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Prior Authorization Crosswalk TableMay 2019

Prior Authorization given with this CPT Code

Claim submitted with this CPT Code

Code Category

11401 11400 Site of Service (SOS) Office Based Programs











































Code Category










13132 13101 Site of Service (SOS) OPH to ASC

14001 14000 Gender Dysphoria Treatment w diagnosis code




























15821 15820 Cosmetic & Reconstructive



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Code Category







19318 19316 Breast Reconstruction (Non-Mastectomy)













































Code Category



20975 20974 Bone Growth Stimulator



21122 21121 Orthognathic Surgery












































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22110 22100 Spine Surgery






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23472 23470 Arthroplasty







































Code Category

















J7330 27412 Cartilage Implants

































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28291 28289 Foot Surgery












29806 29805 Arthroscopy
















Code Category


















































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Code Category





















29867 29866 Cartilage Implants





























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30410 30400 Rhinoplasty




Code Category








































31239 31253 Functional Endoscopic Sinus Surgery (FESS)










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31296 31295 Sinuplasty







32852 32851 Optum Transplant - Lung

32854 32853 Optum Transplant - Lung

32856 32855 Services related to Transplant

33255 33251 Congenital Heart Disease


























Code Category


















































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33362 33361 Potentially Unproven Services






















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33945 33929 Ventricular Assist Devices







36475 36473 Vein Procedures


















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38240 38241 Optum Transplant - Bone Marrow Harvest

21685 41530 Sleep Apnea Procedures & Surgeries





















Code Category


















43238 43245 NHP - Digestive System



























43645 43644 Bariatric Surgery





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Code Category




















































Code Category









43644 43860 Bariatric Surgery w/ Diagnosis Code









































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Code Category












44133 44132 Optum Transplant - Intestine

44132 44133 Optum Transplant - Intestine






G0105 45378 Site of Service (SOS) OPH to ASC

































Code Category


















































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50320 50300 Optum Transplant - Kidney










Code Category


















































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58146 58140 Infertility w/ DX




58152 58150 Hysterectomy - IP and OP





58262 58260 Hysterectomy - IP Only




















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64568 61885 Vagus Nerve Stimulation

















































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63655 63650 Spinal Cord Stimulators

































Code Category


















































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69714 69710 Cochlear Implants and Other Auditory Implants









77386 77385 IMRT

77522 77520 Proton Beam Therapy




Code Category





90937 90935 End Stage Renal Disease (ESRD)

















95807 95805 Sleep Studies













0072T 0071T MR-Guided Focused Ultrasound to treat Uterine Fibroids

0269T 0270T Potentially Unproven Services

0269T 0271T Potentially Unproven Services

0313T 0312T Bariatric Surgery












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Code Category









A0431 A0430 Non Emergency Transport - Air











E0265 E0266 DME greater than $1,000




E0747 E0760 Bone Growth Stimulator

E0748 E0760 Bone Growth Stimulator










77385 G6015 IMRT

77386 G6016 IMRT

J0257 J0256 Injectable Medications - Alpha1 - Proteinase

J0256 J0257 Injectable Medications - Alpha1 - Proteinase

J1556 J1459 Injectable Medications - Immune Globulin













Code Category


















































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Code Category


Q5103 J1745 Injectable Medications - Inflammatory

Q5104 J1745 Injectable Medications - Inflammatory

J3060 J3385 Injectable Medications - Gaucher's Disease

J1786 J3385 Injectable Medications - Gaucher's Disease

L0430 L0220 Orthotics greater than $1,000












































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Code Category

























L5020 L5010 Prosthetics greater than $1,000



























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L8614 L8619 Cochlear Implants and Other Auditory Implants

L8686 L8685 Spinal Cord Stimulators






Q9992 Q9991 Injectable Medications - Opioid Addiction

Q9991 Q9992 Injectable Medications - Opioid Addiction

S9124 S9123 Home Health Care - Skilled Nursing

G0154 S9123 Home Health Care - Skilled Nursing

S9123 S9124 Home Health Care - Skilled Nursing

G0154 S9124 Home Health Care - Skilled Nursing

S9961 S9960 Non Emergency Transport - Air

S9960 S9961 Non Emergency Transport - Air

T1002 T1000 Home Health Care - Private Duty Nursing





M57277 5/19 ©2019 United HealthCare Services, Inc.

Prior Authorization Crosswalk Table - UHCprovider.com › content › dam › provider › docs ›...

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