UnitedHealthcare prior authorization, page 15

Requirements

Commercial, Medicare Advantage, Community Plan, and Exchange each need their own source. This page does not use one requirement sentence for all four. The long descriptor is blank because no AMA-licensed CPT file was available to copy.

Commercial

Prior authorization codes

Prior authorization codes
Code	Description	Source
S4030	Infertility	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 13 Original policy
S4031	Infertility	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 13 Original policy
S4035	Infertility	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 13 Original policy
S4037	Infertility	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 13 Original policy
52402	Infertility	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 13 Original policy
54500	Infertility	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 13 Original policy
54505	Infertility	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 13 Original policy
55550	Infertility	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 13 Original policy
58140	Infertility	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 13 Original policy
58145	Infertility	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 13 Original policy
58146	Infertility	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 13 Original policy
58545	Infertility	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 13 Original policy
89398	Infertility (cont.)	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J0256	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J0257	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J0896	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J1437	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J1439	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J0517	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J2182	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J2356	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J2357	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J2786	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J0223	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J1299	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J1302	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J1303	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J1307	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J9376	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
Q5151	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
Q5152	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J0587	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J1306	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J0174	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J0175	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J0222	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J0225	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J1301	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J1304	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J1426	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J1427	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J1428	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J1429	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J2326	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J3032	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J9256	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J9332	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J9333	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J9334	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy
J0775	Injectable medications	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 14 Original policy

UnitedHealthcare commercial advance notification and prior authorization requirements

Medicare Advantage

No reviewed Medicare Advantage code row is on this page. Medicare Advantage does not inherit the commercial row above.

Community Plan

No reviewed Community Plan code row is on this page. Community Plan does not inherit the commercial row above.

Exchange

No reviewed Exchange code row is on this page. Exchange does not inherit the commercial row above.

Forms

UnitedHealthcare prior authorization and advance notification plan requirements

Updates

Commercial removal supplement
Code	Long descriptor	Code system	Plan scope	Outcome	Source
0006M		CPT	Commercial plans covered by the October removal supplement	RemovedNo under this removal notice, effective October 1, 2026Removal does not establish coverage or code billability; check member-specific exceptions.	p. 1, Global CPT codes; introduction establishes removal of PA.