UnitedHealthcare prior authorization, page 9
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
| Code | Description | Source |
|---|---|---|
| K0885 | End-stage renal disease (ESRD) dialysis services | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 10 Original policy |
| S1040 | End-stage renal disease (ESRD) dialysis services | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 10 Original policy |
| 28285 | Functional endoscopic sinus surgery (FESS) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 11 Original policy |
| 28289 | Functional endoscopic sinus surgery (FESS) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 11 Original policy |
| 28291 | Functional endoscopic sinus surgery (FESS) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 11 Original policy |
| 28292 | Functional endoscopic sinus surgery (FESS) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 11 Original policy |
| 28296 | Functional endoscopic sinus surgery (FESS) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 11 Original policy |
| 28297 | Functional endoscopic sinus surgery (FESS) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 11 Original policy |
| 28298 | Functional endoscopic sinus surgery (FESS) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 11 Original policy |
| 28299 | Functional endoscopic sinus surgery (FESS) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 11 Original policy |
| 31240 | Functional endoscopic sinus surgery (FESS) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 11 Original policy |
| 31253 | Functional endoscopic sinus surgery (FESS) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 11 Original policy |
| 31254 | Functional endoscopic sinus surgery (FESS) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 11 Original policy |
| 31255 | Functional endoscopic sinus surgery (FESS) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 11 Original policy |
| 31256 | Gastroenterology endoscopy (GI) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 11 Original policy |
| 31257 | Gastroenterology endoscopy (GI) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 11 Original policy |
| 31259 | Gastroenterology endoscopy (GI) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 11 Original policy |
| 31267 | Gastroenterology endoscopy (GI) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 11 Original policy |
| 31276 | Gastroenterology endoscopy (GI) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 11 Original policy |
| 31287 | Gastroenterology endoscopy (GI) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 11 Original policy |
| 31288 | Gastroenterology endoscopy (GI) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 11 Original policy |
| 45393 | Gastroenterology endoscopy (GI) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 11 Original policy |
| 14000 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 14001 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 14041 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 15734 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 15738 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 15750 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 15757 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 15758 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 19303 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 21899 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 31599 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 31899 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 53410 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 53430 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 54125 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 54520 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 54660 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 54690 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 55175 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 55180 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 56625 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 56800 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 56805 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 57110 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 57335 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 58260 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 58262 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 Original policy |
| 58290 | Gender dysphoria treatment (cont.) | Prior authorization requirements for UnitedHealthcare commercial plans, Pg 12 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
| 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. |