October 01, 2022
Oxford prior authorization requirement changes
Effective Jan. 1, 2023, UnitedHealthcare will make significant changes to the UnitedHealthcare Oxford plan prior authorization requirements. These changes include a removal of a substantial number of procedure codes and the addition of new procedure codes to the prior authorization requirements.
The reduction in codes that require prior authorization is part of our effort to reduce administrative burden and improve the provider and member experience. The change also helps align our processes with evidence-based clinical guidelines.
Review the new codes requiring prior authorization in the tables below.
Cardiology
| CPT/HCPC Code | Description | Category |
|---|---|---|
| 93319 | 3D echocardiographic imaging and postprocessing during transesophageal echocardiography, or during transthoracic echocardiography for congenital cardiac anomalies, for the assessment of cardiac structure(s) (eg, cardiac chambers and valves, left atrial appendage, interatrial septum, interventricular septum) and function, when performed (List separately in addition to code for echocardiographic imaging) | Cardiology |
Chemotherapy
| CPT/HCPC Code | Description | Category | Additional Information |
|---|---|---|---|
| J1448 | Injection, trilaciclib, 1 mg | Chemotherapy | applies when billed with Oncology diagnosis |
| J1952 | Leuprolide injectable, camcevi, 1 mg | Chemotherapy | applies when billed with Oncology diagnosis |
Continuous Glucose Monitor
| CPT/HCPC Code | Description | Category | Additional Information |
|---|---|---|---|
| A4238 | Supply allowance for adjunctive continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service | Continuous Glucose Monitor | applies when billed with Type II diabetes diagnosis only |
Genetic and Molecular Testing
| CPT/HCPC Code | Description | Category |
|---|---|---|
| 81168 | CCND1/IGH (t(11;14)) (eg, mantle cell lymphoma) translocation analysis, major breakpoint, qualitative and quantitative, if performed | Genetic and Molecular Testing |
| 81191 | NTRK1 (neurotrophic receptor tyrosine kinase 1) (eg, solid tumors) translocation analysis | Genetic and Molecular Testing |
| 81192 | NTRK2 (neurotrophic receptor tyrosine kinase 2) (eg, solid tumors) translocation analysis | Genetic and Molecular Testing |
| 81193 | NTRK3 (neurotrophic receptor tyrosine kinase 3) (eg, solid tumors) translocation analysis | Genetic and Molecular Testing |
| 81194 | NTRK (neurotrophic receptor tyrosine kinase 1, 2, and 3) (eg, solid tumors) translocation analysis | Genetic and Molecular Testing |
| 81278 | IGH@/BCL2 (t(14;18)) (eg, follicular lymphoma) translocation analysis, major breakpoint region (MBR) and minor cluster region (mcr) breakpoints, qualitative or quantitative | Genetic and Molecular Testing |
| 81279 | JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) targeted sequence analysis (eg, exons 12 and 13) | Genetic and Molecular Testing |
| 81329 | SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; dosage/deletion analysis (eg, carrier testing), includes SMN2 (survival of motor neuron 2, centromeric) analysis, if performed | Genetic and Molecular Testing |
| 81338 | MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, myeloproliferative disorder) gene analysis; common variants (eg, W515A, W515K, W515L, W515R) | Genetic and Molecular Testing |
| 81339 | MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, myeloproliferative disorder) gene analysis; sequence analysis, exon 10 | Genetic and Molecular Testing |
| 81347 | SF3B1 (splicing factor [3b] subunit B1) (eg, myelodysplastic syndrome/acute myeloid leukemia) gene analysis, common variants (eg, A672T, E622D, L833F, R625C, R625L) | Genetic and Molecular Testing |
| 81348 | SRSF2 (serine and arginine-rich splicing factor 2) (eg, myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variants (eg, P95H, P95L) | Genetic and Molecular Testing |
| 81351 | TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; full gene sequence | Genetic and Molecular Testing |
| 81352 | TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; targeted sequence analysis (eg, 4 oncology) | Genetic and Molecular Testing |
| 81353 | TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; known familial variant | Genetic and Molecular Testing |
| 81357 | U2AF1 (U2 small nuclear RNA auxiliary factor 1) (eg, myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variants (eg, S34F, S34Y, Q157R, Q157P) | Genetic and Molecular Testing |
| 81360 | ZRSR2 (zinc finger CCCH-type, RNA binding motif and serine/arginine-rich 2) (eg, myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variant(s) (eg, E65fs, E122fs, R448fs) | Genetic and Molecular Testing |
| 81419 | Epilepsy genomic sequence analysis panel, must include analyses for ALDH7A1, CACNA1A, CDKL5, CHD2, GABRG2, GRIN2A, KCNQ2, MECP2, PCDH19, POLG, PRRT2, SCN1A, SCN1B, SCN2A, SCN8A, SLC2A1, SLC9A6, STXBP1, SYNGAP1, TCF4, TPP1, TSC1, TSC2, and ZEB2 | Genetic and Molecular Testing |
| 81513 | Infectious disease, bacterial vaginosis, quantitative real-time amplification of RNA markers for Atopobium vaginae, Gardnerella vaginalis, and Lactobacillus species, utilizing vaginal-fluid specimens, algorithm reported as a positive or negative result for bacterial vaginosis | Genetic and Molecular Testing |
| 81514 | Infectious disease, bacterial vaginosis and vaginitis, quantitative real-time amplification of DNA markers for Gardnerella vaginalis, Atopobium vaginae, Megasphaera type 1, Bacterial Vaginosis Associated Bacteria-2 (BVAB-2), and Lactobacillus species (L. crispatus and L. jensenii), utilizing vaginal-fluid specimens, algorithm reported as a positive or negative for high likelihood of bacterial vaginosis, includes separate detection of Trichomonas vaginalis and/or Candida species (C. albicans, C. tropicalis, C. parapsilosis, C. dubliniensis), Candida glabrata, Candida krusei, when reported | Genetic and Molecular Testing |
| 81523 | Oncology (breast), mRNA, next-generation sequencing gene expression profiling of 70 content genes and 31 housekeeping genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as index related to risk to distant metastasis | Genetic and Molecular Testing |
| 81554 | Pulmonary disease (idiopathic pulmonary fibrosis [IPF]), mRNA, gene expression analysis of 190 genes, utilizing transbronchial biopsies, diagnostic algorithm reported as categorical result (eg, positive or negative for high probability of usual interstitial pneumonia [UIP]) | Genetic and Molecular Testing |
| 0001U | Red blood cell antigen typing, DNA, human erythrocyte antigen gene analysis of 35 antigens from 11 blood groups, utilizing whole blood, common RBC alleles reported | Genetic and Molecular Testing |
| 0229U | BCAT1 (Branched chain amino acid transaminase 1) and IKZF1 (IKAROS family zinc finger 1) (eg, colorectal cancer) promoter methylation analysis | Genetic and Molecular Testing |
| 0230U | AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation), full sequence analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) expansions, mobile element insertions, and variants in non-uniquely mappable regions | Genetic and Molecular Testing |
| 0231U | CACNA1A (calcium voltage-gated channel subunit alpha 1A) (eg, spinocerebellar ataxia), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) gene expansions, mobile element insertions, and variants in non-uniquely mappable regions | Genetic and Molecular Testing |
| 0232U | CSTB (cystatin B) (eg, progressive myoclonic epilepsy type 1A, Unverricht-Lundborg disease), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) expansions, mobile element insertions, and variants in non-uniquely mappable regions | Genetic and Molecular Testing |
| 0234U | MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions | Genetic and Molecular Testing |
| 0235U | PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions | Genetic and Molecular Testing |
| 0236U | SMN1 (survival of motor neuron 1, telomeric) and SMN2 (survival of motor neuron 2, centromeric) (eg, spinal muscular atrophy) full gene analysis, including small sequence changes in exonic and intronic regions, duplications, deletions, and mobile element insertions | Genetic and Molecular Testing |
| 0242U | Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, gene copy number amplifications, and gene rearrangements | Genetic and Molecular Testing |
| 0244U | Oncology (solid organ), DNA, comprehensive genomic profiling, 257 genes, interrogation for single-nucleotide variants, insertions/deletions, copy number alterations, gene rearrangements, tumor-mutational burden and microsatellite instability, utilizing formalin-fixed paraffin-embedded tumor tissue | Genetic and Molecular Testing |
| 0245U | Oncology (thyroid), mutation analysis of 10 genes and 37 RNA fusions and expression of 4 mRNA markers using next-generation sequencing, fine needle aspirate, report includes associated risk of malignancy expressed as a percentage | Genetic and Molecular Testing |
| 0246U | Red blood cell antigen typing, DNA, genotyping of at least 16 blood groups with phenotype prediction of at least 51 red blood cell antigens | Genetic and Molecular Testing |
| 0289U | Neurology (Alzheimer disease), mRNA, gene expression profiling by RNA sequencing of 24 genes, whole blood, algorithm reported as predictive risk score | Genetic and Molecular Testing |
| 0294U | Longevity and mortality risk, mRNA, gene expression profiling by RNA sequencing of 18 genes, whole blood, algorithm reported as predictive risk score | Genetic and Molecular Testing |
| 0308U | Cardiology (coronary artery disease [CAD]), analysis of 3 proteins (high sensitivity [hs] troponin, adiponectin, and kidney injury molecule-1 [KIM-1]), plasma, algorithm reported as a risk score for obstructive CAD | Genetic and Molecular Testing |
| 0309U | Cardiology (cardiovascular disease), analysis of 4 proteins (NT-proBNP, osteopontin, tissue inhibitor of metalloproteinase-1 [TIMP-1], and kidney injury molecule-1 [KIM-1]), plasma, algorithm reported as a risk score for major adverse cardiac event | Genetic and Molecular Testing |
| 0318U | Pediatrics (congenital epigenetic disorders), whole genome methylation analysis by microarray for 50 or more genes, blood | Genetic and Molecular Testing |
| 0319U | Nephrology (renal transplant), RNA expression by select transcriptome sequencing, using pretransplant peripheral blood, algorithm reported as a risk score for early acute rejection | Genetic and Molecular Testing |
| 0320U | Nephrology (renal transplant), RNA expression by select transcriptome sequencing, using posttransplant peripheral blood, algorithm reported as a risk score for acute cellular rejection | Genetic and Molecular Testing |
| 0321U | Infectious agent detection by nucleic acid (DNA or RNA), genitourinary pathogens, identification of 20 bacterial and fungal organisms and identification of 16 associated antibiotic-resistance genes, multiplex amplified probe technique | Genetic and Molecular Testing |
Injectable Medication
| CPT/HCPC Code | Description | Category |
|---|---|---|
| Q5124 | Injection, ranibizumab-nuna, biosimilar, (Byooviz), 0.1 mg | Injectable Medication |
| J0179 | Injection, brolucizumab-dbll, 1 mg | Injectable Medications |
| J3591 | Unclassified drug or biological used for ESRD on dialysis | Injectable Medications |
| C9094 | Injection, sutimlimab-jome, 10 mg | Injectable Medications |
| J0879 | Injection, difelikefalin, 0.1 mcg, (for ESRD on dialysis) | Injectable Medications |
Miscellaneous Diagnostic & Therapeutic Procedures
| CPT/HCPC Code | Description | Category |
|---|---|---|
| P9099 | Blood component or product not otherwise classified | Miscellaneous Diagnostic & Therapeutic Procedures |
Radiology
| CPT/HCPC Code | Description | Category |
|---|---|---|
| 0697T | Quantitative magnetic resonance for analysis of tissue composition (eg, fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained without diagnostic MRI examination of the same anatomy (eg, organ, gland, tissue, target structure) during the same session; multiple organs | Radiology |
| 0698T | Quantitative magnetic resonance for analysis of tissue composition (eg, fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained with diagnostic MRI examination of the same anatomy (eg, organ, gland, tissue, target structure); multiple organs (List separately in addition to code for primary procedure) | Radiology |
| 0710T | Noninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; including data preparation and transmission, quantification of the structure and composition of the vessel wall and assessment for lipid-rich necrotic core plaque to assess atherosclerotic plaque stability, data review, interpretation and report | Radiology |
| 0711T | Noninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; data preparation and transmission | Radiology |
| 0712T | Noninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; quantification of the structure and composition of the vessel wall and assessment for lipid-rich necrotic core plaque to assess atherosclerotic plaque stability | Radiology |
| 0713T | Noninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; data review, interpretation and report | Radiology |
Site of Service - OP Hospital
| CPT/HCPC Code | Description | Category |
|---|---|---|
| 46948 | Hemorrhoidectomy, internal, by transanal hemorrhoidal dearterialization, 2 or more hemorrhoid columns/groups, including ultrasound guidance, with mucopexy, when performed | Site of Service - OP Hospital |
| 66987 | Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; with endoscopic cyclophotocoagulation | Site of Service - OP Hospital |
| 66988 | Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); with endoscopic cyclophotocoagulation | Site of Service - OP Hospital |
Transplant/Car T
| CPT/HCPC Code | Description | Category |
|---|---|---|
| C9098 | Ciltacabtagene autoleucel, up to 100 million autologous B-cell maturation antigen (BCMA) directed CAR-positive T cells, including leukapheresis and dose preparation procedures, per therapeutic dose | Transplant / Car T |
| 0538T | Chimeric antigen receptor T-cell (CAR-T) therapy; preparation of blood-derived T lymphocytes for transportation (eg, cryopreservation, storage) | Transplant/Car T |
| 0539T | Chimeric antigen receptor T-cell (CAR-T) therapy; receipt and preparation of CAR-T cells for administration | Transplant/Car T |
| 0540T | Chimeric antigen receptor T-cell (CAR-T) therapy; CAR-T cell administration, autologous | Transplant/Car T |
Transplant/Cellular Therapy
| CPT/HCPC Code | Description | Category |
|---|---|---|
| Q2053 | Brexucabtagene autoleucel, up to 200 million autologous anti-CD19 CAR positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose | Transplant/Cellular Therapy |
Oxford plan Prior Authorization Requirements document
A new provider tool, the UnitedHealthcare Oxford plan Prior Authorization Requirements document, will be available on Dec. 1, 2022, on the Advance Notification and Clinical Submission Requirements page.
This new document will provide a comprehensive list of all procedure codes requiring prior authorization for our commercial Oxford contracted network providers. The document will encompass current prior authorization plus address any changes as of Jan. 1, 2023.
Until the new provider tool is available, please continue to use the current process to research or request prior authorization as outlined in the 2022 UnitedHealthcare Care Provider Administrative Guide, Oxford Commercial supplement section.
Learn more
Applicable Oxford Commercial policies can be found at UnitedHealthcare® Oxford Clinical and Administrative Policies | UHCprovider.com
Questions?
Visit the Contact Us page for more information.
