duty nursing

ServicePrivate duty nursing services (T1000–T1003) require prior authorization as listed in the policy.

Related itemsPotentially unproven services (example codes: 33289, C2624) also require prior authorization per policy listing.

How to requestSubmit PA requests via the UnitedHealthcare Provider Portal or follow the phone submission instructions in the policy.

inv-100: Proton beam

DefinitionProton beam therapy: focused radiation therapy that uses beams of protons (tiny particles with a positive charge).

Example CPT codesExamples listed in the policy include 77520, 77522, 77523, 77525.

Authorization noteProton beam therapy codes are listed in the policy's radiation therapy section and require prior authorization per the listing.