CurrentUnitedHealthcarePolicy PCA-1-23-01082-Clinical-FLYR_05192023

Prior authorization requirements for UnitedHealthcare Community Plan of Washington

Lists services and specific CPT/HCPCS/diagnosis codes that require prior authorization for providers participating in UnitedHealthcare Community Plan of Washington. Affects inpatient and outpatient providers and facilities serving plan members in Washington.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Washington

Policy CodePolicy PCA-1-23-01082-Clinical-FLYR_05192023

Change TypeNo material changes

Effective DateApr 1, 2023

Next Review DateN/A

Key ActionSubmit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

state-specificdocument for Washington community plan

portal + phoneauthorization request methods provided

>=1explicit bariatric surgery CPT codes listed

6/1/23asterisked-code exception effective

multiple

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CPT/HCPCS codes listed (excerpt)

Coverage Criteria and Service List

Prior authorization required - listed services

Covered when prior authorization is obtained for listed services

Standard prior authorization requirement: Prior authorization is required for the listed inpatient and outpatient services (examples in this partial document include inpatient and outpatient bariatric surgery, inpatient cerebral seizure monitoring, chemotherapy and injectable cancer drugs, and other listed CPT/HCPCS/HCPCS device and DME codes).

This is a partial extract from the full prior authorization list; providers must submit requests via the UnitedHealthcare Provider Portal or call the number on the member's ID card as indicated in the full policy.

Prior authorization is not required for emergency or urgent care. Providers should still follow standard billing and documentation practices, but do not need to submit a prior authorization for services delivered for emergency or urgent conditions. (Note: out-of-network clinicians and facilities must request authorization for non-emergent services per the general instructions.)

For cerebral seizure monitoring the policy distinguishes inpatient and outpatient settings: prior authorization is required for inpatient video electroencephalographic monitoring, while prior authorization is not required for outpatient seizure monitoring. Relevant CPT seizure monitoring codes are listed in the document and should be submitted according to the inpatient requirement when the service is provided in that setting.

Effective 5/1/23, CPT codes 14020, 14021, and 14061 do NOT require prior authorization when billed with the qualifying diagnosis codes referenced in the document (these DX codes are in the C43/C44 series). Ensure the appropriate diagnosis code from the listed series is included on the claim to apply this exception.

The DME section notes that prosthetics are not (statement incomplete in this excerpt). The policy further references DME codes and purchase/rental cost thresholds elsewhere; providers should consult the full DME entries for whether specific prosthetic items require prior authorization or are treated differently under DME rules.

Some listed CPT/HCPCS codes are marked with a red asterisk indicating an exception; codes without the red asterisk are not covered by that asterisk exception and therefore may require prior authorization when billed with the listed diagnosis codes. Confirm whether a code is asterisked in the document and include the appropriate diagnosis code on the claim to determine whether prior authorization is waived.

This portion of the document is administrative and mapping-oriented: it does not state explicit exclusions. It primarily maps CPT/HCPCS and ICD-10 groupings to internal prior-authorization references and therefore does not define coverage criteria or express specific exclusion lists in the excerpted text.

The administrative mapping content in this fragment does not provide clinical coverage or medical necessity criteria. It lists internal code mappings and diagnosis groupings for authorization processing but does not establish clinical requirements for coverage in the excerpt shown.

This fragment contains code listings and administrative annotations without explicit exclusions. It is limited to mapping CPT/HCPCS and ICD-10 entries to internal references and does not define excluded services in the provided text.

Home health care prior authorization is required only in specified circumstances and settings identified in the home health section. The document lists specific home health CPT/HCPCS codes (for example 99504, G0299, G0300, G0493–G0496, S9474, T1021, T1030, T1031) that are subject to prior authorization and indicates that authorization applies only where noted.

For unclassified and temporary codes C9399, J3490, and J3590, prior authorization is required only for certain products. The excerpt specifies that prior authorization is required for named products such as Ryplazim, Xenpozyme, Altuviiio, Cablivi, and Veopoz when billed under these unclassified/temporary codes.

Prior authorization is required for orthotic and prosthetic items when the retail purchase or cumulative rental cost exceeds $500. The orthotics/prosthetics sections list applicable L‑codes and note the >$500 threshold as the trigger for authorization requirements.

If a listed site‑of‑service procedure is performed at a participating ambulatory surgery center (ASC), prior authorization is not required for that procedure per the ASC site‑of‑service guidance in the policy excerpt.

This segment is administrative and does not provide clinical criteria. It indicates that many procedures listed require prior authorization and includes special handling instructions for services such as transplants and CAR T‑cell therapy (including contact information for Optum Transplant Case Management) rather than diagnostic or medical‑necessity criteria.

No explicit statements declaring services or codes as 'not medically necessary' are present in the cited chunks. The excerpt focuses on mappings and prior authorization linkage rather than determinations of medical necessity.

Similarly, this fragment does not contain 'not medically necessary' determinations. It lists diagnostic groupings and internal mapping codes without expressing medical‑necessity decisions in the provided text.

CPT, HCPCS and ICD-10 Code Listings

ICD-10 Diagnosis Codes (Hematologic & Related Malignancies)ICD-10

C86	Peripheral and cutaneous T-cell lymphomas (category)
C86.0	Mycosis fungoides
C86.1	Sézary disease
C86.2	Primary cutaneous CD30-positive T-cell lymphoproliferative disorders
C86.3	Primary cutaneous peripheral T-cell lymphoma, unspecified
C86.4	Primary cutaneous anaplastic large cell lymphoma
C86.5	Primary cutaneous aggressive epidermotropic CD8+ cytotoxic T-cell lymphoma
C86.6	Other specified peripheral and cutaneous T-cell lymphomas
C88	Malignant immunoproliferative diseases and certain other B-cell lymphomas (category)
C88.0	Multiple myeloma and malignant plasma cell neoplasms, solitary plasmacytoma

1–10 of 27

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What Providers Must Do / Submission Instructions

Prior Authorization

Prior Authorization Required

Prior authorization is required for the services and codes listed in this document. Submit prior authorization and notification requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) by signing in with your One Healthcare ID. You may also call the telephone numbers shown for specific programs (examples below). Failure to obtain required prior authorization may result in claim denials or payment delays.

Online submission: Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com)
Phone numbers: general prior auth support 888-397-8129 or 855-766-0344; advanced outpatient imaging 866-889-8054; Optum Transplant Case Management 888-936-7246; Optum VAD fax 855-282-8929; Optum Rx prior notification for select biologics 800-310-6826
For chemotherapy injectable drugs, specific routing and numbers may apply — see Chemotherapy entries and the portal guidance

Prior Authorization

Conditional / Implicit Prior Authorization — Examples

Some codes listed in the code sections have conditional or implicit prior-authorization requirements. Examples include: codes marked with an asterisk (see genetic/molecular testing and transplant entries) that do not require prior authorization when billed with specific diagnosis codes, or codes that require authorization only for certain diagnoses (for example, 38232 requires prior authorization only when billed for an oncology diagnosis). In addition, unclassified or miscellaneous HCPCS (e.g., C9399, J3490, J3590) or temporary/unassigned drug codes may require prior authorization only for specified products; pre-determination is recommended.

Policy Background and Scope

Background: This document segment is administrative and lists the CPT/HCPCS and ICD‑10 code categories and service groups for which prior authorization is required when applicable. It does not supply clinical criteria for medical necessity; instead it maps services (for example, bariatric surgery CPT codes, seizure monitoring, chemotherapy/injectable drugs and many procedural, DME, genetic/molecular testing and orthotics/prosthetics codes) to prior authorization requirements, site‑of‑service exceptions, and submission instructions.

Terms, Tools, and Code Mappings

UnitedHealthcare Provider Portal submission method — Prior Authorization and Notification tool

Tool namePrior Authorization and Notification tool (on the UnitedHealthcare Provider Portal)

Portal URLUHCprovider.com — sign in with One Healthcare ID

Alternate contactCall 888-397-8129 for assistance as noted in the document

Diagnosis code linkage

LinkageA list of ICD-10 diagnosis codes (many C00–C21 and C44 series entries) is provided; when certain CPT/HCPCS codes are billed with these diagnosis codes an asterisked exemption may apply

ImplicationProviders should bill the corresponding ICD-10 diagnosis code when submitting authorization to validate any asterisk exemption

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Washington

Policy CodePolicy PCA-1-23-01082-Clinical-FLYR_05192023

Change TypeNo material changes

Effective DateApr 1, 2023

Next Review DateN/A

Key ActionSubmit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone.

SourceLink

On This Page

Codes with red asterisk: do NOT require prior authorization when billed with specified diagnosis codes (Effective 6/1/23) — confirm DX pairing before submission
Code 38232: prior authorization required only for oncology diagnoses
Unclassified/temporary codes (C9399, J3490, J3590): PA required only for specified drugs (Ryplazim, Xenpozyme, Altuviiio, Cablivi, Veopoz)
Temporary/new-to-market drug codes: follow Review at Launch guidance and consider pre-determination

Documentation Required

Include CPT®/HCPCS, ICD-10 and Internal Cross‑Reference Codes

When submitting prior authorization requests, include the CPT®/HCPCS code(s) and any mapped internal cross-reference codes or catalog codes referenced in this document. Failure to submit the CPT/HCPCS or ICD-10 code that maps to the correct prior authorization entry (including internal cross-reference codes) may result in the authorization not being located and the request denied or delayed.

Use the exact CPT® or HCPCS code(s) billed and the member’s applicable ICD-10 diagnosis code(s)
If the policy references internal cross-reference codes or catalog codes, include those codes on the prior authorization submission
For injectable medications and new-to-market drugs, follow the drug-specific submission instructions and include NDC or HCPCS J-code detail when available

Prior Authorization

Codes Requiring Prior Authorization (Partial Examples)

Certain procedure groups and many individual CPT®/HCPCS codes throughout this document explicitly require prior authorization. Examples (partial list) include bariatric surgery (43644, 43645, 43659, 43770, 43775, 43842, 43845, 43846), joint replacement and related orthotic/prosthetic codes (L0464, L0486, L0632, L0638, L0480, L0624, L0634, L0640, L0629, L0636, L0700), transplant and CAR T-cell services, and advanced outpatient imaging. Check the relevant code lists and program entries for the full set of codes.

Bariatric surgery examples: 43644, 43645, 43659, 43770, 43775, 43842, 43845, 43846
Joint replacement/orthotics: L0464, L0486, L0632, L0638, L0480, L0624, L0634, L0640, L0629, L0636, L0700
Transplant/CAR T-cell: contact Optum Transplant Case Management 888-936-7246 for notification and authorization
Advanced outpatient imaging: notification/prior authorization required — submit via portal or call 866-889-8054

Prior Authorization

Injectable Medications — Submission Requirements

Injectable medications listed in this document require prior authorization. Submit injectable medication prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal and include HCPCS J‑codes, NDCs when applicable, diagnosis, and clinical documentation. Some biologics may require Optum Rx prior notification instead of portal PA.

Examples of injectable drugs requiring PA: J9000–J9999 class (chemotherapy injectables), Actemra J3262, Acthar J0801, Benlysta J0490, Beovu J0179, J9202 and others listed in the injectable medications sections
For certain drugs (e.g., Cimzia, Synagis) obtain prior notification via Optum Rx at 800-310-6826
Unclassified or miscellaneous drug codes billed under J3490/J3590/C9399: include product name and manufacturer; PA required only for specific products per drug list

Note

Use Program‑Specific Contacts When Required

Program-specific submission and notification requirements exist for services such as transplants, VADs, wound VACs, and advanced imaging. Follow the contact and fax instructions provided for each program and use the portal for standard prior authorization submissions. When a specialty intake (Optum Transplant, Optum VAD) is required, use the program phone/fax numbers rather than only the portal.

Transplant/CAR T-cell therapy: call Optum Transplant Case Management at 888-936-7246 or use the notification number on the member’s ID card
Ventricular Assist Devices (VAD): call notification number on member ID card and fax required form to Optum VAD Case Management at 855-282-8929
Wound VAC and other device-based programs: prior authorization required — use portal or program-specific contact information

ExamplesDiagnosis examples include C43.0, C43.10 and multiple C00–C06 and C44.x entries shown in the document

BRCA / breast molecular testing

ContentBRCA and breast molecular testing are included in the genetic/molecular testing category and are referenced alongside ICD mappings (examples: C44.191, C44.192, C4A.*, C22.x series)

Internal codesMapped to internal C-codes (multiple C4A, C22, C79, C84 entries) used for authorization submissions

ActionInclude the appropriate internal code mapping when requesting prior authorization for molecular/BRCA testing

Cxx.x series codes (e.g., C21.1, C44.192) — internal cross-reference code

Example seriesC21.x, C22.x and C4A.x series entries frequently used as internal cross-reference codes in the genetic/molecular testing section

UseProviders should reference these internal Cxx.x codes on prior authorization submissions to locate the mapped authorization criteria

ScopeApplies across multiple genetic/molecular testing entries and BRCA/breast cancer mappings

Genetic/molecular testing (BRCA) references

ReferencesDocument contains multiple references to genetic and molecular testing including BRCA and other gene testing mapped to internal C-codes

ExamplesInternal mappings shown include C79.32, C84.7, C92.4 and many C4A/C22-series entries used for molecular testing authorization

ImplicationGenetic/molecular testing codes are subject to prior authorization and should be submitted with appropriate diagnosis/internal code mapping

Genetic and molecular testing — referenced categories

ScopeGenetic and molecular testing categories (including BRCA and other gene tests) are explicitly referenced with associated internal C-codes and CPT/HCPCS mappings

ActionWhen requesting authorization for molecular/genetic tests, include the mapped internal C-code(s) shown in the policy

ExamplesMany C84.*, C92.* and C79.* series entries are listed as mappings for molecular testing requests