UnitedHealthcare prior authorization, page 21

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
L2038	Orthotics	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
L2330	Orthotics	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
L3253	Orthotics	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
L3766	Orthotics	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
L3900	Orthotics	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
L3901	Orthotics	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
L3904	Out-of-network	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
L3961	Out-of-network	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
L3971	Out-of-network	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
L3975	Out-of-network	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
L3976	Out-of-network	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
L3977	Out-of-network	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
62320	Pain management and injection	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
62322	Pain management and injection	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
62324	Pain management and injection	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
62325	Pain management and injection	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
62326	Pain management and injection	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
62327	Pain management and injection	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
62350	Pain management and injection	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
62351	Pain management and injection	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
62360	Pain management and injection	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
62361	Pain management and injection	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
64451	Pain management and injection	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
64484	Pain management and injection	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
64520	Pain management and injection	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
64620	Pain management and injection	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
64640	Pain management and injection	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
E0782	Pain management and injection	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
E0783	Pain management and injection	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
E0786	Pain management and injection	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
64491	Pain management and injection	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
64492	Pain management and injection	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
64494	Pain management and injection	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
64495	Pain management and injection	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 18 Original policy
26340	Potentially unproven services (including experimental/ investigational and/or linked services)	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 19 Original policy
33289	Potentially unproven services (including experimental/ investigational and/or linked services)	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 19 Original policy
33361	Potentially unproven services (including experimental/ investigational and/or linked services)	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 19 Original policy
33362	Potentially unproven services (including experimental/ investigational and/or linked services)	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 19 Original policy
33363	Potentially unproven services (including experimental/ investigational and/or linked services)	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 19 Original policy
33364	Potentially unproven services (including experimental/ investigational and/or linked services)	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 19 Original policy
33365	Potentially unproven services (including experimental/ investigational and/or linked services)	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 19 Original policy
33366	Potentially unproven services (including experimental/ investigational and/or linked services)	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 19 Original policy
33369	Potentially unproven services (including experimental/ investigational and/or linked services)	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 19 Original policy
33477	Potentially unproven services (including experimental/ investigational and/or linked services)	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 19 Original policy
36514	Potentially unproven services (including experimental/ investigational and/or linked services)	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 19 Original policy
64722	Potentially unproven services (including experimental/ investigational and/or linked services)	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 19 Original policy
A9274	Potentially unproven services (including experimental/ investigational and/or linked services)	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 19 Original policy
C2624	Potentially unproven services (including experimental/ investigational and/or linked services)	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 19 Original policy
L5331	Prosthetics	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 20 Original policy
L5657	Prosthetics	Prior authorization requirements for UnitedHealthcare commercial plans, Pg 20 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.