Prior Authorization and Site of Service Reviews

This is an update to the November 2019 Network Bulletin notice that specific outpatient surgical codes will be subject to prior authorization and site of service medical necessity reviews.

For care providers in Iowa, effective for dates of service beginning on Aug. 1, 2020, the outpatient surgical codes listed below will be subject to notification/prior authorization requirements and site of service medical necessity reviews if performed outside of a physician’s office for UnitedHealthcare commercial benefit plans, including UnitedHealthcare of the River Valley commercial benefit plans.

CPT Codes

  • Dermatologic: 11402, 11403, 11406, 11422, 11426, 11442
  • General Surgery: 19000
  • Musculoskeletal: 27096, 64479, 64490 ,64493
  • Neurologic: 62270, 62321, 64633, 64635
  • OB/GYN: 57460
  • Respiratory: 31579

We use the criteria set forth in our Office Based Procedures – Site of Service Guide to facility our site of service medical necessity reviews. The guideline is available at UHCprovider.com > Policies and Protocols > Commercial Policies > UnitedHealthcare Commercial Medical & Drug Policies and Coverage Determination Guidelines > Office Based Procedures — Site of Service.