CurrentUnitedHealthcarePolicy PCA-4-24-03748-Clinical-ORG_12302024

Prior authorization requirements — UnitedHealthcare Community Plan (Washington) — bariatric, obesity and related services

List of services and CPT/HCPCS/diagnosis codes that require prior authorization for providers participating in UnitedHealthcare Community Plan of Washington and Apple Health Expansion; instructions for submitting prior authorization requests and contact methods are included. Affects in-network participating providers and applies to inpatient and outpatient services (Washington).

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan (Washington) — bariatric & obesity-related and other listed services

Policy CodePolicy PCA-4-24-03748-Clinical-ORG_12302024

Change TypeNo material changes

Effective DateApril 1, 2023

Next Review DateN/A

Key ActionSubmit required prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleCPT/HCPCS codes listed

portal & phoneSubmission methods

no PAEmergency care

PA after 12Outpatient therapy threshold

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.

Coverage Criteria and Prior Authorization Requirements

Prior Authorization Requirement

Covered when prior authorization is obtained for listed services

Prior authorization requirement: Providers must obtain prior authorization for the listed CPT/HCPCS and specified diagnosis codes prior to performing inpatient or outpatient services (examples: bariatric surgery codes, cardiovascular procedure codes, injectable cancer supportive agents).

Requests via Provider Portal (UHCprovider.com) or by phone (877-542-9231); out-of-network requests must be made by a network provider.

Prior Authorization — injectables and procedures

Covered when prior authorization is obtained for listed items

PA requirement for injectables and procedures

Effective-date requirement: Effective Oct 1, 2024: prior authorization is required for codes Q5133, Q5135, and J1748.
From injectable medication section (policy note).

Prior authorization requirements

Services listed require prior authorization under the following conditions

Radiation therapy prior auth conditions: Radiation therapy and associated special/standard services (CPT and G-codes) require prior authorization; standard radiation therapy (2D/3D) requires prior authorization only when billed with diagnosis codes in specified ranges (for example: C34.00–C34.92, C50.011–C50.929, C61).diagnosis code range applied where noted

See radiation therapy code lists in policy chunks for full code set

Advanced outpatient imaging: Certain advanced outpatient imaging procedures (selected CT, MRI, MRA, PET scans, nuclear medicine and nuclear cardiology) require prior authorization and the ordering clinician must notify prior to scheduling; submit requests via the Provider Portal or by phone (866-889-8054).prior authorization required

Notification prior to scheduling is required

Outpatient therapy visits:

Emergency or urgent care services do not require prior authorization. This policy explicitly states that prior authorization is not required for emergency or urgent care and provides separate submission instructions for non-emergent requests through the UnitedHealthcare Provider Portal or by phone. Providers should only seek authorization for non-emergent inpatient or outpatient services as listed elsewhere in the policy.

The policy distinguishes prosthetics from durable medical equipment: prosthetics are not classified as DME. For orthotics and prosthetics, the document directs providers to the orthotics/prosthetics L-code listings and associated prior-authorization requirements rather than treating those items under general DME rules.

This excerpt does not contain full medical-necessity criteria or detailed coverage determinations. Instead, it provides code mappings, internal prior-authorization pointers (e.g., C4A.*), and instructions on how to obtain authorization for a wide range of genetic/molecular tests and other services; clinical justification requirements and complete medical-necessity rules are not included in these chunks.

No explicit standalone coverage criteria or exclusions are provided in these excerpts. The content is largely a listing of CPT/HCPCS/diagnosis codes with annotations such as 'CPT® or HCPCS codes and/or how to obtain prior authorization' and occasional 'Additional information =' notes; it does not present full eligibility rules or exclusion language in this segment.

Prior authorization requirements in this document are limited to outpatient settings. Home health care and other outpatient services (including services provided in a member's home) require authorization when delivered as outpatient care; by implication, inpatient settings and facility-based inpatient care are not subject to the outpatient prior-authorization statements shown here. Providers should follow the portal/phone submission methods for outpatient prior-authorizations.

For unclassified and temporary miscellaneous drug codes (for example C9399, J3490, and J3590), the policy notes that prior authorization is required only for a limited set of products. The excerpt lists these unclassified/temporary codes and indicates they are subject to PA when used for specific named products rather than universally for all uses of the miscellaneous codes.

This segment contains miscellaneous site-of-service and procedural annotations but does not state additional explicit substantive coverage criteria. It primarily documents site-of-service rules and examples where prior authorization may or may not apply.

The policy includes site-of-service exceptions: prior authorization is not required for certain procedures if they are performed at a participating ambulatory surgery center. When services are requested in an outpatient hospital setting the prior-authorization requirement applies; however, the same procedures performed at an in-network ambulatory surgery center may be exempt from PA per the notes in these chunks.

The document lists potentially unproven services and references private duty nursing among other service categories, but does not provide full not-medically‑necessary (NMN) determinations in this excerpt. These entries are cataloged without the accompanying medical necessity rationale in the provided chunks.

CPT, HCPCS and ICD-10 Codes Requiring Prior Authorization

Genetic / Molecular Testing CPT codes (prior auth required)CPT

81162	CPT code 81162
81228	CPT code 81228
81229	CPT code 81229
81401	CPT code 81401
81402	CPT code 81402
81403	CPT code 81403
81404	CPT code 81404
81405	CPT code 81405
81406	CPT code 81406
81407	CPT code 81407

1–10 of 41

1/5

Genetic / Molecular Testing CPT codes (additional list)CPT

81404	CPT code 81404
81408	CPT code 81408
81413	CPT code 81413
81417	CPT code 81417
81433	CPT code 81433
81440	CPT code 81440
81460	CPT code 81460
81518	CPT code 81518
81522	CPT code 81522
81519	CPT code 81519

1–10 of 16

1/2

Miscellaneous / Unclassified HCPCS requiring prior authHCPCSCovered

J3490	Unclassified drug code J3490 (prior auth conditional)
J3590	Unclassified drug code J3590 (prior auth conditional)
C9399	Unclassified HCPCS C9399 (prior auth conditional)
S3870	HCPCS S3870
S3870	S3870 (duplicate consolidated)

ICD-10 Diagnosis codes (malignant neoplasms — required for radiation PA)ICD-10

C34.8	Malignant neoplasm of overlapping sites of bronchus and lung
C34.80	Malignant neoplasm of overlapping sites of bronchus and lung, unspecified side
C34.81	Malignant neoplasm of overlapping sites of bronchus and lung, right
C34.82	Malignant neoplasm of overlapping sites of bronchus and lung, left
C34.90	Malignant neoplasm of unspecified part of bronchus or lung
C34.91	Malignant neoplasm of unspecified part of bronchus or lung, right
C37	Malignant neoplasm of thymus
C38	Malignant neoplasm of heart, mediastinum and pleura
C38.0	Malignant neoplasm of heart
C38.1	Malignant neoplasm of mediastinum

1–10 of 17

1/2

ICD-10 Diagnosis codes (expanded oncology list)ICD-10

C40	Malignant neoplasm of bone and articular cartilage
C40.0	Malignant neoplasm of long bones of upper limb
C40.00	Malignant neoplasm of unspecified part of long bone of upper limb
C40.01	Malignant neoplasm of proximal humerus
C40.02	Malignant neoplasm of other part of humerus
C40.1	Malignant neoplasm of long bones of lower limb
C40.10	Malignant neoplasm of unspecified part of long bone of lower limb
C40.11	Malignant neoplasm of femur
C40.12	Malignant neoplasm of other specified part
C40.2	Malignant neoplasm of short bones of upper limb

1–10 of 32

1/4

C43–C50 and related ICD-10 malignant neoplasm codes (selection)ICD-10

C43.0	Melanoma in situ and related codes
C43.111	Specific melanoma code example
C43.31	Specific melanoma code example
C43.39	Specific melanoma code example
C44.00	Other malignant neoplasm of skin
C44.09	Other specified malignant neoplasm of skin
C44.101	...
C44.1191	...
C45	Mesothelioma codes
C45.0	Mesothelioma of pleura

1–10 of 27

1/3

Additional Genetic / Molecular CPT/HCPCS and Procedure Codesmixed

S3870	HCPCS S3870
0006M	0006M (procedure code)
0007M	0007M (procedure code)
0111U	0111U (genetic test)
0129U	0129U (genetic test)
0018U	0018U (genetic test)
87505	87505 (infectious agent detection)
87506	87506 (infectious agent detection)
Q0111U	0111U (alternate format)

What Providers Must Do — Submission, Notification and Denial Risks

Prior Authorization

Prior Authorization — Submission Requirement and Instructions

Prior authorization is required for many listed services and codes. Submit requests via the UnitedHealthcare Provider Portal (UHCprovider.com — sign in with your One Healthcare ID) or by calling the phone numbers shown for specific service categories (examples in this section include 877-542-9231, 888-397-8129, and 866-889-8054). Failure to obtain required prior authorization or to provide complete documentation may result in administrative delays or claim denial.

How to submit: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) OR call the listed phone number for the service type.
Include supporting clinical documentation (indication, prior treatments, relevant history, and specific HCPCS/CPT codes) with each request.
Some categories require contacting specialty teams (e.g., transplants/CAR T-cell: 888-936-7246; VAD: notification number on member ID, then fax to Optum VAD Case Management at 855-282-8929).

Prior Authorization

Prior Authorization Required for Genetic/Molecular Testing Codes

Genetic and molecular tests listed in this policy require prior authorization. Many entries are annotated with internal routing identifiers (for example, C4A.3, C4A.30–C4A.72 and the C7A–C84 series) that indicate the specific internal prior-authorization workflow to use when submitting requests.

Background and Context

Bariatric and obesity-related inpatient and outpatient surgeries and procedures are included among services that require prior authorization. The policy instructs providers to obtain authorization for listed bariatric CPT/HCPCS codes (examples include 43644, 43645, 43659, 43770, 43775, 43842–43848, 43860) using the UnitedHealthcare Provider Portal or by phone to ensure plan coverage and consistent application of policy rules.

Definitions and Internal References

DefinitionPrior authorization is the process by which providers must obtain approval from UnitedHealthcare before performing certain services or billing specified CPT/HCPCS codes.

Miscellaneous HCPCS useUse miscellaneous HCPCS codes for chemotherapy injectable drugs that have not yet received an assigned code

DME (durable medical equipment)Durable medical equipment (DME) — prior authorization is required for the DME HCPCS codes listed in the policy

BRCAReferenced as breast cancer (BRCA) gene — BRCA testing is included within molecular/genetic testing entries

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan (Washington) — bariatric & obesity-related and other listed services

Policy CodePolicy PCA-4-24-03748-Clinical-ORG_12302024

Change TypeNo material changes

Effective DateApril 1, 2023

Next Review DateN/A

Key ActionSubmit required prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone.

SourceLink

On This Page

Prior authorization is required after the 12th outpatient therapy visit for members age 21 and older.

Applies to outpatient therapy visits for members 21+

Providers must obtain prior authorization for genetic/molecular testing codes in the C4A, C7A, C79, C80–C84 series and related C-code groups listed in the policy.
Some genetic/molecular codes include a mapping note (e.g., “how to obtain prior authorization”) — follow the mapping to route requests correctly to the genetic-testing review team.
Effective June 1, 2023: a subset of codes marked with an asterisk do NOT require prior authorization when billed with specified diagnoses (confirm exceptions before submitting).

Documentation Required

Prior Authorization Code List — Genetic/Molecular Testing

Code groups and examples to use when obtaining prior authorization for genetic/molecular testing are provided in the policy. Use the listed C-code ranges and C7A/C79/C82/C84 entries to ensure correct routing and review.

Relevant code ranges include (but are not limited to): C4A.* series, C7A.* series, C79.*, C80–C84 series, C82.*, C84.* and C94–C96 groupings shown in the policy.
When requesting prior authorization, reference the specific code (e.g., C4A.3 or C84.73) and include clinical indication and any internal mapping pointer shown in the policy entry.

Prior Authorization

Prior Authorization for Select HCPCS/DME/Device Codes

Certain HCPCS device and durable medical equipment (DME) codes require prior authorization; submit these requests via the Provider Portal or the phone numbers listed. For specific devices such as stimulators, ventricular assist devices (VAD), wound VACs, cochlear implants, and other implantable devices, follow the special contact or notification instructions included in the policy.

DME/HME examples requiring prior authorization: A9279, A9280, A9900, E0118, E0194, E0265, E0266, E0270, E0748, E0749, E0760.
Implantable devices and stimulators: multiple neurostimulator and implant CPT/HCPCS codes (see policy) — prior authorization required.
VADs: call the notification number on the member’s ID card and fax the form to Optum VAD Case Management at 855-282-8929.
Transplants and CAR T-cell therapies: contact the transplant management team at 888-936-7246 or use the notification number on the member ID card.

Denial Risk

Submission Completeness Risks — Provide Complete Documentation

Incomplete or incorrect submissions can delay review or cause misrouting and potential denial. Always provide complete coding, diagnosis linkage, clinical rationale, and any internal prior-authorization pointers shown in the policy.

Include exact CPT/HCPCS code(s) and the primary diagnosis code(s) when submitting; missing HCPCS or diagnosis linkage commonly affects injectable and DME requests.
Follow internal mapping/routing notes (e.g., C4A.3, C4A.30–C4A.72) to route genetic/molecular tests correctly — omission may cause misrouting.
For certain injectable medications and devices, Optum Rx prior-notification or specialty phone routing may apply (see the injectable medications and pharmacy-related entries).

Documentation Required

Prior-Authorization Routing and Mapping Notes

Some entries include internal prior-authorization routing identifiers and mapping notes. Reference these pointers exactly when submitting to ensure the request is routed to the correct review team.

Examples of internal pointers: C4A.3, C4A.30–C4A.72 — include the pointer on the request so the authorization is routed properly.
The policy’s code-mapping notes (e.g., ‘how to obtain prior authorization’) indicate routing or specialty review pathways; follow them rather than generic submission steps.

Prior Authorization

Notification Requirement for Advanced Outpatient Imaging

Ordering clinicians are responsible for notifying UnitedHealthcare before scheduling advanced outpatient imaging procedures (CT, MRI, MRA, PET, certain nuclear medicine and nuclear cardiology procedures). Use the Provider Portal or call the radiology prior-authorization number shown in the policy.

Notification required prior to scheduling advanced outpatient imaging — submit via the UnitedHealthcare Provider Portal or call 866-889-8054.
For full CPT/HCPCS lists and radiology-specific requirements, see the Radiology Prior Authorization and Notification guidance referenced in the policy.

Note

Operational Notes — Denial Triggers, Step-Therapy and Unlisted Items

Operational notes and denial-risk clarifications: the policy lists many required prior authorizations but does not enumerate every possible explicit denial trigger or all step-therapy rules. Providers should assume prior authorization is required where stated and follow submission instructions; if a procedure or drug is not explicitly listed, verify via the Provider Portal or by phone. The policy also does not specify any step-therapy requirements within these entries — check plan- or product-specific medical/pharmacy benefit rules for step-therapy.

No explicit denial triggers are listed in each entry beyond the general statement that missing required prior authorization may result in claim denial.
No step-therapy requirements are stated in these section entries — verify step-therapy or utilization management rules via the benefit documents or pharmacy pathways (Optum Rx) where applicable.
When in doubt about coverage, prior authorization requirements, or exceptions, submit a pre-determination through the Provider Portal.

C4A.* mappingInternal prior-authorization pointers (e.g., C4A.3, C4A.30–C4A.72) are used to route prior-authorization requests for genetic/molecular tests

Home health care (outpatient)Home health care requires prior authorization only when provided in an outpatient setting, including the member's home

Review at Launch Medication ListReference list for newly FDA‑approved drugs where pre-determination is recommended (providers should check Review at Launch)

Optum Rx prior notificationOptum Rx prior notification is an alternative prior-notification channel for certain products (example: Cimzia, Synagis)

Site of service (SOS) - outpatient hospitalPrior authorization is required only when requesting the service in an outpatient hospital setting; if performed at a participating ambulatory surgery center PA may not be required

22865 prior authorization effective dateEffective Oct. 1, 2024: Prior authorization required for CPT code 22865 for members age 21 and older