UnitedHealthcare

Experim ental and investigational Prior authorization required

Cosm etic and reconstructive Prior authorization required

Cosm etic and reconstructive Prior authorization required

Cosm etic and reconstructive Prior authorization required

Cosm etic and reconstructive Prior authorization required

Cosmetic procedures that change or

Cosmetic procedures that change or

Cosmetic procedures that change or

Cosmetic procedures that change or

improve physical appearance w ithout

improve physical appearance w ithout

improve physical appearance w ithout

improve physical appearance w ithout

Breast reconstruction Prior authorization required

Breast reconstruction Prior authorization required

Breast reconstruction Prior authorization required

Breast reconstruction Prior authorization required

(non-m astectomy)

(non-m astectomy)

(non-m astectomy)

(non-m astectomy)

Reconstruction of the breast except

Reconstruction of the breast except

Reconstruction of the breast except

Reconstruction of the breast except

19370 19371 19380 19396

19370 19371 19380 19396

19370 19371 19380 19396

19370 19371 19380 19396

Cancer supportive care Prior authorization required for colony- Injectable colony-stim ulating factor drugs

Cancer supportive care Prior authorization required for colony- Injectable colony-stim ulating factor drugs

Cancer supportive care Prior authorization required for colony- Injectable colony-stim ulating factor drugs

Cancer supportive care Prior authorization required for colony- Injectable colony-stim ulating factor drugs

Bone grow th stim ulator Prior authorization required

Orthognathic surgery Prior authorization required

Orthognathic surgery Prior authorization required

Orthognathic surgery Prior authorization required

Orthognathic surgery Prior authorization required

physiological function

physiological function

physiological function

Treatment of maxillofacial/jaw

Treatment of maxillofacial/jaw

Treatment of maxillofacial/jaw

Treatment of maxillofacial/jaw

functional impairment

functional impairment

functional impairment

functional impairment

Orthognathic surgery (cont’d)

Orthognathic surgery (cont’d)

Orthognathic surgery (cont’d)

Orthognathic surgery (cont’d)

physiological function

21182 21183 21184 21230

21182 21183 21184 21230

21182 21183 21184 21230

21182 21183 21184 21230

21235 21256 21275 21280

21235 21256 21275 21280

21235 21256 21275 21280

21196 21198 21199 21206

21196 21198 21199 21206

21196 21198 21199 21206

21196 21198 21199 21206

21208 21209 21210 21215

21208 21209 21210 21215

21208 21209 21210 21215

21208 21209 21210 21215

21240 21242 21244 21245

21240 21242 21244 21245

21240 21242 21244 21245

21240 21242 21244 21245

21235 21256 21275 21280

21282 21295 21740 21742

21246 21247 21248 21249

21246 21247 21248 21249

21246 21247 21248 21249

21246 21247 21248 21249

21255 21296 21299

21255 21296 21299

21255 21296 21299

21255 21296 21299

Orthotics and prosthetics: m ore than Prior authorization required only in L0112 L0170 L0456 L0462

21282 21295 21740 21742

21282 21295 21740 21742

21282 21295 21740 21742

21743 28344 30620 67900

21743 28344 30620 67900

Orthotics and prosthetics: m ore than Prior authorization required only in L0112 L0170 L0456 L0462

Orthotics and prosthetics: m ore than Prior authorization required only in L0112 L0170 L0456 L0462

Sleep apnea procedures and Prior authorization required

21743 28344 30620 67900

21743 28344 30620 67900

67901 67902 67903 67904

Spinal surgery Prior authorization required

Spinal surgery Prior authorization required

Spinal surgery Prior authorization required

Spinal surgery Prior authorization required

22210 22212 22214 22220

22210 22212 22214 22220

22210 22212 22214 22220

22210 22212 22214 22220

22224 22532 22533 22548

22224 22532 22533 22548

22224 22532 22533 22548

22224 22532 22533 22548

22551 22554 22556 22558

22551 22554 22556 22558

22551 22554 22556 22558

22551 22554 22556 22558

22586 22590 22595 22600

22586 22590 22595 22600

22586 22590 22595 22600

22586 22590 22595 22600

22610 22612 22630 22633

22610 22612 22630 22633

22610 22612 22630 22633

22610 22612 22630 22633

22800 22802 22804 22808

22800 22802 22804 22808

22800 22802 22804 22808

22800 22802 22804 22808

22810 22812 22818 22819

22810 22812 22818 22819

22810 22812 22818 22819

22810 22812 22818 22819

22830 22849 22850 22852

22830 22849 22850 22852

22830 22849 22850 22852

22830 22849 22850 22852

22855 22856 22861 22864

22855 22856 22861 22864

22855 22856 22861 22864

22855 22856 22861 22864

22865 22899 63001 63003

22865 22899 63001 63003

22865 22899 63001 63003

22865 22899 63001 63003

63005 63011 63012 63015

63005 63011 63012 63015

Joint replacem ent Prior authorization required

Joint replacem ent Prior authorization required

Joint replacem ent Prior authorization required

Joint replacem ent Prior authorization required

Joint, total hip and knee replacement

Joint, total hip and knee replacement

Joint, total hip and knee replacement

Joint, total hip and knee replacement

27125 27130 27132 27134

27125 27130 27132 27134

27125 27130 27132 27134

27125 27130 27132 27134

27137 27138 27412 27446

27137 27138 27412 27446

27137 27138 27412 27446

27137 27138 27412 27446

27447 27486 27487 29866

27447 27486 27487 29866

27447 27486 27487 29866

27447 27486 27487 29866

29867 29868

29867 29868

29867 29868

67901 67902 67903 67904

29867 29868

Non-em ergent am bulance transport Prior authorization required A0430 A0431 A0435 A0436

Non-em ergent am bulance transport Prior authorization required A0430 A0431 A0435 A0436

Fem oroacetabular im pingement Prior authorization required

Fem oroacetabular im pingement Prior authorization required

Fem oroacetabular im pingement Prior authorization required

Rhinoplasty and septoplasty Prior authorization required

Rhinoplasty and septoplasty Prior authorization required

Rhinoplasty and septoplasty Prior authorization required

Rhinoplasty and septoplasty Prior authorization required

Treatment of nasal functional

Treatment of nasal functional

Treatment of nasal functional

Treatment of nasal functional

impairment and septal deviation

67901 67902 67903 67904

Functional endoscopic sinus Prior authorization required

Functional endoscopic sinus Prior authorization required

Functional endoscopic sinus Prior authorization required

Functional endoscopic sinus Prior authorization required

surgery (FESS)

surgery (FESS)

surgery (FESS)

surgery (FESS)

Hom e health care Prior authorization required only in G0299 G0300 G0493 G0494

Hom e health care Prior authorization required only in G0299 G0300 G0493 G0494

Hom e health care Prior authorization required only in G0299 G0300 G0493 G0494

Sinuplasty Prior authorization required

Sinuplasty Prior authorization required

Sinuplasty Prior authorization required

Sinuplasty Prior authorization required

32854 32855 32856 33930

32854 32855 32856 33930

32854 32855 32856 33930

32854 32855 32856 33930

33933 33935 33940 33944

33933 33935 33940 33944

33933 33935 33940 33944

Experim ental and investigational Prior authorization required

33976 33979 33981 33982

33976 33979 33981 33982

33976 33979 33981 33982

33933 33935 33940 33944

33945 38208 38209 38210

33945 38208 38209 38210

33945 38208 38209 38210

33945 38208 38209 38210

38212 38213 38214 38215

33976 33979 33981 33982

33983 Q0507 Q0508 Q0509

33983 Q0507 Q0508 Q0509

33983 Q0507 Q0508 Q0509

33983 Q0507 Q0508 Q0509

Ventricular assist devices (VAD) Prior authorization required Please call the notification number on the back

Vein procedures Prior authorization required

Vein procedures Prior authorization required

Vein procedures Prior authorization required

Vein procedures Prior authorization required

Experim ental and investigational Prior authorization required

Removal and ablation of the main

Removal and ablation of the main

Removal and ablation of the main

Removal and ablation of the main

Q2040 Q2041 S2107

38212 38213 38214 38215

38212 38213 38214 38215

38212 38213 38214 38215

38232 38240 38241 38242

38232 38240 38241 38242

38232 38240 38241 38242

38232 38240 38241 38242

44132 44133 44135 44136

44132 44133 44135 44136

44132 44133 44135 44136

44132 44133 44135 44136

Q2040 Q2041 S2107

Sleep apnea procedures and Prior authorization required

Sleep apnea procedures and Prior authorization required

Bariatric surgery Prior authorization required

Bariatric surgery Prior authorization required

Bariatric surgery Prior authorization required

Bariatric surgery Prior authorization required

Bariatric surgery and specific obesity

Bariatric surgery and specific obesity

Bariatric surgery and specific obesity

Bariatric surgery and specific obesity

related services

related services

related services

related services

95981 95982

95981 95982

44137 44715 44720 44721

44137 44715 44720 44721

44137 44715 44720 44721

44137 44715 44720 44721

47133 47135 47140 47141

47133 47135 47140 47141

47133 47135 47140 47141

47133 47135 47140 47141

47142 47143 47144 47145

47142 47143 47144 47145

47142 47143 47144 47145

47142 47143 47144 47145

47146 47147 48551 48552

47146 47147 48551 48552

47146 47147 48551 48552

47146 47147 48551 48552

48554 50300 50320 50323

48554 50300 50320 50323

48554 50300 50320 50323

48554 50300 50320 50323

50325 50340 50360 50365

50325 50340 50360 50365

50325 50340 50360 50365

50325 50340 50360 50365

50370 50380 50547 S2060

50370 50380 50547 S2060

50370 50380 50547 S2060

50370 50380 50547 S2060

S2061 S2152

S2061 S2152

S2061 S2152

Experim ental and investigational Prior authorization required

Abortion Prior authorization required

Abortion Prior authorization required

Abortion Prior authorization required

Abortion Prior authorization required

59866

59866

59866

59866

Bariatric surgery Prior authorization required 43644 43645 43648 43659

61886 64555 64722 66180

61886 64555 64722 66180

61886 64555 64722 66180

61886 64555 64722 66180

Vagus nerve stim ulation Prior authorization required

95978 S2102

63005 63011 63012 63015

63005 63011 63012 63015

63016 63017 63020 63030

63016 63017 63020 63030

63016 63017 63020 63030

63016 63017 63020 63030

63040 63042 63045 63046

63040 63042 63045 63046

63040 63042 63045 63046

63040 63042 63045 63046

63047 63050 63055 63056

63047 63050 63055 63056

63047 63050 63055 63056

63047 63050 63055 63056

63064 63075 63077 63081

63064 63075 63077 63081

63064 63075 63077 63081

63064 63075 63077 63081

63085 63087 63090 63101

63085 63087 63090 63101

63085 63087 63090 63101

63085 63087 63090 63101

63102 63170 63172 63173

63102 63170 63172 63173

63102 63170 63172 63173

63102 63170 63172 63173

63180 63182 63185 63190

63180 63182 63185 63190

63180 63182 63185 63190

63180 63182 63185 63190

63191 63194 63195 63196

63191 63194 63195 63196

63191 63194 63195 63196

63191 63194 63195 63196

63198 63199 63200 63250

63198 63199 63200 63250

63198 63199 63200 63250

63198 63199 63200 63250

Spinal cord stimulators w hen implanted

Spinal cord stimulators w hen implanted

Spinal cord stimulators w hen implanted

Spinal cord stimulators w hen implanted

63268 63270 63271 63272

63268 63270 63271 63272

63268 63270 63271 63272

63268 63270 63271 63272

Spinal surgery (cont’d) 63286 63300 63301 63302

Spinal surgery (cont’d) 63286 63300 63301 63302

Spinal surgery (cont’d) 63286 63300 63301 63302

Spinal surgery (cont’d) 63286 63300 63301 63302

Spinal surgery (cont’d)

Spinal surgery (cont’d)

Spinal surgery (cont’d)

Spinal surgery (cont’d)

63307 63308 64570

63307 63308 64570

63307 63308 64570

63307 63308 64570

Transplants Prior authorization required For transplant and CAR T-cell therapy services

Transplants Prior authorization required For transplant and CAR T-cell therapy services

Spinal stim ulator for pain Prior authorization required

Spinal stim ulator for pain Prior authorization required

Spinal stim ulator for pain Prior authorization required

95978 S2102

Vagus nerve stim ulation Prior authorization required

Transplants Prior authorization required For transplant and CAR T-cell therapy services

95981 95982

95978 S2102

95978 S2102

67901 67902 67903 67904

67906 67908 67909 67911

67906 67908 67909 67911

67906 67908 67909 67911

67906 67908 67909 67911

67912 67914 67915 67916

67912 67914 67915 67916

67912 67914 67915 67916

67912 67914 67915 67916

67917 67921 67922 67923

67917 67921 67922 67923

67917 67921 67922 67923

67917 67921 67922 67923

67924 67950 67961 67966

67924 67950 67961 67966

67924 67950 67961 67966

67924 67950 67961 67966

Q2026

Q2026

Q2026

Q2026

Cochlear im plants and other Prior authorization required

Cochlear im plants and other Prior authorization required

Cochlear im plants and other Prior authorization required

Cochlear im plants and other Prior authorization required

auditory im plants

Proton beam therapy Prior authorization required

Proton beam therapy Prior authorization required

Proton beam therapy Prior authorization required

Proton beam therapy Prior authorization required

BRCA genetic testing Prior authorization required

BRCA genetic testing Prior authorization required

BRCA genetic testing Prior authorization required

BRCA genetic testing Prior authorization required

81432 81433

81432 81433

81432 81433

81432 81433

Breast reconstruction Prior authorization required 19316 19318 19324 19325

Breast reconstruction Prior authorization required 19316 19318 19324 19325

J1556 J1557 J1559 J1561

J1556 J1557 J1559 J1561

Probuphine

How to Obtain Prior Authorization

95981 95982

Bone grow th stim ulator Prior authorization required 20975 E0747 E0748 E0760

Bone grow th stim ulator Prior authorization required 20975 E0747 E0748 E0760

Non-em ergent am bulance transport Prior authorization required

Non-em ergent am bulance transport Prior authorization required

Non-em ergent am bulance transport Prior authorization required

Non-em ergent am bulance transport Prior authorization required

Enteral services Prior authorization required

Enteral services Prior authorization required

Enteral services Prior authorization required

Enteral services Prior authorization required

In-home nutritional therapy, either

In-home nutritional therapy, either

In-home nutritional therapy, either

In-home nutritional therapy, either

enteral or through a gastrostomy tube

enteral or through a gastrostomy tube

enteral or through a gastrostomy tube

enteral or through a gastrostomy tube

Experim ental and investigational Prior authorization required 0191T 33477 36514 55866

Experim ental and investigational Prior authorization required 0191T 33477 36514 55866

Experim ental and investigational Prior authorization required 0191T 33477 36514 55866

Experim ental and investigational Prior authorization required 0191T 33477 36514 55866

Durable m edical equipm ent (DME): Prior authorization required only in

Durable m edical equipm ent (DME): Prior authorization required only in

Durable m edical equipm ent (DME): Prior authorization required only in

Durable m edical equipm ent (DME): Prior authorization required only in

m ore than $500 outpatient settings, to include patient’s

m ore than $500 outpatient settings, to include patient’s

m ore than $500 outpatient settings, to include patient’s

m ore than $500 outpatient settings, to include patient’s

purchase or cumulative rental cost of

purchase or cumulative rental cost of

purchase or cumulative rental cost of

purchase or cumulative rental cost of

more than $500

more than $500

more than $500

more than $500

Orthotics and prosthetics. *

Bone grow th stim ulator Prior authorization required

Bone grow th stim ulator Prior authorization required

Bone grow th stim ulator Prior authorization required

Orthotics and prosthetics. *

Orthotics and prosthetics. *

Orthotics and prosthetics. *

Some home health care services E1005 E1006 E1007 E1008

Some home health care services E1005 E1006 E1007 E1008

Some home health care services E1005 E1006 E1007 E1008

Some home health care services E1005 E1006 E1007 E1008

Some home health care services

Some home health care services

Some home health care services

Some home health care services

may qualify but are not subject to

may qualify but are not subject to

may qualify but are not subject to

may qualify but are not subject to

care.

care.

care.

care.

*J&B Medical Supply Co, Inc. is the E1238 E1239 E2100 E2230

*J&B Medical Supply Co, Inc. is the E1238 E1239 E2100 E2230

*J&B Medical Supply Co, Inc. is the E1238 E1239 E2100 E2230

*J&B Medical Supply Co, Inc. is the E1238 E1239 E2100 E2230

*J&B Medical Supply Co, Inc. is the

*J&B Medical Supply Co, Inc. is the

*J&B Medical Supply Co, Inc. is the

*J&B Medical Supply Co, Inc. is the

J&B Medical Supply, please call 800

J&B Medical Supply, please call 800

J&B Medical Supply, please call 800

J&B Medical Supply, please call 800

737-0045

737-0045

737-0045

737-0045

Wound vac Prior authorization required

E8001 K0005 K0108 K0812

E8001 K0005 K0108 K0812

E8001 K0005 K0108 K0812

E8001 K0005 K0108 K0812

K0830 K0831 K0848 K0849

Hom e health care Prior authorization required only in

Hom e health care Prior authorization required only in

Hom e health care Prior authorization required only in

Hom e health care Prior authorization required only in

outpatient settings, to include

outpatient settings, to include

How to Obtain Prior Authorization

Probuphine

Injectable m edications Prior authorization required Botox

Injectable m edications Prior authorization required Botox

Injectable m edications Prior authorization required Botox

Injectable m edications Prior authorization required Botox

), Leucovorin ( ), Levoleucovorin

( )

Denosum ab

Cancer supportive care (cont’d)

How to Obtain Prior Authorization

J1556 J1557 J1559 J1561

J1556 J1557 J1559 J1561

J1566 J1568 J1569 J1572

J1566 J1568 J1569 J1572

J1566 J1568 J1569 J1572

J1566 J1568 J1569 J1572

J1575 J1599

J1575 J1599

J1575 J1599

J1575 J1599

IVIG

IVIG

Makena

Makena

Nucala

Nucala

Probuphine

How to Obtain Prior Authorization

Makena

Cinqair

How to Obtain Prior Authorization

Q2040 Q2041 S2107

 Chemotherapy injectable drugs (

), Leucovorin ( ), Levoleucovorin

K0830 K0831 K0848 K0849

K0830 K0831 K0848 K0849

K0830 K0831 K0848 K0849

K0850 K0851 K0852 K0853

K0850 K0851 K0852 K0853

K0850 K0851 K0852 K0853

K0850 K0851 K0852 K0853

K0854 K0855 K0856 K0857

K0854 K0855 K0856 K0857

K0854 K0855 K0856 K0857

K0854 K0855 K0856 K0857

K0858 K0859 K0860 K0861

K0858 K0859 K0860 K0861

K0858 K0859 K0860 K0861

K0858 K0859 K0860 K0861

K0862 K0863 K0864 K0868

K0862 K0863 K0864 K0868

K0862 K0863 K0864 K0868

K0862 K0863 K0864 K0868

K0869 K0870 K0871 K0877

K0869 K0870 K0871 K0877

K0869 K0870 K0871 K0877

K0869 K0870 K0871 K0877

K0878 K0879 K0880 K0884

K0878 K0879 K0880 K0884

K0878 K0879 K0880 K0884

K0878 K0879 K0880 K0884

K0885 K0886 K0890 K0891

K0885 K0886 K0890 K0891

K0885 K0886 K0890 K0891

K0885 K0886 K0890 K0891

S1040 V5274

S1040 V5274

S1040 V5274

S1040 V5274

Orthotics and prosthetics: m ore than Prior authorization required only in

Orthotics and prosthetics: m ore than Prior authorization required only in

Orthotics and prosthetics: m ore than Prior authorization required only in

Orthotics and prosthetics: m ore than Prior authorization required only in

$500 outpatient settings, to include

$500 outpatient settings, to include

$500 outpatient settings, to include

$500 outpatient settings, to include

w ith a retail purchase or cumulative

w ith a retail purchase or cumulative

w ith a retail purchase or cumulative

w ith a retail purchase or cumulative

rental cost of more than $500

rental cost of more than $500

rental cost of more than $500

rental cost of more than $500

L1000 L1005 L1200 L1300

L1000 L1005 L1200 L1300

L1000 L1005 L1200 L1300

L1000 L1005 L1200 L1300

L1499 L1680 L1700 L1710

L1499 L1680 L1700 L1710

L1499 L1680 L1700 L1710

L1499 L1680 L1700 L1710

L1720 L1730 L1755 L1834

L1720 L1730 L1755 L1834

L1720 L1730 L1755 L1834

L1720 L1730 L1755 L1834

L1840 L1844 L1845 L1846

L1840 L1844 L1845 L1846

L1840 L1844 L1845 L1846

L1840 L1844 L1845 L1846

L1860 L1945 L1950 L1970

L1860 L1945 L1950 L1970