CurrentUCarePolicy N/A

Authorization and Notification Requirements

Defines UCare prior authorization and notification requirements for a range of inpatient, outpatient, procedural, durable medical equipment, behavioral health, and cosmetic services for listed Minnesota plans and affected providers.

Policy Summary

PayerUCare

PolicyAuthorization and Notification Requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJanuary 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization before delivering or dispensing any listed service or DME items that require authorization to avoid claim denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7 daysallowed non-urgent authorization decision time

72 hoursdischarge summary timeframe

$1,500E1399 DME auth threshold

14/24/52PT/OT/psych visit thresholds

YesMedical Assistance coverage indicated

Coverage criteria and medical necessity rules

Codes and thresholds

Artificial Disc CPT CodesCPTCovered

22856	Artificial disc replacement
22857	Artificial disc replacement
22858	Artificial disc replacement

Bariatric / Metabolic Surgery CPT CodesCPTCovered

43644	Bariatric surgery CPT
43645	Bariatric surgery CPT
43770	Bariatric surgery CPT
43773	Bariatric surgery CPT
43775	Bariatric surgery CPT
43842	Bariatric surgery CPT
43845	Bariatric surgery CPT
43846	Bariatric surgery CPT
43847	Bariatric surgery CPT
43848	Bariatric surgery CPT

Air Ambulance CPT/HCPCS CodesHCPCSCovered

A0430	Air ambulance, fixed wing, transport, one way
A0435	Air ambulance, fixed wing, transport, per mile

Cosmetic / Reconstructive CPT CodesCPTCovered

11960	Injection of filling material
15780	Repair of neck/torso
15781	Repair, trunk
15782	Repair, trunk
15783	Repair, trunk
15786	Skin graft
15787	Skin graft
15830	Mammoplasty
15832	Breast reduction
15833	Breast reduction

1–10 of 45

1/5

Adult Rehabilitative Mental Health Services (ARMHS)CPTCovered

H2017

ARMHS

Children's Day TreatmentCPTCovered

H2012

Children's Day Treatment

Children's Behavioral Health CodesCPTCovered

H0019	Children's Residential Treatment
H2014	CTSS service
H2015	CTSS service
H2019	CTSS service
H0031	CTSS service
H0032	CTSS service
90832	Psychotherapy
90834	Psychotherapy
90837	Psychotherapy
90875	Family psychotherapy with patient

1–10 of 11

1/2

Cranial Nerve Stimulation CPT CodesCPTCovered

64553	Percutaneous implantation of neurostimulator lead
64568	Stimulator, cranial nerve
64569	Implantation of stimulation device
64582	Revision or replacement of neurostimulator lead

See also: Orthognathic surgery CPT codesCPT

21249
21255
21256
21260
21261
21263
21267
21268
21270
21275

1–10 of 29

1/3

Cranial Nerve Stimulation CPT codesCPTCovered

64553	Cranial Nerve Stimulation
64568	Cranial Nerve Stimulation
64569	Cranial Nerve Stimulation
64582	Cranial Nerve Stimulation

Durable Medical Equipment (DME) HCPCSHCPCSCovered

E0483	High Frequency Chest Wall Oscillation System
E0652	Pneumatic Compression Device
E0748	Osteogenesis stimulator, electrical, non-invasive, spinal applications
E0749	Osteogenesis stimulator, electrical, surgically implanted
E0766	Electrical Stimulation Device (rental only item)
E1399	Miscellaneous

EIDBI CPT/UB codesmixedCovered

0373T
97153 UB
97154 UB
97155 UB
97156 UB
97157 UB

Physical and Occupational Therapy CPT codes and related rehabilitation codesCPTCovered

97012
97016
97018
97022
97024
97026
97028
97032
97033
97034

1–10 of 35

1/4

Proton Beam Therapy CPT codesCPTCovered

77520	Proton Beam Radiotherapy (PBRT)
77522
77523
77525

Psychotherapy (Group)CPTCovered

90853

Psychotherapy Group

Psychotherapy (Individual)CPTCovered

90832	Psychotherapy Individual (30 min)
90834	Psychotherapy Individual (45 min)
90837	Psychotherapy Individual (60 min)

Sleep Studies - Facility Based CPT codesCPTCovered

95807	Polysomnography
95808	Polysomnography with PAP titration
95810	Sleep study
95811	Multiple sleep latency test / maintenance of wakefulness

Spinal Cord Stimulation CPT codesCPTCovered

63650	SCS lead insertion
63655
63663
63664
63685

TMS CPT codesCPTCovered

90867	TMS with stimulation
90868	TMS subsequent delivery
90869	TMS with neuronavigation

Vein Procedures CPT codesCPTCovered

36465
36466
36470
36471
36473
36474
36475
36476
36478
36479

1–10 of 14

1/2

Wheelchair accessory miscellaneous K-codes requiring authorization if billed charges exceed $1,500HCPCSCovered

K0108
K0669

Power wheelchair rental K-codes (full list provided in source)HCPCSCovered

K0800
K0801
K0802

Wheelchair accessories and related HCPCSHCPCSCovered

E0986
E1002
E1003
E1004
E1005
E1006
E1007
E1008
E1009
E1010

1–10 of 33

1/4

Wheelchair rental/purchase K-codesHCPCSCovered

K0800
K0801
K0802
K0806
K0807
K0808
K0813
K0814
K0815
K0816

1–10 of 61

1/7

Power-operated vehicle / power wheelchair purchase codes requiring prior authorizationHCPCSCovered

K0005
K0006
K0007
E1161

ARMHS authorization — threshold rule

ThresholdAuthorization required for more than 300 hours (H2017) / 1,200 units per calendar year

Applicable codeH2017 (ARMHS)

Action requiredSubmit prior authorization request when projected treatment will exceed the calendar year threshold

90882 — authorization required after 72 sessions

ThresholdAuthorization required after more than 72 sessions per calendar year for CPT 90882

Applicable code90882

Modifier noteAdd HM, HQ, U3 or U3 HM modifiers as appropriate

H0034 — authorization required after 26 hours/104 units

ThresholdAuthorization required after more than 26 hours / 104 units per calendar year for H0034

Applicable codeH0034

Action requiredSubmit prior authorization when services exceed the annual hour/unit threshold

Children's Day Treatment — authorization threshold

ThresholdAuthorization required when Children's Day Treatment exceeds 150 hours per calendar year

Applicable codeH2012 (Children's Day Treatment)

Medical necessity sourceMinnesota Health Care Programs Provider Manual: Mental Health Services, CTSS Children's Day Treatment

CTSS threshold — authorization required after 200 cumulative hours

ThresholdAuthorization required when CTSS specified services exceed 200 cumulative hours per calendar year

Applicable codesH2014, H2015, H2019, H0031, H0032 and psychotherapy codes billed with UA modifier (90832, 90834, 90837, 90875, 90876)

Medical necessity sourceMinnesota Health Care Programs Provider Manual: Children's Therapeutic Services and Supports (CTSS)

Occupational Therapy visits — prior authorization after 24 visits

ThresholdPrior authorization required after 24 occupational therapy visits per year

Applicable codesOT CPT codes including 97012, 97110, 97530, 97760, etc.

Medical necessity sourceInterQual LOC: Rehabilitation (appropriate subset selected by procedure code)

Physical Therapy visits — prior authorization after 14 visits

ThresholdPrior authorization required after 14 physical therapy visits per calendar year

Applicable codesPT CPT codes including 97012, 97110, 97116, 97140, 97750, etc.

Medical necessity sourceInterQual LOC: Rehabilitation (appropriate subset selected by procedure code)

Psychotherapy (Group/Individual) visits — threshold limit

ThresholdThreshold limit of 52 visits per year for psychotherapy (group and individual); prior authorization required for additional visits

Applicable codesGroup: 90853; Individual: 90832, 90834, 90837

Billing noteTwo units of 90837 billed on the same day may be considered one service

DME miscellaneous code authorization threshold — E1399 $1,500 billed charges

ThresholdHCPCS E1399 (miscellaneous DME) requires authorization if billed charges exceed $1,500

Applicable codeE1399 (Miscellaneous)

Action requiredObtain prior authorization before delivery/dispensing of DME items when billed charges for E1399 exceed $1,500

Rental authorization months — all months must be authorized

RequirementAll months of a wheelchair rental must be authorized (authorization required prior to delivery/dispensing)

Applicable codesPower wheelchair rental K-codes (K0800–K0891 series as listed)

Action requiredObtain authorization that specifies all rental months before providing rental equipment

Repair or replacement of rental equipment — provider responsibility

Operational responsibilityRepair or replacement of rental equipment is the DME provider's responsibility

UCare rightsUCare reserves the right to determine rental versus purchase for wheelchair items

Authorization impactFailure to obtain prior authorization for items that require authorization may result in denied claims

Prior authorization, notification, and provider responsibilities

Denial Risk

Prior Authorization Required — Denial Risk

Prior authorization is required prior to many procedures and services listed in this section. Failing to obtain required prior authorization in advance may result in a denied claim. Allow up to seven calendar days for a non-urgent authorization decision. All services remain subject to member eligibility and benefit coverage.

Providers may request the criteria used for a medical necessity determination on UCare's Authorization page
Not all plans offer out-of-network benefits; contact UCare Provider Assistance Center at 612-676-3300 or 1-888-531-1493 for eligibility, benefits, and network questions

Prior Authorization

Visit/Session/Unit Thresholds — Prior Authorization

Some services have visit, session, unit, or day thresholds. Prior authorization is required when those thresholds are exceeded. Examples below indicate common thresholds; always verify with the specific service entry for exact limits.

Physical Therapy — prior authorization required after 14 visits per calendar year
Occupational Therapy — prior authorization required after 24 visits per calendar year
Psychotherapy (Individual) — threshold limit of 52 visits per year; prior authorization required for additional visits
Psychotherapy (Group) — threshold limit of 52 visits per year; prior authorization required for additional visits
Partial Hospitalization Program — treatment exceeding 21 calendar days following admission requires authorization
Adult Residential Crisis Stabilization Services — treatment exceeding 10 days in a calendar month requires authorization
H0034 (rehabilitation units) — authorization required for more than 26 hours / 104 units per calendar year
90882 (psychotherapy) — authorization required for more than 72 sessions per calendar year
SUD Outpatient Treatment — treatment exceeding six hours per day or thirty hours per week requires prior authorization (hours calculated in a rolling seven-day span)
Substance Use Disorder Outpatient Treatment authorizations can be given for up to a 28-day time span

Prior Authorization

Prior Authorization Required — Service Examples

UCare requires prior authorization prior to delivery, purchase, or performance of many high-cost or specialized services. This includes, but is not limited to, DME items that require authorization (E1399 when billed charges exceed $1,500), power-operated vehicles and power wheelchairs (purchase and rental), artificial disc replacement, bariatric surgery, cranial nerve stimulation, spinal cord stimulation (trial and permanent placement), proton beam therapy, TMS, transplant evaluation and listing, orthognathic surgery, and EIDBI services.

Durable Medical Equipment (DME) — prior authorization required prior to delivery or dispensing of items that require authorization; miscellaneous code E1399 requires authorization if billed charges exceed $1,500
Wheelchair purchase/rental — prior authorization required prior to purchase for K0005–K0007, E1161, all power-operated vehicles and power wheelchairs; prior authorization required prior to delivery/dispensing for rental months and delivery
Artificial Disc Replacement (CPT 22856, 22857, 22858) — prior authorization required prior to service
Bariatric Surgery (CPT 43644, 43645, 43770, 43773, 43775, 43842, 43845–43848) — prior authorization required prior to service
Cranial Nerve Stimulation (CPT 64553, 64568, 64569, 64582) — prior authorization required prior to service; route requests involving mental health diagnoses to the Mental Health and Substance Use Disorders fax line
Spinal Cord Stimulation (CPT 63650, 63655, 63663, 63664, 63685) — prior authorization required prior to trial and permanent placement

Documentation Required

Inpatient Notification, Concurrent Review, and Documentation

For inpatient and facility-based admissions where notification or concurrent review is required, providers should follow the stated notification timelines and submit required documentation (for example, discharge summaries). Failure to notify or obtain authorization when required may lead to claim denial.

Acute Inpatient Hospitalization (medical, mental health, SUD) — concurrent review required when applicable; discharge summary required upon discharge; notification within 24 hours if not enrolled in UCare EAS
Neonatal Intensive Care Unit (NICU) — authorization required for Levels II–IV; notification within 24 hours of admission; concurrent review required for additional days; discharge summary required upon discharge
Long-Term Acute Care (LTAC) — discharge summary required upon discharge; concurrent review for additional days
Psychiatric Residential Treatment Facilities (PRTF) — prior authorization required prior to admission; concurrent review required for additional days; discharge summary required to be sent

Note

Clinical Criteria and Documentation Expectations

UCare applies InterQual and Minnesota Health Care Programs Provider Manual criteria where applicable to determine medical necessity for many services and DME. Providers should be prepared to submit clinical documentation that supports the requested service according to the referenced criteria.

DME and wheelchairs — InterQual DME criteria and Minnesota Health Care Programs Provider Manual criteria will be applied
Rehabilitation services (PT/OT/SLP) — InterQual LOC Rehabilitation subsets will be used based on procedure code
Behavioral health services (TMS, VNS, SUD) — InterQual BH criteria or ASAM criteria will be applied as specified

Key definitions

Prior authorization — definition and scope

DefinitionPrior authorization: An approval by an approval authority prior to delivery of a specific service or treatment; requires clinical review to determine medical necessity.

ScopeApplies to services and items listed in this policy that explicitly require prior authorization prior to delivery or admission.

Approval authorityUCare or an organization delegated by UCare has authority to approve or deny prior authorization requests.

Notification — definition and timing expectations

DefinitionNotification: The process of informing UCare, or delegates of UCare, of a specific medical treatment or service prior to, or within a specified time period after, the start of the treatment or service.

Timing expectationExamples include notification within 24 hours of admission for NICU and transplant procedures where specified

PurposeAllows UCare to perform appropriate concurrent review and care coordination as required by the policy

Approval authority — definition (UCare or delegated organization)

DefinitionApproval authority: UCare, or an organization delegated by UCare, with authority to approve or deny prior authorization requests.

RolePerforms clinical review and determines whether medical necessity criteria are met for requested services or items.

ImplicationProviders must submit requests to the approval authority identified by UCare or its delegates to avoid denial risk

Background and scope references

This policy references external clinical criteria sources when determining medical necessity. Specifically, UCare will apply InterQual Care Plan criteria for Durable Medical Equipment and related procedures, and where applicable will consult the Minnesota Health Care Programs Provider Manual to select the appropriate coverage subset for a requested wheelchair item.

Operational coding notes and thresholds

DME miscellaneous code authorization threshold (E1399 $1,500 billed charges)

ThresholdE1399 requires authorization if billed charges exceed $1,500

ContextApplies to miscellaneous wheelchair accessory items and other DME billed under E1399

Action requiredObtain prior authorization for E1399 items when billed charges exceed $1,500 to avoid denial

Rental authorization months — all months must be authorized

RequirementAll months of a wheelchair rental must be authorized prior to delivery/dispensing

Applicable itemsPower-operated vehicles and power wheelchairs requiring authorization (K0800–K0891 series)

Provider actionRequest authorization that specifies the total rental period (all months) before furnishing rental equipment

Policy revision history

Effective January 1, 2026policy_effective_dateLatest

Document effective date establishing the authorization and notification requirements described in this policy.

auth_requirements_added

Established prior authorization requirements for Artificial Disc procedures (CPT 22856, 22857, 22858) requiring authorization prior to service.

dme_auth_threshold

Defined DME authorization rules including requirement that miscellaneous code E1399 requires authorization if billed charges exceed $1,500.

Policy Summary

PayerUCare

PolicyAuthorization and Notification Requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJanuary 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization before delivering or dispensing any listed service or DME items that require authorization to avoid claim denial.

SourceLink

On This Page

Proton Beam Therapy (CPT 77520, 77522, 77523, 77525) — prior authorization required prior to service

Transcranial Magnetic Stimulation (CPT 90867, 90868, 90869) — prior authorization required prior to service

Transplant — prior authorization required prior to evaluation and listing; notification required within 24 hours of admission for transplant procedures

Early Intensive Developmental and Behavioral Intervention (EIDBI) — prior authorization required prior to service

Orthognathic Surgery (CPT 21121, 21141–21147, 21193–21198, 21249, 21255–21296, 30120, 30400–30450, 30540–30560, 30620, 40500, 67900, 67912, 69090, 69300, 69320) — prior authorization required prior to service