CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for bariatric surgery and related obesity services (UnitedHealthcare Community Plan of Washington / Apple Health Expansion)

Lists prior authorization requirements and CPT/HCPCS codes for inpatient and outpatient bariatric surgery and related obesity services for UnitedHealthcare Community Plan of Washington and Apple Health Expansion providers.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for bariatric surgery and related obesity services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateEffective April 1, 2023; Effective July 1, 2024; Effective March 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or call 877-542-9231.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

RequiredPrior auth stance

4Bariatric CPTs listed

UHCprovider.comPortal

877-542-9231Phone

>$500O&P cost threshold

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Coverage Criteria

This section contains no detailed clinical coverage criteria or explicit exclusions beyond repeated references to procedures described as non-mastectomy. The document lists CPT/HCPCS procedure codes associated with non-mastectomy breast procedures (for example, CPT codes 19357, 19361, 19364, 19367) but does not provide clinical indications, inclusion/exclusion logic, or medical necessity language in these chunks.

For breast reconstruction entries identified as non-mastectomy, the document explicitly indicates that Prior Auth NOT required for diagnosis codes listed below. The listing groups CPT/HCPCS codes for reconstruction (for example, CPTs 19368–19371, 19380, 19396 and HCPCS L8600) and states that prior authorization is not required for the diagnosis codes shown in the referenced lines.

Inpatient video electroencephalogram (EEG) monitoring is addressed in this section. It notes that Prior authorization required for inpatient services in some contexts, but also includes the fragmentary statement Prior authorization is not required for certain entries. Relevant CPT codes cited for inpatient video EEG include 95700, 95714, 95720, 95711, 95715.

Prosthetics and related DME codes are listed with the clarification that prosthetics are not (followed by fragmentary text). The chunks reference multiple HCPCS device codes (examples include E0693, E0694, E0710, E0731) and indicate prosthetics are discussed separately from orthotics or other DME requirements in this section.

Items explicitly labeled Experimental and investigational are called out separately and the text indicates Prior authorization is required for these services. Example CPT/HCPCS codes listed in this experimental/investigational group include 36514, 64722, 65765–65767, 66180, A4638, A6000, A9274.

For medication-related items the document refers providers to other UnitedHealthcare policies for current management. It instructs providers to check the Medications and the Review at Launch for New to Market Medications policy for up-to-date prior authorization and coverage details for newly marketed drugs.

No additional coverage criteria are stated in this fragment.

This portion of the document does not list explicit coverage exclusions. It provides general information about items that meet a cost threshold (for example, HCPCS codes L0810, L0820, L0830, L0859) but does not present standalone exclusion language in the cited chunks.

There are no explicit not medically necessary determinations stated in these chunks. The content focuses on code lists, cost thresholds, and prior authorization mappings rather than explicit non-coverage statements.

Coding (CPT / HCPCS / ICD-10)

Referenced ICD-10 diagnosis codes (selected oncology & related codes)ICD-10

C45.	Mesothelioma (group code)
C45.0	Pleural mesothelioma
C45.1	Peritoneal mesothelioma
C45.2	Pericardial mesothelioma
C45.7	Other specified mesothelioma sites
C45.9	Mesothelioma, unspecified
C46.1	Kaposi sarcoma of lower limb, including hip
C46.2	Kaposi sarcoma of upper limb, including shoulder
C46.3	Kaposi sarcoma of lower limb, including hip (alternate)
C46.4	Kaposi sarcoma of face, head and neck

1–10 of 180

1/18

Provider Actions & Prior Authorization

Prior Authorization

How to Request Prior Authorization

Prior authorization is required for many listed CPT/HCPCS codes and services. Submit requests online via the UnitedHealthcare Provider Portal (UHCprovider.com — Sign In with One Healthcare ID) or by phone at 877-542-9231. Prior authorization is not required for emergency or urgent care; out-of-network requests must be made by a network care provider.

How to request prior authorization: UHCprovider.com (Prior Authorization and Notification tool) or call 877-542-9231.

Prior Authorization

Prior Authorization Required for Listed CPT/HCPCS Codes

Specific CPT/HCPCS codes and code ranges require prior authorization. Examples include (but are not limited to): bariatric surgery (43644, 43645, 43659, 43770); cochlear/auditory implants (69710, 69714, 69930, L8614, A4226, A9278); many cosmetic/reconstructive codes (e.g., 11960, 14020, 14021, 14041, 14061, 15820-15830, 15847, 15877); select DME/ durable medical codes (A9279, A9280, A9900, E0118, E0194, E0265, E0266); and numerous others listed in the table of services.

Bariatric surgery CPTs: 43644, 43645, 43659, 43770
Cochlear/auditory implant CPTs/HCPCS: 69710, 69714, 69930, L8614, A4226, A9278

Background

The available chunks do not include clinical background material. Content in this portion is predominantly code listings and administrative notes, with repeated reference to procedures described as non-mastectomy. No clinical rationale, pathophysiology, or evidence summaries are provided in the cited text.

Definitions & Terms

Use of 'non-mastectomy'

Term'non-mastectomy' appears repeatedly in association with listed CPT codes.

Associated codesExamples include CPT 19357, 19361, 19364, 19367 noted with 'non-mastectomy'.

Implication for codingIndicates these CPT codes are referenced in contexts not involving mastectomy and may affect prior authorization applicability.

Breast reconstruction (non-mastectomy) codes

SubjectBreast reconstruction (non-mastectomy) and related CPT/HCPCS codes are listed.

Example codesCPT 19368, 19369, 19370, 19371 and HCPCS L8600 are included under reconstruction entries.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for bariatric surgery and related obesity services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateEffective April 1, 2023; Effective July 1, 2024; Effective March 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or call 877-542-9231.

SourceLink

On This Page

Cosmetic/reconstructive examples: 11960, 14020, 14021, 14041, 14061, 15820, 15821, 15822, 15823, 15830, 15847, 15877

DME examples: A9279, A9280, A9900, E0118, E0194, E0265, E0266

Prior Authorization

Injectable Supportive Care Agents — Prior Authorization

Many injectable medications used in cancer supportive care and other specialties require prior authorization for outpatient administration. This includes colony-stimulating factors, certain erythropoiesis-stimulating agents, bone-modifying agents, antineoplastic injectables and select antiemetics.

Colony-stimulating factors: J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125, Q5148 (also require prior auth for non-oncology diagnoses where noted)
Specific agents: J1449 (eflapegrastim-xnst), J2820 (sargramostim), J1447 (tbo-filgrastim), J1448 (trilaciclib)
Pegfilgrastim and biosimilars: J2506, Q5122, Q5120, Q5108, Q511? (as listed)
Erythropoiesis-stimulating agent: J0885 (Procrit)
Bone-modifying agent: J0897 (denosumab)
Antiemetic injectable codes: J1456, J1434, J2468

Prior Authorization

Chemotherapy Injectables — Prior Authorization

Prior authorization is required for outpatient injectable chemotherapy agents (J9000–J9999 range) and certain specific J-/Q-codes, including leucovorin (J0640), levoleucovorin (J0641, J0642), leuprolide/Lupron depot (J1950, J1952), and miscellaneous or Q‑coded chemotherapy products (including drugs awaiting permanent codes billed as miscellaneous HCPCS).

Chemotherapy injectables: J9000–J9999
Leucovorin/Levoleucovorin: J0640, J0641, J0642
Leuprolide/Lupron Depot: J1950, J1952
Q‑code chemotherapies and miscellaneous HCPCS billed oncology injectables

Prior Authorization

DME/Orthotics & Prosthetics — Cost Threshold and Prior Authorization

Certain DME, orthotic and prosthetic items require prior authorization when the retail purchase or cumulative rental cost exceeds $500. A set of HCPCS codes is specifically associated with this cost threshold and prior authorization requirement.

Cost threshold: retail purchase or cumulative rental > $500 triggers prior authorization
Example HCPCS codes associated with threshold: L0638, L0640, L0700, L0710, L0810, L0820, L0830, L0859, L0638, L0810, L0820, L0830, L0859

Documentation Required

Enteral Services & In‑Home Nutritional Therapy — Prior Authorization and Documentation

Enteral nutrition services and in‑home nutritional therapy require prior authorization and documentation. Relevant HCPCS codes include B4034–B4036 series, B4100, B4102–B4104 and B4149.

Enteral product codes: B4034, B4035, B4036, B4100
In‑home nutritional therapy: B4102, B4103, B4104, B4149
Documentation: In‑home nutritional therapy is noted as required (submit supporting clinical documentation with the prior authorization request)

Denial Risk

Documentation & Denial Risk — Notes and Limitations

Authorization rules and documentation expectations are referenced throughout this section but are not fully specified in every entry. Many entries direct providers to submit requests via the Provider Portal or call the specified phone number. Explicit denial triggers and detailed documentation checklists are not provided here — providers should follow portal prompts and any specialty prior authorization guidance (e.g., Cardiology Prior Authorization and Notification, Medications policies, Review at Launch for New to Market Medications).

No explicit denial triggers or complete documentation checklists are stated in this section; failure to obtain required prior authorization may result in claim denial per plan rules
For specialty-specific requirements, see referenced policies (Cardiology Prior Authorization and Notification; Medications; Review at Launch) and portal guidance

Prior Authorization

How to Obtain Prior Authorization — Operational Notes

Where code‑to‑authorization mappings are shown, the instruction is typically: submit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com — sign in) or call the applicable phone number (e.g., 866‑889‑8054 for certain Cardiology services). For unspecified or newly marketed drugs, check the Medications policy and the Review at Launch list; pre‑determination is recommended.

Portal submission recommended for most services; call numbers where provided (877‑542‑9231 general; 866‑889‑8054 for some cardiology items)
Newly approved drugs: check Review at Launch; pre‑determination highly recommended
Some products require prior notification rather than full prior authorization (e.g., Cimzia and Synagis per notes)

Prior auth noteSection includes 'Prior Auth NOT required for diagnosis codes listed below' for non-mastectomy reconstruction entries.

ICD-10 diagnosis codes related to breast neoplasms

ScopeICD-10 diagnosis codes for breast cancer and related neoplasms are listed in relation to reconstruction prior authorization status.

ExamplesCodes include C50.011, C50.012, C50.019, C50.021, C50.022, C50.029, C50.111, C50.112, C50.119, C50.121, C50.122, C50.129 and others.

ContextThese diagnosis codes appear alongside reconstruction CPT/HCPCS entries and prior-auth notes.

Cancer supportive care — agents requiring prior authorization

Agent classesColony-stimulating factors, bone-modifying agents, antiemetics listed as supportive cancer treatment agents requiring prior authorization.

Example codesJ1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125, Q5148 are cited.

Usage noteSome listed J/Q-codes also require prior authorization for non-oncology diagnoses.

Continuous glucose monitor / glucose monitor

SubjectContinuous glucose monitor / glucose monitor entries reference multiple diabetes-related ICD-10 codes.

ExamplesCodes include E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9 and pregnancy-related O24 codes.

ContextThese entries are under 'Continuous glucose monitor' general information indicating coding for prior authorization mapping.

Genetic / molecular testing code group

GroupGenetic / molecular testing code group references BRCA and breast cancer contexts for testing.

MappingGeneral information links genetic/molecular testing to ICD-10 headings (e.g., C23, C24, C25, C26, C30) and BRCA-related entries.

ImplicationProviders should reference these code mappings when seeking prior authorization for genetic/molecular tests.

Prior authorization threshold

ThresholdRetail purchase or cumulative rental cost of more than $500 triggers prior authorization.

Applies toOrthotics and prosthetics L‑codes listed in the section.

NoteSection repeatedly states requirement only applies when retail purchase or cumulative rental cost exceeds $500.

HCPCS L08xx codes and cost note

ExamplesHCPCS L0810, L0820, L0830, L0859 are listed as examples associated with items costing more than $500.

Cost thresholdCost of more than $500 is referenced in the general information section.

ImplicationThese listed HCPCS codes are associated with the >$500 cost threshold for prior authorization handling.