UnitedHealthcare AZ Developmental Disabilities Prior Auth

Coverage criteria and scope

General prior authorization coverage criteria

Covered when ALL of the following are met:

Service must be an AHCCCS-covered benefit to be eligible for prior authorization.

Rendering health care professionals, facilities and vendors must be actively registered with AHCCCS.

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

Only medically necessary, cost-effective, federal- and state-reimbursable services are covered.

Experimental and investigational services are excluded from coverage.

Routine circumcision is not covered; prior authorization is required only when medical necessity is documented.

Chemotherapy and supportive care prior authorization

Prior authorization is required for outpatient chemotherapy and related supportive injectable agents when billed for a cancer diagnosis.

Prior authorization is required for chemotherapy injectable drugs (J9000–J9999) and other specified chemotherapy injectables (e.g., Leucovorin J0640, Levoleucovorin J0641/J0642, Lupron Depot J1950).

Prior authorization is required for colony-stimulating factor drugs and specified bone‑modifying agents administered in an outpatient setting for a cancer diagnosis (selected J/Q codes listed in the document).

Chemotherapy agents without assigned codes billed under miscellaneous HCPCS codes also require prior authorization; submit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

General prior authorization and exclusions

Prior authorization requirements and exclusions across service categories — providers must consult the online resources and AHCCCS policy for details.

Examples

Cosmetic procedures furnished solely for cosmetic purposes are excluded and require prior authorization when indicated for reconstructive or other exceptions.
Providers should visit UHCprovider.com/AZcommunityplan > Prior Authorization and Notification Resources and review AHCCCS AMPM references for policy details.

Dental and related services

For dental prior authorization requirements, contact UnitedHealthcare Dental at 855-812-9208 and consult AHCCCS AMPM as applicable.

General exclusions

DME prior authorization criteria

Durable medical equipment (DME) requires prior authorization under these conditions:

Prior authorization is required for the specific DME codes listed in the document.

Prior authorization is required for DME items with a retail purchase or cumulative rental cost greater than $500; some items require prior authorization regardless of dollar amount.

To request DME items and in many cases DME-related supplies, contact Preferred Homecare at 800-636-2123 (or follow vendor-specific instructions in the document).

Enteral/parenteral nutrition authorization

Enteral and parenteral nutrition services require prior authorization with supporting clinical documentation:

In‑home nutritional therapy (enteral, gastrostomy tube feeding, total parenteral nutrition (TPN), lipids and oral supplements) requires prior authorization when billed; clinical documentation must accompany the request to establish medical necessity.

A Certificate of Medical Necessity (for oral supplements/enteral services), when applicable, must accompany the prior authorization request.

To request enteral/parenteral nutrition services and supplies, call Preferred Homecare at 800-636-2123 and provide the required documentation.

Coverage criteria and operational rules

Selected operational rules and coverage highlights:

Members younger than 21: one routine eye exam every 12 months; lenses and frame benefit up to $79.99 retail; one replacement pair if lost/stolen/damaged.

Enteral/parenteral/TPN/oral supplement requests must include clinical documentation and Certificate of Medical Necessity where applicable; Preferred Homecare is the contact for requests (800-636-2123).

Incontinence supplies are a benefit only when provided through Preferred Homecare; contact Preferred Homecare to request these supplies.

In‑home infusion/injectable medications and related services require prior authorization when not covered by Optum Infusion; contact Optum Infusion at 800-985-3059 for services/medication requests and vendor guidance.

For members 21 and older, many services (e.g., genetic testing, certain surgeries and specific injectable medications) require prior authorization; AMPM references in the document provide additional guidance on experimental/service exceptions.

Prior authorization criteria summary

Prior authorization or notification is required for the following service groups for members 21 and older:

Injectable medications listed by HCPCS/J-codes in the document require prior authorization; providers should submit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call the plan as instructed.

Unclassified and temporary codes (e.g., C9094, C9149, C9157, C9166, C9172, C9399) and miscellaneous codes (J3490, J3590) require prior authorization.

Inpatient admissions and post‑acute services for specified drugs require prior authorization and notification of the admission date for acute care hospitals and acute inpatient rehabilitation.

Joint replacement procedures (total hip and knee) listed by CPT codes in the document require prior authorization for members 21 and older.

Laboratory services listed in the document require prior authorization; providers should call the plan to determine specific requirements.

Orthotics and prosthetics coverage criteria

Orthotics and prosthetics are covered when ALL of the following conditions are met:

The orthotic or prosthetic use is medically necessary and is the preferred treatment option consistent with Medicare guidelines.

The orthotic or prosthetic is less expensive than alternative treatment options or surgical procedures to treat the same diagnosed condition.

The orthotic or prosthetic is ordered by a physician or primary care provider.

Reasonable repairs or adjustments of purchased orthotics are covered for members subject to orthotic limitation.

Orthotics and prosthetics with a retail purchase or cumulative rental cost greater than $500 require prior authorization.

Prior authorization requirements (procedures and services)

For members 21 and older, prior authorization is required for the listed procedure and service groups:

Prior authorization is required for the joint replacement CPT/HCPCS codes listed (total hip and knee replacement and related codes).

Prior authorization is required for laboratory services listed; providers must call the plan to determine exact prior authorization requirements.

Prior authorization is required for nonemergent air ambulance codes listed (e.g., A0430, A0431, A0435, A0436).

Prior authorization is required for orthognathic and maxillofacial surgical procedure codes listed for members 21 and older.

Authorization and coverage criteria (partial)

Stated coverage and authorization rules (select highlights):

Outpatient speech therapy is not a covered benefit.

Service requests for listed medications must include J-codes and NDC codes; prior authorization is required for listed hemophilia factor/biotech drugs and for pregnancy termination medications (including mifepristone); clinical documentation and Certificate of Medical Necessity must accompany pregnancy termination requests.

Certain advanced outpatient imaging procedures (CT, MRI, MRA, PET and nuclear medicine) require prior authorization and notification prior to scheduling; requests may be submitted via the Provider Portal or by phone (866-889-8054).

Many CPT/HCPCS procedure codes across specialties require prior authorization; site-of-service rules in the document (SOS) may affect whether prior authorization is required for a given facility type.

Prior authorization stance for listed service categories

Prior authorization requirements and documentation notes for multiple listed service categories:

Categories requiring prior authorization

Skilled and custodial nursing facility services require prior authorization for the codes listed.
Sleep apnea procedures and related surgeries require prior authorization for the codes listed.
Specialty/enclosed beds and other specified DME (E02xx series) require prior authorization for the codes listed.

Sterilization procedures require prior authorization and an appropriate Consent to Sterilization form per AMPM Chapter 400, Section 420, Section E.

Spinal surgery and stimulator implantation procedures require prior authorization for the codes listed; clinical documentation should accompany requests as applicable.

Prior authorization coverage nodes

Specific prior authorization nodes and operational notes for the listed services and codes:

Transplant and CAR T‑cell therapies: prior authorization is required; clinical documentation must support medical necessity and providers should call the UnitedHealthcare Community and State Transplant Case Management Team at 800-418-4994 or use the notification number on the member ID.

Code 38232: prior authorization is required only when billed for an oncology diagnosis.

Transportation (nonemergent taxi and stretcher van): prior authorization is required; schedule via Medical Transportation Management at 888-700-6822.

Vein procedures (e.g., 36473, 36475, 36478): prior authorization is required for the codes listed.

Ventricular assist devices and related codes (e.g., 33927–33929, 33975–33983, Q0507–Q0509): prior authorization is required; follow notification instructions (call the notification number on the member ID and fax required forms as directed).

Coding rules and operational notes

One requester per prior authorization

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

ScopeApplies to all rendering health care professionals, facilities and vendors participating with AHCCCS.

ExceptionServices delivered inside multi-specialty interdisciplinary clinics to CRS-designated members do not require prior authorization.

DME prior authorization dollar threshold

ThresholdPrior authorization is required for DME items with a retail purchase or cumulative rental cost greater than $500.

Always-PA itemsSome DME items require prior authorization regardless of dollar amount (see Preferred Homecare list).

How to requestTo request DME items call Preferred Homecare at 800-636-2123 or follow Provider resources for items not covered by Preferred Homecare.

Frame retail allowance (members <21)

Retail frame allowance$79.99 retail price allowance for frames (members younger than 21)

FrequencyOne routine eye exam every 12 months for members younger than 21.

ReplacementOne replacement pair if lost, stolen or damaged; member may pay difference for more expensive frames with signed waiver.

predetermination_recommendation

RecommendationPredetermination is highly recommended for drugs on the Review at Launch Medication List.

Where to find listReview at Launch policy available at UHCprovider.com/policies > Medical & Drug Policies and Coverage Determination Guidelines for Community Plan.

How to submitSubmit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-397-8129.

Orthotics/prosthetics prior authorization cost threshold

ThresholdPrior authorization required for orthotics and prosthetics with retail purchase or cumulative rental cost over $500.

Coverage criteriaOrthotic must be medically necessary as preferred treatment consistent with Medicare guidelines and be less expensive than alternatives.

OrderingOrthotics must be ordered by a physician or primary care provider; reasonable repairs/adjustments of purchased orthotics are covered where limitations apply.

38232 oncology PA rule

Rule for 38232CPT code 38232 requires prior authorization only when billed for an oncology diagnosis.

Context38232 referenced among transplant/CAR T-Cell and hematopoietic cell transplantation codes with special PA notes.

Related instructionFor transplant and CAR T-Cell therapy services, clinical documentation must accompany requests and providers should call the Transplant Case Management Team at 800-418-4994.

How providers request authorization and required actions

Prior Authorization

How to request prior authorization

This list contains prior authorization requirements for participating UnitedHealthcare Community Plan providers. To request prior authorization, submit your request using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com — Sign In with One Healthcare ID) or call the appropriate phone number below. For pharmacy prior authorization contact UnitedHealthcare Pharmacy Prior Authorization: Phone 800-310-6826; Fax 866-940-7328. For specialty pharmacy prior authorization fax 866-940-7328. For transplant and CAR T-Cell therapy services call the Community and State Transplant Case Management Team at 800-418-4994. For DME and enteral/parenteral nutrition requests call Preferred Homecare at 800-636-2123. For infusion/injectable in-home medication requests call Optum Infusion at 800-985-3059. For dental prior authorization call UnitedHealthcare Dental at 855-812-9208.

Online: UHCprovider.com > Sign In > Prior Authorization and Notification tool
General prior authorization phone numbers: 800-445-1638 (general); 866-889-8054 (radiology/cardio programs); 888-397-8129 (drug prior auth line referenced for certain members)
Pharmacy prior authorization: Phone 800-310-6826; Fax 866-940-7328; Specialty fax 866-940-7328
Transplant/CAR T notification: 800-418-4994
DME / Enteral / Parenteral nutrition: Preferred Homecare 800-636-2123
In-home infusion/injectable medications: Optum Infusion 800-985-3059
Dental: UnitedHealthcare Dental 855-812-9208

Note

Eligibility and exclusions for prior authorization

Prior authorization applies only to services that are covered benefits per AHCCCS. Experimental or investigational services are not covered. Services provided by out-of-network or non-participating providers require prior authorization and supporting documentation. Only one requesting provider may submit a prior authorization request. All rendering providers, facilities and vendors must be actively registered with AHCCCS.

Services must be AHCCCS-covered benefits to be eligible for prior authorization
Out-of-network services require prior authorization with supporting documentation
Experimental/investigational services are not covered
Only one provider per prior authorization request
Providers/facilities/vendors must be registered with AHCCCS

Prior Authorization

Oncology supportive care and chemotherapy prior authorization

Injectable chemotherapy and oncology-supportive drugs require prior authorization. This includes chemotherapy injectable drugs billed J9000–J9999, leucovorin (J0640), levoleucovorin (J0641, J0642), Lupron Depot (J1950), chemotherapy drugs with Q-codes, and drugs billed under miscellaneous HCPCS (unassigned codes). Submit requests online via the Provider Portal Prior Authorization and Notification tool.

Chemotherapy injectable drugs: J9000 - J9999
Leucovorin/Levoleucovorin: J0640, J0641, J0642
Lupron Depot: J1950
Q-code chemotherapy drugs and miscellaneous HCPCS (unassigned) require prior authorization
Provide J-codes and NDCs for medication prior authorization requests

Note

General prior authorization resources

Use the UnitedHealthcare Provider Portal Prior Authorization and Notification resources for program-specific guidance (radiology, cardiology, etc.) and the Review at Launch for New-to-Market Medications policy for newly approved drugs. Predetermination is recommended for medications on the Review at Launch list.

Prior Authorization and Notification Resources: UHCprovider.com/AZcommunityplan > Prior Authorization and Notification Resources
Review at Launch for New-to-Market Medications: UHCprovider.com/policies > Medical & Drug Policies and Coverage Determination Guidelines for Community Plan
Predetermination recommended for drugs on the Review at Launch list

Documentation Required

Documentation requirement for enteral/parenteral nutrition

For enteral (including gastrostomy), total parenteral nutrition (TPN), lipids, and oral supplements, prior authorization is required and clinical documentation must accompany the request. Submit requests to Preferred Homecare. A completed certificate of medical necessity and supporting clinical records must be included to establish medical necessity.

Call Preferred Homecare to request enteral/parenteral services and supplies: 800-636-2123
Include clinical documentation and certificate of medical necessity (as applicable)
Oral supplement requests require supporting clinical documentation

Prior Authorization

DME and enteral/parenteral authorization contact

Certain durable medical equipment (DME) and orthotics/prosthetics require prior authorization regardless of dollar amount or when retail purchase/cumulative rental exceeds $500. Preferred Homecare manages many DME requests; call them for authorizations. For orthotics/prosthetics with retail or cumulative rental cost > $500 prior authorization is required.

DME prior authorization: Preferred Homecare 800-636-2123
Orthotics/prosthetics prior authorization if retail purchase or cumulative rental cost > $500
Examples of prosthetic codes requiring prior authorization: L0112, L0170, L0456, L0462, L0464, L0480

Prior Authorization

In-home infusion / injectable medication prior authorization

In-home infusion and injectable medication services require prior authorization when not provided through the designated vendors. Optum Infusion and Preferred Homecare are the primary contacts. Provide medication J-codes and NDCs with the request.

In-home infusion/injectable prior authorization: Optum Infusion 800-985-3059
Preferred Homecare used for some infusion services — call 800-636-2123
Include J-codes and NDCs for medication prior authorization

Prior Authorization

Prior authorization required for specific surgeries and experimental services

Prior authorization is required for many specific surgeries and procedures (e.g., joint replacements, orthognathic surgery, spinal surgery, sterilization) and for services deemed experimental. Refer to the procedure-specific code lists in the Prior Authorization and Notification Resources and include supporting clinical documentation when submitting requests.

Examples of procedures requiring prior authorization: total hip and knee replacements (e.g., 27130, 27132, 27447, 27486, 27487), orthognathic and maxillofacial codes (21121, 21123, 21141, etc.), spinal surgery codes (22100, 22514, 63308, 0098T), sterilization codes (52601, 58600, 58605, 58611, etc.)
Cosmetic procedures and reconstructions require review; cosmetic-only services are excluded
Provide operative reports, clinical notes, imaging, and other documentation to support medical necessity

Note

Prior authorization process and unclassified/temporary codes

Unclassified and temporary HCPCS/CPT codes (for example C9094, C9149, C9157, C9166, C9172, C9399, J3490, J3590) require prior authorization. When submitting requests for new-to-market or unclassified codes, include full clinical documentation, drug/generic names, dosing, and expected billing code(s).

Unclassified/temporary codes requiring prior authorization example list: C9094, C9149, C9157, C9166, C9172, C9399, J3490, J3590
Include product name, clinical rationale, dosing, and any available literature when requesting authorization for unclassified codes

Prior Authorization

Inpatient admission and post-acute prior authorization / notification

Notification (or prior authorization) is required for inpatient admissions and select post-acute services. For acute care hospital admissions and acute inpatient rehabilitation, notify or obtain prior authorization as indicated. Certain inpatient drug administrations may require prior authorization or notification per the drug list.

Notification required for admissions — follow portal or phone process for admission notification/prior authorization
Prior authorization and admission date notification required for acute care hospitals and acute inpatient rehabilitation when applicable
Some drugs (examples listed in policy) require inpatient prior authorization or notification

Prior Authorization

Nonemergent air ambulance prior authorization

Nonemergent air ambulance transports require prior authorization. Include clinical justification and transport details when requesting authorization.

Nonemergent air ambulance HCPCS codes: A0430, A0431, A0435, A0436
Prior authorization required for listed air ambulance codes

Prior Authorization

Pharmacy and medication prior authorization requirements

Pharmacy and medication prior authorization: include J-codes and NDCs on requests, provide clinical documentation, and use the Provider Portal or pharmacy prior authorization contact. A list of specialty and physician-administered medications requires prior authorization (including many biotech and hemophilia products). For pharmacy prior authorization call 800-310-6826 or fax 866-940-7328.

Include J-code and NDC on all medication prior authorization requests
Examples of medications on the prior authorization list: Aldurazyme, Cerezyme, Cimzia, Cinryze, Kalydeco, Lumizyme, Myozyme, Soliris, Spinraza, Xolair, Zolgensma, and others
For specialty pharmacy prior authorization fax 866-940-7328
Review the Review at Launch policy for new-to-market medications and consider predetermination

Definitions and interpretive notes

Covered benefit (AHCCCS)

Covered benefit (AHCCCS)To be eligible for prior authorization, services must be covered benefits as defined by AHCCCS.

Registration requirementAll rendering health care professionals, facilities and vendors must be actively registered with AHCCCS.

ExclusionsExperimental and investigational services are not covered benefits and are excluded from PA eligibility.

Experimental/investigational

DefinitionExperimental and investigational services are not covered benefits; prior authorization is required for services considered experimental/investigational.

ReferenceSee AMPM Chapter 300, Section 320, Policy 320-B for more information on experimental/investigational services.

ExamplesDocument lists specific codes associated with experimental/investigational services (e.g., 33477, A4638, G0293, S9991).

Cosmetic/Reconstructive procedures

Cosmetic vs ReconstructiveProcedures furnished solely for cosmetic purposes are excluded; reconstructive procedures that change or improve physical function may require prior authorization.

ResourceFor details and CPT codes that require prior authorization visit UHCprovider.com/AZcommunityplan > Prior Authorization and Notification Resources.

ApplicabilityPrior authorization applies where AHCCCS coverage criteria indicate medical necessity for reconstructive services.

Enteral/parenteral nutrition

DefinitionIn-home nutritional therapy includes enteral (oral or gastrostomy tube), total parenteral nutrition (TPN), lipids and oral supplements.

DocumentationClinical documentation and Certificate of Medical Necessity (for oral supplements) must accompany service requests to establish medical necessity.

How to requestTo request enteral/parenteral nutrition services and supplies call Preferred Homecare at 800-636-2123.

Certificate of Medical Necessity (for oral supplements/enteral services)

Certificate requiredClinical documentation and the Certificate of Medical Necessity must accompany prior authorization requests for oral supplements and pregnancy termination where applicable.

Where to findCertificate of Medical Necessity for Commercial Oral Nutritional Supplements available at azahcccs.gov under AMPM Chapter 300 attachment references.

Use caseRequired to establish medical necessity for in-home nutritional therapy (enteral/TPN/oral supplements).

Experimental or investigational

StatementServices considered experimental or investigational (and linked services) are not covered and require prior authorization when applicable.

ReferenceSee AMPM Chapter 300, Section 320, Policy 320-B for details on experimental/investigational services.

ExamplesDocument lists example codes tied to experimental/investigational services (e.g., 36514, 64722, 66180).

Review at Launch

DefinitionReview at Launch is the policy for New to Market Medications; predetermination is highly recommended for drugs on this list.

LocationReview at Launch policy available at UHCprovider.com/policies > Medical & Drug Policies and Coverage Determination Guidelines for Community Plan.

Provider actionSubmit prior authorization requests online via the Provider Portal or call the number provided for predetermination guidance.

Inpatient admission/post-acute notification

RequirementPrior authorization and notification of admission date are required for inpatient admissions and post-acute services at acute care hospitals and acute inpatient rehabilitation.

ExamplesApplies to specified drug-related inpatient admissions (examples listed include Nulibry, Revcovi, Rivfloza, Steqeyma IV, Vabysmo, Yesintek IV).

ActionProviders must notify prior to admission and obtain prior authorization per facility type requirements.

Repairs/adjustments coverage

CoverageReasonable repairs or adjustments of purchased orthotics are covered for members with orthotic limitations.

ConditionRepairs/adjustments apply when orthotic was purchased and member is subject to orthotic limitation.

Related ruleReplacement and repair rules are consistent with AHCCCS orthotics coverage criteria in the document.

Criteria for orthotics coverage

Primary criteriaOrthotic considered medically necessary when it is the preferred treatment option consistent with Medicare guidelines.

Cost testOrthotic must be less expensive than other treatment options or surgeries to treat the same diagnosed condition.

OrderOrthotic must be ordered by a physician or primary care provider.

Advanced outpatient imaging

DefinitionAdvanced outpatient imaging includes certain CT, MRI, MRA, PET scans and nuclear medicine procedures that require prior authorization.

Provider responsibilityHealth care professionals ordering advanced outpatient imaging must notify prior to scheduling the procedure.

How to requestSubmit PA requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 866-889-8054.

Certificate of Medical Necessity

Certificate useThe Certificate of Medical Necessity is required to accompany prior authorization requests for pregnancy termination and certain nutritional services.

Where to findCertificate location referenced in AMPM Chapter 300 attachment C on azahcccs.gov.

Documentation requirementClinical documentation plus the certificate establish medical necessity for prior authorization decisions.

Site of service (SOS)

DefinitionSite of service (SOS) guidance affects prior authorization requirements; outpatient hospital vs ambulatory surgery center may differ in PA rules.

ExamplesSOS notes reference specific procedures (tonsillectomy/adenoidectomy, GI endoscopy) where site-of-service may determine PA need.

Provider actionCheck the CPT/HCPCS listings and SOS guidance in the document or portal resources to determine PA requirements.

Consent to Sterilization form

Form locationThe Consent to Sterilization form can be found at azahcccs.gov under AMPM Chapter 400, Section 420, Attachment A.

RequirementSterilization requires prior authorization and an appropriate consent to sterilization form per AMPM references.

ReferenceReview AMPM Chapter 400, Section 420, Section E for sterilization policy details.

Transplant/CAR T-cell prior auth contact

ContactFor transplant and CAR T-Cell therapy services, call the UnitedHealthcare Community and State Transplant Case Management Team at 800-418-4994.

DocumentationClinical documentation must accompany and establish medical necessity for transplant/CAR T-Cell service requests.

ScopeApplies to named CAR T-Cell products (e.g., Abecma, Breyanzi, Tecartus, Yescarta) and related transplant services.

Transportation prior authorization

Transportation PATransportation prior authorization is required for nonemergent taxi and stretcher van services.

How to scheduleTo schedule nonemergent transportation, call Medical Transportation Management at 888-700-6822.

Related codesTransportation PA instructions are listed alongside other high-visibility codes and PA notes in the transplant/CAR T-cell section.

36590	Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump, age 5 years or older
36832	Removal of tunneled centrally inserted central venous catheter
43644	Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (Roux limb 150 cm or less)
43645	Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption
43659	Unlisted laparoscopy procedure, stomach
43770	Laparoscopy, surgical, gastric restrictive procedure; with adjustable gastric band
43775	Laparoscopy, surgical, gastric restrictive procedure; conversion of adjustable gastric band to another bariatric procedure
43842	Gastric restrictive procedure, vertical-banded gastroplasty
43845	Gastric restrictive procedure, sleeve gastrectomy

OpenPayer

Prior authorization requirements for Arizona Developmental Disabilities

Coverage criteria and scope

Codes and code groups requiring prior authorization

Coding rules and operational notes

How providers request authorization and required actions

Definitions and interpretive notes