CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization requirements for Michigan Medicaid, Healthy Michigan Plan (HMP) and Children's Special Health Care Services (CSHCS)

Lists prior authorization requirements, codes, submission methods, vendor routing, and exceptions (including emergency/urgent care exclusions) for UnitedHealthcare Community Plan providers in Michigan.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Michigan Medicaid, HMP and CSHCS

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal or call 800-903-5253 or fax 855-225-9847.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Online/Phone/Faxsubmission methods

800-903-5253phone (prior auth)

855-225-9847fax (prior auth)

Excludedemergency/urgent care

144PT/OT annual units

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36Speech visits/year

Coverage Criteria and Prior Authorization Requirements

No prior authorization required

Categories that do not require prior authorization:

No prior authorization required (general statement).

Services requiring prior authorization

Covered when PRIOR AUTHORIZATION is required for the specific listed services or codes:

Examples of services requiring prior authorization

Abortion procedures (CPT codes including 59840–59866) require prior authorization.
Bariatric surgery and obesity-related procedures (examples: 43644, 43645, 43659, 43770, 43775, 43842–43848, 43860) require prior authorization.
Bone growth stimulators (e.g., CPT 20975) require prior authorization.
Breast reconstruction (non-mastectomy) procedures (examples: CPT 11971, 19316, 19318, 19325, 19328–19330, 19340–19342, 19350, 19357, 19361, 19364, 19367–19371, 19380, 19396) require prior authorization.
Cardiovascular procedures (examples: CPT 37220–37231) require prior authorization.

CMS inpatient-only billing requirement

CMS inpatient-only procedures must be requested and billed as inpatient:

Services designated inpatient-only by CMS must be requested as inpatient; if performed outpatient they are not payable under CMS Outpatient Prospective Payment System guidelines. (See CMS Addendum B Status Indicator C list on cms.gov.)

Prior authorization required

Devices and procedures that require prior authorization (selected examples):

Implants and devices

Cochlear implants and other auditory implants require prior authorization for listed CPT/HCPCS codes (examples: 69710, 69714, 69930, L8691, L8692, L8619).
Continuous glucose monitors require prior authorization when used for type 2 or gestational diabetes (listed HCPCS: A4238, A9278, A4239, E2102, A9276, E2103, A9277).

Procedures

Cosmetic procedures that change appearance without significantly improving or restoring physiologic function require prior authorization for listed CPT codes (examples: 14061, 15820–15823, 15830, 15847, 15877–15879).
Reconstructive procedures that treat a medical condition or restore physiologic function require prior authorization for the specific listed codes (examples: 67950, 67966 and related HCPCS E-codes).

Reconstructive/prosthetic PA and cost threshold

Reconstructive procedures and prosthetics — prior authorization and cost threshold:

Reconstructive procedures and prosthetics that improve or restore physiologic function require prior authorization only for the specific listed CPT/HCPCS codes and when the retail purchase or cumulative rental cost of the listed orthotic/prosthetic codes exceeds $500 (cost threshold).

Chemotherapy PA stance

Chemotherapy coverage stance:

No prior authorization required for chemotherapy (as stated).

Prior authorization and vendor restrictions (excerpt)

Vendor routing and other vendor-specific prior authorization rules (excerpt):

Catheter supplies, diabetic supplies (including external insulin pumps), electric breast pumps, and incontinence supplies are benefits only when provided through J&B Medical Supply Company, Inc.; providers should call J&B at 800-737-0045 to request these supplies.

Respiratory supplies are a benefit only when provided through Binson's Hospital Supplies or Binson's Medical; providers should call 888-246-7667 to request respiratory supplies.

Enteral services (in-home nutritional therapy, enteral or gastrostomy) require prior authorization (examples: B4034, B4035, B4036, B4102, B4149, B4150, B4152, B4153, B4155, B4160, B4161).

Genetic and molecular testing (including BRCA) requires prior authorization/notification; ordering provider must notify the laboratory and identify the laboratory and test; payment is authorized for CPT codes registered with the Genetic and Molecular Testing Prior Authorization/Notification program (examples: 81162–81164, 81228–81229, 81400–81408).

Prior authorization code and category list

Prior authorization required for the following categories and sample codes:

Joint replacement

Total hip and knee replacement procedures require prior authorization (sample CPT codes include 24360, 24361, 24362, 24363, 24370, 24371, 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27412, 27446, 27447, 27486, 27487, 29866–29868).

Orthotics and prosthetics: prior authorization is required only for the orthotics/prosthetic codes listed when the retail purchase or cumulative rental cost exceeds $500 (sample L-codes include L0112, L0170, L0456, L0462, L0464, L0480).

Injectable and specialty drugs: many injectable/specialty medications require prior authorization or notification (sample HCPCS/CPT includes J7171, J0801, J1931, Q5121, J0490, J0597, J0567, J1786, J9226, 90378); pre-determination is recommended for drugs on the Review at Launch list and some drugs require notification through OptumRx.

Extracted coverage criteria (partial)

Selected coverage rules and operational limits:

Physical therapy limited to 144 units per calendar year; prior authorization required for services above this limit.

Occupational therapy limited to 144 units per calendar year; prior authorization required for services above this limit.

Speech therapy limited to 36 visits per calendar year; speech therapy is not a covered benefit when provided to meet developmental milestones.

Proton beam therapy (CPT 77520–77525) requires prior authorization.

Site-of-service rule: prior authorization is required only when requesting service in an outpatient hospital setting; prior authorization is not required if the service is performed at a participating ambulatory surgery center (ASC).

Prior authorization coverage criteria (partial)

Service categories and example codes requiring prior authorization (partial list):

Spinal surgery: prior authorization required for listed spinal procedure CPT codes; for dates of service on or after April 1, 2022, prior authorization is required in all places of service (sample codes: 22100, 22101, 22102, 22110, 22510–22515, 22532–22533, 22548, 22551, 22554, 22556, 22558, 22586, 22590, 22595, 22600, 22610, 22612, 22630, 22633, 22800–22812, 22818–22819, 22830, 22849–22852, 22855–22861, 63001, 63003, 63005, 63011–63017, 63020, 63030, 63040, 63042, 63045–63047, 63050, 63055–63056, 63064, 63075–63081, 63085–63090, 63101–63102, 63170–63173, 63185, 63190–63191, 63200, 63250–63252, 63265–63272, 63286, 63300–63308).

Stimulators (implantation of devices that send electrical impulses) require prior authorization; bone growth stimulator and neurostimulator HCPCS/CPT codes listed (examples: E0747, E0748, E0760, 63650, 63655, 63685, 64555, 64568, 64570, 64590).

Transplants and CAR T‑cell therapies require prior authorization; inpatient transplant procedures are carved out to the state. For transplant and CAR T‑cell therapy services (including Carvykti, Kymriah, Lyfgenia, Yescarta), providers must call UnitedHealthcare Community and State Transplant Case Management at 888-936-7246 or the notification number on the member's ID card.

Sleep apnea procedures and surgeries (e.g., maxillomandibular advancement, oral‑pharyngeal tissue reduction) require prior authorization (example code: 42145).

Prior authorization requirements (excerpt)

Additional service categories and codes that require prior authorization or notification (excerpt):

ANY of the following

Transplant and CAR T‑cell therapy products and associated procedure codes require prior authorization/notification; contact UnitedHealthcare Community and State Transplant Case Management at 888-936-7246 or use the notification number on the member's ID card (examples: Carvykti, Kymriah, Lyfgenia, Yescarta).
Ventricular assist device (VAD) services require prior authorization; providers should call the notification number on the member's ID card and fax the form provided by the nurse to the Optum VAD Case Management team at 855-282-8929 (VAD-related CPT/HCPCS examples include 33927–33929, 33975–33983, Q0507–Q0509).
Vein procedures (removal and ablation of saphenous veins/main trunks and named branches for venous disease/varicose veins) require prior authorization (sample CPT codes: 36473, 36475, 36478, 37700, 37718, 37722, 37765, 37766).
Wound vacuum therapy (wound vac, HCPCS E2402) requires prior authorization.

Codes and Billing Guidance

Cardiovascular/related ICD-10 codes (covered)ICD-10Covered

I70.*	Atherosclerosis and related peripheral vascular disease codes (all subcodes)
I72.*	Other aneurysm and arterial malformations (all subcodes)
I74.*	Arterial embolism and thrombosis (all subcodes)
I75.*	Other disorders of cerebral arteries (all subcodes)
M86.*	Osteomyelitis codes (all subcodes)
T82.818A	Embolism of vascular prosthetic devices, implants and grafts, initial encounter
T82.868A	Other complications of vascular prosthetic devices, implants and grafts, initial encounter
S81.*	Open wound of lower leg (all subcodes)
S91.*	Open wound of ankle and foot (all subcodes)

How Providers Request Prior Authorization and Operational Workflows

Prior Authorization

How to request prior authorization and key exceptions

Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com), or by phone at 800-903-5253, or by fax to 855-225-9847. Prior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all procedures and services except emergent or urgent care. Exceptions where prior authorization is not needed include orthopedic physician services, medically necessary obstetric physician services, and 23-hour observation.

Online: Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) — select the Prior Authorization and Notification tile after signing in.
Phone: 800-903-5253
Fax: 855-225-9847
Emergency/urgent care excluded from prior authorization requirement
Exceptions: orthopedic physician services; medically necessary obstetric physician services; 23-hour observation

Prior Authorization

Service-level prior authorization requirement overview

Definitions and Policy Terms

Definition of Prior authorization

DefinitionPrior authorization is the payer's approval process required before certain services are provided to ensure coverage and medical necessity.

Emergency/urgent carePrior authorization is not required for emergency or urgent care.

Submission methodsRequests may be submitted online via the UnitedHealthcare Provider Portal, by phone (800-903-5253), or by fax (855-225-9847).

CMS inpatient-only procedures — Definition

DefinitionCMS inpatient-only procedures are services designated by CMS to be performed and requested as inpatient; if performed outpatient they are not payable under the CMS Outpatient Prospective Payment System (OPPS).

ReferenceFor the inpatient-only code list see CMS Addendum B (Status Indicator C in column D) on cms.gov.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Michigan Medicaid, HMP and CSHCS

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal or call 800-903-5253 or fax 855-225-9847.

SourceLink

On This Page

Provider prior authorization contact: phone 800-903-5253; fax 855-225-9847 for prior authorization requests.

Note: some listed surgical and transplant codes require special handling or contact with case management; code 38232 requires prior authorization only for an oncology diagnosis.

The policy lists specific services and service categories that require prior authorization; examples include abortion, bariatric surgery, breast reconstruction (non-mastectomy), and various cardiovascular procedures — associated CPT/HCPCS and diagnosis codes are provided throughout the document.

Abortion, bariatric surgery, breast reconstruction (non-mastectomy) — prior authorization required (codes listed).
Cardiovascular procedures — prior authorization required (codes listed).

Prior Authorization

CMS inpatient-only procedures - request as inpatient

Services designated by CMS as inpatient-only must be requested and billed as inpatient; if performed as outpatient they are not payable under CMS Outpatient Prospective Payment System (OPPS) guidance.

For the list of inpatient-only codes see CMS Addendum B (Status Indicator C) on cms.gov.

Prior Authorization

Cochlear implants prior authorization

Prior authorization is required for cochlear implants and other auditory implants for the CPT/HCPCS codes listed in the policy (e.g., 69710, 69714, 69930, L8691, L8692, L8619).

Cochlear implant codes: 69710, 69714, 69930, L8691, L8692, L8619

Prior Authorization

Continuous glucose monitor prior authorization

Continuous glucose monitors require prior authorization when used for type 2 or gestational diabetes; the policy lists the applicable HCPCS codes (e.g., A4238, A9278, A4239, E2102, A9276, E2103, A9277).

CGM HCPCS examples: A4238, A9278, A4239, E2102, A9276, E2103, A9277
Prior authorization required with a diagnosis of type 2 or gestational diabetes

Prior Authorization

Cosmetic procedure prior authorization

Cosmetic procedures that primarily change appearance (and do not significantly improve or restore physiologic function) require prior authorization for the CPT codes listed in the policy (examples include 14061, 15823, 15878, 15820, 15830, 15879, 15821, 15847, 15822, 15877).

Examples of cosmetic CPT codes requiring prior authorization: 14061, 15820, 15821, 15822, 15823, 15830, 15847, 15877, 15878, 15879

Prior Authorization

Reconstructive/prosthetic prior authorization and cost threshold

Reconstructive procedures and prosthetics that treat a medical condition or restore physiologic function require prior authorization only for the specific HCPCS/CPT codes listed and when the retail purchase or cumulative rental cost threshold applies.

Reconstructive/prosthetic HCPCS examples: A9900, E0277, E0465, E0194, E0328, E0466, E0636, E0265, E0329, E0470, E0637, E0457
Prior authorization required only for the listed codes when retail purchase or cumulative rental cost exceeds $500

Prior Authorization

E-code prior authorization listing

The policy includes numerous internal E-code combinations used to obtain prior authorization; examples include E2331, E2351, E2373, E2510, E2511, E2512, E2599, E2626, E8000, and E8001.

E-codes used in prior authorization examples: E2331, E2351, E2373, E2510, E2511, E2512, E2599, E2626, E8000, E8001

Documentation Required

Contact for prior authorization

Multiple entries reference 'Additional information = 800-737-0045' as a contact number for requesting certain supplies and prior authorization-related assistance.

Additional information / contact: 800-737-0045 (repeated in multiple entries)

Billing Rule

DME vendor routing and prior authorization

Certain DME categories (including catheter supplies, diabetic supplies/external insulin pumps, electric breast pumps, and incontinence supplies) are benefits only when provided through J&B Medical Supply Company, Inc.; requests for these supplies must be made by calling J&B Medical Supply at 800-737-0045.

Preferred vendor for catheters, diabetic supplies, external insulin pumps, electric breast pumps, and incontinence supplies: J&B Medical Supply Company, Inc.
Vendor phone for requests: 800-737-0045

Prior Authorization

Enteral and experimental services

Enteral (in-home nutritional) services and certain experimental/investigational services require prior authorization; listed HCPCS and CPT examples include B4034, B4035, B4036, B4102 and experimental codes such as 33477 and 64722.

Enteral service HCPCS examples: B4034, B4035, B4036, B4102, B4149, B4150
Experimental/investigational examples: 33477, 64722
Prior authorization required for enteral and experimental/Investigational linked services

Documentation Required

Genetic and molecular testing prior authorization/notification

Genetic and molecular testing (including BRCA testing) requires prior authorization/notification; the ordering provider must notify the laboratory and indicate the laboratory and test name. Payment is authorized only for CPT codes registered with the Genetic and Molecular Testing Prior Authorization/Notification program.

BRCA and genetic testing examples: 81162, 81163, 81164, 81228, 81229, 81400–81408, 81415, 81479
Ordering provider must notify the laboratory and include the test name
Payment authorized only for CPT codes registered with the Genetic and Molecular Testing Prior Authorization/Notification program

Prior Authorization

Home health and hysterectomy

Home health services (Home Health Agency bill type 03xx) and hysterectomy procedures require prior authorization; hysterectomy CPT examples include 58150, 58152, 58180, 58260 and related codes.

Home Health Agency bill type: 03xx — prior authorization required
Hysterectomy examples: 58150, 58152, 58180, 58260, 58542

Billing Rule

Vendor-specific supply routing (J&B Medical Supply)

Catheter, diabetic supplies (including external insulin pumps), electric breast pumps, and incontinence supplies are benefits only when provided through J&B Medical Supply Company, Inc.; call 800-737-0045 to request supplies.

Vendor: J&B Medical Supply Company, Inc.
Call to request supplies: 800-737-0045

Billing Rule

Vendor-specific supply routing (Binson's)

Respiratory supplies are benefits only when provided through Binson's Hospital Supplies or Binson's Medical; providers should call 888-246-7667 to request respiratory supplies.

Respiratory supply vendor: Binson's Hospital Supplies / Binson's Medical
Vendor phone to request supplies: 888-246-7667

Prior Authorization

How to obtain prior authorization and notifications

Submit prior authorization and notification requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com). The policy also provides an alternate phone number (888-397-8129) for prior authorization in some sections and notes that predetermination is recommended for drugs on the Review at Launch list.

Portal submission: Prior Authorization and Notification tool on UHCprovider.com
Alternate phone (section-specific): 888-397-8129
Pre-determination recommended for drugs on the Review at Launch Medication List

Prior Authorization

Prior authorization required — surgeries and transport

Prior authorization is required for listed joint replacement procedure codes (total hip and knee) and for non-emergent air ambulance transport codes; examples include CPT 27130, 27132, 27486, 27487 and HCPCS A0430–A0436.

Joint replacement examples: 27120, 27125, 27130, 27132, 27134, 27486, 27487
Non-emergent air ambulance examples: A0430, A0431, A0435, A0436

Prior Authorization

Orthotics and prosthetics prior authorization threshold

Prior authorization is required only for orthotics and prosthetic codes listed when the retail purchase or cumulative rental cost exceeds $500; numerous L-codes are enumerated in the policy.

Cost threshold: retail purchase or cumulative rental cost > $500 triggers prior authorization requirement
Orthotics/prosthetics L-code examples: L0112, L0170, L0456, L0462, L0480, L0631, L0710

Prior Authorization

How to obtain prior authorization and contact

Providers may request prior authorization by phone at 800-903-5253 or by fax to 855-225-9847. The policy states prior authorization is required for outpatient therapy services above listed limits and for specified procedures; speech therapy is not covered when provided to meet developmental milestones.

Phone: 800-903-5253
Fax: 855-225-9847
Outpatient therapy limits and other procedure prior authorization requirements detailed in the policy
Speech therapy exclusion: not covered if provided to meet developmental milestones

Prior Authorization

Site of service prior authorization rule

Site-of-service prior authorization is required only when requesting a service in an outpatient hospital setting; prior authorization is not required if the same service is performed at a participating ambulatory surgery center (ASC).

Prior authorization required for outpatient hospital setting requests
No prior authorization required when performed at a participating ASC for listed codes

Prior Authorization

Proton beam therapy

Proton beam therapy requires prior authorization; the CPT codes listed include 77520, 77522, 77523 and 77525.

Proton beam therapy CPT codes: 77520, 77522, 77523, 77525
Prior authorization required

Prior Authorization

ENT / Rhinoplasty / Sinuplasty

Selected ENT procedures and rhinoplasty/septoplasty/sinuplasty codes require prior authorization; examples include CPT codes 30400, 30435, 30465, 31295–31298 and 31295–31298 for sinuplasty.

Rhinoplasty/septoplasty examples: 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465
Sinuplasty examples: 31295, 31296, 31297, 31298
Prior authorization required

Prior Authorization

Prior authorization required — Spinal surgery

Spinal surgery procedures require prior authorization; the policy lists numerous spinal CPT codes (e.g., 22100, 22101, 22102, 22510, 22511, 63001) and notes that for dates of service on or after April 1, 2022 prior authorization is required in all places of service under the spinal surgery category.

Spinal surgery examples: 22100, 22101, 22102, 22510, 22511, 63001
For services on/after April 1, 2022, prior authorization required in all places of service

Prior Authorization

Prior authorization required — Stimulators

Implantable stimulators (including bone growth stimulators and neurostimulators) require prior authorization; listed HCPCS/CPT examples include E0747, E0748, E0760 and CPT codes such as 43648, 61863, 63650.

Stimulator HCPCS examples: E0747, E0748, E0760
Related CPT examples: 43648, 61863, 63650
Prior authorization required

Prior Authorization

Prior authorization required — Transplants and CAR T-cell therapies

Transplant procedures and CAR T-cell therapies require prior authorization; for these services providers must call the UnitedHealthcare Community and State Transplant Case Management team at 888-936-7246 (or the notification number on the member's ID card) for authorization/notification.

Contact for transplant/CAR T authorization/notification: UnitedHealthcare Community and State Transplant Case Management at 888-936-7246
Examples of CAR T products listed: Carvykti (ciltacabtagene autoleucel), Kymriah (tisagenlecleucel), Lyfgenia (lovotibeglogene autotemcel), Yescarta (axicabtagene ciloleucel)

Prior Authorization

Prior authorization required — Sleep apnea surgeries

Sleep apnea surgical procedures (e.g., maxillomandibular advancement and oral-pharyngeal tissue reduction) require prior authorization; listed CPT examples include 21685 and 41599 (and 42145).

Sleep apnea surgery examples: 21685, 41599, 42145
Prior authorization required

Prior Authorization

Transplant and CAR T-cell therapy notification/prior authorization

For transplant and CAR T-cell therapy services (including listed products), call the UnitedHealthcare Community and State Transplant Case Management team at 888-936-7246 or use the notification number on the back of the member's health plan ID card for authorization/notification.

Transplant/CAR T contact: 888-936-7246
Alternatively, use the notification number on the member's ID card

Prior Authorization

VAD prior authorization and submission workflow

Ventricular assist device (VAD) services require prior authorization. Providers should call the notification number on the member's ID card, then fax the form provided by the nurse to the Optum VAD Case Management team at 855-282-8929.

Call the notification number on the member's health plan ID card first
Fax the nurse-provided form to Optum VAD Case Management at 855-282-8929

Prior Authorization

Vein procedures prior authorization

Vein procedures for removal and ablation of saphenous veins and named branches (for venous disease/varicose veins) require prior authorization; CPT examples include 36473, 36475, 36478, 37700, 37718, 37722, 37765, 37766.

Vein procedure examples: 36473, 36475, 36478, 37700, 37718, 37722, 37765, 37766
Prior authorization required

Prior Authorization

Wound vac prior authorization

Wound vacuum (wound vac) therapy requires prior authorization; the HCPCS code listed is E2402.

Wound vac HCPCS: E2402
Prior authorization required

J&B Medical Supply Company, Inc. (preferred vendor for E0784)

Vendor nameJ&B Medical Supply Company, Inc. is the preferred vendor for HCPCS code E0784.

Contact instructionTo request catheter, diabetic, incontinence supplies or electric breast pumps provided through J&B Medical Supply, call 800-737-0045 (as noted in policy).

E-code usage — internal prior authorization identifiers

E-code usageE2331, E2351, E2373, E2510, E2511, E2512, E2599, E2626, E8000, E8001 are listed and used as internal HCPCS/E-codes for prior authorization purposes.

PurposeThese E-codes are included in the policy's prior authorization listings to obtain authorization for related DME/prosthetic items.

Vendor-specific supply routing — Preferred vendor routing

DefinitionVendor-specific supply routing means certain supplies (catheter, diabetic supplies including external insulin pumps, electric breast pumps, incontinence supplies) are benefits only when provided through the named preferred vendor(s).

ExamplesJ&B Medical Supply provides catheter/diabetic/incontinence supplies (call 800-737-0045); Binson's Hospital Supplies provides respiratory supplies (call 888-246-7667).

Genetic and molecular testing prior authorization/notification

RequirementGenetic and molecular testing (including BRCA) requires prior authorization/notification.

Ordering provider responsibilityThe ordering provider must notify the laboratory and indicate the laboratory and test name; payment is authorized only for CPT codes registered with the Genetic and Molecular Testing Prior Authorization/Notification program.

Review at Launch — New to Market Medications Policy

DefinitionReview at Launch refers to the 'Review at Launch for New to Market Medications' policy used to identify newly FDA-approved drugs that may require pre-determination; the policy is available on UHCprovider.com.

ActionPre-determination is highly recommended for drugs on the Review at Launch Medication List; prior notification for specified products (e.g., Cimzia, Synagis) is through OptumRx at 800-310-6826.

Orthotics/prosthetics prior authorization rule

RulePrior authorization is required for orthotics and prosthetics only when the specific listed codes have a retail purchase price or cumulative rental cost greater than $500.

ScopeApplies only to the codes explicitly listed in the policy; some home health items may be exempt from the cost threshold.

Site of service (SOS) - outpatient hospital

DefinitionOutpatient hospital site of service: prior authorization is required only when requesting a service in an outpatient hospital setting; it is not required if the service is performed at a participating ambulatory surgery center (ASC).

ExamplesSite-of-service guidance applies to codes listed under outpatient hospital entries (e.g., 31298, 36590, 36832).

Speech therapy coverage limitation

LimitationSpeech therapy is limited to 36 visits per calendar year; additionally, speech therapy is not a covered benefit if provided to meet developmental milestones.

Prior authorizationPrior authorization is required for outpatient therapy services above the listed yearly limits.

Site of service (SOS) — additional reference

Site of service (SOS)Site of service (SOS) indicates whether prior authorization is required based on the setting (e.g., outpatient hospital vs participating ASC); prior authorization is required for outpatient hospital requests but not when performed at a participating ASC for the listed codes.

Reference codesExamples of SOS-listed codes include arthroscopy and other outpatient procedures (see policy code lists such as 29835–29893, G0260).

Transplant prior authorization process

ProcessInpatient transplant procedures are carved out to the state; for transplant and CAR T-cell therapy services, contact UnitedHealthcare Community and State Transplant Case Management at 888-936-7246 or use the notification number on the member's ID card.

ScopePrior authorization is required for transplant and CAR T-cell therapy services (specific products such as Carvykti, Kymriah, Lyfgenia, Yescarta are listed).

Ventricular assist devices (VAD) — Definition and workflow

DefinitionVentricular assist device (VAD) services refer to implantable mechanical circulatory support devices (policy references specific CPT and Q-codes such as 33927–33929, 33975–33983, Q0507–Q0509).

Submission workflowProviders should call the notification number on the member's ID card then fax the form provided by the nurse to the Optum VAD Case Management team at 855-282-8929.

Vein procedures (saphenous vein ablation/removal) — Definition

DefinitionVein procedures include removal and ablation of the main trunks and named branches of the saphenous veins for treating venous disease and varicose veins of the extremities.

Examples of CPT codesPolicy examples include 36473, 36475, 36478, 37700 and related vein ablation/removal codes that require prior authorization.