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Prior Authorization Requirements forUnitedHealthcare of the River ValleyEffective September 1, 2022General InformationThis list comprises prior authorization review requirements for care providers who participate with UnitedHealthcare of theRiver Valley for in-network services. Updates to the list are announced routinely in the UnitedHealthcare Network News.For more information, please call Provider Services at 877-842-3210.To request prior authorization, please submit your request online or by phone: Online: Use the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal. Go toUHCprovider.com and click on the UnitedHealthcare Provider Portal button in the top right corner. Then, select thePrior Authorization and Notification tool on your Provider Portal button dashboard.Phone: 877-842-3210Prior authorization is not required for emergency or urgent care. Out-of-network physicians, facilities and otherhealth care providers must request prior authorization for all procedures and services, excluding emergent orurgent care.The following procedures and services and listed CPT codes require prior authorization for all UnitedHealthcare of theRiver Valley plan members in both outpatient and inpatient settings,unless otherwise noted.Procedures andServicesAdditional InformationArthroplastyPrior authorization requiredArthroscopyPrior authorization requiredCPT or HCPCS Codes and/orHow to Obtain Prior 70327487Prior authorization is required for all states.298262984329871Prior authorization is required for all states. In addition, site ofservice will be reviewed as part of the prior authorization process forthe following codes except in AK, MA, PR, TX, UT, VI, and 825298272982829830298342983529836Insurance coverage provided by or through UnitedHealthcare Insurance Company, All Savers Insurance Company, Oxford Health Insurance, Inc. ortheir affiliates. Health Plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California,UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc.,UnitedHealthcare of Texas, LLC, UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc.,Oxford Health Plans (NJ), Inc. and Oxford Health Plans (CT), Inc. or other affiliates. Administrative services provided by United HealthCare Services,Inc., OptumRx, OptumHealth Care Solutions, LLC, Oxford Health Plans LLC or their affiliates. Behavioral health products are provided by U.S.Behavioral Health Plan, California (USBHPC), United Behavioral Health (UBH) or its affiliates.CPT is a registered trademark of the American Medical Association.PCA-1-20-02170-Clinical-WEB 07232020 2020 United HealthCare Services, Inc. All rights reserved.

Procedures andServicesArthroscopy(continued)Bariatric surgeryBariatric surgery andspecific obesityrelated servicesAdditional InformationPrior authorization requiredThere is a Center of Excellencerequirement for coverage ofbariatric surgery and services.In certain situations, bariatricsurgery and other obesityrelated services aren’t coveredby some benefit plans. For moreinformation, please call877-842-3210.Behavioral healthMany of our benefit plans onlyprovide coverage for behavioralserviceshealth services through adesignated behavioral healthnetwork.Bone growth stimulato Prior authorization requiredElectronic stimulationor ultrasound to healfracturesBreast reconstruction Prior authorization required(non-mastectomy)Reconstruction of thebreast, except whenfollowing mastectomyCPT or HCPCS Codes and/orHow to Obtain Prior 438864388743888*Notification/prior authorization required for the following diagnosiscodes: E66.01, E66.09, E66.1-E66.3, E66.8, E66.9, Z68.1, Z68.20Z68.22, Z68.30-Z68.39, Z68.41-Z68.45For specific codes requiring prior authorization, please call thenumber on the member’s health plan ID card to refer for mentalhealth and substance abuse/substance 9380193691939619370L8600Prior authorization not required for thefollowing diagnosis 2C50.229Insurance coverage provided by or through UnitedHealthcare Insurance Company, All Savers Insurance Company, Oxford Health Insurance, Inc. ortheir affiliates. Health Plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California,UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc.,UnitedHealthcare of Texas, LLC, UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc.,Oxford Health Plans (NJ), Inc. and Oxford Health Plans (CT), Inc. or other affiliates. Administrative services provided by United HealthCare Services,Inc., OptumRx, OptumHealth Care Solutions, LLC, Oxford Health Plans LLC or their affiliates. Behavioral health products are provided by U.S.Behavioral Health Plan, California (USBHPC), United Behavioral Health (UBH) or its affiliates.CPT is a registered trademark of the American Medical Association.PCA-1-20-02170-Clinical-WEB 07232020 2020 United HealthCare Services, Inc. All rights reserved.

Procedures andServicesBreast l InformationCancer supportive care Prior authorization required forinjectable chemotherapy drugsadministered in an outpatientsetting, including intravenous,intravesical and intrathecal for acancer diagnosisPrior authorization required forcolony-stimulating factor drugsadministered in an outpatientsetting for a cancer diagnosis*Codes J0897, J1442, J1447,J2506, Q5101, Q5108, Q5110,Q5111, Q5120, Q5122 andQ5125 also require priorauthorization for non-oncologyDX. See Injectable medicationssection below.CPT or HCPCS Codes and/orHow to Obtain Prior 3Anti-Emetics that require prior authorizationAkynzeo (palonosetron/fosnetupitant)J1454CinvantiTM (aprepitant)J0185Emend (fosaprepitant)J1453Sustol (granisetron extended release)J1627Bone-modifying agent that requires prior authorization:Denosumab (Prolia , Xgeva )J0897*Injectable colony-stimulating factor drugs that require priorauthorization:Filgrastim (Neupogen )J1442*Filgrastim-aafi (NivestymTM)Q5110*Filgrastim-sndz (Zarxio )Q5101*Pegfilgrastim (Neulasta )J2506*Pegfilgrastim-apgf (NyvepriaTM)Q5122*Pegfilgrastim-bmez (Ziextenzo )Q5120*Pegfilgrastim-cbqv (UDENYCATM)Q5111*Pegfilgrastim-jmdb (FulphilaTM)Q5108*Insurance coverage provided by or through UnitedHealthcare Insurance Company, All Savers Insurance Company, Oxford Health Insurance, Inc. ortheir affiliates. Health Plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California,UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc.,UnitedHealthcare of Texas, LLC, UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc.,Oxford Health Plans (NJ), Inc. and Oxford Health Plans (CT), Inc. or other affiliates. Administrative services provided by United HealthCare Services,Inc., OptumRx, OptumHealth Care Solutions, LLC, Oxford Health Plans LLC or their affiliates. Behavioral health products are provided by U.S.Behavioral Health Plan, California (USBHPC), United Behavioral Health (UBH) or its affiliates.CPT is a registered trademark of the American Medical Association.PCA-1-20-02170-Clinical-WEB 07232020 2020 United HealthCare Services, Inc. All rights reserved.

Procedures andAdditional InformationServicesCancer supportive care(continued)CPT or HCPCS Codes and/orHow to Obtain Prior AuthorizationSargramostim (Leukine )J2820Tbo-filgrastim (Granix )J1447*Trilaciclib (Cosela )J1448CardiologyPrior authorization required foroutpatient and office-baseddiagnostic catheterizations,electrophysiology implants,echocardiograms and stressechoes prior to performanceCardiovascularPrior authorization requiredFor Vascular codes, priorauthorization required for lowerextremity angiogramFor prior authorization requests, please submit requests online byusing the Prior Authorization and Notification tool onUnitedHealthcare Provider Portal. Go to UHCprovider.com andclick on the UnitedHealthcare Provider Portal button in the top rightcorner. Then, select the Prior Authorization and Notification tool onyour Provider Portal button dashboard. Or, call 888-397-8129.For prior authorization, please submit requests online by using thePrior Authorization and Notification tool on UnitedHealthcare ProviderPortal. Go to UHCprovider.com and click on the UnitedHealthcareProvider Portal button in the top right corner. Then, select the PriorAuthorization and Notification tool on your Provider Portal buttondashboard. Or, call 866-889-8054.For more details and the CPT codes that require prior authorization,please visit UHCprovider.com/priorauth Cardiology 0*75716***Prior authorization is required for patients ages 18 and older. Seethe Congenital Heart Disease section in this document for patientsunder age 18.*Prior authorization required for the following diagnosis 0.25I70.261I70.262Insurance coverage provided by or through UnitedHealthcare Insurance Company, All Savers Insurance Company, Oxford Health Insurance, Inc. ortheir affiliates. Health Plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California,UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc.,UnitedHealthcare of Texas, LLC, UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc.,Oxford Health Plans (NJ), Inc. and Oxford Health Plans (CT), Inc. or other affiliates. Administrative services provided by United HealthCare Services,Inc., OptumRx, OptumHealth Care Solutions, LLC, Oxford Health Plans LLC or their affiliates. Behavioral health products are provided by U.S.Behavioral Health Plan, California (USBHPC), United Behavioral Health (UBH) or its affiliates.CPT is a registered trademark of the American Medical Association.PCA-1-20-02170-Clinical-WEB 07232020 2020 United HealthCare Services, Inc. All rights reserved.

Procedures andServices(continued)Additional InformationCPT or HCPCS Codes and/orHow to Obtain Prior 18I70.719I70.721Insurance coverage provided by or through UnitedHealthcare Insurance Company, All Savers Insurance Company, Oxford Health Insurance, Inc. ortheir affiliates. Health Plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California,UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc.,UnitedHealthcare of Texas, LLC, UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc.,Oxford Health Plans (NJ), Inc. and Oxford Health Plans (CT), Inc. or other affiliates. Administrative services provided by United HealthCare Services,Inc., OptumRx, OptumHealth Care Solutions, LLC, Oxford Health Plans LLC or their affiliates. Behavioral health products are provided by U.S.Behavioral Health Plan, California (USBHPC), United Behavioral Health (UBH) or its affiliates.CPT is a registered trademark of the American Medical Association.PCA-1-20-02170-Clinical-WEB 07232020 2020 United HealthCare Services, Inc. All rights reserved.

Procedures andServicesCardiovascular(continued)Additional InformationCPT or HCPCS Codes and/orHow to Obtain Prior 82.856AZ95.820T82.858AZ98.62Cartilage implantsPrior authorization erebral seizuremonitoring –Inpatient videoElectroencephalogram (EEG)Prior authorization required forinpatient services.95700957119571295713Prior authorization is notrequired for outpatient hospitalor ambulatory surgical center.Prior authorization required forinjectable chemotherapy drugsadministered in an outpatientsetting, including 26ChemotherapyservicesInjectable chemotherapy drugs that require prior authorization: Chemotherapy injectable drugs (J9000-J9999), Leucovorin(J0640), Levoleucovorin (J0641, J0642), Leuprolide acetate(J1950), Leuprolide (J1952) Chemotherapy injectable drugs that have a Q codeInsurance coverage provided by or through UnitedHealthcare Insurance Company, All Savers Insurance Company, Oxford Health Insurance, Inc. ortheir affiliates. Health Plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California,UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc.,UnitedHealthcare of Texas, LLC, UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc.,Oxford Health Plans (NJ), Inc. and Oxford Health Plans (CT), Inc. or other affiliates. Administrative services provided by United HealthCare Services,Inc., OptumRx, OptumHealth Care Solutions, LLC, Oxford Health Plans LLC or their affiliates. Behavioral health products are provided by U.S.Behavioral Health Plan, California (USBHPC), United Behavioral Health (UBH) or its affiliates.CPT is a registered trademark of the American Medical Association.PCA-1-20-02170-Clinical-WEB 07232020 2020 United HealthCare Services, Inc. All rights reserved.

Procedures andServicesChemotherapyservices (continued)Clinical trialsA rigorouslycontrolled study of anew drug, medicaldevice or othertreatment on eligiblehuman subjectssubject to oversightby an InstitutionalReview Board (IRB)Cochlear and otherauditory implantsA medical devicewithin the inner earand with an externalportion to helppersons withprofoundsensorineuraldeafness achieveconversationalspeechCongenital heartdiseaseCongenital heartdisease-relatedservices, includingpre-treatmentevaluationAdditional Informationintravesical and intrathecal for acancer diagnosisPrior authorization requiredPrior authorization requiredPrior authorization requiredCPT or HCPCS Codes and/orHow to Obtain Prior Authorization Chemotherapy injectable drugs that have not yet received anassigned code and will be billed under a miscellaneousHealthcare Common Procedure Coding System (HCPCS) codePrior authorization requests:Please submit requests online by using the Prior Authorization andNotification tool on UnitedHealthcare Provider Portal. Go toUHCprovider.com and click on the UnitedHealthcare ProviderPortal button in the top right corner. Then, select the PriorAuthorization and Notification tool on your Provider Portal buttondashboard. Or, 14L8619L8690L8691L8692For notification/prior authorization, please call 888-936-7246 or thenotification number on the back of the member’s health plan ID 33750Insurance coverage provided by or through UnitedHealthcare Insurance Company, All Savers Insurance Company, Oxford Health Insurance, Inc. ortheir affiliates. Health Plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California,UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc.,UnitedHealthcare of Texas, LLC, UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc.,Oxford Health Plans (NJ), Inc. and Oxford Health Plans (CT), Inc. or other affiliates. Administrative services provided by United HealthCare Services,Inc., OptumRx, OptumHealth Care Solutions, LLC, Oxford Health Plans LLC or their affiliates. Behavioral health products are provided by U.S.Behavioral Health Plan, California (USBHPC), United Behavioral Health (UBH) or its affiliates.CPT is a registered trademark of the American Medical Association.PCA-1-20-02170-Clinical-WEB 07232020 2020 United HealthCare Services, Inc. All rights reserved.

Procedures andServicesAdditional InformationCongenital heartdisease (continued)Continuous GlucoseMonitorPrior authorization required withType 2 Diabetes DiagnosisCosmetic andreconstructiveproceduresPrior authorization requiredCPT or HCPCS Codes and/orHow to Obtain Prior 92433853935803391793581Congenital heart disease codes:In combination with the followingICD-10-CM See the Cardiovascular section of this document for patients ages18 and older,A4226A9276A9277E0787K0553K0554Prior authorization is required for all 30A9278140201557015733Insurance coverage provided by or through UnitedHealthcare Insurance Company, All Savers Insurance Company, Oxford Health Insurance, Inc. ortheir affiliates. Health Plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California,UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc.,UnitedHealthcare of Texas, LLC, UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc.,Oxford Health Plans (NJ), Inc. and Oxford Health Plans (CT), Inc. or other affiliates. Administrative services provided by United HealthCare Services,Inc., OptumRx, OptumHealth Care Solutions, LLC, Oxford Health Plans LLC or their affiliates. Behavioral health products are provided by U.S.Behavioral Health Plan, California (USBHPC), United Behavioral Health (UBH) or its affiliates.CPT is a registered trademark of the American Medical Association.PCA-1-20-02170-Clinical-WEB 07232020 2020 United HealthCare Services, Inc. All rights reserved.

Procedures andServicesCosmetic andreconstructiveprocedures(continued)Cosmetic proceduresthat change orimprove physicalappearance withoutsignificantly improvingor restoringphysiological functionAdditional InformationReconstructiveprocedures that treata medical condition orimprove or restorephysiologic functionCPT or HCPCS Codes and/orHow to Obtain Prior 026Prior authorization is required for all states. In addition, site ofservice will be reviewed as part of the prior authorization process forthe following codes except in AK, MA, PR, TX, UT, VI, and WI.171061710717108Durable medicalequipment (DME)Prior authorization required onlyfor DME codes listed with aretail purchase or cumulativerental costof more than 1,000Some home health careservices may qualify under thedurable medical equipmentrequirement but are not subjectto the 1,000 retail purchase orcumulative retail rental costthreshold – see Home healthcare.Some payer groups may havedifferent DME prior authorizationrequirements for their 880K0877K0884K0885S1040K0886K0890K0891Insurance coverage provided by or through UnitedHealthcare Insurance Company, All Savers Insurance Company, Oxford Health Insurance, Inc. ortheir affiliates. Health Plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California,UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc.,UnitedHealthcare of Texas, LLC, UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc.,Oxford Health Plans (NJ), Inc. and Oxford Health Plans (CT), Inc. or other affiliates. Administrative services provided by United HealthCare Services,Inc., OptumRx, OptumHealth Care Solutions, LLC, Oxford Health Plans LLC or their affiliates. Behavioral health products are provided by U.S.Behavioral Health Plan, California (USBHPC), United Behavioral Health (UBH) or its affiliates.CPT is a registered trademark of the American Medical Association.PCA-1-20-02170-Clinical-WEB 07232020 2020 United HealthCare Services, Inc. All rights reserved.

Procedures andServicesEnd-stage renaldisease(ESRD) dialysisservicesServices for treatingend-stage renaldisease, includingoutpatient dialysisservicesFoot surgeryAdditional InformationPrior authorization requiredwhen members are referred toan out-of-network care providerfor dialysis services.Prior authorization not requiredfor ESRD when a membertravels outside of the servicearea.Please note: Your agreementwith us may include restrictionson referring members outside ofthe UnitedHealthcare network.Prior authorization requiredFunctionalendoscopic sinussurgery (FESS)Prior authorization requiredGender dysphoriatreatmentPrior authorization requiredCPT or HCPCS Codes and/orHow to Obtain Prior AuthorizationPlease call 888-936-7246 to initiate case management and utilizationmanagement.Prior authorization is required for all states. In addition, site ofservice will be reviewed as part of the prior authorization process forthe following codes except in AK, MA, PR, TX, UT, VI, and ior authorization required for the following regardless ofdiagnosis code:5597055980Prior authorization required for the following when submittedwith a diagnosis code F64.0, F64.1, F64.2, F64.8, F64.9 64896Genetic andmoleculartesting to includeBRCA gene testingPrior authorization required forgenetic and molecular testingperformed in an re providers requestinglaboratory testing will berequired to complete the priorauthorization/notificationprocess, which includesindicating the laboratory and testname. Payment will beauthorized for those CPT codesregistered with the Genetic andMolecular Testing 812058120181208Insurance coverage provided by or through UnitedHealthcare Insurance Company, All Savers Insurance Company, Oxford Health Insurance, Inc. ortheir affiliates. Health Plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California,UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc.,UnitedHealthcare of Texas, LLC, UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc.,Oxford Health Plans (NJ), Inc. and Oxford Health Plans (CT), Inc. or other affiliates. Administrative services provided by United HealthCare Services,Inc., OptumRx, OptumHealth Care Solutions, LLC, Oxford Health Plans LLC or their affiliates. Behavioral health products are provided by U.S.Behavioral Health Plan, California (USBHPC), United Behavioral Health (UBH) or its affiliates.CPT is a registered trademark of the American Medical Association.PCA-1-20-02170-Clinical-WEB 07232020 2020 United HealthCare Services, Inc. All rights reserved.

Procedures andServicesGenetic andmolecular testing toinclude BRCA genetesting (continued)Additional InformationAuthorization/ NotificationProgram for each specifiedgenetic test.Notification/prior authorizationrequired for BRCA testing beforeDNA sequencing is performed.The ordering care provider mustnotify the laboratory conductingthe test and the laboratory willnotify UnitedHealthcare.CPT or HCPCS Codes and/orHow to Obtain Prior 43581436814378143881439Insurance coverage provided by or through Unite

Sep 1, 2022