UnitedHealthcare Prior Auth Listing (MA & D‑SNP)

Coverage and Prior Authorization Criteria

Prior authorization general criteria

Covered/managed when prior authorization is obtained

Prior authorization requirement: Prior authorization or notification must be obtained for the listed services and codes for participating and out-of-network providers except for emergency or urgent care.

Providers must submit requests via the UnitedHealthcare Provider Portal (Prior Authorization and Notification tool), fax for non‑participating providers, or to eviCore for services managed by eviCore; behavioral health and admitting facility notifications have separate contacts.

Services requiring prior authorization/notification

Covered when prior authorization/notification is obtained for listed services

Prior authorization required: Providers must obtain prior authorization or provide notification for the specific services and CPT/HCPCS codes listed in this document (examples include cardiovascular procedures, injectable chemotherapy J‑codes, chiropractic care, cochlear implants, continuous glucose monitors, cosmetic procedures, digestive procedures, and durable medical equipment).

When indicated, submit cardiovascular and other eviCore‑managed services via evicore.com or 800‑792‑8750; follow code‑specific 'how to obtain prior authorization' instructions where provided.

Prior Authorization Coverage Condition

Covered when prior authorization is obtained for the listed items

Prior authorization requirement: Services, supplies, and drugs listed in this section (including home health services, hysterectomy/infusion/injectable codes, many J‑ and Q‑codes for specialty drugs and medical/surgical supplies) are covered only when prior authorization is obtained where indicated.

Medical and surgical supplies (Q‑codes) and named specialty drugs require prior authorization; failure to obtain prior authorization may result in claim denial.

Emergency or urgent care is explicitly exempt from prior authorization under this policy; no prior authorization is required for care that meets the document's definition of emergency or urgent services.

Within the extracted document segments there are no explicit exclusions listed beyond the general emergency/urgent care exemption; the content focuses on services and codes that require prior authorization rather than enumerating exclusions.

The section does not list explicit exclusions other than the implication that items shown require prior authorization — meaning that services and drugs not on the list are not addressed here, and claims for listed items provided without authorization may be at risk of denial.

No statements in the provided segments declare any listed service or code to be not medically necessary; the content is administrative and centers on prior authorization requirements.

The document segments supplied do not designate any services or codes as not medically necessary; rather, they identify drugs, supplies, and procedures that require prior authorization to be considered for coverage.

CPT, HCPCS, and Other Codes Requiring Authorization

Prosthetics & orthotics — advanced componentsHCPCSCovered

L6655	Powered knee prosthesis
L6660	Powered ankle prosthesis
L6670	Prosthetic liner, silicone
L6672	Prosthetic liner, gel
L6675	Socket insert, custom
L6676	Socket insert, prefabricated
L6677	Prosthetic suspension, vacuum
L6680	Prosthetic foot, multi-axial
L6682	Prosthetic pylon, custom
L6684	Prosthetic adapter, connector

HCPCS L-codes — miscellaneous orthotics/prostheticsHCPCSCovered

L6687	Prosthetic hand, myoelectric
L6688	Prosthetic partial hand
L6689	Prosthetic activity-specific component
L6691	Prosthetic accessory, thermoplastic
L6694	Fabrication of custom prosthesis
L6695	Maintenance/replacement of prosthesis
L6696	Prosthetic fitting, initial
L6697	Prosthetic fitting, subsequent
L6704	Custom upper limb prosthesis
L6706	Hybrid prosthetic component

HCPCS L-codes — continued inventoryHCPCSCovered

L6707	Prosthetic device, below-knee
L6708	Prosthetic device, above-knee
L6709	Prosthetic device, hip disarticulation
L6711	Prosthetic harness or socket accessory
L6712	Prosthetic suction sleeve
L6713	Prosthetic knee module
L6714	Prosthetic ankle module
L6715	Transport/storage case for prosthesis
L6721	Prosthetic consultation/evaluation

HCPCS L-codes — further devicesHCPCSCovered

L6805	Custom cranial prosthesis
L6810	Cranial prosthesis, prefabricated
L6881	Orthotic device, spinal, component
L6882	Orthotic device, spinal, custom
L6883	Back orthosis alteration
L6884	Orthotic pelvic support
L6885	Orthotic hip support

HCPCS L-codes — lower limb, knee, footHCPCSCovered

L6890	Ankle-foot orthosis accessory
L6900	Foot orthosis, molded to patient model
L6905	Prefabricated foot orthosis
L6910	Toe filler, preformed
L6915	Foot plate
L6920	Heel wedge, adjustable
L6925	Initial fitting of foot orthosis
L6930	Replacement foot shell
L6935	Foot orthosis modification
L6940	Knee orthosis upgrade

HCPCS L-codes — continued lower limb & accessoriesHCPCSCovered

L6945	Knee orthosis, replacement part
L6950	Knee orthosis, custom interface
L6955	Knee orthosis, dynamic
L6965	Foot-ankle brace, custom
L6970	Ankle-foot orthosis, secondary
L6975	Orthotic repair, major
L7007	Orthotic sensor component
L7008	Orthotic smart module
L7009	Orthotic electronic accessory
L7040	Orthotic padding, custom

HCPCS L-codes — specialty and high-cost devicesHCPCSCovered

L7402	Seating system component
L7403	Wheelchair positioning accessory
L7404	Adaptive seating custom
L7405	Complex rehab technology component
L7499	Unlisted orthotic/prosthetic device
L7510	Orthotic sensor, diagnostic
L7520	Prosthetic sensor, diagnostic

HCPCS L-codes — hearing/vision assistive (selected)HCPCSCovered

L8500	Hearing aid, behind-the-ear
L8501	Hearing aid, in-the-ear
L8505	Hearing aid accessory
L8507	Hearing aid rechargeable
L8509	Hearing aid custom mold
L8510	Vision assistive device
L8511	Visual aid accessory
L8512	Device for low vision
L8513	Assistive listening device
L8514	Aural rehab device

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HCPCS L-codes — additional listed codesHCPCSCovered

L8614	Prosthetic knee, microprocessor component
L8615	Prosthetic knee, battery component
L8616	Orthotic knee actuator
L8617	Orthotic microprocessor controller
L8618	Orthotic power source
L8619	Orthotic charging station
L8621	Prosthetic electronic sensor
L8622	Prosthetic adaptive foot
L8623	Prosthetic dynamic ankle
L8624	Prosthetic accessory, advanced

HCPCS L-codes — remaining listed codesHCPCSCovered

L8625	Orthotic interface, advanced
L8627	Prosthetic component, sensor-driven
L8628	Prosthetic component, AI-enabled
L8629	Orthotic/prosthetic software component
L8658	Orthotic specialty item
L8679	Therapeutic prosthetic device
L8680	Custom adaptive device
L8681	Sensory prosthetic component
L8682	Advanced orthotic assembly
L8683	Orthotic/prosthetic replacement

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Musculoskeletal and extremity MRI/CT (selected)CPT

73200	MRI shoulder without contrast
73201	MRI shoulder with contrast
73202	MRI shoulder without & with contrast
73206	MRI elbow
73218	MRI wrist
73219	MRI hand
73220	CT shoulder
73221	CT elbow
73222	CT wrist
73223	CT hand

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Cardiology & Vascular Imaging CPT codes (evicore-managed)CPT

70336	Radiology skull/CT (placeholder)
70460	CT head/neck (placeholder)
70470	CT facial bones (placeholder)
71260	CT chest with contrast (placeholder)
71270	CT chest without contrast (placeholder)
71551	CT chest advanced (placeholder)
72125	MRI lumbar spine without contrast (placeholder)
72126	MRI lumbar spine with contrast (placeholder)

Provider Submission, Authorization, and Denial Risk Guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required for the CPT/HCPCS codes and services listed below. Failure to obtain prior authorization for non-emergent services may result in claim denial for participating and non‑participating providers. Prior authorization is not required for emergency or urgent care.

Obtain prior authorization before performing services marked "Prior authorization required" or "Notification/prior authorization required".
Radiology and certain cardiology services are managed by eviCore — submit requests at www.evicore.com or call 800-792-8750 where indicated.
Submit general prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or call 800-666-1353 if specified.

Note

How to Submit Requests

Providers must submit prior authorization requests using the methods noted in this section. Use the UnitedHealthcare Provider Portal Prior Authorization and Notification tool to submit online. For eviCore-managed services (cardiology, many radiology procedures), submit at evicore.com or call 800-792-8750. Non‑participating providers may fax requests and documentation to 800-262-2567 or 970-255-5681.

Policy Background

This policy is an administrative listing of services and codes that require prior authorization or notification for participating UnitedHealthcare Rocky Mountain Health Plan Medicare Advantage and Dual-Special Needs Plan providers. It applies to both inpatient and outpatient services and establishes that, except for urgent or emergency care, providers must obtain prior authorization or provide notification for the services and codes enumerated in the document. Submission channels include the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, fax for non‑participating providers, and eviCore for certain managed services; behavioral health and admitting facility contacts are provided in the document.

Key Definitions

Emergency or urgent care — prior authorization exemption and submission methods

DefinitionEmergency or urgent care: care for which prior authorization is not required under this policy.

Provider submission methodsPrior authorization requests are submitted via the UnitedHealthcare Provider Portal, fax for non-participating providers, or eviCore for certain services (evicore.com; 800-792-8750).

Notification contactsBehavioral health: 888-282-8801; admitting facility notification: 800-416-2157 (option 4) or 970-248-5197.

Cochlear implant — definition and coding context

DefinitionCochlear implant: a medical device within the inner ear with an external portion to help persons with profound sensorineural deafness achieve conversational hearing.

Associated codes

OpenPayer

Prior authorization and notification requirements — Rocky Mountain Health Plans Medicare Advantage & D‑SNP

Coverage and Prior Authorization Criteria

CPT, HCPCS, and Other Codes Requiring Authorization

Provider Submission, Authorization, and Denial Risk Guidance

Policy Background

Key Definitions