This section consolidates coverage criteria, prior authorization requirements, and code-level lists for services and injectable medications. Preserve prior authorization rules, pediatric exceptions (members younger than 21), instructions for submitting requests, and lists of HCPCS/CPT/J-codes where provided.
Please note: • Services must be covered benefits as defined by AHCCCS to be eligible for prior authorization. • Services by non-network or out-of-state providers require prior authorization with supporting documentation. • Experimental and investigational services are not covered. • All rendering providers, facilities and vendors must be actively registered with AHCCCS. • Only one provider may request services on a prior authorization form. • Only medically necessary, cost-effective, federally- and state-reimbursable services are covered.
Allergy immunotherapy and testing: • For members younger than 21: allergy immunotherapy and testing are covered under EPSDT when medically necessary. • For members 21 and older: allergy immunotherapy (including subcutaneous injections, sublingual immunotherapy or other routes) is not a covered benefit; allergy testing is covered only when meeting severe criteria (e.g., prior anaphylactic reaction to unknown allergen or severe life-threatening reaction). Prior authorization required when criteria met.
Augmentative and alternative communication: Prior authorization is required for listed codes (examples: 92607, 92608, 92609, A9901, E2500, E2502, E2504, E2506, E2508).
Cerebral seizure monitoring and EEG: Prior authorization required for many outpatient monitoring codes (examples: 95700, 95711–95713, 95720, 95722, 95724, 95726). Inpatient video monitoring (95714–95718) prior authorization not required.
Chemotherapy (injectable): Prior authorization required for outpatient injectable chemotherapy (IV, intravesical, intrathecal) for cancer diagnosis. Applies to chemotherapy J-codes J9000–J9999, leucovorin (J0640), levoleucovorin (J0641, J0642), Lupron Depot (J1950), chemotherapy Q-codes, and miscellaneous HCPCS billed agents. Submit requests via UnitedHealthcare Provider Portal (Prior Authorization and Notification tool) or call designated numbers.
Injectable medications: Prior authorization required for injectable medications not covered by specified vendors/medical benefit. Long list of HCPCS/J-codes require prior authorization (examples include J0222, J0896–J0897, J1301, J1412, J1558, J2350/J2353, J3032, J9322 variants, Q5104, Q5123–Q5135, C9094, C9149, C9157, C9166, C9172, C9399, J3490, J3590). Unclassified/temporary codes require PA only for specific products (e.g., Nulibry, Revcovi, Rivfloza, Vabysmo). See Review at Launch policy for new-to-market medications and consider pre-determination.
Intravitreal VEGF agents: Specific codes listed (examples across document include J0178, J0179, J2777–J2779, Q5124, Q5128) and others; prior authorization instructions as above.
Pediatric-specific services (members younger than 21): Numerous procedures and services have pediatric exceptions and coverage under EPSDT; examples include functional endoscopic sinus surgery (31240, 31253–31259, 31267, 31276, 31287, 31288), genetic testing panels (81265, 81302, 81321–81325, 81401, 81403–81408, 81415, 81416, 81460, 81479, 86353, 88245, 88248–88249, 88261–88264, 88267, 88269, 88271–88275, 88280, 88283, 88285, 88289, 88291, 88299, biomarker codes, 81313, 81327, 81435, 81490) and hearing services/hearing aids (92590–92595, 92593–92595, V5010–V5011, V5014, V5030, V5040, V5050, V5060, V5095, V5100, V5120, V5190, V5230, V5242–V5249, V5250). Prior authorization requirements vary by age and service; some pediatric services do not require prior authorization.
Outpatient therapy and speech therapy: For members younger than 21, occupational, physical and speech therapy are covered when medically necessary with no annual limits; prior authorization required after the initial evaluation and before the initial therapy visit and for ongoing therapy visits. For members 21 and older, outpatient speech therapy is generally not covered (QMB exception applies).
Incontinence supplies: Benefit only when provided through Preferred Homecare; requests handled by Preferred Homecare contact.
Infusion in-home services: Prior authorization required for services not covered by Optum Infusion; to request services call Optum Infusion at 888-705-4470.
Orthotics and prosthetics: Prior authorization required for many orthotics/prosthetics codes (examples: L3901, L3904, L3905, L3961, L3971, L3975–L3977, L3999–L4020, L4350, L4392, L4394, L4631, L5010, L6920–L6940, L6925–L6945, L6930, L6935–L6955); follow Medicare-consistent coverage considerations and cost-effectiveness. Prior authorization required for out-of-network services.
Site-of-service restrictions (SOS): Prior authorization may be required when requesting services in an outpatient hospital setting for selected codes; prior authorization not required if performed at a participating ambulatory surgery center in many cases. (Examples referenced in document.)
Sinuplasty and endoscopic sinus procedures: Prior authorization required for sinuplasty codes (31295–31298) and many endoscopic sinus surgery codes listed above.
Pain injections and management: Prior authorization required for selective pain injection codes (examples: 64490, 64493).
Transportation and non-emergent transport: Prior authorization required for listed transportation codes (including non-emergent taxi and stretcher van); for inpatient admissions and certain post-acute facilities notification/authorization required.
Transplant and CAR T-cell therapy: Clinical documentation must accompany transplant/CAR T requests. For transplant and CAR T services (examples Abecma, Breyanzi, Carvykti, Kymriah, Lyfgenia, Tecartus, Yescarta), call UnitedHealthcare Community and State Transplant Case Management Team at 800-418-4994 or the notification number on the member's ID card.
Ventricular assist devices (VAD): Prior authorization required; follow notification processes on member ID card and fax forms to Optum VAD Case Management Team when instructed.
Temporary and unclassified codes / wound vac and other devices: Specific temporary/unclassified and wound VAC codes (e.g., E2402 for VAC supplies) may require prior authorization; follow device/program-specific instructions.
Submission instructions: For prior authorization, submit requests online using the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com) or call the provider phone numbers listed (e.g., 888-397-8129, 866-889-8054) and follow plan-specific instructions for specialty services (Labcorp, Optum, Preferred Homecare, transplant team).