CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization requirements for Arizona Long Term Care (Arizona Long-Term Care — prior auth list)

List of services and codes that require prior authorization for UnitedHealthcare Community Plan of Arizona Long Term Care providers; includes instructions for submitting authorization requests and state-specific coverage notes affecting members under and over age 21.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Arizona Long Term Care

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal or call 877-842-3210 and include the applicable CPT/HCPCS and HCPCS J-codes with supporting clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2024-07-01policy effective date

<21 vs ≥21age-based coverage

Online & Phonerequest methods

20+distinct code entries

>$500DME PA threshold

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria and Service Rules

Allergy immunotherapy — age-based coverage

Coverage stance for allergy immunotherapy and testing

Age-based coverage: For members younger than 21, allergy immunotherapy and allergy testing are covered under Early and Periodic Screening, Diagnostic and Treatment (EPSDT) when medically necessary; for members 21 and older, allergy immunotherapy (including desensitization treatments administered by subcutaneous injections, sublingual immunotherapy (SLIT), or other routes) is not a covered benefit.age <21

EPSDT coverage applies to members <21; age-based exclusion for ≥21 noted in source.

Allergy testing — life-threatening exposure risk

Authorization requirement for allergy testing in high-risk scenarios

Life‑threatening exposure risk: Prior authorization is required for allergy testing when there is a reasonable assumption that further exposure to an unknown allergen may result in a life‑threatening reaction (examples: severe facial swelling, breathing difficulties, epiglottal swelling, extensive urticaria).clinical judgment of life‑threatening risk

Examples of life‑threatening reactions are listed in the source.

Prior authorization required — general and device-specific

Covered with prior authorization when codes and corresponding diagnoses are present

General PA for listed services: When a listed CPT or HCPCS code is billed with the mapped ICD‑10 diagnosis codes shown in the source, prior authorization is required for that service or device.code + diagnosis pairing per coding lists

Examples include inpatient cerebral seizure monitoring, cochlear implants, CGM supplies, and enumerated cosmetic/reconstructive procedures.

Cochlear and other auditory implants: Prior authorization is required for cochlear implants and related HCPCS L‑codes; for members 21 and older prior authorization is required for supplies, equipment maintenance and repair of component parts and hardware may not be a covered benefit. Clinical documentation must be provided to establish medical necessity.documented medical necessity (per member age rules)

Source specifies pediatric EPSDT distinctions and adult hardware limitations.

General PA and coverage rules

Coverage and PA rules in this section include:

Cosmetic procedures exclusion: Procedures performed solely to change or improve physical appearance without significantly improving or restoring physiological function are excluded from AHCCCS coverage when solely cosmetic.solely cosmetic indication

Specific CPT examples are listed in the source (e.g., 15847, 17106–17108, 17999, 21137–21184, etc.).

PA for reconstructive/cosmetic procedures: Prior authorization is required for the enumerated reconstructive and cosmetic CPT/HCPCS codes listed in this section.code listed in cosmetic/reconstructive group

See coding groups in document for exact codes.

DME prior authorization: Prior authorization is required for listed DME HCPCS and K‑codes and for any DME where retail purchase or cumulative rental cost exceeds $500; Arizona Long‑Term Care will review Medicare denials of DME and clinical documentation plus a copy of the denial must accompany requests to establish medical necessity.

Prior authorization required

Covered when prior authorization is obtained where required

PA required for listed services and quantity thresholds: Provider must obtain prior authorization for the services and codes enumerated in the policy and for requests that exceed specified quantity thresholds (for example incontinence supplies quantities, DME cost thresholds).see specific code groups and quantity thresholds in policy

Examples include incontinence supplies thresholds (240/mo for <21; 180/mo for ≥21), extensive K‑code lists, enteral nutrition codes, genetic testing, and injectable medications lists.

High-level coverage summaries

Service coverage and PA requirements summarized by service type

Orthotics and prosthetics HCPCS L‑codes listed require prior authorization. Orthotics are covered when serviceable and replacement or repair may be approved when documentation establishes the component is not operating effectively.repair/replace documentation requirement

See L‑code lists in the source for exact codes and replacement rules.

Outpatient therapy for members younger than 21: Occupational, physical and speech therapy are covered when medically necessary for members <21; listed outpatient therapy CPT/HCPCS codes require prior authorization and requests will be reviewed for medical necessity.medical necessity per EPSDT

Therapy CPT codes listed in source (e.g., 97014–97140 series).

Occupational and speech therapy for members 21 and older: Prior authorization is required for occupational and speech therapy for members ≥21; services are covered when medically necessary and requests are reviewed for medical necessity.

Prior Authorization Required (general)

Prior authorization required for listed services and codes

General prior authorization requirement: Provider must obtain prior authorization for the CPT/HCPCS codes listed in this document and follow the contact/fax instructions specific to service type (for example pharmacy PA phone/fax, specialty pharmacy fax, transplant/CAR‑T notification, VAD notification and Optum fax, transportation scheduling).prior authorization obtained via specified contact methods

See source for phone/fax numbers and program‑specific instructions (pharmacy PA: 800‑310‑6826 / fax 866‑940‑7328; transplant team: 800‑418‑4994; VAD fax 855‑282‑8929; MTM 888‑700‑6822).

Allergy immunotherapy is subject to an age-based coverage distinction. For members <21 years old, allergy immunotherapy and allergy testing are covered under EPSDT when medically necessary. For members 21 years and older, allergy immunotherapy (including desensitization treatments administered by subcutaneous injections, sublingual immunotherapy, or other routes) is not a covered benefit. Experimental and investigational services are also not covered benefits.

Circumcision performed in an outpatient hospital or ambulatory surgical center setting does not require prior authorization. Prior authorization is required for many listed inpatient services, but the policy explicitly states prior authorization is not required for outpatient hospital or ambulatory surgical center circumcision.

Procedures performed solely to change or improve physical appearance that do not significantly improve or restore physiological function are excluded from coverage. In other words, services that are solely cosmetic are not covered under AHCCCS and may be denied when billed for cosmetic-only indications.

Infusion services delivered in the context of hospice care are noted as not requiring prior authorization. The hospice-specific guidance indicates that prior authorization is not required for hospice infusion services as described in the hospice section.

This portion of the policy primarily lists injectable products, associated HCPCS/J-codes and administrative prior authorization instructions. There are no discrete clinical coverage criteria or exclusion statements provided in these entries; the section functions as a code/product list and PA index.

No specific clinical coverage criteria or exclusions are explicitly stated in this section of the document; the content continues to enumerate injectable medications and their associated HCPCS/J-codes with PA instructions.

Replacement of orthotic components is permitted only when documentation demonstrates the existing component is not operating effectively. Purchasing an additional unit may be restricted unless the prior authorization request includes documentation establishing the component’s malfunction or lack of serviceability.

Negative pressure wound therapy (wound VAC) supplies and equipment will be denied when the supplies or equipment are no longer being used by the member. The policy explicitly lists non‑use as a ground for denial of ongoing supplies/equipment.

The policy reiterates that services considered experimental or investigational are not covered benefits. Requests for such services are ineligible for authorization under the plan’s coverage rules.

Cochlear and other auditory implant hardware is specifically addressed: for members 21 and older, hardware is not a covered benefit. Prior authorization is required for listed cochlear implant codes and clinical documentation must be provided; supplies, maintenance and repair for members ≥21 require PA but the hardware itself may be excluded from coverage.

Arizona’s AHCCCS guidance considers procedures performed solely for cosmetic purposes to be excluded from coverage. If a procedure’s primary purpose is cosmetic and it does not materially improve or restore physiological function, it is treated as not covered.

Requests for services listed in the therapy and procedure sections will be reviewed for medical necessity. The policy indicates reviewers will assess medical necessity for submitted requests, although specific not‑medically‑necessary (NMN) conditions are not listed in these chunks.

Negative pressure wound therapy (NPWT) pump and supplies will be denied when specific clinical conditions are present (examples include cancer tissue in the wound, necrotic tissue with eschar if debridement is not attempted, untreated fistula or untreated osteomyelitis near the wound) or when criteria for continued coverage are no longer met.

Code Lists and Coding Details

Allergy immunotherapy CPT/HCPCS codesmixed

No codes listed

Augmentative and alternative CPT/HCPCS codes (examples listed)CPT | HCPCSCovered

92607	Augmentative and alternative
92608	Augmentative and alternative
92609	Augmentative and alternative
A9901	Augmentative and alternative

Genetic and reconstruction example codesCPT | HCPCSCovered

81163	BRCA testing (example code listed)
81212	BRCA testing (example code listed)
81164	BRCA testing
81215	BRCA testing
81165	BRCA testing
81216	BRCA testing
81433	BRCA testing
81162	Breast reconstruction (non-mastectomy)
81166	Breast reconstruction (non-mastectomy)
81217	Breast reconstruction (non-mastectomy)

Example procedural codes requiring prior authorizationCPTCovered

20975	Outpatient service example
20979	Outpatient service example

ICD-10 codes referenced repeatedlyICD-10

I70.228	ICD-10 code listed in document
I70.221	ICD-10 code listed in document
I70.229	ICD-10 code listed in document
I70.231	ICD-10 code listed in document
I70.233	ICD-10 code listed in document
I70.234	ICD-10 code listed in document
I70.235	ICD-10 code listed in document
I70.238	ICD-10 code listed in document
I70.239	ICD-10 code listed in document
I70.241	ICD-10 code listed in document

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Referenced ICD-10 codesICD-10

I70.268	ICD-10 code referenced repeatedly
I70.269	ICD-10 code referenced repeatedly
I70.321	ICD-10 code referenced repeatedly
I70.322	ICD-10 code referenced repeatedly
I70.262	ICD-10 code referenced in combinations
I70.261	ICD-10 code referenced in combinations
I70.263	ICD-10 code referenced in combinations
I70.25	ICD-10 code referenced in combinations

ICD-10 codes annotated with prior authorization instructions (sample)ICD-10

I70.323	ICD-10 code with 'how to obtain prior authorization' note
I70.329	ICD-10 code with 'how to obtain prior authorization' note
I70.331	ICD-10 code with 'how to obtain prior authorization' note
I70.332	ICD-10 code with 'how to obtain prior authorization' note
I70.333	ICD-10 code with 'how to obtain prior authorization' note
I70.334	ICD-10 code with 'how to obtain prior authorization' note
I70.335	ICD-10 code with 'how to obtain prior authorization' note

Inpatient cerebral seizure monitoring CPT codesCPTCovered

95700	Cerebral seizure monitoring - Inpatient video
95711	Cerebral seizure monitoring - Inpatient video
95712	Cerebral seizure monitoring - Inpatient video
95713	Cerebral seizure monitoring - Inpatient video

Circumcision CPT codesCPT

54150	Circumcision
54160	Circumcision
54161	Circumcision
54162	Circumcision

Cochlear implant CPT/HCPCS codesmixedCovered

69710	Cochlear and other auditory implants
69714	Cochlear and other auditory implants
69930	Cochlear and other auditory implants
L8690	Cochlear implant HCPCS
L8691	Cochlear implant HCPCS
L8614	Cochlear implant HCPCS
L8692	Cochlear implant HCPCS
L8619	Cochlear implant HCPCS

Continuous glucose monitor HCPCS/E codesHCPCSCovered

A4226	Continuous glucose monitor supplies
A9277	Continuous glucose monitor supplies
E2103	Continuous glucose monitor system
A4238	Continuous glucose monitor supplies
A9278	Continuous glucose monitor supplies
A4239	Continuous glucose monitor supplies
E0787	Continuous glucose monitor
A9276	Continuous glucose monitor supplies
E2102	Continuous glucose monitor system

Cosmetic and reconstructive procedure CPT/HCPCS codesmixedCovered

11960	Cosmetic/reconstructive procedure
14041	Cosmetic/reconstructive procedure
11971	Cosmetic/reconstructive procedure
14061	Cosmetic/reconstructive procedure
14020	Cosmetic/reconstructive procedure
15823	Cosmetic/reconstructive procedure
14021	Cosmetic/reconstructive procedure
15830	Cosmetic/reconstructive procedure
A9278	Listed among cosmetic/reconstructive entries
L8692	Appears as mapping for cosmetic/reconstructive group

Example ICD-10 diagnosis codes used in mappingsICD-10

M86.40	ICD-10 - referenced in multiple mappings
M86.461	ICD-10
M86.472	ICD-10
L03.116	ICD-10
Q27.8	ICD-10

Mixed diagnosis and HCPCS present in procedure listsmixed

M86.379
M86.451
M86.462
M86.479
M86.551
M86.562
M86.58
M86.652
M86.669
M86.68

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Cosmetic and reconstructive CPT codes (exclusions noted)CPTNot Covered

15847	Cosmetic procedure code listed as excluded when solely cosmetic
17106	Cosmetic procedure code listed as excluded when solely cosmetic
17107	Cosmetic procedure code listed as excluded when solely cosmetic
17108	Cosmetic procedure code listed as excluded when solely cosmetic
17999	Cosmetic procedure code listed as excluded when solely cosmetic
21137	Cosmetic procedure code listed as excluded when solely cosmetic
21138	Cosmetic procedure code listed as excluded when solely cosmetic
21139	Cosmetic procedure code listed as excluded when solely cosmetic
21172	Cosmetic procedure code listed as excluded when solely cosmetic
21175	Cosmetic procedure code listed as excluded when solely cosmetic

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DME HCPCS codes requiring prior authorizationHCPCSCovered

E0193
E0270
E0194
E0277
E0265
E0266
E0302
E0300
E0465
E0466

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K-codes (assistive technology/mobility devices) requiring prior authorizationHCPCSCovered

K0005
K0008
K0013
K0108
K0800
K0801
K0802
K0806
K0807
K0808

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Additional procedure and supply codes referenced in reconstructive/cosmetic listsmixed

14020
14021
14041
14061
11971
11960
15823
15830
11971
A4239

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K codesHCPCSCovered

K0828
K0829
K0830
K0831
K0836
K0837
K0838
K0839
K0840
K0841

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Enteral/TPN/home nutritionHCPCSCovered

B4034	Enteral services/parental/oral
B4035	Enteral services/parental/oral
B4036	Enteral services/parental/oral
B4100	Enteral services/parental/oral
B4150	In-home nutritional therapy
B4152	In-home nutritional therapy
B4155	In-home nutritional therapy and/or lipids and oral supplements
B4160	In-home nutritional therapy and/or lipids and oral supplements
B9002
B9998

ENT / FAI codesCPTCovered

31240	Functional endoscopic sinus
31253	Functional endoscopic sinus
31254	Functional endoscopic sinus
31255
31256	FESS
31257	FESS
31259	FESS
31267
29914	Femoroacetabular impingement syndrome
29915	Femoroacetabular impingement syndrome

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Genetic testing and relatedmixedCovered

81265	Genetic testing
81325	Genetic testing
81479
88249
88264
88272
88280
88291
81327
92591

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Home/community/home healthmixedCovered

92594	Home- and community-based services
V5014
V5060
V5190
V5244
V5248
92595
V5030
V5095
V5230

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Hysterectomy / related obstetric codesCPTCovered

58150	Hysterectomy
58152	Hysterectomy
58180	Hysterectomy
58200	Hysterectomy
58210	Hysterectomy
58263	Hysterectomy
58240	Hysterectomy
58267	Hysterectomy
58260
58270

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Injectable medications / J and Q codesHCPCSCovered

J3262	Actemra
J0801	Acthar
J0791	Adakveo
J0172	Aduhelm
J7171	Adzynma
J1426	Amondys 45
J0225	Amvuttra
J0739	Apretude
J0256	Aralast NP, Prolastin-C, Zemaira
Q5121	Avsola

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Listed injectable J-codes (sample group)HCPCS

J1554
J1555
J1556
J1557
J1559
J1561
J1566

Additional injectable J-codes and product namesHCPCS

J1575
J1599
J2782
J0217	Lamzede
J2507	Krystexxa
J0219	Nexviazyme / Nglazyme (appears in list)
J1437	Monoferric

Frequently repeated J-codes in sectionHCPCS

J1458
J2796	Nplate
J2182	Nucala / Ocrevus (appears paired)
J2350	Ocrevus
J0129	Orencia

Injectable HCPCS J-codes listedHCPCSCovered

J2350	Referenced in multiple injectable medication entries (Ocrevus)
J0129	Referenced in multiple injectable medication entries (Orencia)

Covered HCPCS/J-codes listedHCPCSCovered

J2267	Onpattro
J0222	Panzyga
J1576	Parsabiv
J0606	Pombiliti
J1203	Prolia
J0897	Qalsody
J1304	Radicava
J1301	Reblozyl
J0896	Remicade
J1745	Remicade

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Sodium Hyaluronate code mappings and equivalenciesHCPCS

J7320	Sodium Hyaluronate (mapping/equivalencies noted)
J7321	Sodium Hyaluronate (mapping/equivalencies noted)
J7322	Sodium Hyaluronate (mapping/equivalencies noted)
J7324	Sodium Hyaluronate (mapping/equivalencies noted)
J7325	Sodium Hyaluronate equivalent
J7326	Sodium Hyaluronate equivalent
J7327	Sodium Hyaluronate equivalent
J7329	Sodium Hyaluronate equivalent
J7331	Sodium Hyaluronate equivalent
J7332	Sodium Hyaluronate equivalent

Injectable medication HCPCS/J/C codesHCPCSCovered

J7320	listed for multiple injectable medications (placeholder in document)
J7321	listed for multiple injectable medications (placeholder in document)
J7322	listed for multiple injectable medications (placeholder in document)
J7324	listed for multiple injectable medications (Additional information placeholder)
J2781	Triptodur (example mapping in text)
90378	Synagis (example mapping in text)
J3241	Tepezza (example mapping in text)
J2356	Triptodur (alternate mapping)
J3316	Triptodur (alternate mapping)
J9381	Tzield (example mapping)

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Non-emergent air ambulance transport codesCPT | HCPCSCovered

A0430	Non-emergent air ambulance ground/other transport
A0431	Non-emergent air ambulance
A0435	Non-emergent air ambulance
A0436	Non-emergent air ambulance

Joint replacement CPT codesCPTCovered

24360	Joint replacement related code
24370	Joint replacement related code
27130	Total hip arthroplasty
24361	Joint replacement related code
24371	Joint replacement related code
24362	Joint replacement related code
27120	Hip procedure
27134	Hip procedure
24363	Joint replacement related code
27125	Hip procedure

Orthognathic and maxillofacial CPT codesCPTCovered

21121	Orthognathic CPT code
21123	Orthognathic CPT code
21125	Orthognathic CPT code
21127	Orthognathic CPT code
21141	Treatment of jaw CPT code
21142	Treatment of jaw CPT code
21143	Treatment of jaw CPT code
21145	Treatment of jaw CPT code
21146	Treatment of maxillofacial/jaw CPT code
21147	Treatment of maxillofacial/jaw CPT code

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Orthotics and prosthetics HCPCS L-codesHCPCSCovered

L0112	Orthotics/prosthetics HCPCS L-code
L0170	Orthotics/prosthetics HCPCS L-code
L0456	Orthotics/prosthetics HCPCS L-code
L0462	Orthotics/prosthetics HCPCS L-code
L0464	Orthotics/prosthetics HCPCS L-code
L0480	Orthotics/prosthetics HCPCS L-code
L0482	Orthotics/prosthetics HCPCS L-code
L0484	Orthotics/prosthetics HCPCS L-code
L0486	Orthotics/prosthetics HCPCS L-code (cumulative rental cost > $500 note)
L0624	Orthotics/prosthetics HCPCS L-code

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Orthotics / prosthetics HCPCS L-codesHCPCSCovered

L5460
L5500
L5505
L5510
L5520
L5530
L5535
L5540
L5560
L5570

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Outpatient therapy CPT/HCPCS codesCPT | HCPCSCovered

97012
97014
97016
97018
97022
97026
97028
97033
97034
97039

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Pharmacy / J-codesHCPCS | NDCCovered

90378
J0224
J0717
J1290
J1300
J1303
J1427
J1428
J1429
J1786

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Prostate procedures and proton beam therapy CPT codesCPTCovered

37243
52441
52442
55874
53850
77520	Proton beam therapy
77522	Proton beam therapy
77523	Proton beam therapy
77525	Proton beam therapy

Selected listed CPT codes (prostate, proton beam, rhinoplasty/septoplasty)CPTCovered

37243	Prostate procedures - prior authorization required (listed)
52441	Prostate procedures - prior authorization required (listed)
52442	Prostate procedures - prior authorization required (listed)
55874	Prostate procedures - prior authorization required (listed)
53850	Prostate procedures - prior authorization required (listed)
77520	Proton beam therapy - prior authorization required
77522	Proton beam therapy - prior authorization required
77523	Proton beam therapy - prior authorization required
77525	Proton beam therapy - prior authorization required
30400	Rhinoplasty/septoplasty - prior authorization required

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What Providers Must Do (Prior Authorization, Documentation, Notification)

Prior Authorization

General prior authorization requirement

Prior authorization is required for services and codes listed in this document. Submit requests using the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by phone at 877-842-3210. To be eligible, services must be covered benefits per AHCCCS; experimental/investigational services are not covered. Out-of-network or out-of-state non‑emergent services require prior authorization and supporting documentation. All rendering providers, facilities and vendors must be actively enrolled with AHCCCS.

How to submit: UHCprovider.com Prior Authorization and Notification tool or call 877-842-3210
Services must be AHCCCS‑covered benefits; experimental/investigational services excluded
Out-of-network/out-of-state non‑emergent services require PA and documentation
Only one provider may request a PA on a form
All providers must be actively enrolled with AHCCCS

Prior Authorization

I70.* codes requiring prior authorization

Background and Policy Context

Background: Allergy immunotherapy includes desensitization treatments administered by subcutaneous injections (allergy shots), sublingual immunotherapy (SLIT) or other routes of administration. The policy clarifies that allergy immunotherapy and allergy testing are covered under EPSDT for members younger than 21 when medically necessary, while for members 21 and older allergy immunotherapy is not a covered benefit.

Definitions and Key Terms

Allergy immunotherapy

DefinitionDesensitization treatments administered by subcutaneous injections (allergy shots), sublingual immunotherapy (SLIT) or another route of administration.

Coverage noteAllergy immunotherapy is covered under EPSDT for members younger than 21 when medically necessary; not a covered benefit for members 21 and older.

Related actionPrior authorization may be required for allergy testing in situations where further exposure to an unknown allergen could be life-threatening.

Life-threatening allergic reaction (examples)

ExamplesSevere facial swelling; breathing difficulties; epiglottal swelling; extensive urticaria.

UseThese examples illustrate life‑threatening allergic reactions that may trigger prior authorization for allergy testing.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Arizona Long Term Care

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2024

Next Review DateN/A

SourceLink

On This Page

Continuous glucose monitor (CGM):

Prior authorization is required for listed CGM HCPCS/E codes when used with a Type 2 diabetes diagnosis as indicated in the coding lists.

Type 2 diabetes diagnosis

Multiple A‑ and E‑codes are listed in the source for CGM supplies/systems.

> $500 retail purchase or cumulative rental

DME code lists and Medicare denial review instructions are provided in the source.

PA required after initial evaluation and for ongoing visits as specified.

Outpatient physical therapy for members 21 and older: Prior authorization is NOT required for outpatient physical therapy in general, but services are limited to 15 visits per benefit year (Oct. 1–Sept. 30) for acquiring or maintaining function; prior authorization is required after the initial evaluation and for ongoing therapy visits per administrative rules.15 visits per benefit year

Source clarifies outpatient PT PA expectations and visit limits.

Selected listed CPT codes (shoulder, sinuplasty, spinal, sterilization groups continued)CPTCovered

29805	Shoulder surgery - prior authorization required
29806	Shoulder surgery - prior authorization required
29807	Shoulder surgery - prior authorization required
29819	Shoulder surgery - prior authorization required
31295	Sinuplasty - prior authorization required
31296	Sinuplasty - prior authorization required
31297	Sinuplasty - prior authorization required
31298	Sinuplasty - prior authorization required
22100	Spinal surgery - prior authorization required
22101	Spinal surgery - prior authorization required

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Sterilization-related CPT codesCPTCovered

52601	Sterilization - prior authorization required
52630	Sterilization - prior authorization required
52647	Sterilization - prior authorization required
52648	Sterilization - prior authorization required
52649	Sterilization - prior authorization required
55250	Sterilization - prior authorization required
55801	Sterilization - prior authorization required
55821	Sterilization - prior authorization required
55831	Sterilization - prior authorization required
58565	Sterilization - prior authorization required

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Stimulators / neurostimulator HCPCS and CPTmixedCovered

E0747	Bone growth stimulator - prior authorization required
E0749	Stimulators - prior authorization required
E0760	Stimulators - prior authorization required
L8680	Neurostimulator/implantable device HCPCS - prior authorization required
L8682	Neurostimulator HCPCS - prior authorization required
L8685	Neurostimulator HCPCS - prior authorization required
L8686	Neurostimulator HCPCS - prior authorization required
L8687	Neurostimulator HCPCS - prior authorization required
L8688	Neurostimulator HCPCS - prior authorization required

CAR-T / temporary codes and VAD codesmixedCovered

0537T	CAR-T cell therapy series (0537T/0538T/0539T/0540T) - listed
J9999	Temporary/unclassified code mappings (J9999→Q2041/Q2042/Q2053) for Amgtagvi, Casgevy, Lantidra
C9399	Temporary/unclassified code - listed
J3490	Temporary/unclassified code - listed
J3590	Temporary/unclassified code - listed
Q0507	VAD-related code - prior authorization required
Q0508	VAD-related code - prior authorization required
Q0509	VAD-related code - prior authorization required

Ventricular assist devices and wound VACCPT|HCPCSCovered

33927	Ventricular assist device implantation - prior authorization required
33928	VAD - prior authorization required
33929	VAD - prior authorization required
33975	VAD - prior authorization required
33976	VAD - prior authorization required
33979	VAD - prior authorization required
33981	VAD - prior authorization required
33982	VAD - prior authorization required
33983	VAD - prior authorization required
E2402	Negative pressure wound therapy pump (wound VAC) - prior authorization required

Selected transplant-related CPT mappings (partial list)CPTCovered

32850	Listed in transplant-related code mapping table
32851	Listed in transplant-related code mapping table
32852	Listed in transplant-related code mapping table
33930	Listed in transplant-related code mapping table
33933	Listed in transplant-related code mapping table
33935	Listed in transplant-related code mapping table

Age threshold for allergy immunotherapy coverage

Age thresholdMembers younger than 21: allergy immunotherapy and allergy testing are covered under EPSDT when medically necessary; Members 21 and older: allergy immunotherapy (including desensitization via injections, SLIT, or other routes) is not a covered benefit.

Coverage basisEPSDT applies for members <21 — services must be medically necessary to be covered.

Not covered for adultsAllergy immunotherapy for members 21 and older is explicitly not a covered benefit under this plan.

Member age threshold for cochlear implant rules

Age threshold21 — cochlear and other auditory implant rules distinguish members younger than 21 versus 21 and older (different documentation/prior authorization expectations).

Documentation noteClinical documentation must be provided for cochlear and other auditory implants when prior authorization is required.

Adult benefit noteFor members 21 and older: prior authorization required for supplies, equipment maintenance and repair of component parts; hardware may not be a covered benefit.

DME PA retail/rental cost threshold

Retail/purchase rental thresholdPrior authorization required when retail purchase or cumulative rental cost exceeds $500.

Applies toDurable medical equipment (DME) HCPCS and K-codes listed in the policy.

Medicare denial reviewArizona Long-Term Care will review Medicare denials of DME; clinical documentation and a copy of the Medicare denial must accompany requests.

Incontinence supplies (members <21)

Quantity threshold (members <21)> 240 briefs/diapers (including pull-ups) per month — prior authorization required when requests exceed this quantity.

Product scopeApplies to incontinence briefs and diapers, including pull-ups.

Action requiredObtain prior authorization for requests exceeding the monthly limit for members under 21.

Incontinence supplies (members >=21)

Quantity threshold (members ≥21)> 180 briefs/diapers (including pull-ups) per month — prior authorization required when requests exceed this quantity.

Product scopeApplies to incontinence briefs and diapers, including pull-ups.

Action requiredObtain prior authorization for requests exceeding the monthly limit for members 21 and older.

Repair cost threshold

Repair cost thresholdRepair cost is referenced as a criterion for orthotics/prosthetics replacement decisions, with a check that repair cost is less than (referenced — exact amount not specified in these chunks).

ContextUsed when assessing replacement versus repair for orthotics/prosthetics components; documentation must show component isn't operating effectively.

DocumentationAuthorization requests should include documentation establishing that the component is not serviceable or repairable when replacement is sought.

Outpatient physical therapy visit limit (age ≥21)

Visit limit (age ≥21)15 outpatient physical therapy visits per benefit year (Oct. 1 - Sept. 30).

PA requirementPrior authorization is NOT required for outpatient physical therapy generally, but prior authorization is required after the initial evaluation and before the initial therapy visit and for all ongoing therapy visits as noted elsewhere.

Inpatient notePhysical therapy provided in skilled nursing or custodial facilities is considered inpatient and not subject to the outpatient visit limit.

Sterilization age threshold referenced

Age threshold for sterilizationAge 21 — prior authorization is required for sterilization codes; members younger than age 21 have additional prior authorization and consent requirements.

Consent requirementAny member requesting sterilization must sign an appropriate Consent for Sterilization form as referenced in AMPM Chapter 400, Section 420.

ReferenceFor more information providers should review AMPM Chapter 400, Section 420 (Sterilization).

Numerous I70.* ICD‑10 diagnosis codes are listed in this policy with the annotation indicating prior authorization is required. When requesting authorization for vascular/cardiovascular services tied to I70.* diagnoses, include the specific I70.* code(s) and related clinical documentation.

Diagnosis codes: I70.323, I70.329, I70.331, I70.332, I70.333, I70.334, I70.335, I70.338, I70.339, I70.341, I70.342, I70.343, I70.344, I70.345, I70.348, I70.349, I70.35, I70.361, I70.362, I70.363, I70.369, I70.421, I70.422, I70.423, I70.428, I70.429, I70.431, I70.432, I70.433, I70.434, I70.435, I70.438, I70.439, I70.441, I70.442, I70.443, I70.444, I70.445, I70.448, I70.449, I70.461, I70.462, I70.463, I70.468, I70.469, I70.521, I70.522, I70.523, I70.528, I70.529, I70.531, I70.532, I70.533, I70.534, I70.535, I70.538, I70.539, I70.541, I70.542, I70.543, I70.544, I70.545, I70.548, I70.549, I70.561, I70.562, I70.563, I70.568, I70.569, I70.621, I70.622, I70.623, I70.628, I70.629, I70.631, I70.632, I70.633, I70.634, I70.635, I70.638, I70.639, I70.641, I70.642

Prior Authorization

DME and durable medical equipment codes requiring prior authorization

Durable medical equipment (DME), orthotics and prosthetics listed in this policy require prior authorization when retail purchase or cumulative rental cost exceeds $500. AHCCCS Long‑Term Care will review Medicare denials for DME — include clinical documentation and a copy of the Medicare denial when requesting review.

DME examples (requiring PA when > $500 purchase or cumulative rental): E0193, E0194, E0265, E0266, E0270, E0277, E0300, E0302, E0465, E0466, E0483, E0486, E0670, E0675, E0693, E0694, E2298, E2301, E2322, E2325, E2327, E2329, E2331, E2351, E2373, E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, E2599, E2626, E2627, E2628, E2629, E2630
Orthotics/prosthetics L‑codes listed throughout (select examples): L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631, L0632, L0634, L0636, L0637, L0638, L0640, L0700, L0710
Include clinical documentation and Medicare denial (if applicable) when requesting review

Prior Authorization

Pharmacy prior authorization (J‑codes / NDCs)

Pharmacy and physician‑administered medications require prior authorization. For pharmacy PA call 800‑310‑6826 or fax 866‑940‑7328. Specialty pharmacy PA fax 866‑940‑7328. Physician‑administered drug requests must include the HCPCS/J‑code and NDC for the medication.

How to request pharmacy PA: Phone 800‑310‑6826, Fax 866‑940‑7328
Specialty PA fax: 866‑940‑7328; forms at UHCprovider.com/AZcommunityplan > Pharmacy Prior Authorization Forms
Physician‑administered drugs: include J‑code and NDC on service request
Pre‑determination recommended for New‑to‑Market medications on Review at Launch list

Documentation Required

Pharmacy / physician‑administered drug documentation

Many injectable medications listed require prior authorization. When submitting requests for injectables include the drug name and corresponding HCPCS/J‑code. Review the 'Review at Launch for New to Market Medications' policy and pre‑determine for drugs on that list.

Include drug name + HCPCS/J‑code (examples): Orencia J0129, Remicade J1745, Ocrevus J2350, IVIG J1459, Xembify J1558
Selected injectable products require PA; see policy lists for specific J/C/Q codes
New‑to‑market drugs: pre‑determination highly recommended; review UHCprovider.com policies

Prior Authorization

Transplant / CAR‑T prior authorization notification

Prior authorization and clinical documentation are required for transplant and CAR‑T services. For transplant and CAR‑T therapy (examples: Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta) call the UnitedHealthcare Community and State Transplant Case Management Team at 800‑418‑4994 or the notification number on the member's ID card.

Call 800‑418‑4994 for transplant and CAR‑T authorization/notification
Include clinical documentation to support medical necessity with the PA request
Examples of CAR‑T products requiring notification/authorization: idecabtagene cileucel (Abecma), lisocabtagene maraleucel (Breyanzi), ciltacabtagene autoleucel (Carvykti), tisagenlecleucel (Kymriah), axicabtagene ciloleucel (Yescarta)

Prior Authorization

Transportation prior authorization / scheduling

Transportation: prior authorization is required for non‑emergent taxi and stretcher van transport. To schedule non‑emergent medical transportation call Medical Transportation Management (MTM) at 888‑700‑6822.

MTM scheduling phone: 888‑700‑6822
Prior authorization required for non‑emergent taxi and stretcher van transport

Denial Risk

Triggers for denial or ineligibility

Triggers that may lead to denial or ineligibility: services not AHCCCS‑covered, experimental/investigational services, providers not actively enrolled with AHCCCS, failure to obtain required prior authorization, exceeding quantity thresholds, or missing required clinical documentation.

Non‑AHCCCS covered services or experimental/investigational services are not eligible
Providers or vendors not actively registered with AHCCCS risk denial
Claims submitted without required prior authorization may be denied
Requests lacking required clinical documentation or exceeding quantity limits may be denied

Denial Risk

Cosmetic exclusion

Cosmetic procedures solely for appearance without restoring or improving physiological function are excluded from AHCCCS coverage and may be denied. Reconstructive procedures to treat a medical condition may be covered with prior authorization and supporting documentation.

Cosmetic exclusion examples (codes listed in source): 15847, 17106, 17107, 17108, 17999, 21137, 21138
Reconstructive procedures addressing medical conditions require PA and documentation

Denial Risk

Quantity threshold denial risk

Quantity‑limit thresholds that trigger prior authorization and potential denial: incontinence briefs/diapers (including pull‑ups) — for members <21: requests >240/month require PA; for members 21 and older: requests >180/month require PA. Other supplies may have specified quantity limits in code lists.

Incontinence supplies PA thresholds: <21 years = >240/month; 21+ years = >180/month
Requests exceeding documented supply limits may be denied if medical necessity not shown

Prior Authorization

Notification instructions for home / community services

Notification and intake instructions for home‑ and community‑based services: prior authorization is required. For home‑ and community‑based services call UnitedHealthcare Community Plan of Arizona at 800‑293‑3740 or use the notification number on the member's health plan ID card. Include clinical documentation to establish medical necessity.

Call 800‑293‑3740 or use notification number on member ID card to complete requests
Codes include V5014, V5060, V5190, V5244, V5248, 92594, 92591, 92595 and multiple V‑codes listed in policy
Provide clinical documentation to support medical necessity

Prior Authorization

Inpatient notification / observation

Inpatient admissions require prior authorization for planned/elective admissions including behavioral/substance abuse, elective surgical admissions, hospice, long‑term acute care/rehabilitation, skilled nursing facility placements. Emergency services do not require prior authorization. If a member is admitted inpatient, notification is required; observation status does not require PA but must be ordered in writing by an authorized practitioner.

PA required for inpatient admissions: behavioral/substance abuse, elective surgical with admission, hospice, LTAC/rehab, SNF placements
Emergency services do not require PA
Notification required upon inpatient admission
Observation status does not require PA but must be physician‑ordered in writing

Note

New‑to‑market medication review

New‑to‑market medications: review the 'Review at Launch for New to Market Medications' policy for recently FDA‑approved drugs. Pre‑determination is highly recommended for medications on the Review at Launch list; use the UHCprovider policy page for current details.

Review at Launch policy available at UHCprovider.com/policies > Community Plan Policies
Pre‑determination highly recommended for drugs on Review at Launch list
Example note: prior authorization may be required for temporary/unclassified codes when associated with specific new drugs

Documentation Required

Pregnancy termination documentation

Pregnancy termination: prior authorization is required for termination procedures and associated codes. Clinical documentation and the Certificate of Medical Necessity for Pregnancy Termination (available via AZ AHCCCS resources) must accompany the prior authorization request. Mifepristone (Mifeprex) and related items require inclusion in the request where applicable.

PA required for pregnancy termination procedure codes (see AMPM Chapter 400 reference)
Include clinical documentation and Certificate of Medical Necessity (available at azahcccs.gov)
Mifepristone (Mifeprex) inclusion and documentation required where applicable

Prior Authorization

Prior authorization required for listed codes

Prior authorization is required for the numerous specific codes enumerated throughout this document (CPT, HCPCS, ICD‑10 and temporary/unclassified codes). When requesting authorization reference the exact code(s) listed in this policy and supply supporting clinical documentation to establish medical necessity.

Submit exact CPT/HCPCS/ICD‑10 code(s) from the policy when requesting PA
Temporary/unclassified codes (C9399, J3490, J3590) may require PA when associated with specific products
Provide full clinical documentation to support medical necessity for listed procedures/devices

Documentation Required

Transplant documentation

Transplant documentation: clinical documentation to support the need for transplant services must accompany the prior authorization request to establish medical necessity. Contact the Transplant Case Management Team for guidance and required documentation.

Include comprehensive clinical records, diagnostic studies, prior treatment history, and justification for transplant
Call UnitedHealthcare Transplant Case Management Team at 800‑418‑4994 for guidance

Policy linkageWhen reasonable to assume further exposure to an unknown allergen may result in these reactions, prior authorization for testing is required.

Cochlear and other auditory implants

DefinitionMedical devices within the inner ear with external components to help persons with profound sensorineural hearing loss.

Prior authorizationPrior authorization is required for the listed cochlear and auditory implant codes; clinical documentation must be provided.

Age-specific rulesDifferent prior authorization/documentation expectations apply for members younger than 21 versus members 21 and older; hardware may not be covered for adults.

Continuous glucose monitor

DefinitionContinuous glucose monitor (CGM) supplies and devices (A- and E-codes) used for diabetes management.

PA requirementPrior authorization is required for listed CGM HCPCS/E codes when used for members with a Type 2 diabetes diagnosis.

Codes referencedExamples of CGM HCPCS codes in the policy include A4226, A9277, E2103, A4238, A9278, A4239, E0787, A9276, E2102.

Cosmetic procedures

DefinitionProcedures that change or improve physical appearance without significantly improving or restoring physiological function; when solely cosmetic they are excluded from AHCCCS coverage.

Coverage implicationSolely cosmetic procedures may be denied and many reconstructive/cosmetic CPT/HCPCS codes require prior authorization.

ExamplesPolicy lists numerous CPT codes (e.g., 15847, 17106–17108, 17999, 21137–21184) illustrating cosmetic exclusions.

DME PA threshold

DME PA thresholdPrior authorization is required for the listed DME codes when retail purchase or cumulative rental cost exceeds $500.

Applies toDME HCPCS codes and K-codes enumerated in the policy (extensive list provided).

Provider actionInclude clinical documentation and, if applicable, Medicare denial documentation when requesting review.

Certificate of Medical Necessity

DefinitionCertificate of Medical Necessity — form referenced for Commercial Oral Nutritional Supplements and available via AMPM resources.

UseRequired documentation to accompany prior authorization requests for in‑home nutritional therapy and related enteral/TPN services.

ReferenceSee AMPM Chapter 400/430 resources as noted in the policy for the Certificate of Medical Necessity form.

Prior authorization

DefinitionPrior authorization — payer approval required before a service or drug will be reimbursed.

RequirementProvider must obtain prior authorization for services and codes listed in this document where indicated.

Submission methodsRequests should be submitted via the UnitedHealthcare Provider Portal or by phone per policy instructions (contact details elsewhere in document).

Orencia

Orencia mappingOrencia is referenced in the policy with HCPCS code J0129.

PA implicationPrior authorization entries reference drug name and HCPCS J-code — include J0129/Orencia on PA requests where applicable.

LocationOrencia appears in the injectable medications section paired with its HCPCS code.

Ocrevus

Ocrevus mappingOcrevus is referenced in the policy with HCPCS code J2350.

PA implicationInclude J2350/Ocrevus on prior authorization requests for the injectable medication as indicated in the policy.

LocationOcrevus appears repeatedly in the injectable medications section paired with J2350.

Out-of-state services

Out-of-state servicesBenefit approved only when service is emergent or unavailable in Arizona.

Out-of-network servicesPrior authorization is required for all out-of-network services.

Provider documentationOut-of-network/out-of-state requests require supporting documentation and the rendering provider/facility/vendor must be actively registered with AHCCCS.

Out-of-network services

Out-of-network PAPrior authorization is required for all out-of-network services.

DocumentationRequests must include documentation supporting the out-of-network request; rendering provider must be actively registered with AHCCCS.

Denial riskLack of prior authorization for out-of-network services may trigger denial of payment.