Prior Authorization List for Physician Alliance of the Rockies, UnitedHealthcare Medicare Advantage Effective January 1, 2019
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1 MEDICAL MANAGEMENT CONTACT INFO- MONDAY - FRIDAY FROM 8:00 AM TO 5:00 PM - (720) *ALL REFERRALS TO SPECIALISTS REQUIRE PRIOR AUTHROIZATION* *ALL OUT OF NETWORK SERVICES REQUIRE PRIOR AUTHROIZATION* ***THE SERVICES LISTED BELOW REQUIRE PRIOR AUTHORIZATION*** Referrals Admission: acute care inpatient hospital admissions Physician to physician referrals (all E&M Codes) are required to be submitted to Physician Alliance of the Rockies prior to all services rendered except the following: Gastroenterology, solely for a colonoscopy Obstetrics or gynecology Ophthalmology Referrals to preferred providers are granted for 6 visits/6 months Referrals to non-preferred providers are granted for 3 visits/3 months *exceptions may be made for oncology Notification is required for emergent/urgent and planned hospital admissions upon admission Inpatient admissions-post acute services: Bariatric Surgery Behavioral health services Bone Growth Stimulator Prior authorization and notification of admission date required for these facilities providing post-acute inpatient services: Acute care hospitals Acute inpatient rehabilitation Critical access hospitals Long-term acute care hospitals Skilled nursing facilities Please call the number on the member s ID card to refer for mental health and substance abuse/substance use services E0747 E0748 E0749 E L8600 Breast reconstruction (nonmastectomy) Reconstruction of the breast or other than following mastectomy Notification or prior authorization is not required for the following diagnosis codes: C50.019, C50.011, C50.012, C50.111, C50.112, C50.119, C50.211, C50.212, C50.219, C50.311, C50.312, C50.319, C50.411, C50.412, C50.419, C50.511, C50.512, C50.519, C50.611, C50.612, C50.619, C50.811, C50.812, C50.819, C50.911, C50.912, C50.919, C50.029, C50.021, C50.022, C50.121, C50.122, C50.129, C50.221, C50.222, C50.229, C50.321, C50.322, C50.329, C50.421, C50.422, C50.429, C50.521, C50.522, C50.529, C50.621, C50.622, C50.629, C50.821, C50.822, C50.829, C50.921, C50.922, C50.929, C79.81, D05.90, D05.00, D05.01, D05.02, D05.10, D05.11, D05.12, D05.80, D05.81, D05.82, D05.91, D05.92, Z85.3, Z90.10, Z90.11, Z90.12, Z90.13, Z42.1 Cardiology Diagnostic catheterization
2 Electrophysiology Implants Pacemaker Implants CRT Defibrillator Echocardiogram Stress Echo TEE Cochlear and other auditory implants L8614 L8619 L8690 L8691 L8692 Complex Radiology Computed Tomography * G0297 S8092* Magnetic Resonance Imaging Nuclear Medicine C8909 C8910 C * C8931* C8932* C8933* C8918 C8919 C * C8934* C8935* C8936* C8912 C8913 C S C8900 C8901 C C8903 C8904 C C8906 C8907 C8908 S8042* D CT/MRI PET Therapeutic radiology services G0235* G0252* S8085* Intensity modulated radiation therapy G6015 G6016 Stereotactic radiosurgery and stereotactic body radiation therapy G0173 G0251 G0339 G0340 2
3 Cosmetic and reconstructive surgery Cosmetic procedures that change or improve physical appearance, without significantly improving or restoring physiological function Q2026 Reconstructive procedures that either treat a medical condition or improve or restore physiologic function Drug/Drug Therapies Hyaluronic Acid (Hyalgan, Synvisc, Orthovisc, Euflexxa, Supartz Crysvita J7320 J7321 J7322 J7323 J7324 J7325 J7326 J7327 J7328 J7329 J0584 Erythropoiesis-Stimulating agents Remicaid Luxturna Onpattro Radicava SpinrazaTM J0881 J1745 J3398 C9036 J1301 J2326 J0885 Unclassified codes* C9399 J3490 J3590. Durable Medical Equipment (continue to send requests to Apria) NOT SUBJECT TO $1000 threshold Prosthetics are not DME (see separate Prosthetics and Orthotics notification requirement in this grid) for Medicare Advantage Members. E0466 E0666 E0667 E0668 E0669 E0671 E0672 E0673 E0675 E1230 E1239 E2310 E2311 E2321 K0800 K0801 K0802 K0806 K0808 K0812 K0813 K0814 K0815 K0816 K0820 K0821 K0822 K0823 K0824 K0825 K0826 K0827 K0828 K0829 K0830 K0831 K0835 K0836 K0837 K0838 K0839 K0840 K0841 K0842 K0843 K0848 K0849 K0850 K0851 K0852 K0853 K0854 K0855 K0856 K0857 K0858 K0859 K0860 K0861 K0862 K0863 K0864 K0869 K0870 K0871 K0877 K0878 K0879 K0880 K0884 K0885 K0886 K0890 K0891 K0898 K0899 3
4 Power mobility devices and accessories, lymphedema pumps and pneumatic compressors require notification or prior authorization regardless of the cost. Durable medical equipment: more than $1,000 (continue to send requests to Apria) Durable medical equipment with a retail purchase or cumulative rental cost over $1,000 Prosthetics are not durable medical equipment (see separate Prosthetics and Orthotics notification requirement in this grid) for Medicare Advantage members. E0170 E0193 E0194 E0246 E0277 E0300 E0302 E0304 E0316 E0328 E0329 E0350 E0373 E0459 E0462 E0465 E0483 E0603 E0616 E0617 E0618 E0635 E0636 E0639 E0640 E0642 E0692 E0693 E0694 E0700 E0710 E0740 E0746 E0761 E0764 E0770 E0782 E0783 E0784 E0785 E0786 E0830 E0970 E0983 E0984 E0986 E0988 E1002 E1003 E1004 E1005 E1006 E1007 E1008 E1009 E1011 E1016 E1017 E1018 E1020 E1029 E1030 E1035 E1036 E1037 E1050 E1070 E1084 E1085 E1086 E1087 E1089 E1100 E1110 E1161 E1170 E1171 E1172 E1180 E1190 E1195 E1200 E1222 E1224 E1227 E1228 E1229 E1231 E1232 E1233 E1234 E1235 E1236 E1237 E1238 E1270 E1280 E1295 E1296 E1297 E1298 E1310 E1399 E1500 E1510 E1520 E1530 E1540 E1550 E1560 E1575 E1580 E1590 E1592 E1594 E1600 E1615 E1620 E1625 E1630 E1632 E1634 E1635 E1636 E1637 E1639 E1699 E1812 K0020 K0037 K0039 K0044 K0046 K0047 K0050 K0051 K0056 K0065 K0072 K0073 K0098 K0105 K0108 K0455 K0609 K0730 K0743 K0744 K0745 K0746 End stage renal disease dialysis services when members are referred to an out of network provider for dialysis services. Advance notification is not required for end stage renal disease when a UnitedHealthcare Medicare Solutions member travels outside of the service area. Verbal Notification is required. Please call Optum Kidney Resource Services at to refer members into UnitedHealthcare s disease management program. Gastroenterology Colonoscopy EGD Capsule Endoscopy Gender dysphoria treatment G0105 G The following surgical codes when billed with these DX codes: F64.0; F64.1; F64.2; F64.8: F64.9; Z
5 Home health care - Nonnutritional For service days 1-60, no notification is required. For service days 61 and beyond, the services in the next column require prior authorization or advance notification. Hysterectomy inpatient only Vaginal hysterectomies - No authorization required for outpatient vaginal hysterectomies. Hysterectomy inpatient and outpatient procedures Abdominal and laparoscopic Surgeries Non-emergency air transport Non-urgent ambulance transportation by air between specified locations Orthognathic surgery Treatment of maxillofacial functional impairment Orthotics: more than $1,000 Orthotics with a retail purchase or cumulative rental cost more than $1, Certified Nurse s Aide in the home G0156 S A0430 A0431 A0435 A L0112 L0113 L0140 L0150 L0170 L0200 L0220 L0452 L0462 L0464 L0466 L0468 L0480 L0482 L0484 L0486 L0622 L0623 L0624 L0629 L0631 L0632 L0634 L0636 L0638 L0700 L0710 L0810 L0820 L0830 L0859 L0999 L1000 L1001 L1005 L1200 L1300 L1310 L1499 L1630 L1640 L1680 L1685 L1700 L1710 L1720 L1730 L1755 L1834 L1844 L1904 L1920 L2000 L2005 L2010 L2020 L2030 L2034 L2036 L2037 L2038 L2040 L2050 L2060 L2070 L2080 L2090 L2126 L2128 L2136 L2232 L2320 L2387 L2520 L2525 L2526 L2627 L2628 L2800 L2861 L3160 L3201 L3202 L3203 L3204 L3206 L3207 L3208 L3209 L3211 L3212 L3213 L3214 L3215 L3250 L3251 L3252 L3253 L3254 L3255 L3257 L3265 L3320 L3485 L3649 L3674 L3720 L3764 L3765 L3766 5
6 L3891 L3900 L3901 L3904 L3921 L3956 L3961 L3967 L3971 L3973 L3975 L3976 L3977 L3978 L4000 L4030 L4040 L4045 L4050 L4055 L4631 Orthopedic surgeries Spine and joint surgeries Vertebroplasty/Kyphoplasty Out-of-network services J T 0201T For UnitedHealthcare Medicare Advantage Members: Advance notification is required for UnitedHealthcare Medicare Advantage members when: A network physician or health care professional refers them to an out-of-network care provider and the member s benefit plan does not cover out-of-network services Pain Management ESI Facet Blocks Potentially unproven services (including experimental/ investigational) Services, including medications, determined to be ineffective effective for treating the medical condition and/or to have no beneficial effect on health outcomes. This determine is made when there is insufficient clinical evidence from well-conducted randomized controlled trials or cohort studies in the prevailing published, peer-reviewed medical literature Prosthetics: more than $1,000 L5010 L5020 L5050 L5060 L5100 L5105 L5150 L5160 L5200 L5210 L5220 L5230 L5250 L5270 L5280 L5301 L5312 L5321 L5331 L5341 L5400 L5420 L5500 L5505 L5510 L5520 L5530 L5535 L5540 L5560 L5570 L5580 L5585 L5590 L5595 L5600 L5610 L5611 L5613 L5614 6
7 Prosthetics with a retail or cumulative rental cost more than $1,000. L5616 L5639 L5643 L5649 L5651 L5681 L5683 L5700 L5701 L5702 L5703 L5707 L5724 L5726 L5728 L5780 L5781 L5782 L5795 L5814 L5818 L5822 L5824 L5826 L5828 L5830 L5840 L5845 L5848 L5856 L5857 L5858 L5930 L5960 L5961 L5966 L5968 L5973 L5979 L5980 L5981 L5987 L5988 L5990 L6000 L6010 L6020 L6026 L6050 L6055 L6100 L6110 L6120 L6130 L6200 L6205 L6250 L6300 L6310 L6320 L6350 L6360 L6370 L6380 L6382 L6384 L6400 L6450 L6500 L6550 L6570 L6580 L6582 L6584 L6586 L6588 L6590 L6621 L6624 L6638 L6646 L6648 L6693 L6696 L6697 L6707 L6709 L6712 L6713 L6714 L6715 L6721 L6722 L6880 L6881 L6882 L6883 L6884 L6885 L6895 L6900 L6905 L6910 L6920 L6925 L6930 L6935 L6940 L6945 L6950 L6955 L6960 L6965 L6970 L6975 L7007 L7008 L7009 L7040 L7045 L7170 L7180 L7181 L7185 L7186 L7190 L7191 L7499 L8035 L8039 L8041 L8042 L8043 L8044 L8049 L8499 L8505 L8604 L8609 L8699 Proton beam therapy Focused radiation therapy using beams of protons Indicate whether proton beam therapy is performed as part of a clinical trial. Please reference the Clinical Trials sections. Rhinoplasty Treatment of nasal functional impairment and septal deviation Sleep apnea procedures and surgeries Maxillomandibular advancement or oralpharyngeal tissue reduction for treatment of obstructive sleep apnea Applies to inpatient or outpatient, including but not limited to: Palatopharyngoplasty: oral pharyngeal reconstructive surgery that includes laserassisted uvulopalatoplasty Applies only for surgical sleep apnea procedures and not sleep studies. 7
8 Sleep studies Spinal stimulator for pain management Spinal cord stimulators when implanted for pain management Transplant of tissue organs Organ or tissue transplant or transplant related services before pre-treatment or evaluation Must request for transplant or transplant-related services before pre-treatment or evaluation. For transplant and CAR-T cell therapy services including Kymriah (tisagenlecleucel) and Yescarta (axicabtagene ciloleucel), please call the Optum Transplant Case Management Team at or the notification number on the back of the member s health plan ID card. Evaluation for transplant Bone marrow harvest Heart/lung Heart Lung S2060 S2061 Kidney Pancreas Liver Intestine Services related to transplants S2152 CAR-T Cell Therapy 0537T 0538T 0539T 0540T Q2041 Q2042 8
9 Vagus nerve stimulation Implantation of a device that sends electrical impulses into one of the cranial nerves Vein procedures Removal and ablation of the main trunks and named branches of the saphenous veins to treat venous disease and varicose veins of the extremities Ventricular assist devices A mechanical pump that takes over the function of the damaged ventricle of the heart and restores normal blood flow
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