CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization requirements for Ohio Medicaid

Lists prior authorization requirements, CPT/HCPCS/ICD-10 codes and submission instructions for participating UnitedHealthcare Community Plan of Ohio providers; applies to inpatient and outpatient services and excludes emergency/urgent care.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Ohio Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul. 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or call 877-842-3210.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Since Jul. 1, 2024effective date shown

UHCprovider.comportal for prior auth

877-842-3210phone for prior auth

Multiplecodes listed

$500DME PA threshold

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Coverage and Prior Authorization Criteria

General prior authorization criteria

Prior authorization is required for the listed services, procedures and drugs unless otherwise noted (e.g., emergency/urgent care or specified diagnosis exceptions).

Prior authorization is required for services, procedures or drugs listed in this document before the service is provided (submit via UnitedHealthcare Provider Portal or phone).

Prior authorization stance for listed services

Sections below identify specific services and code groups that require prior authorization.

ONE of

Inpatient video EEG (CPT 95700, 95711-95713) requires prior authorization for inpatient services.
Injectable chemotherapy administered in outpatient settings (chemotherapy J9000-J9999, and specified J-codes such as J0640, J0641, J0642, J1950, J1952) requires prior authorization for cancer diagnoses.
Cochlear implants and other auditory implants (e.g., CPT 69710, 69714, 69930) require prior authorization.
Continuous glucose monitors (e.g., HCPCS A4226, A4239, E0787, E2102, E2103) require prior authorization.

Prior authorization requirements (excerpt)

Coverage actions for listed supportive care items include prior authorization requirements as noted below.

ANY of the following

Outpatient administration of colony-stimulating factors, erythropoiesis-stimulating agents and bone-modifying agents requires prior authorization (see listed J/Q codes such as J1442, J1447, J2506, Q5101, Q5110, Q5125 and others).
Drug screening (G0483) requires prior authorization.
Enteral services and in-home nutritional therapy (e.g., B4034–B4036, B4100–B4104, B4150 series) require prior authorization.
Genetic and molecular testing including BRCA and multiple 8xx/81x/814xx/815xx/PLA codes require prior authorization and follow the authorization/notification program (ordering provider must indicate laboratory and test name).

Prior authorization criteria (excerpt)

Services and code groups in this excerpt require prior authorization or notification as noted.

BRCA genetic/molecular testing: notification/prior authorization is required before DNA sequencing; the ordering provider must notify the laboratory and the laboratory will notify UnitedHealthcare.

Home health care (G0151, G0152, G0153, G0156): prior authorization is required only in outpatient settings, including the member's home.

Hysterectomy procedures (listed CPT codes such as 58150, 58152, 58180, 58260, 58262, 58263, etc.) require prior authorization.

Injectable medications and IVIG: listed injectable HCPCS/J-codes require prior authorization (multiple J-codes listed across sections).

Coverage stance - section excerpt

This section enumerates HCPCS codes and references for specific drugs; explicit clinical coverage criteria are not provided in these entries.

Certain specialty drug products (example: Lanreotide J1932) are listed with prior authorization references; see the full HCPCS listing for additional drugs requiring prior authorization.

Extracted coverage criteria (partial)

Prior authorization and notification requirements and notable exceptions in this excerpt:

Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call the phone numbers provided in the document; follow portal instructions for oncology and non-oncology submissions.

White blood cell colony-stimulating factor codes (e.g., J1442, J1447, J2506, Q51xx) require prior authorization for both oncology and non-oncology diagnoses; ESRD diagnosis is exempt from prior authorization.

Inpatient post-acute admissions: prior authorization and notification of admission date is required for facilities providing post-acute inpatient services (acute care hospitals, acute inpatient rehab, critical access hospitals, long-term acute care hospitals).

Joint replacement procedures (total hip/knee and related CPT codes) require prior authorization.

Orthotics and prosthetics: prior authorization is required only for items with a retail purchase or cumulative threshold; selected L-codes are listed in the document.

Prior authorization criteria summary

Summary of prior authorization requirements and any special conditions for listed services.

ANY of the following

Orthotics and prosthetics: PA required only for retail purchase/cumulative threshold for listed L-codes (see orthotics section).
Standard radiation therapy (2D/3D): prior authorization required only when associated with diagnosis codes in specified ICD-10 ranges (e.g., C34.00–C34.92; C50.011–C50.929; C61; C79.51–C79.52; C84.7A; D05.00–D05.92).

Prior authorization criteria

Prior authorization requirements and constraints noted in this section:

Standard radiation therapy (2D/3D): prior authorization required only when obtained with diagnoses in the ranges C34.00-C34.92, C50.011-C50.929, C61, C79.51-C79.52, C84.7A, D05.00-D05.92.

Prior authorization submission: providers must submit requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call the numbers provided (portal resources at UHCprovider.com/OHcommunityplan are referenced).

Site-of-service rule: prior authorization is required when the service is requested in an outpatient hospital setting; prior authorization is not required if performed at a participating Ambulatory Surgery Center (ASC).

Prior authorization / notification criteria (excerpt)

Prior authorization or notification is required for the specific procedure groups and specialized therapies listed below.

ANY of the following

Selected surgeries (e.g., maxillomandibular procedures, sleep apnea surgeries, spinal surgeries like CPT 22100–22101) are labeled 'Prior authorization required.'
Transplants and CAR T-Cell therapies: prior authorization/notification required; contact the Transplant Case Management team as directed in the document for authorization and case management instructions.
Ventricular assist devices (VAD): prior authorization required; providers must call the notification number on the member's ID card and fax the form to the Optum VAD Case Management team at 855-282-8929 as instructed.

CPT, HCPCS and ICD-10 Codes

White blood cell colony-stimulating factor HCPCS/J-codes requiring prior authorizationHCPCSCovered

J1442	Filgrastim (Neupogen)
J1447	Pegfilgrastim (example)
J2506	Erythropoiesis-stimulating agent (example)
Q5101	Filgrastim-sndz (Zarxio)
Q5108	Biosimilar (example)
Q5110	Filgrastim-aafi (Nivestym)
Q5111	Biosimilar (example)
Q5120	Biosimilar (example)
Q5122	Biosimilar (example)
Q5125	Filgrastim-ayow (Releuko)

1–10 of 14

1/2

Selected Injectable / Colony-Stimulating Factor HCPCS/J-codesHCPCSCovered

J1442	Filgrastim (Neupogen)
J1447	Pegfilgrastim (example)
J2506	Erythropoiesis-stimulating agent (example)
Q5101	Filgrastim-sndz (Zarxio)
Q5108	Biosimilar (example)
Q5110	Filgrastim-aafi (Nivestym)
Q5111	Biosimilar (example)
Q5120	Biosimilar (example)
Q5122	Biosimilar (example)
Q5125	Filgrastim-ayow (Releuko)

1–10 of 11

1/2

ICD-10 Diagnosis Codes referenced (examples)ICD-10Covered

I70.*	Atherosclerosis and related arterial disease (all subcodes)
I72.*	Other aneurysm (all subcodes)
I74.*	Arterial embolism and thrombosis (all subcodes)
I77.*	Other disorders of arteries and arterioles (all subcodes)
E08.52	Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene
E09.52	Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy without gangrene
E10.52	Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene
E11.52	Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene
E13.52	Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene

Noted HCPCS/J codes requiring prior authorization (partial list)HCPCSCovered

J2820	Injectable medication (example)
J1447	Pegfilgrastim (example)
J1448	Filgrastim product (example)
J0897	Denosumab (Prolia/Xgeva) - prior auth for non-oncology DX
J0885	Injectable drug (example)

Cancer diagnosis ICD-10 codes referenced (selected)ICD-10Covered

C34.00	Malignant neoplasm bronchus and lung
C50.011	Malignant neoplasm of right female breast, nipple and areola
C61	Malignant neoplasm of prostate
C79.51	Secondary malignant neoplasm of bone
D05.00	Lobular carcinoma in situ of breast
C44.01	Basal cell carcinoma of skin of lip
C43.10	Malignant melanoma of unspecified eyelid

ICD-10 malignant neoplasm codes (examples)ICD-10Covered

C44.*	Other malignant neoplasms of skin (various subcodes)
C43.*	Melanoma in situ / malignant melanoma codes (various subcodes)

Sample DME / enteral service HCPCS codesHCPCSCovered

E1239	DME item (example)
E2310	DME item (example)
B4034	Enteral nutrition product
B4100	In-home nutritional therapy
K0812	DME code (example)

Genetic and molecular testing CPT/HCPCS codesmixedCovered

81162	BRCA sequencing
81163	BRCA duplication/deletion analysis
81228	BRCA1/BRCA2 analysis
81400	Molecular pathology (example)
81401	Molecular pathology (example)
81479	Unlisted molecular pathology procedure

Genetic/molecular testing codes (sample)CPTCovered

81432	Genetic test (example)
81433	Genetic test (example)
81436	Genetic test (example)

Injectable and IVIG sample codesHCPCSCovered

J1551	Cutaquig®
J1556	IVIG product
J1566	IVIG product
J1575	IVIG product
90284	IVIG administration

HCPCS codes (selected)HCPCSCovered

Lanreotide

J1932 (Lanreotide)

Injectable medication HCPCS codes (partial list)HCPCSCovered

J0174	Leqembi
J1306	Leqvio
J1950	Lupron Depot
J0218	Xenpozyme
J1558	Xembify
J1449	Rolvedon (eflapegrastim-xnst)

Joint replacement / related procedure CPT codes (partial)CPTCovered

27130	Total hip arthroplasty
27132	Revision, hip
27447	Total knee arthroplasty (example)

White blood cell colony-stimulating factor codesHCPCSCovered

J1442	Filgrastim (Neupogen)
J1447	Pegfilgrastim (example)
J2506	Erythropoiesis-stimulating agent (example)
Q5101	Filgrastim-sndz (Zarxio)
Q5125	Releuko (filgrastim-ayow)

Selected L-codes (orthotics/prosthetics)HCPCSCovered

L0170	Orthotic code (example)
L0480	Prosthetic code (example)
L3901	Prosthetic - knee (example)

Outpatient therapy CPT codesCPTCovered

92508	Speech/hearing therapy
97110	Therapeutic exercise
97112	Neuromuscular re-education

Radiation therapy codesCPTCovered

77385	IMRT planning complex
77520	Proton therapy
77371	SBRT/SRS delivery
77470	Standard radiation therapy

Special/Associated Services and SBRT/SRS codesCPTCovered

77331	Stereotactic planning
77370	SBRT planning
77399	Unlisted radiation procedure

Standard radiation therapy CPT/HCPCS codes (selected)CPTCovered

77525	Radiation therapy delivery
77470	Radiation therapy management
77387	Complex radiation therapy

Various procedure codes across specialties that require prior authorization (selection)mixedCovered

37226	Peripheral vascular procedure
93580	Invasive cardiology procedure
33927	VAD related procedure
Q0507	VAD supply HCPCS (example)

Selected CPT codes from excerptCPTCovered

21121	Orthognathic surgery
21215	Maxillofacial procedure (example)
44132	Colectomy (example)

VAD-related codesmixedCovered

33927	Ventricular assist device implant
33976	VAD management
Q0507	VAD related supply

How to Request Prior Authorization and Provider Responsibilities

Prior Authorization

How to obtain prior authorization and contact information

For participating providers: prior authorization is required for many services listed below. Submit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com -> UnitedHealthcare Provider Portal -> Prior Authorization and Notification tile) or call the numbers below. Prior authorization is not required for emergency or urgent care.

Online: UHCprovider.com > UnitedHealthcare Provider Portal > Prior Authorization and Notification tile
Phone (general): 888-397-8129 or 877-842-3210 (when noted)

Prior Authorization

Services requiring prior authorization (examples)

Examples of services that require prior authorization. This is a representative (not exhaustive) list — refer to individual code entries and program-specific resources for full details.

Selected surgeries (see separate callout) including joint replacement, spinal surgery, and other inpatient procedures

Definitions and Key Terms

inv-70: Prior authorization is the process by which providers submit requests via the UHC Provider Portal or phone to obtain approval before providing certain services; not required for emergency/urgent care.

DefinitionPrior authorization is the process by which providers submit requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone (877-842-3210) to obtain approval before providing certain services.

ExemptionPrior authorization is not required for emergency or urgent care.

Out-of-network ruleOut-of-network providers must request prior authorization for all procedures and services, excluding emergent or urgent care.

inv-71: Colony-stimulating factors, erythropoiesis-stimulating agents, and bone-modifying agents administered outpatient that require prior authorization

Drugs coveredColony-stimulating factors, erythropoiesis-stimulating agents, and bone-modifying agents administered outpatient require prior authorization.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Ohio Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul. 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or call 877-842-3210.

SourceLink

On This Page

Non-emergent air ambulance transport (A0430, A0431, A0435, A0436) requires prior authorization.

Outpatient advanced imaging and radiology as specified in radiology prior authorization resources

Durable Medical Equipment (DME) and orthotics/prosthetics when purchase or cumulative rental thresholds apply

Genetic and molecular testing (including BRCA) and laboratory-notification requirements

Outpatient injectable chemotherapy, colony-stimulating factors, and other specialty injectables

Outpatient therapy services (PT/OT/ST codes listed separately)

Cochlear implants, continuous glucose monitors, and enteral / in-home nutrition supplies

Prior Authorization

DME prior authorization and cost threshold

Durable medical equipment (DME) prior authorization rules: prior authorization is required for DME items as specified in the DME list. Prior authorization is required for orthotics and prosthetics when a retail purchase or cumulative rental cost exceeds the program threshold.

Edgepark handles incontinence supplies benefit and ordering: call Edgepark Medical Supplies at 844-564-1008
Prior authorization is required only for orthotics/prosthetics with a retail purchase or cumulative rental cost over $500
DME HCPCS examples listed in the program (E1239, E2310, E2311, K0812, etc.) — see DME listing for full codes

Prior Authorization

FAI (Femoroacetabular impingement) prior authorization

Femoroacetabular impingement (FAI) surgical procedures require prior authorization.

Relevant CPT codes include 29914, 29915, 29916

Prior Authorization

Hysterectomy prior authorization

Hysterectomy procedures require prior authorization.

Relevant CPT codes include 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58290, 58291, 58292, 58541–58544, 58550, 58552–58554, 58570–58573

Prior Authorization

Prior authorization - Lanreotide

Prior authorization is required for the medication lanreotide (J1932).

Drug: Lanreotide — HCPCS J1932
Follow standard prior authorization submission via Provider Portal or contact number listed above

Prior Authorization

Prior authorization - Lemtrada

Prior authorization is required for Lemtrada® (alemtuzumab).

Drug: Lemtrada® — HCPCS J1932 referenced in the listing
Submit requests through the Provider Portal or applicable specialty pharmacy/prior authorization process

Prior Authorization

Outpatient therapy prior authorization

Outpatient therapy services (physical, occupational, speech) require prior authorization for the CPT/HCPCS codes listed.

Examples of covered CPT codes requiring prior authorization: 92507, 92508, 92526, 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032–97039
Therapy evaluation and treatment codes: 97110, 97112–97113, 97116, 97124, 97129, 97139, 97140, 97150
Higher-level rehab and specialized codes: 97169–97172, 97530, 97533, 97535, 97537, 97542, 97545–97546, 97750, 97755, 97761, 97763
Submit prior authorization via the Provider Portal prior to scheduling services

Prior Authorization

Site-of-service (SOS) prior authorization rule

Site-of-service rule: prior authorization is required when services are requested in an outpatient hospital setting; the same services do not require prior authorization when performed at a participating Ambulatory Surgery Center (ASC). Review the site-of-service list for specific CPT groups and procedures.

SOS prior authorization applies to select outpatient hospital procedures (examples include certain cardiovascular, carpal tunnel, cataract, and other listed CPTs)
Prior authorization is not required if the procedure is performed at a participating ASC

Prior Authorization

Prior authorization required — selected surgeries

Selected surgeries require prior authorization. This includes, but is not limited to, joint replacement procedures, spinal surgery, maxillomandibular and other sleep apnea surgeries, rhinoplasty/septoplasty, sinuplasty, and vein procedures. Providers must obtain prior authorization before scheduling.

Joint replacement (total hip/knee and related procedures) — see joint replacement code list
Spinal surgery — CPT codes starting 22100 and the spine surgery series require prior authorization
Rhinoplasty/septoplasty and sinuplasty — CPT codes 30400–30465 and 31295–31298 require prior authorization
Vein procedures for venous disease (e.g., 36473, 36475, 36478, 37700, 37718, 37722, 37765, 37780) require prior authorization
Sleep apnea surgeries (including maxillomandibular advancement) require prior authorization

Example codesWhite blood cell CSF codes include J1442, J1447, J2506 and HCPCS Q51xx/Q52xx entries listed in the CSF section.

Non-oncology noteSome CSF codes require PA for non-oncology diagnoses; see white blood cell colony-stimulating factor listing.

inv-72: Injectable chemotherapy prior authorization

RulePrior authorization is required for injectable chemotherapy drugs administered in outpatient settings (intravenous, intravesical, intrathecal) for a cancer diagnosis.

Code rangeApplies broadly to chemotherapy injectable drugs in the J9000–J9999 range and specified J-codes (e.g., J0640, J0641, J0642, J1950, J1952).

SettingRequirement applies when these agents are administered in outpatient settings; inpatient chemotherapy may follow other rules.

inv-73: Inpatient video EEG prior authorization

ServiceInpatient video EEG (cerebral seizure monitoring) requires prior authorization for inpatient services.

Example CPT codesIncluded CPT codes: 95700, 95711, 95712, 95713.

ContextListed in the cancer supportive care / monitoring section where inpatient PA is emphasized.

inv-74: Incontinence supplies (DME)

Vendor requirementIncontinence supplies are a benefit only when provided through Edgepark Medical Supplies; to request call Edgepark at 844-564-1008.

CategoryIncontinence supplies are classified under DME and require vendor-specific ordering per this policy.

PA noteDME items generally require prior authorization as noted in the DME section of the document.

inv-75: Genetic/molecular testing authorization process

RequirementGenetic and molecular testing (including BRCA and numerous CPT/HCPCS/PLA codes) require prior authorization and follow an authorization/notification program.

Provider obligationsProviders must indicate the laboratory and test name as part of the prior authorization process; for BRCA testing the ordering provider must notify the laboratory and the laboratory will notify UnitedHealthcare before DNA sequencing.

Example codesRepresentative CPT codes include 81229, 81400–81408, 81431–81440, 81507, 81518–81521 and various PLA/U-codes referenced in the testing sections.

inv-76: BRCA testing (genetic/molecular testing)

RequirementNotification/prior authorization is required for BRCA testing before DNA sequencing is performed.

ProcessThe ordering provider must notify the laboratory conducting the test; the laboratory will then notify UnitedHealthcare.

CodesBRCA-related CPT codes listed in the document include examples such as 81229, 81277, 81400 and related 814xx series codes.

inv-77: Home health care (authorization scope)

ScopeHome health care prior authorization is required only in outpatient settings, including services provided in the member's home.

Example CPT/G codesHome health care codes referenced include G0151, G0299, G0152, G0300, G0153, G0156.

Setting noteInpatient home health or facility-based services may follow different admission/PA rules described elsewhere in the document.

inv-78: CPT®/HCPCS prior authorization listing

ListingSpecific CPT/HCPCS codes for which prior authorization is required are enumerated throughout the document (examples include radiation therapy codes 77385, 77386, 77520, 77522, and standard RT codes 77525, 77470, 77387).

How to obtain PASubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by the phone numbers provided in the document (varies by service).

ReferenceProviders should consult the document's code listings and sections for service-specific PA instructions and code groups.

inv-79: Prior authorization: the process by which providers must obtain approval (online via the UnitedHealthcare Provider Portal or by phone) before certain services or medications will be covered.

DefinitionPrior authorization: providers must obtain approval online via the UnitedHealthcare Provider Portal (Prior Authorization and Notification tile) or by phone before certain services or medications will be covered.

Portal accessAccess the portal at UHCprovider.com using One Healthcare ID; if you do not have an ID, visit UHCprovider.com/access for registration.

Phone contactsPhone numbers provided include 877-842-3210 and other service-specific numbers listed in the document (e.g., 888-397-8129, 866-889-8054).

inv-80: A policy referenced for the most up-to-date information on newly FDA-approved drugs and recommendations to seek predetermination.

Related policyReview at Launch for New to Market Medications is referenced for the most up-to-date information on newly FDA-approved drugs and predetermination recommendations.

Where to findAvailable at UHCprovider.com > Menu > Policies and Protocols > Community Plan Policies > Medical & Drug Policies and Coverage Determination Guidelines for Community Plan.

RecommendationPredetermination is highly recommended for drugs on the Review at Launch Medication List.

inv-81: Proton Beam Therapy

Proton beam therapyProton Beam Therapy is a focused radiation therapy that uses beams of protons; codes include 77520 and 77522.

PA requirementPrior authorization applies to proton beam therapy services as listed in the radiation therapy section.

Relation to other RT modalitiesProton beam therapy is listed alongside IMRT and SBRT/SRS as advanced radiation modalities requiring PA per code lists.

inv-82: IMRT

DefinitionIMRT (Intensity-Modulated Radiation Therapy) is listed with relevant CPT codes (e.g., 77385, 77386) and requires prior authorization as noted.

CodesIMRT planning codes include 77385 and 77386.

ContextIMRT is grouped with other advanced radiation services for PA processes in the radiation therapy section.

inv-83: Site of service (SOS) - outpatient hospital

Site-of-service rulePrior authorization is required only when requesting service in an outpatient hospital setting; PA is not required if performed at a participating Ambulatory Surgery Center (ASC).

ExamplesSite-of-service guidance appears in the Standard Radiation Therapy and other procedure sections that reference outpatient hospital vs ASC distinctions.

Provider actionWhen scheduling, verify site-of-service; obtain PA if procedure will be at an outpatient hospital as specified.

inv-84: VAD

DefinitionVentricular assist devices (VAD) are mechanical pumps that take over the function of a damaged ventricle and restore normal blood flow.

PA processPrior authorization is required; call the notification number on the member's ID card and fax the nurse-provided form to the Optum VAD Case Management team at 855-282-8929.

Associated codesAssociated CPT/HCPCS codes provided in the VAD section (e.g., 33927, 33976, 33983 and related Q05xx entries).

inv-85: CAR T-Cell therapy

DefinitionCAR T-Cell therapy services (examples: Abecma, Breyanzi, Kymriah, Tecartus, Yescarta) require prior authorization and notification to the UnitedHealthcare Community and State Transplant Case Management team.

ContactFor transplant and CAR T-Cell therapy services call the UnitedHealthcare Community and State Transplant Case Management team at 888-936-7246 or use the notification number on the member's health plan ID card.

ContextCAR T-Cell therapies are listed in the transplants section alongside prior authorization instructions.