CurrentUnitedHealthcarePolicy N/A

Prior authorization and notification requirements (CPT/HCPCS/ICD codes) — Rocky Mountain Health Plans Medicare Advantage & D-SNP

Lists prior authorization and notification requirements (CPT/HCPCS/ICD codes and submission methods) for UnitedHealthcare Rocky Mountain Health Plans Medicare Advantage and Dual-Special-Needs Plans; applies to participating and non-participating providers delivering inpatient and outpatient services.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization and notification requirements for Rocky Mountain Health Plans Medicare Advantage & D-SNP

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization via the UnitedHealthcare Provider Portal or evicore (www.evicore.com or phone) before billing listed non-emergent CPT/HCPCS codes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>100listed CPT/HCPCS/ICD entries

evicoreevicore vendor

Online, fax, phonesubmission methods

Exemptemergency/urgent exempt

Coverage Criteria and Scope

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.

Prior authorization required — Covered when prior authorization obtained for listed services/codes

Covered when prior authorization obtained for listed services/codes.

Prior authorization required: Prior authorization or notification is required for the listed CPT/HCPCS/ICD codes and services; certain specialties (for example, many cardiology services) are managed by eviCore and require submission to that vendor.

No clinical medical-necessity criteria are provided in this section; this entry is an administrative list of codes that require prior authorization.

This administrative listing sets the operational expectation that prior authorization is not required for emergency or urgent care. Providers should follow the instructions in the general information section for submitting authorizations for non-emergent services (online via the UnitedHealthcare Provider Portal, by fax for non‑participating providers, or to eviCore for specified services).

This section segment contains an administrative listing of procedure ranges and entries and does not include explicit clinical coverage criteria or medical‑necessity rules. It identifies CPT ranges (for example, musculoskeletal and obstetrical/orthognathic ranges) and marks many entries with Prior authorization required but provides no clinical criteria within these chunks.

The content in these chunks is presented as an administrative list of CPT/HCPCS codes and related “how to obtain prior authorization” notes. There are no standalone clinical coverage criteria in these administrative code lists; the entries are focused on code-level prior authorization instructions and contact routing.

The document references unclassified and temporary codes (for example, entries labelled as Unclassified codes* or specific temporary/unlisted codes) but does not enumerate or provide clinical criteria for those unclassified codes in this segment. These entries are administrative placeholders indicating such codes are subject to prior authorization processes as noted elsewhere.

These chunks contain extensive code lists, HCPCS/K‑series and CPT ranges, and repeated prior authorization notations, but they do not define medical necessity rules or clinical eligibility criteria. The sections are principally code‑level instructions indicating where prior authorization is required and how certain services are routed (e.g., to eviCore).

Within these chunks there are no explicit statements declaring services to be ‘not medically necessary.’ The material is limited to prior authorization requirements for named medications and code lists and to notation of unclassified/temporary codes; it does not include negative medical‑necessity determinations in this segment.

Codes and Code Lists

Genetic / Molecular CPT/HCPCS requiring prior authorizationmixed

0143U	Temporary CPT® code - genetic test (listed)
0144U	Temporary CPT® code - genetic test (listed)
0145U	Temporary CPT® code - genetic test (listed)
0146U	Temporary CPT® code - genetic test (listed)
0610T	Category III CPT® code
81164	CPT® - Molecular pathology; genomic sequence analysis
81165	CPT® - Molecular pathology; genomic sequence analysis
81166	CPT® - Molecular pathology; genomic sequence analysis
81167	CPT® - Molecular pathology; genomic sequence analysis
81173	CPT® - Chromosome analysis, microarray; postnatal

1–10 of 45

1/5

Extended genetic / lab CPT codes (covered/require prior auth)CPT

81335	Genetic test
81336	Genetic test
81337	Genetic test
81346	Genetic test
81349	Genetic test
81350	Genetic test
81351	Genetic test
81353	Genetic test
81355	Genetic test
81361	Genetic test

1–10 of 13

1/2

Broad genomic testing CPT codesCPT

81400	CPT® - Molecular pathology, tier 1
81401	CPT® - Molecular pathology, tier 2
81402	CPT® - Molecular pathology
81403	CPT® - Advanced molecular testing
81404	CPT® - Advanced molecular testing
81405	CPT® - Advanced molecular testing
81406	CPT® - Advanced molecular testing
81407	CPT® - Advanced molecular testing
81408	CPT® - Advanced molecular testing
81410	CPT® - Genomic sequencing

1–10 of 14

1/2

Laboratory and specialty test CPT/HCPCS that require prior authorizationmixed

81427	Genomic test
81430	Genomic test
81431	Genomic test
81432	Genomic test
81434	Genomic test
81435	Genomic test
81554	Proteomic assay
81560	Specialty molecular test
81595	Specialty test
81596	Specialty test

1–10 of 25

1/3

New and miscellaneous temporary (Category III/PLA/U) codesmixed

0001U	PLA/Proprietary lab analyte
0002U	PLA/Proprietary lab analyte
0003U	PLA/Proprietary lab analyte
0004M	PLA/Proprietary lab analyte
0005U	PLA/Proprietary lab analyte
0006M	PLA/Proprietary lab analyte
0007M	PLA/Proprietary lab analyte
0007U	PLA/Proprietary lab analyte
0437T	Category III code
0443T	Category III code

1–10 of 19

1/2

Additional Category III / Temporary codesmixed

0514T	Category III
0523T	Category III
0524T	Category III
0541T	Category III
0542T	Category III
0546T	Category III
0554T	Category III
0555T	Category III
0556T	Category III
0557T	Category III

1–10 of 16

1/2

Extensive listed CPT/HCPCS/Q/C codes requiring authorization (selected)mixed

0600T	Category III
0601T	Category III
0602T	Category III
0603T	Category III
0604T	Category III
0605T	Category III
0606T	Category III
0607T	Category III
0608T	Category III
0613T	Category III

1–10 of 29

1/3

C-codes, HCPCS, G-codes and Miscellaneous (selected)mixed

C1761	HCPCS - implantable device
C1772	HCPCS
C1821	HCPCS
C1840	HCPCS
C1849	HCPCS
C1891	HCPCS
C2616	HCPCS
C2626	HCPCS
C9352	HCPCS
C9353	HCPCS

1–10 of 21

1/3

Additional HCPCS / Misc codesmixed

C9766	HCPCS
C9767	HCPCS
C9778	HCPCS
P9020	HCPCS - enteral formula
Q4112	HCPCS
S2107	HCPCS
G0176	Medicare G-code
G0276	G-code
G0283	G-code
G0460	G-code

1–10 of 13

1/2

Evicore-managed Radiology and Cardiology (examples)CPTCovered

70300	Radiology - skull x-ray
70310	Radiology - facial bones
70320	Radiology - sinus
70328	Radiology - orbit
74170	CT abdomen/pelvis
74174	CT abdomen w/contrast
74175	CT abdomen/pelvis w/contrast
74176	CT abdomen/pelvis perfusion
74177	CT abdomen/pelvis multi
74178	CT abdomen/pelvis other

1–10 of 14

1/2

Selected procedural CPTs that require authorizationCPT

31641	Thoracic procedure
31647	Thoracic procedure
31648	Thoracic procedure
31649	Thoracic procedure
31651	Thoracic procedure
31660	Thoracic procedure
31661	Thoracic procedure
32994	Cardiothoracic procedure
32999	Unlisted cardiac procedure
30400	Rhinoplasty

1–10 of 13

1/2

Provider Responsibilities and Submission Instructions

Prior Authorization

Prior Authorization Required — High-level provider actions

Providers must obtain prior authorization or notification for many services listed below. Failure to obtain required prior authorization or notification for non-emergent services may result in denial or non-payment. Use the UnitedHealthcare Provider Portal (UHCprovider.com) or eviCore for services they manage. For behavioral health, use the Behavioral Health number; for facility admissions, follow admitting facility notification instructions.

Submit requests online via the UnitedHealthcare Provider Portal: UHCprovider.com > Prior Authorization and Notification tab.
Non-participating providers may fax to 800-262-2567 or 970-255-5681.
eviCore-managed services: submit at www.evicore.com or call 800-792-8750.
Behavioral health services: call 888-282-8801.
Admitting facility notification: phone 800-416-2157, option 4 or 970-248-5197.

Prior Authorization

Extensive codes requiring prior authorization (summary)

This policy contains an extensive list of CPT and HCPCS codes (including many genetic/test lab codes, DME L-/K-/E-/A-codes, radiology CPT ranges, orthognathic and musculoskeletal surgery codes, infusion/injectable drug codes, and many T/C and temporary codes) that require prior authorization or notification. Many entries explicitly note "Additional information = Prior authorization required". When submitting requests, include the specific CPT/HCPCS code(s) and medication names (for injectables) on the prior authorization request.

Extensive lists include: genetic/test lab codes (e.g., 0019U–0041U, 81437–81599 series, etc.).
DME and orthotics/prosthetics L- and K-codes (many L59xx, L32xx, K06xx–K08xx ranges).
Radiology ranges managed by eviCore (e.g., 70300–79999 series and many 7xxxx ranges).
Musculoskeletal/orthognathic/spine/transplant surgery codes (e.g., 21029–21209, 21100–21150, 22505–22634, 20930–20999).
Infusion and injectable medications (e.g., many J- and C- codes; specific named drugs listed require prior authorization).
Home health and other service codes (e.g., 99600, G0248–G0250, S9364–S9368).

Prior Authorization

Submit via evicore or UnitedHealthcare as indicated

Certain services require submission to eviCore for review (radiology, cardiology, and some interventional procedures). For these, use eviCore’s online portal or phone number. Other services should be submitted to UnitedHealthcare via the Provider Portal or the phone number listed below.

Radiology services managed by eviCore — notification/prior authorization required for participating and non-participating providers through eviCore; submit at www.evicore.com or call 800-792-8750.
Cardiology services managed by eviCore — many cardiac CPTs listed (e.g., 33206–33227, 93456–93462, 93593–93597) require eviCore submission.
For radiology and cardiology managed by eviCore, follow eviCore submission instructions in the respective specialty prior authorization pages.
All other listed codes should be submitted via the UnitedHealthcare Provider Portal or by calling 800-666-1353 when indicated.

Documentation Required

DME / Orthotics & Prosthetics — Prior authorization required

Durable medical equipment and orthotics/prosthetics entries include many specific HCPCS L-/K-/E-/A-/B-codes that require prior authorization. Providers must follow code-level instructions and include device model numbers, descriptors, and clinical justification in requests.

DME and supplies with prior authorization notes include A42xx, E02xx, E26xx ranges and specific L-codes (L1499, L3000–L3260, L58xx–L61xx, L59xx–L61xx series).
K-code ranges K0001–K0864 and K08xx–K09xx entries listed require prior authorization.
Provide device specifics (brand/model), diagnosis, and clinical rationale when requesting authorization.
Failure to include required documentation for DME/orthotics may result in denial.

Prior Authorization

K-codes, injectable medications and code-level instructions

Multiple K-codes and many CPT/HCPCS codes listed (see code lists in the policy) require prior authorization. When requesting authorization for items or services billed with K- or J-/C-/G-codes, include the exact code and description and, for drugs, the medication name and NDC if applicable.

K-code examples in the policy include K0001–K0864 and many K08xx–K09xx entries.
Injectable and chemotherapy drug codes (e.g., J0185, J0640–J0642, J0897, J1453–J1454, J1627, J1950, J2506, J9019–J9047, J9198) require notification/prior authorization.
For unlisted/unclassified codes (e.g., C9172, C9399, J3490, J3590) include the specific drug name and clinical indication; these also require prior authorization.
Use exact code and drug name on the prior authorization request to avoid processing delays.

Denial Risk

Obtain authorization before services are provided — risk of denial if not obtained

Obtain prior authorization before providing services in categories that explicitly state prior authorization is required (examples below). Failure to obtain prior authorization when required may lead to claim denial or reduction in benefit.

OT/PT/ST/RT services — examples: 97533, 97597, 97598 require prior authorization.
Pain management procedures — e.g., 64451, 64461–64463, 64490–64495, 64628–64636 require prior authorization.
Musculoskeletal, orthognathic, obstetrical and related procedures — many CPT ranges (see policy) require prior authorization.
Spine surgery, stimulators, transplant procedures — listed high-acuity procedures require prior authorization before scheduling.

Documentation Required

Documentation of authorization requirement and specialty referral instructions

The policy repeatedly includes the phrase 'Additional information = Prior authorization required' for many entries. Use those entries as triggers that a prior authorization is mandatory. When an entry lists 'how to obtain prior authorization' pointing to a specialty prior authorization page (e.g., Cardiology Prior Authorization and Notification, Radiology Prior Authorization and Notification), follow that specialty-specific process.

Treat any line with 'Additional information = Prior authorization required' as requiring authorization.
Follow specialty-specific prior authorization pages when the entry references them (cardiology, radiology, etc.).
If a line notes eviCore management, submit requests to eviCore per their web/phone instructions.

Documentation Required

Use specific codes and medication/device names on prior authorization requests

Include specific codes, medication names, device model information, and supporting clinical documentation on all prior authorization requests to speed review and reduce denials. For injectable medications and unclassified codes, name the drug and include regimen/dosing and diagnosis.

For injectables and chemotherapy, include the CPT/HCPCS and J-/C-code plus medication name and indication (e.g., J0185 with drug name).
For unclassified temporary codes (e.g., C9172, C9399, J3490, J3590) include the actual drug name and strength.
For devices and DME, include brand/model numbers, measurements, and clinical justification.
When a line instructs 'Please submit requests online using the UnitedHealthcare Provider Portal' follow that channel; for eviCore-managed services use evicore.com.

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests for the codes listed in this document through the channel noted for each service (UnitedHealthcare Provider Portal or eviCore). If no specialty manager is specified, use the UnitedHealthcare Provider Portal or call 800-666-1353 for assistance.

Radiology/cardiology/interventional services managed by eviCore — submit at www.evicore.com or call 800-792-8750.
All other services listed — submit via UnitedHealthcare Provider Portal (UHCprovider.com) or call 800-666-1353 when the portal is unavailable.
Non-participating providers may fax documentation to the fax numbers listed earlier.
Include supporting clinical records and documentation as specified by the service type.

Denial Risk

Documentation and retention of authorization information — risk of denial if missing

Maintain documentation of prior authorization decisions and include authorization numbers on claims. If prior authorization is not obtained for a required non-emergent service, the claim may be denied. Keep records of submission method, decision, and any clinical notes used in the review.

Record the authorization number and include it on the claim submission.
Retain clinical documentation and correspondence used to support the authorization.
If an authorization is denied, follow UnitedHealthcare’s appeal or reconsideration processes as outlined in provider resources.

Definitions and Vendor Notes

eviCore-managed services

DefinitioneviCore-managed services are service categories (notably many cardiology and radiology procedures) for which prior authorization/notification is managed by eviCore.

How to submitSubmit requests online at www.evicore.com (sign in) or call eviCore at 800-792-8750.

ScopeeviCore submission requirement applies to participating and non-participating providers where entries indicate 'managed by eviCore' or direct providers to evicore.com.

Unclassified and temporary codes

Examples of unclassified/temporary codesC9172, C9399, J3490, J3590 are noted as unclassified or temporary and applicable for prior authorization processing.

Treatment for authorizationUnclassified/temporary codes should be included in prior authorization submissions when used; follow the same authorization process as for listed CPT/HCPCS codes.

NoteThe document flags these codes as unclassified/temporary but does not enumerate additional examples beyond the listed codes.

Orthognathic surgery

DefinitionOrthognathic surgery refers to surgical procedures of the jaw and facial skeleton referenced by CPT ranges and specific CPTs in this policy (e.g., 21100–21150 ranges).

CPT ranges requiring prior authorizationOrthognathic/maxillofacial ranges listed include 21100–21145, 21141–21146, 21142–21147, 21143–21150; related CPTs such as 21194–21199 and 21195–21215 are also referenced.

Provider actionObtain prior authorization for orthognathic and related maxillofacial procedures as indicated in the code lists before scheduling elective/non-emergent surgery.

Orthotics and prosthetics (L-codes)

DefinitionOrthotics and prosthetics (L-codes) are HCPCS L-series codes for orthotic and prosthetic devices; many specific L-codes listed in the document require prior authorization.

ExamplesThe policy lists numerous L-codes and ranges (e.g., L1499, L3000–L3999, L4000–L4999, L5000–L5999 and many specific L5xxx codes) with 'how to obtain prior authorization' entries.

Provider actionSubmit prior authorization requests referencing the specific L-code provided on the claim; follow the listed 'how to obtain prior authorization' guidance.

evicore

Roleevicore is the external vendor that manages prior authorization for many radiology and select specialty services for this plan.

Submission portalSubmit requests online at www.evicore.com (sign in) for services managed by eviCore.

Phone contactCall eviCore for authorizations at 800-792-8750.

OpenPayer

Prior authorization and notification requirements (CPT/HCPCS/ICD codes) — Rocky Mountain Health Plans Medicare Advantage & D-SNP

Coverage Criteria and Scope

Codes and Code Lists

Provider Responsibilities and Submission Instructions

Policy Background

Definitions and Vendor Notes