CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization requirements for Texas STAR

A list of prior authorization review requirements and submission methods for participating UnitedHealthcare Community Plan of Texas STAR providers for inpatient and outpatient services.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Texas STAR

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOctober 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID, or via chat or fax.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Oct 1, 2024document effective date

Online/Chat/Faxsubmission methods

Texas STARprogram governed

100+codes listed (partial)

Coverage & Prior Authorization Criteria (Selected)

Stated coverage requirements (partial)

Prior authorization requirements and exceptions (partial).

Submit prior authorization requests via the UnitedHealthcare Provider Portal, chat, or fax (877-940-1972).

Prior authorization is not required for emergency or urgent care.

Out-of-network requests must be made by a network care provider.

Many chemotherapy and oncology-related injectable codes require prior authorization; for oncology diagnosis prior authorization call 866-604-3267 or submit via the Provider Portal.

Procedure exceptions and conditional prior authorization

Cosmetic, reconstructive, and other procedures — prior authorization notes and exceptions appear in-line with CPT codes.

Cosmetic/reconstructive exceptions

Certain cosmetic and reconstructive CPT codes (examples: 14020, 14021 and related series) will NOT require prior authorization when billed with skin cancer diagnoses.
Effective dates and code series vary by entry (see code list); specific entries show July 1, 2021 and other dates.

Dental anesthesia (code 00170): prior authorization is required for members younger than 21 when billed with Modifier U3.

Oncology and DME prior authorization criteria

Oncology injectables and DME rules

Selected J-codes used for oncology require prior authorization for oncology and non-oncology diagnoses; for Oncology DX submit requests via the UnitedHealthcare Provider Portal.

Durable Medical Equipment (DME): prior authorization is required when retail purchase or cumulative rental cost exceeds $500.

Listed prior authorization requirements (partial)

Prior authorization/notification requirements as listed for code groups and products in this section (partial).

Enteral and genetic testing

Enteral/in-home nutritional therapy codes (e.g., B4034, B4036, B4103, B4150, B4153) have prior authorization entries; some entries show an effective date of May 1, 2019.
Genetic and molecular testing (including BRCA-related codes such as 81520, 0111U, 0129U) require prior authorization/notification when performed outpatient; labs/tests must notify UnitedHealthcare before DNA sequencing for BRCA testing.

Injectable and specialty medications

Multiple injectable and specialty medication codes (examples include J1748, J9333, J1576, J2329, J1203) require prior authorization; some products (e.g., Acthar Gel) require authorization through Optum SGP.
Many drug entries include explicit prior authorization effective dates (examples: Nov. 1, 2023 for several products) and may reference 'Review at Launch for New to Market' guidance.

For items listed in this section, providers should follow the Additional information/How to obtain prior authorization guidance included with each code entry.

Partial coverage criteria nodes

Per-entry prior authorization status and instructions (partial):

Panzyga® / Syfovre® (code J1576, sometimes paired with J2781): prior authorization entries reference 'Launch for New to Market' and show Nov. 1, 2023 as an effective date in multiple listings.

Selected injectable medication groups (examples: Q5128, J1449, J1747) include prior authorization effective dates such as July 1, 2023; providers are directed to Review at Launch for New to Market Medication List for up-to-date guidance.

Ocular anti-VEGF agents (examples: J0218, J0178, J0179, J2777, J2778) are listed with diagnosis guidance (VEGF) and prior authorization effective date May 1, 2023; pre-determination is highly recommended for drugs on the list.

Prior authorization items (listing only)

Items listed require prior authorization per the effective dates shown; no clinical criteria are included in this excerpt.

Examples of listed medication entries

Several specialty medications (e.g., J1951, C9075) and orphan-drug codes are listed with prior authorization effective dates (examples include Sept. 1, 2021).
Various injectable medication subcategories (e.g., Nplate®, Lupron Depot®) appear in the listing and include prior authorization references where applicable.

Orthopedic and major procedure CPT code series appear in the listing (examples shown) and are included with their respective prior authorization entries; specific clinical criteria are not present in the excerpt.

Prior authorization criteria (partial excerpt)

Authorization/coverage notes appearing in the listed sections.

Outpatient therapy: prior authorization is required for all re-evaluations and the listed outpatient therapy codes; initial evaluations do not require prior authorization (effective date for listed outpatient therapy codes: July 1, 2017).

Orthotics and prosthetics (selected L-codes): prior authorization is required when retail purchase or cumulative rental cost exceeds $500 for specified codes.

Potentially Unproven Services (examples: code 33289, C2624) are listed with a prior authorization effective date of April 1, 2023.

Outpatient Therapy

Outpatient therapy coverage stance and prior authorization rules (partial):

Initial therapy evaluations are not subject to prior authorization, but all re-evaluations and the other outpatient therapy CPT/HCPCS codes listed require prior authorization.

Radiology / Advanced Imaging

Radiology and advanced imaging prior authorization and notification requirements (partial):

Prior authorization is required for listed proton beam and advanced outpatient imaging/radiology codes (examples include 77520-77525 and numerous CT/MRI series).

Care providers ordering advanced outpatient imaging are responsible for providing notification prior to scheduling; radiology prior authorization resources are available at UHCprovider.com/TXcommunityplan > Prior Authorization and Notification Resources.

Visible coverage/prior authorization rules

Selection of coverage/prior authorization rules visible in this document segment:

Site of Service (SOS) — Outpatient Hospital: prior authorization is only required when requesting the service in an outpatient hospital setting; prior authorization is not required if performed at a participating Ambulatory Surgery Center (ASC).

Specific sleep apnea procedure codes listed have a prior authorization effective date of Jan. 1, 2015.

Spinal surgery procedures require prior authorization; site of service will be reviewed as part of the prior authorization process (effective date for listed spinal surgery codes: April 1, 2022).

Prior authorization requirements and contact instructions

Prior authorization is required for the listed procedures, devices, and services for Texas STAR; some items include explicit effective dates and contact instructions.

Neurostimulator implantation and related device procedures are listed as requiring prior authorization (codes and effective dates provided in the listing; some device/device-implantation codes show Jan. 1, 2015 effective guidance).

Transplant and CAR T-Cell therapy services require prior authorization/notification; providers must call the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 (or use the notification number on the member's ID card) before services.

VAD and related device notifications: call the notification number on the back of the member's health plan ID card and then fax the nurse-provided form to the Optum VAD Case Management team at 855-282-8929.

Codes, Code Groups, and Coding Notes (Selected)

DME / Equipment HCPCS (selected)HCPCS

E0639	Durable medical equipment (example)
E0640	Durable medical equipment (example)
E0465	Durable medical equipment (example)
E0277	Durable medical equipment (example)
E0329	Durable medical equipment (example)
E0328	Durable medical equipment (example)
E0470	Durable medical equipment (example)
E1130	Durable medical equipment (example)
E1825	Durable medical equipment (example)
E0642	Durable medical equipment (example)

1–10 of 42

1/5

Injectable / Specialty J-/Q- Codes (selected)HCPCS

J1449	Colony-stimulating factors (example)
Q5125	Colony-stimulating (example)
J0217	Lamzede® (example)
J1748	Zymfentra (example)
J0218	Tzield/Xenpozyme (example)
J0178	Eylea HD (example)
J1576	Panzyga® (example)
J7039	Leqvio® (example)
J0256	Elaprase/Aralast NP (example)
J1951	Amondys 45 (example)

1–10 of 14

1/2

Chemotherapy / Infusion J-codes (partial)HCPCS

J9331	Chemotherapy agent (example)
J9332	Chemotherapy agent (example)
J9071	Chemotherapy agent (example)
J9017	Chemotherapy agent (example)
J9027	Chemotherapy agent (example)
J9035	Chemotherapy agent (example)
J9040	Chemotherapy agent (example)
J9050	Chemotherapy agent (example)
J9058	Chemotherapy agent (example)
J9059	Chemotherapy agent (example)

1–10 of 14

1/2

Cochlear and Auditory Implant Codesmixed

69714	Cochlear implant procedure (example)
L8614	Cochlear implant device HCPCS (example)
L8690	Auditory implant device HCPCS (example)
69930	Cochlear implant procedure (example)
L8619	Cochlear device (example)
L8691	Auditory implant (example)

Cosmetic / Reconstructive CPT Codes (examples)CPT

14020	Adjacent tissue transfer (cosmetic example)
14021	Adjacent tissue transfer (cosmetic example)
14041	Cosmetic procedure (example)
14061	Cosmetic procedure (example)
21121	Orthognathic procedural example
30400	Rhinoplasty example
13101	Cosmetic code example

DME HCPCS K-/K0 Series (selected)HCPCS

K0850	DME K-code example
K0851	DME K-code example
K0852	DME K-code example
K0853	DME K-code example
K0856	DME K-code example
K0858	DME K-code example
K0860	DME K-code example
K0862	DME K-code example
K0864	DME K-code example
K0868	DME K-code example

1–10 of 14

1/2

Enteral and Nutrition HCPCSHCPCS

B4034	Enteral formula (example)
B4035	Enteral formula (example)
B4036	Enteral formula (example)
B4103	Enteral supply (example)
B4104	Enteral supply (example)
B4150	Enteral supply (example)
B4153	Enteral supply (example)
B4150	Duplicate consolidated entry

Selected HCPCS / L-codes (prosthetics/orthotics)HCPCS

L7186	Prosthetic/orthotic example
L7190	Prosthetic/orthotic example
L7191	Prosthetic/orthotic example
L7405	Prosthetic/orthotic example
L8040	Prosthetic/orthotic example
L8042	Prosthetic/orthotic example
L8043	Prosthetic/orthotic example
L8044	Prosthetic/orthotic example
L8045	Prosthetic/orthotic example
L8046	Prosthetic/orthotic example

1–10 of 18

1/2

CPT Procedure Examples (selected clusters)CPT

45378	Colonoscopy, diagnostic; with or without biopsy (CPT 45378)
45380	Colonoscopy with polypectomy (CPT 45380)
45384	Colonoscopy with removal of tumor (CPT 45384)
45385	Colonoscopy with endoscopic mucosal resection (CPT 45385)
69930	Cochlear implant procedure (example)
31295	Sinuplasty (example)
31296	Sinuplasty (example)

Sinuplasty CodesCPT

31295	Sinuplasty (balloon) CPT code
31296	Sinuplasty (balloon) CPT code
31298	Sinuplasty (other) CPT code

Musculoskeletal / Injection Codes (examples)CPT

20552	Injection procedure (example)
20553	Injection procedure (example)
20680	Joint injection (example)
27327	Musculoskeletal procedure example

Urologic / Endoscopy Codes (selected)CPT

52000	Cystoscopy diagnostic (example)
52204	Urologic procedure (example)
52320	Urologic procedure (example)
52344	Urologic procedure (example)

Spinal Surgery and Related CPT Codes (examples)CPT

22510	Arthrodesis (spine) example
22512	Arthrodesis (spine) example
22515	Spinal fusion example
63001	Laminectomy example
22630	Spinal fusion example

Neurostimulator / Implantation Codes (selected)mixed

64561	Insertion of neurostimulator lead (example)
64568	Neurostimulator code (example)
64570	Neurostimulator code (example)
64590	Neurostimulator code (example)

Transplant Procedure Codes (selected)CPT

32852	Transplant procedure example
33933	Cardiac transplant (example)
38208	Bone marrow harvest (example)
50320	Transplant procedure (example)

Provider Actions, Submission Methods & Contact Instructions

Note

Submission methods and exceptions

Prior authorization requirements for Texas STAR Effective October 1, 2024 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR health care professionals providing inpatient and outpatient services. Please submit your requests in one of the following ways: - Online: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal. To get started, go to UHCprovider.com and click Sign In at the top-right corner to log in using your One Healthcare ID and password. Then, select the Prior Authorization and Notification tab on your dashboard. If you don't have a One Healthcare ID, visit UHCprovider.com/access. - Chat: You can also connect with us through chat 24/7 using our Contact us page. - Fax: 877-940-1972. The fax form is available at Prior Authorization Forms. Prior authorization is not required for emergency or urgent care. Out-of-network requests must be made by a network care provider.

Note

Behavioral health referral instruction

Many of our benefit plans provide coverage for behavioral health services through a designated behavioral health network. When referring for mental health and substance use services, please call 888-887-9003 for assistance and to obtain prior authorization or referral instructions as applicable.

Prior Authorization

Chemotherapy/Oncology prior authorization

Oncology and certain chemotherapy agents require prior authorization. For oncology diagnoses and oncology-specific drugs, please submit requests online using the UnitedHealthcare Provider Portal. For questions or to obtain prior authorization for oncology drugs, please call 866-604-3267. Injectable chemotherapy and oncology-administered drugs may have separate submission requirements—refer to the Injectable/Specialty Medications and Oncology sections for details.

Prior Authorization

Oncology injectable medications prior auth note

Some oncology injectable medications require prior authorization and, for oncology diagnoses, requests should be submitted via the UnitedHealthcare Provider Portal. For non-oncology diagnoses, see the Injectable Medications section for prior authorization requirements and submission methods.

Prior Authorization

DME prior authorization threshold

Prior authorization is required for durable medical equipment (DME) when the retail purchase or cumulative rental cost exceeds $500. This threshold applies to DME items; prosthetics are not considered DME and follow orthotics/prosthetics guidance. Review the DME code list for specific codes that require prior authorization and obtain authorization before billing when the cost threshold is exceeded.

Prior Authorization

Dental anesthesia prior auth note

Prior authorization is required for dental anesthesia for members younger than 21 when billed with Modifier U3. Check procedure coding and member age/diagnosis to confirm whether prior authorization is necessary before scheduling or billing.

Prior Authorization

Enteral/In-home nutritional therapy prior authorization

Enteral and in-home nutritional therapy (including enteral nutrition delivered via gastrostomy tube) require prior authorization. This includes common enteral product HCPCS codes such as B4034, B4035, B4036, B4103, B4104 and related supply codes. Submit requests for in-home nutritional therapy prior to initiating services to ensure coverage and appropriate authorization.

Affected HCPCS codes include: B4034, B4035, B4036, B4103, B4104, B4150, B4153

Definitions & Thresholds

prior authorization

DefinitionPrior authorization: a review requirement listed for services and codes in this document; requests must be submitted via Provider Portal, chat, or fax

Submission methodsOnline via UHCprovider.com Prior Authorization and Notification tool; Chat 24/7 via Contact us page; Fax to 877-940-1972

ExceptionsPrior authorization is not required for emergency or urgent care; out-of-network requests must be made by a network care provider

designated behavioral health network

DefinitionDesignated behavioral health network: many benefit plans provide behavioral health services through a designated behavioral health network

Referral instructionProviders should call 888-887-9003 when referring for mental health and substance use services

ApplicabilityApplies to mental health and substance use referrals as noted in behavioral health services section

Cochlear Implants

DefinitionCochlear Implants and Other Auditory Implants: medical device with an inner‑ear component and external portion to assist persons with profound sensorineural deafness

Codes / ExamplesProcedure and device codes listed include 69930, L8614, L8619 (PA effective date noted Jan. 1, 2015)

Effective datePrior authorization effective date for cochlear implants: Jan. 1, 2015

Prior authorization/notification for genetic testing

RequirementGenetic and molecular testing (including BRCA testing) requires prior authorization/notification when performed in an outpatient setting

Provider obligationCare providers requesting lab testing must complete the prior authorization/notification process and indicate the laboratory and test name

Effective dates / notesVarious effective dates shown for genetic testing entries (examples include Oct. 1, 2015; July 1, 2018; Nov. 1, 2019/2020/2022)

Medication prior authorization notes

NoteCertain specialty/injectable medication prior authorizations may be processed through third‑party programs (e.g., Optum SGP) or per 'Review at Launch' guidance

ExampleActhar Gel prior authorization effective Dec. 1, 2023 processed through Optum SGP

Launch guidanceMany new‑to‑market medications reference the 'Review at Launch for New to Market Medications' policy and Medication List for details

Launch for New to Market Medications

Policy reference'Launch for New to Market Medications' guidance applies to newly approved drugs; providers should check the Review at Launch Medication List for up‑to‑date PA requirements

ExamplesEntries reference Panzyga®, Syfovre®, Tzield™, Vabysmo®, Eylea® and others that are covered by Review at Launch guidance

How to find detailsReview at Launch information is available at UHCprovider.com under Policies and Protocols > Community Plan Policies

Texas STAR

Definition / ProgramTexas STAR: the program governed by this prior authorization listing

ScopeThis document enumerates PA requirements and effective dates specific to UnitedHealthcare Community Plan of Texas STAR providers

UseApply the listed PA rules and contact instructions for services billed under Texas STAR

Outpatient Therapy prior authorization

Requirement summaryPrior authorization required for all re‑evaluations and the listed outpatient therapy codes; initial evaluations do not require prior authorization

Effective datePA effective date for listed outpatient therapy codes: July 1, 2017

ExamplesListed therapy codes include 97024, 97035, 97139, 97164, 97535, 97760, etc.

Orthotics/Prosthetics prior authorization threshold

ThresholdCertain orthotics and prosthetics require prior authorization when retail purchase or cumulative rental cost exceeds $500

Example codesL5647/L5649 and other L‑codes listed reference the cost threshold; see DME section for analogous E‑codes (E0639)

NotesProsthetics are distinguished from DME — consult orthotics/prosthetics entries for specific PA rules and dates

Prior authorization is a requirement for listed codes (varies by code/subcategory); some services require notification prior to scheduling.

General rulePrior authorization is required for the codes listed in this document; requirements vary by code and subcategory, and some services require notification prior to scheduling

Notification examplesAdvanced outpatient imaging/radiology procedures require notification prior to scheduling; radiology resources available at UHCprovider.com/TXcommunityplan

Where to checkRefer to the specific code entry and additional information fields for effective dates and how to obtain prior authorization

UHCprovider.com/TXcommunityplan > Prior Authorization and Notification Resources

ResourceUHCprovider.com/TXcommunityplan > Prior Authorization and Notification Resources for radiology and other PA programs

AccessUse the UnitedHealthcare Provider Portal (UHCprovider.com) Prior Authorization and Notification tool to submit requests and find resources

Contact optionCall 866‑889‑8054 for some radiology prior authorization inquiries as noted in radiology entries

Site of Service (SOS) - Outpatient Hospital

DefinitionSite of Service (SOS) - Outpatient Hospital: prior authorization is only required when requesting a service in an outpatient hospital setting

ExceptionPrior authorization is not required if the procedure is performed at a participating Ambulatory Surgery Center (ASC)

ApplicabilityApplies to specified procedures where site of service influences PA requirement (see SOS entries)

Prior authorization effective date

Effective dateEffective October 1, 2024 (date the prior authorization requirements list is effective)

ScopeThis effective date applies to the document listing prior authorization review requirements for Texas STAR providers

Submission reminderSubmit PA requests via Provider Portal, chat, or fax as described in the document

VAD

DefinitionVentricular Assist Device (VAD): a mechanical pump that takes over the function of the damaged ventricle and restores normal blood flow

Notification stepsCall the notification number on the back of the member's health plan ID card, then fax the nurse‑provided form to Optum VAD Case Management at 855‑282‑8929

Related codes / examplesVAD and related wound vac/vascular device codes are listed in the VAD section (see chunk 155 for example codes like 33927, 33929)

Neurostimulator implantation

DefinitionNeurostimulator implantation: implantation of a device that sends electrical impulses (device and procedure codes listed)

Examples / CodesProcedure/device codes listed include 61863, 63650, 43648 and device HCPCS such as L8680/L8682 in neurostimulator entries

Effective dateSome neurostimulator entries show prior authorization effective dates (e.g., Jan. 1, 2015) — consult specific code entry

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Texas STAR

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOctober 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID, or via chat or fax.

SourceLink

On This Page