CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Arizona Developmental Disabilities

Governs prior authorization requirements and submission methods for providers participating with UnitedHealthcare Community Plan of Arizona Developmental Disabilities; affects in-network and out-of-network health care professionals delivering inpatient and outpatient services to covered members in Arizona.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Arizona Developmental Disabilities

Policy CodePolicy N/A

Change TypeAdministrative (no material coverage changes)

Effective DateMar 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 800-445-1638.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Mar 1, 2025policy effective date (stated)

Online & phoneprior auth methods

EPSDT covers allergy immunotherapyEPSDT note (<21)

Not coveredadult allergy immunotherapy

$500

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Coverage criteria and limitations

inv-01: Coverage notes and prior authorization criteria

Selected coverage notes and limitations

All services eligible for prior authorization must be covered benefits as defined by AHCCCS; only medically necessary, cost‑effective, federal- and state‑reimbursable services are covered.

Services provided by non‑network or out‑of‑state providers require prior authorization and supporting documentation; all rendering providers, facilities and vendors must be actively registered with AHCCCS.

Experimental and investigational services are not covered benefits and require prior authorization when considered; consult AHCCCS policy for examples.

Only one health care professional may request services on a prior authorization request form.

Allergy immunotherapy

Members younger than 21: allergy immunotherapy and allergy testing are covered under EPSDT when medically necessary.
Members 21 and older: allergy immunotherapy (including subcutaneous injections, sublingual immunotherapy, or other routes) is not a covered benefit except as specified for severe reactions meeting criteria.

inv-02: Vision services coverage by age

Vision and ophthalmology coverage notes by age group

Members younger than 21: one routine eye exam every 12 months; standard lenses and frame up to $79.99 retail; one replacement pair if lost, stolen, or damaged; member may pay difference for more expensive frames with a waiver.

Members 21 and older: prior authorization is required when medically necessary to diagnose or treat diseases and conditions of the eye.

inv-03: Nutrition and experimental service criteria

Enteral/parenteral nutrition and experimental services

Enteral/parenteral nutrition (including in‑home enteral, gastrostomy tube feedings), total parenteral nutrition (TPN), lipids and oral supplements require a request to Preferred Homecare at 800-636-2123 with clinical documentation; a Certificate of Medical Necessity must accompany requests as applicable.

Members younger than 21: follow AHCCCS AMPM Chapter 400 Section 430 (EPSDT) and use the Commercial Oral Nutritional Supplements Certificate of Medical Necessity per AMPM guidance.

Members 21 and older: follow AMPM Chapter 300 Policy 310-GG and use Attachment C for the Certificate of Medical Necessity.

Experimental or investigational services require prior authorization per AMPM Chapter 300 Section 320 Policy 320-B; listed example codes include 33477 and 36514.

inv-04: DME coverage criteria

Durable medical equipment coverage and authorization rules

Prior authorization is required only for DME codes listed with a retail purchase or cumulative rental cost greater than $500.

Certain DME items require prior authorization regardless of dollar amount; to request DME items call Preferred Homecare at 800-636-2123.

Some DME HCPCS codes listed in the document are not covered; consult the DME listings for specific excluded HCPCS codes.

inv-05: Summary of requirements for members 21+

Coverage and prior authorization/notification requirements for members 21 and older include:

Prior authorization is required when medically necessary to diagnose or treat diseases and conditions of the eye for members 21 and older.

Prior authorization is required for listed surgical procedures for members 21 and older, including femoroacetabular impingement (FAI) codes (29914–29916) and FESS codes (31240–31288).

Genetic testing services not covered by LabCorp require prior authorization; providers should call LabCorp at 800-788-9743 to determine requirements.

Hearing evaluations and hearing aids: prior authorization not required for members <21; for members 21 and older prior authorization is required; incontinence supplies and in‑home infusion/infusion medications are benefits only when provided through Preferred Homecare or Optum Infusion—prior authorization is required for services not covered by those vendors.

Inpatient admissions and post‑acute services (acute care hospitals, acute inpatient rehabilitation, long‑term acute care) require prior authorization and notification of the admission date.

inv-06: Coverage criteria for services requiring prior authorization

Coverage and prior authorization expectations for listed services for members 21 and older.

Laboratory services: prior authorization is required; providers should call to determine specific requirements.

Nonemergent air ambulance transport (A0430, A0431, A0435, A0436): prior authorization is required.

Orthognathic/maxillofacial surgery and treatment of maxillofacial/jaw functional impairment: prior authorization is required for the listed CPT codes (e.g., 21121–21299, 21296, 21299).

Orthotics and prosthetics: prior authorization is required for many L‑codes; requirements include documentation, cumulative rental cost considerations and repair vs replacement rules with a referenced $500 threshold.

Joint replacement procedures (total hip and knee and related procedures): prior authorization is required for the listed CPT codes.

inv-07: Therapy coverage and limits

Outpatient therapy coverage and limits (from document):

Outpatient occupational and physical therapy (members younger than 21) is limited to 15 visits per benefit year (Oct 1–Sept 30) to restore a skill or level of function and maintain it.

Outpatient occupational and physical therapy (members younger than 21) is limited to 15 visits per benefit year (Oct 1–Sept 30) to acquire a new skill or level of function and then maintain it.

Outpatient speech therapy is not a covered benefit.

Coverage for OT/PT in general

Occupational and physical therapy provided in inpatient or outpatient settings is covered when medically necessary (no benefit limits noted for inpatient).
Qualified Medicare beneficiaries: coverage for unlimited visits when medically necessary.

inv-08: Prior authorization examples

Service-specific prior authorization requirements (examples):

Out‑of‑network services: prior authorization is required for all out‑of‑network services; out‑of‑state services are approved only when emergent or unavailable in Arizona.

Advanced outpatient imaging (certain CT, MRI, MRA, PET, nuclear medicine, nuclear cardiology): ordering providers must provide notification prior to scheduling and submit prior authorization requests online via the UnitedHealthcare Provider Portal.

Pregnancy termination: prior authorization is required and clinical documentation plus certificate of medical necessity must accompany the request.

Pharmacy (specialty/physician‑administered drugs): prior authorization is required; include J codes and NDCs on requests and use the pharmacy prior authorization contact resources.

Proton beam therapy and certain advanced radiology procedures: prior authorization is required for the listed codes.

inv-09: Prior authorization-based coverage criteria (excerpt)

Services explicitly stated to require prior authorization for qualified Medicare beneficiaries in these chunks:

Skilled and custodial nursing facility services: prior authorization is required.

Sleep apnea procedures and surgeries (maxillomandibular advancement and oral‑pharyngeal tissue): prior authorization is required for the listed codes (examples cited in the document).

Specialty/enclosed beds (multiple HCPCS E‑codes such as E0260, E0291, E0295, E0315, E0261, E0292, E0300, E0316, E0280, E0293, E0301, E0328, E0290, E0294, E0303, E0329): prior authorization is required for the HCPCS codes listed.

Spinal surgery: prior authorization is required for the listed spinal surgery CPT codes (examples include 22100, 22101, 22102, 22110, 22112, 22114 and others shown).

Sterilization procedures (e.g., CPT codes 52601, 52630, 52647, 52648): prior authorization is required for qualified Medicare beneficiaries.

inv-10: Prior authorization coverage criteria (excerpt)

Prior authorization stance for listed procedures (qualified Medicare beneficiaries):

Prior authorization is required for many listed CPT and HCPCS procedure codes; entries include numerous neurosurgical, spinal and sterilization procedure codes.

Sterilization procedures (multiple CPT codes such as 52601, 52630, 52647, 52648, 52649, 55821) require prior authorization and are repeatedly annotated as such in the document.

Multiple neurosurgical and spine procedure codes are listed with associated authorization references (examples include code ranges such as 63005–63191 and 22804–22899); consult the full policy for complete coding and authorization instructions.

Some entries include special annotations (for example '*SOS applies' and Category III code 0098T) — consult the full policy for interpretation and applicable documentation requirements.

This excerpt is partial; providers should consult the complete policy for the full list of codes and the prior authorization process.

inv-11: Sterilization prior auth and code mapping criteria

Operational criteria appearing in this part:

Prior authorization is required for sterilization procedures for qualified Medicare beneficiaries.

Specific CPT/HCPCS code mappings are provided (examples: 55700 mapped to 52601; 57288 mapped to 52630; multiple entries list 52647 and 52648 as related codes); providers should use these mappings when requesting authorization.

Providers must complete the appropriate Consent to Sterilization form where applicable and include clinical documentation; consult AMPM Chapter 400 Section 420 for sterilization consent requirements.

inv-12: Prior Authorization Requirements

Prior authorization is required for the services and codes listed below for qualified Medicare beneficiaries.

Prior authorization is required for the multiple services and CPT/HCPCS codes enumerated in this section (including but not limited to sterilization, transplant/CAR T‑cell therapies, implantable stimulators, specialty beds, spinal surgery, and select device/procedure codes).

Transplant and CAR T‑cell therapy services require prior authorization; for specific products (e.g., Abecma, Breyanzi, Tecartus, Yescarta) contact the UnitedHealthcare Community and State Transplant Case Management Team at 800-418-4994 or the notification number on the member ID card.

Implantable stimulators and bone growth stimulators (example HCPCS E0747 and related codes) require prior authorization; clinical documentation must accompany requests.

Codes and thresholds

Examples of drug/HCPCS codes requiring prior authorizationHCPCSCovered

J1442	Filgrastim (Neupogen) - example listed for colony-stimulating factor prior auth
J2506	Pegfilgrastim (Neulasta) - example listed for colony-stimulating factor prior auth
J9000-J9999	Chemotherapy injectable drugs range requiring prior authorization
J0897	Denosumab (Xgeva) - bone-modifying agent requiring prior authorization

Surgery/procedure CPT codesCPTCovered

19316	Breast reconstruction procedure code listed as requiring prior authorization
17106	Cosmetic procedure-related code listed as requiring prior authorization
54150	Circumcision code listed where prior authorization required when medically necessary (routine excluded)

Sample DME HCPCS codesHCPCSCovered

E0656	Bone stimulator (example listed)
E0745	Insulin pump (example listed)
E1009	Wound vac (example listed)

Surgical CPT codes requiring prior authorization for adultsCPTCovered

29914-29916	Arthroscopic femoroacetabular impingement syndrome procedure codes (listed)
31240-31288	Functional endoscopic sinus surgery (FESS) codes (listed)

Example codes flagged as experimental/investigationalmixedNot Covered

33477	Example code listed under experimental/investigational requiring prior auth
36514	Example code listed under experimental/investigational requiring prior auth

FAI procedure codesCPTCovered

29914	Arthroscopic procedure code listed under FAI
29915	Arthroscopic procedure code listed under FAI
29916	Arthroscopic procedure code listed under FAI

FESS procedure codesCPTCovered

31240	FESS-related code
31253	FESS-related code
31254	FESS-related code
31255	FESS-related code

Selected genetic testing codesCPTCovered

81265	Genetic testing code
81401	Genetic testing code
88245	Cytogenetic/microarray code

Selected injectable J-codesHCPCSCovered

J3262	Actemra (example injectable)
J0791	Adakveo (example injectable)
J0172	Aduhelm (example injectable)

Orthotics & prosthetics L-codesHCPCSCovered

L0112	Orthotic/prosthetic supply code listed requiring prior authorization
L0170	Orthotic/prosthetic supply code listed requiring prior authorization
L0456	Orthotic/prosthetic supply code listed requiring prior authorization
L0462	Orthotic/prosthetic supply code listed requiring prior authorization
L0464	Orthotic/prosthetic supply code listed requiring prior authorization
L0480	Orthotic/prosthetic supply code listed requiring prior authorization

Air ambulance codesHCPCS

A0430	Nonemergency air ambulance transport
A0431	Nonemergency air ambulance transport
A0435	Nonemergency air ambulance transport
A0436	Nonemergency air ambulance transport

Selected joint replacement CPT codesCPT

27130	Total hip arthroplasty
27132	Revision, acetabular component
27486	Revision, total knee arthroplasty

Therapy and related codesCPT

92507	Outpatient speech therapy (listed)
92508	Outpatient speech therapy (listed)
92521	Speech therapy code listed
92522	Speech therapy code listed
97012	Therapy modality code listed
97014	Therapy modality code listed
97110	Therapeutic exercise / outpatient therapy
97112	Therapeutic procedure
97116	Therapeutic procedure
97161	OT/PT assessment

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Pain management injection codesCPTCovered

64490	Pain injection
64493	Pain injection

Private duty nursing codesHCPCSCovered

T1002	Private duty nursing
T1003	Private duty nursing

Sinuplasty codesCPTCovered

31295	Sinuplasty
31296	Sinuplasty
31297	Sinuplasty
31298	Sinuplasty

Shoulder surgery example codesCPTCovered

29805	Arthroscopic shoulder surgery (example)
29820	Arthroscopic shoulder surgery (example)

Selected CPT codes from cosmetic/reconstructive and digestive system sectionsCPT

13101	Repair or reconstruction (listed in cosmetic/reconstructive group)
13132	Repair or reconstruction (listed in cosmetic/reconstructive group)
14040	Skin grafting / reconstructive procedure
14301	Reconstruction of facial soft tissue
21552	Musculoskeletal / excision or repair code listed
21931	Musculoskeletal procedure listed
42415	Digestive system procedure

Selected ophthalmologic, gynecologic, integumentary CPT codesCPT

65710	Ophthalmologic procedure
66986	Ophthalmologic procedure (e.g., intraocular)
57240	Female genital system procedure (e.g., repair/reconstruction)
58561	Obstetric/gynecologic procedure
10121	Integumentary system - incision and drainage
11440	Excision lesion of skin
15120	Skin graft

Durable medical equipment HCPCS for specialty bedsHCPCSCovered

E0260	Specialty/enclosed bed HCPCS code
E0291	Specialty/enclosed bed HCPCS code
E0295	Specialty/enclosed bed HCPCS code
E0315	Specialty/enclosed bed HCPCS code
E0261	Specialty/enclosed bed HCPCS code
E0329	Specialty/enclosed bed HCPCS code

Spinal surgery and related CPT codesCPT

22100	Spinal surgery CPT code (posterior segmental instrumentation)
22101	Spinal surgery CPT code
22102	Spinal surgery CPT code
22514	Spinal fusion/sterilization context referenced with *SOS applies
0098T	Category III CPT referenced alongside spinal/sterilization listing

Neurosurgery / spine codes (examples)CPT

63005-63056,63064,63077-63087

Spinal and cranial neurosurgical procedure code ranges referenced in this section (multiple specific codes enumerated).

Sterilization/genitourinary codesCPT

52601,52630,52647,52648,52649,55821

Sterilization and related genitourinary procedure codes referenced repeatedly.

Sterilization CPT/HCPCS mappingsCPT | HCPCS | mixed

55700	Listed mapped to 52601 in document
57288	Listed mapped to 52630 in document
52601	Target mapping for 55700
52630	Target mapping for 57288
52647	Frequently shown mapping/related sterilization code
52648	Frequently shown mapping/related sterilization code
63251	Appears grouped with 63268 and 63286
63268	Appears grouped with 63251 and 63286
63286	Appears grouped with 63251 and 63268

Selected procedure and device codes requiring prior authorizationmixed

E0747	Bone growth stimulator (example HCPCS listed)
L8680	Example implantable device HCPCS listed
32850	Transplant-related CPT listed

CAR T-cell and related codesmixed

50340	CAR T-cell therapy related CPT (example)
38232	Apheresis code (requires prior auth only for oncology diagnosis per note)

DME prior authorization dollar threshold

DME prior authorization thresholdPrior authorization required only for DME codes with retail purchase or cumulative rental cost greater than $500

Vendor routing for DME requests

How to request authorization and vendor routing

Prior Authorization

How to request prior authorization

To request prior authorization submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal at UHCprovider.com (Sign In with One Healthcare ID). For prior-authorization questions or phone submissions call 800-445-1638.

Prior authorization is required for all out-of-network services and for non-network or out-of-state providers; include documentation supporting the out-of-network or out-of-state request.
Only one health care professional may request services on a prior authorization request form.

Prior Authorization

Dental prior authorization and exceptions

Dental prior authorization requests and questions should be directed to UnitedHealthcare Dental. Providers must obtain prior authorization when required; exceptions and benefit details are governed by AHCCCS policy referenced below.

Prior authorization phone: UnitedHealthcare Dental 855-812-9208.
Refer to AHCCCS Medical Policy Manual (AMPM) Chapter 300, Section 310, Policy 310-D1 for dental coverage rules and exceptions.

Terminology and vendor definitions

EPSDT

Program definitionEarly and Periodic Screening, Diagnostic and Treatment (EPSDT) — federal/state program covering medically necessary services for members younger than 21

ApplicabilityEPSDT coverage applies to services such as allergy immunotherapy and testing for members under 21 when medically necessary

Relationship to prior authorizationServices must be covered benefits as defined by AHCCCS to be eligible for prior authorization under EPSDT rules

Medically necessary

Medically necessary definitionServices must be medically necessary, cost-effective, and federal- and state-reimbursable as outlined by AHCCCS

Coverage requirementOnly medically necessary services that are covered benefits per AHCCCS are eligible for prior authorization

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Arizona Developmental Disabilities

Policy CodePolicy N/A

Change TypeAdministrative (no material coverage changes)

Effective DateMar 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 800-445-1638.

SourceLink

On This Page

Inpatient admissions/post‑acute services require prior authorization and notification of admission date for applicable facility types.

The section lists multiple system‑specific CPT code groups for reference; prior authorization may apply as noted elsewhere in the policy.

To request DME items call Preferred Homecare at 800-636-2123 (for items not covered by Preferred Homecare, review provider resources)

ExceptionsCertain DME items require prior authorization regardless of dollar amount (document annotated with '*Requires prior authorization regardless of dollar')

Orthotics repair vs replacement cost threshold

Orthotics repair vs replacement thresholdReasonable repairs or adjustments of purchased orthotics are covered; repair cost less than purchasing another unit — $500 repair threshold referenced

Coverage for repairsReasonable repairs or adjustments of purchased orthotics are covered for all members to make the orthotic serviceable

Prior authorization for L-codesPrior authorization is required for orthotics and prosthetic L-codes listed; documentation and cumulative rental cost considerations apply

OT/PT visit limit (outpatient, members <21)

OT/PT outpatient visit limits (members <21)Limited to 15 occupational therapy visits and 15 physical therapy visits per benefit year (Oct. 1–Sept. 30) to restore or acquire and maintain skills

ScopeApplies to outpatient occupational and physical therapy for members younger than 21

Speech therapyOutpatient speech therapy is not a covered benefit

Where AHCCCS/plan guidance exempts a service, prior authorization may not be required — verify case-by-case per AMPM and plan resources.

Prior Authorization

Inpatient admission and post-acute notification and prior authorization

Notification and prior authorization requirements apply to inpatient admissions and many post-acute services. Providers must notify UnitedHealthcare at the time of admission and obtain prior authorization when required prior to or as indicated by the type of facility.

Notification is required for inpatient admissions.
Prior authorization and notification of admission date required for: acute care hospitals, acute inpatient rehabilitation, and long-term acute care hospitals.
For admissions that require prior authorization, submit requests via the Prior Authorization and Notification tool on the Provider Portal or call the number on the member’s ID card or 888-397-8129 where indicated in plan resources.

Prior Authorization

Joint replacement procedures prior authorization

Joint replacement procedures (total hip and knee and related surgeries) require prior authorization. Submit documentation to support medical necessity when requesting authorization.

Examples of CPT codes that require prior authorization include: 24360, 24370, 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27412, 27446, 27447, 27486, 27487, 29866, 29867.
Use the Provider Portal Prior Authorization and Notification tool to submit requests.
Refer to UHCprovider.com and Community Plan guidelines for full code lists and clinical criteria.

Prior Authorization

Specialty/enclosed beds - prior authorization

Specialty and enclosed beds require prior authorization. Requests must include clinical justification and any vendor-specific information when applicable.

HCPCS codes commonly requiring prior authorization include E0260, E0261, E0280, E0290, E0291, E0292, E0293, E0294, E0295, E0300, E0301, E0303, E0315, E0316, E0328, E0329, E0462.
To request these items, contact Preferred Homecare or follow the Provider Portal vendor routing instructions when indicated.
Prior authorization is required regardless of dollar threshold for certain specialty bed codes as listed.

Prior Authorization

Spinal surgery - prior authorization

Spinal surgery procedures require prior authorization. Providers must submit clinical documentation supporting the indication and planned procedure.

Representative CPT codes requiring prior authorization include 22100, 22101, 22102, 22110, 22112, 22114 and related spine procedure codes listed in plan resources.
Submit requests online via the Prior Authorization and Notification tool and include imaging reports, prior nonoperative treatment, and surgeon notes.
Refer to UHCprovider.com/AZcommunityplan Prior Authorization and Notification Resources for the complete list and clinical criteria.

Prior Authorization

Sterilization - prior authorization

Sterilization procedures require prior authorization and, where applicable, completion of the AHCCCS Consent to Sterilization form. Clinical documentation and necessary consent forms must accompany the prior-authorization request.

Common CPT codes requiring prior authorization include 52601, 52630, 52647, 52648, 55821, 55831, 58600, 58605, 58611 and related codes noted in AMPM guidance.
Sterilization requires that the member sign the appropriate consent for sterilization form; see AMPM Chapter 400, Section 420 and Attachment C for the Consent to Sterilization form location.
Submit prior-authorization requests via the Provider Portal and include the completed consent form and supporting clinical documentation.

Prior Authorization

Transplant and CAR T‑cell prior authorization/notification

Transplant and CAR T‑cell therapy services require prior authorization and coordination with UnitedHealthcare’s transplant case management team. Clinical documentation to establish medical necessity must accompany the request.

For transplant and CAR T‑cell therapies (including Abecma®, Breyanzi®, Tecartus®, Yescarta® and others), contact the UnitedHealthcare Community and State Transplant Case Management Team at 800-418-4994 or use the notification number on the member’s ID card.
Certain therapies require direct routing to the transplant case management team for review and authorization; include full clinical records, prior treatments, and specialist consults.
Follow plan guidance at UHCprovider.com and the Provider Portal for submission details and any additional vendor routing requirements.

Provider registrationAll rendering providers, facilities and vendors must be actively registered with AHCCCS to provide medically necessary services

Certificate of Medical Necessity

Certificate requirementClinical documentation and the Certificate of Medical Necessity must accompany requests for oral supplements and enteral/parenteral nutrition

Request routingTo request enteral/parenteral nutrition or supplies call Preferred Homecare at 800-636-2123

Reference guidanceCommercial Oral Nutritional Supplements Certificate can be found in AHCCCS AMPM Chapter 300 (Attachment C) for members 21 and older

Experimental or investigational services

Prior authorization for experimental servicesPrior authorization is required for all services considered experimental and/or investigational

Reference policySee AHCCCS AMPM Chapter 300, Section 320, Policy 320-B for details on experimental/investigational services

Example codesDocument lists example codes flagged as experimental/investigational (e.g., 33477, 36514) requiring prior authorization

Preferred Homecare

Preferred Homecare rolePreferred Homecare is the vendor for in-home infusion services and incontinence supplies; to request DME or in-home nutrition services call Preferred Homecare at 800-636-2123

Incontinence suppliesIncontinence supplies are a benefit only when provided through Preferred Homecare

Interaction with OptumInfusion in-home services are benefits when provided through Preferred Homecare; prior authorization required for services not covered by Optum Infusion

LabCorp

LabCorp routingLabCorp is the routing vendor for genetic testing — to determine prior authorization requirements call LabCorp at 800-788-9743

Prior authorization notePrior authorization is required for genetic testing services not covered by LabCorp

Example codesMultiple genetic testing CPT codes are listed in the document with LabCorp routing guidance (e.g., 81401, 81403, 88245)

Optum Infusion

Optum Infusion roleOptum Infusion is the vendor for in-home infusion medications; to request medications call Optum Infusion at 800-985-3059

Prior authorization routingPrior authorization is required for services not covered by Optum Infusion; some injectable medications route through Optum or Preferred Homecare

Contact infoOptum Infusion phone: 800-985-3059 (documented for infusion and in-home medication requests)

Reasonable repairs or adjustments of purchased orthotics

DefinitionReasonable repairs or adjustments of purchased orthotics are covered to make the orthotic serviceable or when repair cost is less than purchasing another unit

Coverage scopeRepairs/adjustments are covered for all members

Replacement considerationIf repair cost equals or exceeds replacement, replacement or purchase rules apply (repair threshold referenced in policy)

Notification

Notification requirementNotification of the inpatient admission date is required for acute care hospitals, acute inpatient rehabilitation and long-term acute care hospitals

Prior authorizationPrior authorization and notification required for inpatient admissions and post-acute services

Provider resourceGuidelines and contact for inpatient prior authorization available at UHCprovider.com or via provided phone numbers in the document

Prior authorization

Prior authorization definitionPrior authorization is a required approval process before coverage for certain services or equipment will be granted; providers must submit requests via the UnitedHealthcare Provider Portal or phone

Operational meaningApplies to all out-of-network services and numerous listed CPT/HCPCS codes; advanced outpatient imaging requires notification prior to scheduling

Submission methodsSubmit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call the listed phone numbers

Qualified Medicare beneficiaries

Qualified Medicare beneficiaries coverageQualified Medicare beneficiaries are covered for unlimited visits when medically necessary

Exceptions/notesSome services for qualified Medicare beneficiaries still require prior authorization (document lists many codes and services)

Relation to therapy limitsTherapy visit limits do not apply to qualified Medicare beneficiaries when medically necessary (document notes unlimited visits)

Prior authorization

Prior authorization (operational)Prior authorization is required prior to coverage for certain services or equipment and must be obtained per the processes described in the policy

Applies toApplies to listed CPT/HCPCS entries, out-of-network services, specialty beds, spinal surgery, sterilization procedures and others enumerated in the document

Provider responsibilitiesProviders ordering advanced outpatient imaging must provide notification prior to scheduling and submit prior authorization requests online via the Provider Portal

Specialty/enclosed beds (HCPCS E-codes)

Specialty/enclosed beds definitionDurable medical equipment HCPCS codes such as E0260, E0291, E0295, E0315 (and related E-codes) represent specialty/enclosed beds that require prior authorization

Authorization notePrior authorization is required for the listed HCPCS E-codes for specialty/enclosed beds

Code examplesDocument maps several HCPCS E-codes to specialty/enclosed bed entries (e.g., E0260, E0291, E0295, E0315)

Qualified Medicare beneficiaries

Qualified Medicare beneficiaries (sterilization context)Qualified Medicare beneficiaries are subject to prior authorization for sterilization procedures; multiple CPT/HCPCS mappings and required documentation noted

Consent requirementSterilization requires completion of an appropriate Consent to Sterilization form (see AMPM Chapter 400, Section 420)

Code mapping examplesDocument shows code mappings (e.g., 55700 → 52601; 57288 → 52630) to be used when requesting prior authorization for sterilization

Consent to Sterilization

Consent to Sterilization requirementCompletion of an appropriate Consent to Sterilization form is required for sterilization procedures; reference AMPM Chapter 400, Section 420

Where to find formConsent to Sterilization form available at azahcccs.gov under AMPM Chapter 400 resources

Prior authorization linkagePrior authorization is required for listed sterilization CPT codes in addition to the consent requirement

Temporary/Unclassified Codes

Temporary/Unclassified Codes examplesTemporary and Unclassified Codes referenced for CAR T-cell and novel therapies include codes such as J9999, J3490, J3590, C9399 (document lists these under Temporary and Unclassified Codes)**

ContextThese temporary/unclassified codes are shown alongside CAR T-cell therapy CPT and HCPCS entries and may require prior authorization

Oncology noteCode 38232 will only require prior authorization for an oncology diagnosis (document footnote)