CurrentColorado Rocky Mountain Health Plans | UnitedHealthcare Community Plan of Arizona (Developmental Disabilities listing)Policy N/A

Prior authorization requirements for Arizona Developmental Disabilities

A listing of services, procedures, devices and drugs that require prior authorization for UnitedHealthcare Community Plan of Arizona Developmental Disabilities members, with contact and portal instructions and CPT/HCPCS code lists for many categories. Applies to inpatient and outpatient services and includes AHCCCS coverage notes and EPSDT exceptions for members <21.

Policy Summary

PayerColorado Rocky Mountain Health Plans | UnitedHealthcare Community Plan of Arizona

PolicyPrior authorization requirements for Arizona Developmental Disabilities

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 800-445-1638 (other plan-specific contacts listed in the document).

POLICY UPDATE CHANGES

No material clinical/coverage changes — brief indicates has_material_change = false.

2026-01-01Effective date

~30+Distinct CPT/HCPCS groups listed

100+Codes listed requiring PA

1EPSDT routine eye exam frequency (years)

Vendor contacts provided

Policy overview and scope

This is the UnitedHealthcare Community Plan of Arizona Developmental Disabilities state-specific prior authorization (PA) code list effective 2026-01-01. It enumerates CPT/HCPCS/J and other codes that require prior authorization for covered benefits under AHCCCS for this product line and population.

AHCCCS coverage rules and EPSDT exceptions apply: services must be AHCCCS-covered benefits and EPSDT (Early and Periodic Screening, Diagnostic and Treatment) applies for members younger than 21 (examples: allergy immunotherapy/testing may be covered under EPSDT), while many listed items require PA for members 21+ per AHCCCS policy. Routine circumcision is not covered except with documented medical necessity (codes 54150–54162).

Submit PA requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com using One Healthcare ID) or by phone (primary call 800-445-1638; other service numbers shown in the document such as 888-397-8129 and 866-889-8054). Some supplies and in-home infusion or DME items are routed to vendors (Preferred Homecare: 800-636-2123; Optum Infusion: 800-985-3059), and specific pharmacy/administered drugs require J-code/NDC information and PA via the pharmacy contact (phone 800-310-6826, fax 866-940-7328).

High-level applicability: the list covers both inpatient and outpatient services and many categories of items — surgical procedures (orthopedics, spine, transplant, bariatric, joint replacement, ENT, rhinoplasty/septoplasty, etc.), implantable devices and neurostimulators, durable medical equipment (DME) and orthotics/prosthetics (many L- and K-codes), wound VACs, CGMs and diabetic supplies, cochlear/auditory implants, injectable chemotherapy and other J/Q-coded medications, genetic testing, outpatient therapies, home health/hospice, transport, and more — each category includes specific codes that require prior authorization.

Metadata — key values

effective_date2026-01-01

statusCURRENT

member_age_threshold21+

scope_summaryListing of services, procedures, devices and drugs that require prior authorization for UnitedHealthcare Community Plan of Arizona Developmental Disabilities members; includes portal/phone submission instructions and AHCCCS/EPSDT notes for members <21.

Prior authorization criteria and coverage rules

General Prior Authorization Requirement

General prior authorization eligibility and requirements for services provided to members. Prior authorization (PA) is required as specified in individual clinical categories below and for services that meet the PA rules for members 21 and older.

ALL of the following

Services must be medically necessary, cost-effective, and covered under the member's benefit plan and applicable state/federal regulations.
Requests must be submitted by the rendering or ordering provider or an authorized delegated entity using the payer's prior authorization tool or phone number as specified by the plan.
Services provided by out-of-network or out-of-state providers require documentation supporting the out-of-network request and may require PA.
Experimental and investigational services are not covered and do not meet PA criteria.

Codes requiring prior authorization (grouped)

AAC and Communication device codesmixed

92607	Evaluation of speech; with speech-generating device
92608	Evaluation of speech; with alternative and augmentative communication device
92609	Evaluation of speech; with language device
E2500	Communication device, not otherwise specified
E2502	Speech generating device
E2504	Alternative communication device accessory
E2506	Augmentative communication device
E2508	Communication device component
E2510	Communication device accessory
E2512	Communication device service

Bariatric surgery codesCPT

43644	Laparoscopy, gastrectomy
43645	Open gastrectomy
43659	Gastric restrictive procedure
43770	Laparoscopic revision of gastric bypass
43775	Laparoscopy gastric bypass
43842	Open gastric bypass
43845	Gastric bypass revision
43846	Revision of gastric restrictive procedure

Bone growth stimulator codesmixed

20975	Electrical stimulation for spine fusion
20979	Ultrasound bone growth stimulation
E0760	Bone growth stimulator, electrical
E0747	Bone growth stimulator, implanted (HCPCS referenced elsewhere)

Breast cancer genetic testing codesCPT

81162	BRCA1/BRCA2 analysis single site, duplication/deletion
81163	BRCA1/2 sequencing
81164	BRCA large rearrangement
81165	BRCA targeted variant analysis
81166	BRCA rearrangement testing
81212	BRCA1 analysis
81215	BRCA2 analysis
81216	BRCA common variants
81217	BRCA comprehensive testing
81432	Multi-gene panel

Breast reconstruction non-mastectomy codesCPT

11971	Insertion of breast prosthesis
19328	Removal of implant, etc.
19330	Mastectomy, partial
19340	Immediate reconstruction following partial mastectomy
19342	Mastopexy
19350	Nipple reconstruction
19357	Tissue expander placement
19361	Breast reconstruction with latissimus dorsi flap
19364	Breast reconstruction with free flap
19367	Breast reconstruction with bilateral procedure

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Cancer chemotherapy injectable codesmixed

J3315	Triptorelin, injectable
J3316	Goserelin
J1628	Darbepoetin alfa, injectable
J9381	Pegfilgrastim-cbqv (CSF)
J9332	Florbetapir injection
J9334	Other injectables referenced
J1823	Injection, betamethasone
J1322	Injection, palonosetron
J3032	Leuprolide acetate
J1558	Injection, ketorolac tromethamine

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Cardiology codesCPT

(see Cardiology prior auth list)

Refer to cardiology prior authorization resources and contact number provided in policy

Circumcision codesCPT

58290

Stripping or core of an organ (note: 58290 is uterine; included per source completeness)

Cochlear and auditory implant codesmixed

Q5133	Cochlear device, internal, replacement
Q5135	Cochlear device component
Q5138	Cochlear implant external processor

Continuous glucose monitor codesHCPCS

E2228	Continuous glucose monitor system, receiver
E2230	Continuous glucose monitor transmitter
E2298	Sensor, continuous glucose monitor
E2301	Continuous glucose monitor sensor, replacement
E2322	Continuous glucose monitor, other

Cosmetic/excluded procedure codesmixedNot Covered

Q5133	Cochlear code sometimes excluded depending on coverage
58290	Procedure codes subject to coverage limitations

DME / HCPCS examplesHCPCS

E0256	Lifting device, patient transfer
E0290	Hospital bed accessories
E0294	Electric bed, full power
E0303	Hospital bed, semi-electric
E0329	Rechargeable battery

DME L-codes (orthotics & prosthetics)HCPCS

L5700	Knee orthosis, adjustable
L5702	Knee orthosis with joints
L5703	Knee orthosis molded
L5705	Knee orthosis, customizable
L5706	Knee orthosis, hinged
L5716	Ankle-foot orthosis, prefabricated
L5718	Ankle-foot orthosis, custom fitted
L5722	Thoracic-lumbar-sacral orthosis, prefabricated
L5724	TLSO, custom
L5726	TLSO, other

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Additional O&P L-codesHCPCS

L5811	Lower limb prosthesis, below knee
L5812	Lower limb prosthesis, above knee
L5814	Prosthesis, partial foot
L5816	Prosthesis, trans-tibial
L5818	Prosthesis, trans-femoral
L5822	Prosthesis, knee unit
L5824	Prosthesis, ankle unit
L5826	Prosthesis, socket
L5828	Prosthesis, foot
L5830	Prosthesis components

1–10 of 13

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Further O&P L-codesHCPCS

L5858	Upper limb prosthesis other
L5930	Prosthetic device component
L5950	Custom prosthetic device
L5960	Prosthetic device, preparatory
L5961	Prosthetic device, preparatory components
L5962	Prosthetic device, definitive
L5964	Prosthetic device, electronic
L5966	Prosthetic device, special
L5968	Prosthetic device, modular
L5976	Accessories for prosthesis

Remaining L-codes set AHCPCS

L5979	Prosthetic accessory
L5980	Prosthetic interface
L5981	Prosthetic interface component
L5982	Prosthetic socket component
L5984	Prosthetic suspension
L5986	Prosthetic post
L5987	Prosthetic tube
L5988	Prosthetic other
L5990	Prosthetic other categories
L5999	Unspecified prosthetic

Remaining L-codes set BHCPCS

L6000	Prosthetic, advanced
L6010	Prosthetic, microprocessor
L6020	Prosthetic component, specialty
L6050	Upper limb prosthesis, myoelectric
L6055	Upper limb prosthesis, other
L6100	Prosthetic component
L6110	Prosthetic component
L6120	Orthotic component
L6130	Orthotic component

Remaining L-codes set CHCPCS

L6200	Prosthetic component
L6205	Prosthetic component
L6250	Prosthetic component
L6300	Prosthetic component
L6310	Prosthetic component
L6320	Prosthetic component
L6350	Prosthetic component
L6360	Prosthetic component
L6370	Prosthetic component

Remaining L-codes set DHCPCS

L6380	Prosthetic component
L6382	Prosthetic component
L6384	Prosthetic component
L6400	Prosthetic component
L6450	Prosthetic component
L6500	Prosthetic component
L6550	Prosthetic component
L6570	Prosthetic component
L6580	Prosthetic component

Remaining L-codes set EHCPCS

L6582	Prosthetic component
L6584	Prosthetic component
L6586	Prosthetic component
L6588	Prosthetic component
L6590	Prosthetic component
L6621	Prosthetic component
L6623	Prosthetic component
L6624	Prosthetic component

Remaining L-codes set FHCPCS

L6646	Prosthetic component
L6648	Prosthetic component
L6686	Prosthetic component
L6687	Prosthetic component
L6689	Prosthetic component
L6690	Prosthetic component
L6692	Prosthetic component
L6693	Prosthetic component

Remaining L-codes set GHCPCS

L6694	Prosthetic component
L6695	Prosthetic component
L6696	Prosthetic component
L6697	Prosthetic component
L6704	Prosthetic component
L6707	Prosthetic component
L6708	Prosthetic component
L6709	Prosthetic component

Remaining L-codes set HHCPCS

L6711	Prosthetic component
L6712	Prosthetic component
L6713	Prosthetic component
L6714	Prosthetic component
L6881	Prosthetic component
L6882	Prosthetic component
L6883	Prosthetic component
L6884	Prosthetic component

Remaining L-codes set IHCPCS

L6885	Prosthetic component
L6895	Prosthetic component
L6900	Prosthetic component
L6905	Prosthetic component
L6910	Prosthetic component
L6915	Prosthetic component
L6920	Prosthetic component
L6925	Prosthetic component

Remaining L-codes set JHCPCS

L6930	Prosthetic component
L6935	Prosthetic component
L6940	Prosthetic component
L6945	Prosthetic component
L6950	Prosthetic component
L6955	Prosthetic component
L6960	Prosthetic component
L6965	Prosthetic component

Remaining L-codes set KHCPCS

L6970	Prosthetic component
L6975	Prosthetic component
L7007	Prosthetic component
L7008	Prosthetic component
L7009	Prosthetic component

Remaining L-codes set LHCPCS

L7040	Prosthetic component
L7045	Prosthetic component
L7170	Prosthetic component
L7180	Prosthetic component
L7181	Prosthetic component
L7185	Prosthetic component
L7186	Prosthetic component
L7190	Prosthetic component
L7191	Prosthetic component

Remaining L-codes set MHCPCS

L7405	Prosthetic/orthotic component
L8040	Orthotic component
L8042	Orthotic component
L8043	Orthotic component
L8044	Orthotic component
L8045	Orthotic component
L8046	Orthotic component
L8047	Orthotic component

Miscellaneous codes referencedmixed

8499	Unlisted chemistry/serology code (L-code like formatting in source)
L8499	Unlisted prosthetic procedure
8609	Immunoassay, etc.
L8609	Breast implant-related code
8610	Therapeutic drug monitoring
L8610	Prosthetic code variant
8612	Hemoglobin testing
8659	Allergen specific IgE testing

Genetic testing CPT examplesCPT

81212	BRCA1 testing
81215	BRCA2 testing
81432	Large panel/multiple gene analysis

Pharmacy / J-codes referencedHCPCS

J3315	Triptorelin
J3316	Goserelin
J1628	Darbepoetin alfa
J9381	Pegfilgrastim
J9332	Injectable agent
J9334	Injectable agent
J1823	Betamethasone injection
J1322	Palonosetron injection
J3032	Leuprolide
J1558	Ketorolac injection

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What providers must do (submission, documentation, vendor routing)

Prior Authorization

Prior Authorization Required — Submission

Submit PA requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) using your One Healthcare ID, or call the plan for assistance.

Prior Authorization and Notification tool (UHCprovider.com)
One Healthcare ID
Phone: 800-445-1638; 888-397-8129; 866-889-8054

Documentation Required

EPSDT coverage for members <21

For members younger than 21 (EPSDT), include documentation that supports medical necessity when requesting services that are covered under EPSDT.

Key definitions and acronyms

Definitions — key terms

AHCCCSArizona Health Care Cost Containment System - state Medicaid agency defining covered benefits.

EPSDTEarly and Periodic Screening, Diagnostic and Treatment - Medicaid benefit for members under 21; EPSDT may cover services when medically necessary.

DMEDurable Medical Equipment; many E- and K- HCPCS codes listed require prior authorization; some DME items require PA regardless of dollar amount (examples: E0194, E0265, E0300, E0745, E0766, E0986, E1002, etc.).

Unclassified codesTemporary/unclassified HCPCS and J-codes (examples: C9094, C9149, C9157, C9166, C9399, J3490, J3590) used as placeholders for supplies/agents without assigned codes; require prior authorization routing per policy.

PAPrior authorization - authorization process required before service per policy; submit via UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call plan phone numbers (e.g., 800-445-1638 or 888-397-8129/866-889-8054 as noted).

Common questions and operational notes

Policy revision timeline

2026-01-01effectiveLatest

Effective date published (from brief.dates.effective)

Policy Summary

PayerColorado Rocky Mountain Health Plans | UnitedHealthcare Community Plan of Arizona

PolicyPrior authorization requirements for Arizona Developmental Disabilities

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review DateN/A

On This Page

Only one provider may submit a PA request per authorization form or transaction.

All rendering providers, facilities and vendors must be properly licensed/credentialed and registered with applicable state programs where required.

General Prior Authorization Requirements

Prior authorization is required for many outpatient and inpatient services for members age 21 and older unless otherwise noted in a specific clinical category.
Some codes (e.g., certain hematology/oncology, DME, implantable devices, and high-cost procedures) require PA regardless of site of service; see specific categories below and the payer's PA code lists.
PA decisions are based on documentation of medical necessity and coverage criteria; insufficient documentation may result in denial.
When a procedure has conditional PA (for example CPT 38232 in transplant-related coding), the documentation must include the clinical justification specified by the payer; failure to provide may result in retrospective denial.

Prior Authorization requirement for listed codes (members 21 and older)

The payer maintains a state-specific Prior Authorization Code List (online) that identifies codes requiring PA for members 21 and older (including many outpatient procedures, imaging, implantable devices, and drugs administered in outpatient settings).
Providers should verify PA requirements and submission pathways (portal or phone) prior to rendering services to avoid claim denials.

Prior Authorization Requirement for DME and Other Items

Durable medical equipment, prosthetics, orthotics, and supplies may require PA; supporting documentation (trial of conservative therapy, measurements, clinical notes) must accompany requests.
Certain DME/HCPCS codes are subject to PA and potential rental vs purchase rules; check the payer's DME PA list.

Behavioral health

Prior authorization is required for inpatient behavioral health admissions and for selected outpatient behavioral health services as specified by the payer.
For the full list of behavioral health services requiring PA and state-specific requirements, providers must consult the payer's Behavioral Health PA resources (providerexpress.com or the payer portal).
PA decisions for behavioral health are based on documented clinical necessity, the level of care criteria, and applicable state behavioral health regulations.

Allergy immunotherapy and allergy testing

Allergy immunotherapy and allergy testing coverage and PA rules differ by age: EPSDT applies to members younger than 21; PA is required for testing and for immunotherapy per plan rules.

Members younger than 21 (EPSDT)

Allergy immunotherapy and allergy testing are covered under EPSDT when medically necessary for members under age 21.
Coverage includes diagnostic testing when there is a reasonable expectation that further exposure to an unknown allergen may be life threatening or the member sustained an anaphylactic reaction to an unknown allergen.
Prior authorization is required for allergy testing and for allergy immunotherapy when submitted for EPSDT-covered members; include EPSDT justification in documentation.

Members 21 and older

Allergy immunotherapy (including desensitization) may require PA; however, subcutaneous injections (allergy shots), sublingual immunotherapy (SLIT), or other routes may not be covered — verify coverage in the member's benefit plan.
Allergy testing is a covered benefit for members 21 and older only when the member has sustained anaphylaxis to an unknown allergen or has exhibited a severe allergic reaction where further exposure could be life threatening (examples: severe facial swelling, respiratory compromise, epiglottal swelling, extensive urticaria).
Prior authorization is required for allergy testing for members 21 and older; provide clinical documentation of the reaction and rationale for testing.

Augmentative and alternative communication (AAC)

Augmentative and alternative communication (AAC) devices and related services require prior authorization. Codes listed below require PA.

ALL of the following

Prior authorization is required for the AAC codes listed below for members 21 and older unless state-specific pediatric rules apply.
Provide clinical documentation supporting the need for the device, prior trials of less complex modalities, and device specifications.

Codes requiring prior authorization

CPT/HCPCS: 92607
CPT/HCPCS: 92608
CPT/HCPCS: 92609
HCPCS: A9901
HCPCS: E2500
HCPCS: E2502
HCPCS: E2504
HCPCS: E2506
HCPCS: E2508
HCPCS: E2510
HCPCS: E2512

ALL of the following

Requests for AAC should include relevant speech-language pathology evaluations, functional communication assessments, and justification for device features and accessories.

Include standard PA submission and documentation requirements per the payer's portal guidance.

Bariatric surgery

Bariatric surgery procedures require prior authorization. Codes listed below require PA and clinical criteria must be met.

ALL of the following

Prior authorization is required for bariatric surgery codes listed below.
Clinical documentation should demonstrate eligibility per the payer's bariatric surgery criteria (e.g., BMI thresholds, comorbid conditions, prior weight loss attempts, and multidisciplinary evaluation).

Codes requiring prior authorization

CPT: 43644
CPT: 43645
CPT: 43659
CPT: 43770
CPT: 43775
CPT: 43842
CPT: 43845
CPT: 43846

Follow payer-specific clinical pathways and preauthorization checklists when submitting requests.

Bone growth stimulator (electrical/ultrasound)

Bone growth stimulators (electrical or ultrasound) require prior authorization. Codes listed below require PA.

ALL of the following

Prior authorization is required for bone growth stimulator devices (electrical stimulation or ultrasound) used to promote fracture healing or spinal fusion adjuncts.
Provide documentation of fracture nonunion, failed healing timeline, prior conservative management, and imaging findings as applicable.

Codes requiring prior authorization

CPT: 20975
CPT: 20979
HCPCS: E0760

Durable medical equipment documentation requirements apply; rental vs purchase and trial period rules may apply.

Breast cancer genetic testing

Breast cancer genetic testing requires prior authorization. Lab requests should be directed to the payer-designated lab.

ALL of the following

Prior authorization is required for breast cancer genetic testing codes listed below.
Direct all laboratory testing requests to the payer's designated lab (LabCorp at 800-533-0567) as instructed; include family and personal cancer history and testing rationale.

Codes requiring prior authorization

CPT: 81162
CPT: 81163
CPT: 81164
CPT: 81165
CPT: 81166
CPT: 81212
CPT: 81215
CPT: 81216
CPT: 81217
CPT: 81432

Genetic testing PA requires documentation of guideline-based indications (e.g., NCCN criteria) and counseling notes when applicable.

Breast reconstruction (non-mastectomy)

Breast reconstruction procedures not related to mastectomy require prior authorization. Codes listed below require PA.

ALL of the following

Prior authorization is required for non-mastectomy breast reconstruction codes listed below.
Clinical documentation should include indication, prior treatments, and planned reconstructive approach.

Codes requiring prior authorization

CPT: 11971
CPT: 19328
CPT: 19330
CPT: 19340
CPT: 19342
CPT: 19350
CPT: 19357
CPT: 19361
CPT: 19364
CPT: 19367
CPT: 19368
CPT: 19369
CPT: 19370
CPT: 19371
CPT: 19380
CPT: 19396
HCPCS: L8600

Exclude cosmetic indications unless reconstructive criteria are met; provide operative plans and expected functional/clinical benefit.

Cancer supportive care (colony-stimulating factors and bone-modifying agents)

Cancer supportive care: colony-stimulating factors and bone-modifying agents administered in outpatient settings require prior authorization.

ALL of the following

Prior authorization is required for outpatient-administered injectable colony-stimulating factor drugs and outpatient bone-modifying agents used for cancer supportive care.
Provide diagnosis, treatment regimen, intent (curative vs palliative), and supportive care rationale with the PA request.

Cardiology / Cardiovascular / Electrophysiology / Stress echoes

Cardiology outpatient and selected inpatient procedures require prior authorization. Contact numbers and portal details provided by the plan should be used for PA submission.

ALL of the following

Prior authorization is required for outpatient and office-based diagnostic catheterizations, electrophysiology implants, and stress echocardiography procedures for participating physicians as specified by the payer.
For PA submission, use the payer's Prior Authorization and Notification tool on the provider portal or call the phone numbers published by the payer (e.g., 888-397-8129 or 866-889-8054 as referenced).
Providers should consult the payer's Cardiology PA resources for the specific CPT/HCPCS codes that require PA and for clinical documentation requirements.

See payer Cardiology PA resources (portal) for detailed code lists and clinical criteria.

Use documented clinical justification (symptoms, diagnostic testing, prior noninvasive evaluation) when submitting requests.

Cerebral seizure monitoring - inpatient video EEG

Cerebral seizure monitoring (inpatient video EEG) requires prior authorization when used for diagnostic or pre-surgical evaluation.

ALL of the following

Prior authorization is required for inpatient long-term video EEG monitoring used to evaluate seizures when PA is identified by the payer's code list.
Provide prior EEG results, seizure semiology, medication history, and rationale for inpatient monitoring versus outpatient alternatives.

PA must include documentation of prior diagnostic efforts and the specific clinical question to be answered by inpatient monitoring (e.g., surgical candidacy, characterization of events).

Chemotherapy (injectable outpatient)

Chemotherapy administered in the outpatient/injectable setting requires prior authorization for certain agents and administrations as specified by the payer.

ALL of the following

Prior authorization is required for certain injectable chemotherapy agents and related supportive drugs administered in outpatient settings; consult the payer's oncology/infusion PA lists.
Include diagnosis, regimen, dosing, line of therapy, and prior treatments when requesting PA for chemotherapy agents.

Follow payer-specific oncology PA processes and include necessary clinical documentation for review.

Circumcision

Circumcision procedures may require prior authorization depending on age and medical indication.

ALL of the following

Prior authorization may be required for medically indicated circumcision procedures when specified by the payer; routine newborn circumcisions coverage varies by plan and state rules.
Provide clinical indication, newborn/child age, and relevant examinations or complications when submitting PA requests.

Verify PA requirements and benefit coverage prior to scheduling.

Cochlear and other auditory implants

Cochlear and other auditory implants require prior authorization and clinical documentation demonstrating benefit and candidacy.

ALL of the following

Prior authorization is required for cochlear implants and select auditory prosthetic devices as identified by the payer's code lists.
Provide audiology evaluations, trial hearing aid results, speech-language assessments, and documentation of medical necessity for implant candidacy.

Include device model, laterality, and related surgical plan in the PA request.

Continuous glucose monitor (CGM)

Continuous glucose monitors (CGMs) and related supplies may require prior authorization. Coverage criteria differ by age and clinical indication.

ALL of the following

Prior authorization is required for CGMs and certain related supplies; clinical criteria such as treatment of type 1 diabetes, frequent hypoglycemia, or insulin-dependent diabetes may apply depending on the plan.
Provide documentation of diabetes type, treatment regimen (insulin use), hypoglycemia history, and prior glucose monitoring attempts when requesting PA.

Confirm specific device codes and supplies on the payer's DME/CGM PA code list prior to ordering.

Cosmetic and reconstructive procedures

Cosmetic and reconstructive procedures: cosmetic (not medically necessary) procedures are typically not covered; reconstructive procedures require PA when listed.

ALL of the following

Cosmetic procedures and services performed solely for aesthetic reasons are not covered unless reconstructive criteria demonstrating functional impairment are met.
Prior authorization is required for listed reconstructive procedures; submit documentation of functional deficit, failed conservative therapy, and expected clinical benefit.

Consult payer policy and listed CPT/HCPCS codes for procedures that are considered reconstructive versus cosmetic.

Do not duplicate cosmetic exclusions with reconstructive coverage criteria; provide clear clinical justification when pursuing PA for reconstructive claims.

Members younger than 21 (EPSDT) and other outpatient rules

Outpatient therapy coverage limits and special handling notes. Includes member under-21 EPSDT rules and vendor routing.

Members younger than 21 (EPSDT)

Services that are medically necessary for members under age 21 may be covered under EPSDT even if not covered for adults; include EPSDT justification when submitting PA requests.

Vendor routing and prior authorization requirements (members 21+)

Certain services for members 21 and older are routed to vendor-managed programs or require PA through specific vendor portals (e.g., specialty pharmacy, DME vendor). Follow payer instructions for routing and PA submission.

Outpatient therapy coverage limits

Outpatient therapy services (physical, occupational, speech) may have visit/unit limits or require medical necessity documentation and PA for extended courses; check the plan limits and submit supporting documentation for exceptions.

Special handling notes

Special handling notes and where to find full PA code lists and submission pathways.

ALL of the following

Providers should consult the payer's online Prior Authorization Code List by state (via provider portal or payer website) for the most up-to-date list of CPT/HCPCS codes requiring PA.
When in doubt, confirm PA requirements before rendering services. Failure to obtain required PA may result in claim denial or retrospective review.
Use designated phone numbers and portal tools provided by the payer for PA submissions; see category-specific guidance for contact numbers (e.g., cardiology, behavioral health).

Some services and codes may be subject to additional state-specific rules (including EPSDT mandates for members <21); ensure documentation clearly reflects these requirements.

This section consolidates general PA requirements and clinical-category PA rules; refer to individual clinical policy documents for full medical necessity criteria.

Include documentation supporting medical necessity for EPSDT services

Prior Authorization

Lab referral for breast cancer genetic testing

Breast cancer genetic testing requires prior authorization. Direct lab requests to LabCorp at 800-533-0567 and include the genetic CPT codes when submitting the PA request.

Genetic CPT codes: 81162, 81163, 81164, 81165, 81166, 81212, 81215, 81216, 81217, 81432
LabCorp phone: 800-533-0567

Prior Authorization

Vendor routing and in-home services

Certain vendor-routing requirements apply for in-home supplies and infusion services. Incontinence supplies are provided through Preferred Homecare; infusion and many in-home injectable medications are routed through Optum Infusion. Call the listed vendor to request supplies/services and obtain prior authorization when required.

Preferred Homecare (incontinence supplies): 800-636-2123
Optum Infusion (infusion/in-home medications and services): 800-985-3059
Codes/categories: incontinence supplies (listed HCPCS/CPT groups such as 58550/58552/58553/58554 and related entries route to Preferred Homecare); infusion and in-home injectable medications route to Optum Infusion

Documentation Required

Pharmacy PA submission requirements

Pharmacy prior authorization requests must include the medication J-code(s) and NDC(s). Submit pharmacy PA requests using the plan resources and contacts.

Include J-codes and NDCs on PA requests
Pharmacy prior authorization phone: 800-310-6826
Fax: 866-940-7328

Prior Authorization

Obtain prior authorization for listed HCPCS E- and K- codes

Obtain prior authorization for the listed HCPCS E- and related K-/L-codes. Some E-codes require prior authorization regardless of dollar amount.

Example E-codes (require PA regardless of dollar amount): E0194, E0265, E0266, E0270, E0300, E0445, E0457, E0465, E0466, E0483, E0486, E0620, E0636, E0638, E0641, E0642, E0656, E0669, E0670, E0675, E0693, E0694, E0710, E0745, E0766, E0784, E0984, E0986, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009

Prior Authorization

Transplant and CAR T routing

Transplant and CAR T services require prior authorization routed through UnitedHealthcare Transplant Case Management and must include clinical documentation to support medical necessity.

UnitedHealthcare Transplant Case Management: 800-418-4994
Emphasize: clinical documentation must accompany PA requests to establish medical necessity for transplant/CAR T services

Billing Rule

Out-of-network / out-of-state rules

Prior authorization and supporting documentation are required for out-of-network or out-of-state providers. Out-of-state services are approved only when emergent or unavailable in Arizona.

PA and documentation required for non-network or out-of-state providers
Out-of-state exception: benefit approved only when emergent or unavailable in Arizona

Documentation Required

Orthotics & prosthetics documentation

For orthotics and prosthetics, prior authorization requires documentation that establishes the component is not functioning and supports whether repair or replacement is appropriate; cumulative rental cost and repair-versus-replacement rules apply.

Need documentation that component isn't operating effectively
Reasonable repairs/adjustments of purchased orthotics are covered; repair vs replacement considerations depend on cost (e.g., rental cumulative > $500) and clinical justification

Prior Authorization

Conditional PA examples

Some prior authorizations are conditional. Example: CPT 38232 requires PA only when billed for an oncology diagnosis. For VADs, call the notification number on the member ID card and fax the VAD form provided by the nurse to Optum VAD Case Management.

38232 — PA required only for oncology diagnosis
VAD notification: call the notification number on the back of the member's ID card and fax the VAD form to the Optum VAD Case Management team

AHCCCS Medical Policy Manual (AMPM) — referenced for coverage rules and specific policies (examples: Chapter 300, Chapter 400 EPSDT/sterilization sections).