CurrentUnitedHealthcarePolicy N/A

Children's Special Health Care Services - Prior Authorization Requirements

Lists prior authorization requirements and submission methods for participating UnitedHealthcare Community Plan of Michigan, Healthy Michigan Plan and Children's Special Health Care Services providers for inpatient and outpatient services.

Policy Summary

PayerUnitedHealthcare

PolicyChildren's Special Health Care Services - Prior Authorization Requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by phone at 800-903-5253, or by fax to 855-225-9847.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3submission methods listed

~200+listed codes (approx.)

144/144/36therapy limits (PT/OT/Speech)

Exemptemergency/urgent care

Multipleservice categories flagged

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Coverage Criteria and Authorization Requirements

Prior authorization requirements and exceptions

Covered when the following apply; submission methods and exceptions are noted.

Prior authorization is required for listed services and procedures except for emergency or urgent care.

Prior authorization requests may be submitted online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by phone at 800-903-5253, or by fax to 855-225-9847.

Out-of-network physicians, facilities and other health care providers must request prior authorization for all procedures and services (excluding emergent or urgent care).

Exceptions (no prior authorization needed)

Orthopedic physician services
Medically necessary obstetric physician services
23-hour observation

Examples of services that require prior authorization

Abortion procedures (e.g., CPT 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, 59866)
Bariatric surgery and obesity-related services (e.g., CPT 43644, 43770, 43842–43848, 43860)
Breast reconstruction procedures (e.g., CPT 11971, 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19367–19371, 19380)
Bone growth stimulator (CPT 20975)

Prior authorization is not required for cancer supportive care/certain chemotherapy supportive services as noted in the document.

Partial coverage/authorization rules

Partial rules and notable vendor/threshold requirements in this extract:

Services determined by CMS to be inpatient-only must be requested as inpatient; outpatient performance is not payable per CMS OPPS guidance.

Cochlear implants and other auditory implants require prior authorization (examples: CPT 69710, 69714, 69930; HCPCS L8691, L8692, L8619).

Continuous glucose monitors require prior authorization when billed with type 2 or gestational diabetes diagnoses (examples: A4238, A4239, A9276/E2103, A9277).

Durable medical equipment (DME) requires prior authorization when retail purchase or cumulative rental cost exceeds $500 (examples: E0277, E0328, E0329, E0457, E0465–E0471, E0483, E0636–E0638, E0641, E0642, E0652, E0656).

Preferred vendor note: J&B Medical Supply Company, Inc. is identified as the preferred vendor for specific DME items (notably E0784) and is referenced repeatedly.

Coverage criteria and vendor/authorization rules (excerpt)

Coverage conditions, vendor requirements, and authorization rules (excerpt):

Catheter supplies, diabetic supplies, electric breast pumps and incontinence supplies are benefits only when provided through J&B Medical Supply Company, Inc.; requests directed to J&B Medical Supply at 800-737-0045.

Respiratory supplies are a benefit only when provided through Binson's Medical Equipment & Supplies; contact 888-246-7667 for requests.

In‑home enteral nutritional therapy (enteral or gastrostomy) requires prior authorization; applicable HCPCS/B-codes include B4034, B4149, B4155, B4161, B4035, B4150, B4158, B4036, B4152, B4159, B9998, B4102, B4153.

Genetic and molecular testing (including BRCA) requires prior authorization when performed in an outpatient setting (examples: CPT 81162, 81163, 81164, 81228, 81229, 81277, 81400–81408, 81520).

A comprehensive list of injectable medications and associated J-codes is provided; pre-determination is recommended for new-to-market medications and prior notification is required for certain drugs via Optum Rx.

Prior authorization coverage criteria (partial)

Prior authorization is required for the procedures and situations below:

Joint replacement (total hip and knee) procedures require prior authorization for the listed CPT procedure codes.

Non-emergent air ambulance transport requires prior authorization (examples: A0430, A0431, A0435, A0436).

Orthognathic (maxillofacial/jaw) surgery for functional impairment requires prior authorization (examples: CPT 21121, 21123, 21125, 21127, 21141–21147, 21150, 21155, 21159, 21194, 21199).

Prostate and proton beam therapy rules

Prostate procedures: prior authorization required for dates of service on or after April 1, 2022 (examples: CPT 37243, 53852, 52441, 55873, 52442, 55874, 53850).
Proton beam therapy requires prior authorization (examples: CPT 77520, 77522, 77523, 77525).

Coverage stance for listed procedures

Service-category coverage stance for the procedures listed:

Spinal surgery: prior authorization is required in all places of service (site-of-service rules also apply); this requirement applied for dates of service on or after April 1, 2022.

Sleep apnea procedures and surgeries (including maxillomandibular advancement and oral‑pharyngeal tissue reduction) require prior authorization (examples: CPT 21685, 41599, 42145).

Extensive CPT code lists are provided by body system (integumentary, digestive, ENT, ocular, gynecologic, hemic/lymphatic, musculoskeletal, respiratory, urology); these code groupings are informational in this excerpt and linked to prior authorization requirements per category.

Prior authorization-required services and code groupings

Specific high-acuity services and code groupings that require prior authorization (and routing to specialized case management where noted):

Stimulator implantation and neurostimulator procedures require prior authorization (examples include E0760 and listed CPT/HCPCS codes for implantation and neurostimulator services).

Transplant and CAR T-cell therapy services require prior authorization; providers must call the Optum Transplant Case Management team at 888-936-7246 or the number on the member's ID card for coordination.

Vein procedures (removal and ablation of saphenous veins) require prior authorization (examples: S2061, S5152).

Ventricular assist device (VAD) services require prior authorization and coordination with the VAD Case Management team (examples: CPT/HCPCS 33927, 33928, 33975, 33982; VAD Case Management at 855-282-8929).

Wound vacuum therapy (wound vac) requires prior authorization (example device code E2402).

Code Lists and Coding Rules

Sample CPT/HCPCS codes requiring prior authorizationCPTCovered

59840	Abortion procedure (listed as prior authorization required)
59841	Abortion procedure (listed as prior authorization required)
59850	Abortion procedure (listed as prior authorization required)
59851	Abortion procedure (listed as prior authorization required)
20975	Bone growth stimulator (listed as prior authorization required)
43644	Bariatric surgery (example CPT listed)
43770	Bariatric surgery (example CPT listed)
19316	Breast reconstruction/reconstruction-related CPT listed

Sample ICD-10 diagnosis codes referencedICD-10

I70.221	Atherosclerosis-related diagnosis codes listed for prior authorization
I70.331	Atherosclerosis-related diagnosis codes listed for prior authorization
M86.051	Osteomyelitis diagnosis codes listed for prior authorization

ICD-10 codes (partial list shown)ICD-10

M86.10	Osteomyelitis code listed in series
M86.151	Osteomyelitis code listed in series
M86.152	Osteomyelitis code listed in series
M86.159	Osteomyelitis code listed in series
M86.161	Osteomyelitis code listed in series
M86.162	Osteomyelitis code listed in series

CPT/HCPCS codes (examples)mixed

69710	Cochlear implant code
69714	Cochlear implant code
69930	Cochlear implant/procedure code
67961	Eyelid/ocular procedure code (example listed)
Q2026	Implantable device code (example listed)

DME/orthotics/prosthetics HCPCS/K-codesHCPCSCovered

E0784	Specific DME code with preferred vendor
E0636	DME codes listed
E0637	DME codes listed
K0868	Orthotics/prosthetics codes listed
K0890	Orthotics/prosthetics codes listed

Enteral nutrition HCPCS/B-codes (examples)HCPCSCovered

B4034	Enteral nutrition product/service
B4149	Enteral supply code (example)
B4155	Enteral supply code (example)

Injectable medication J-codes (sample list)J-codesCovered

J3262	Actemra
J0225	Amvuttra
J1459	IVIG mapping/example

IVIG CPT mappingsCPT | J-codes

90283	IVIG CPT/administration reference
90284	IVIG CPT/administration reference

White blood cell colony-stimulating factors and related Q-codesHCPCS

J1442	White blood cell colony-stimulating factor
J1447	White blood cell colony-stimulating factor
J2506	White blood cell colony-stimulating factor
Q5101	Related Q-code
Q5108	Related Q-code
Q5110	Related Q-code
Q5111	Related Q-code
Q5120	Related Q-code
Q5122	Related Q-code

Drugs listed by name and HCPCSHCPCS

J1558	Xembify
J0218	Xenpozyme
J2357	Xolair
J9202	Zoladex

Procedures requiring prior authorization (selected CPT codes)CPT

77520	Proton beam therapy
77522	Proton beam therapy
77523	Proton beam therapy
77525	Proton beam therapy
31295	Sinuplasty
31296	Sinuplasty
31297	Sinuplasty
31298	Sinuplasty
30400	Rhinoplasty/septoplasty
30435	Rhinoplasty/septoplasty

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Orthotics and prosthetics HCPCS L-codes (partial list)HCPCS

L0112	Orthotics/prosthetics HCPCS L-code (listed)
L0464	Orthotics/prosthetics HCPCS L-code (listed)
L0486	Orthotics/prosthetics HCPCS L-code (listed)
L0170	Orthotics/prosthetics HCPCS L-code (listed)
L0480	Orthotics/prosthetics HCPCS L-code (listed)
L0456	Orthotics/prosthetics HCPCS L-code (listed)
L0484	Orthotics/prosthetics HCPCS L-code (listed)
L0631	Orthotics/prosthetics HCPCS L-code (listed)

Selected CPT codes by category (partial list)CPT

13101	Repair; intermediate
21931	Excision, lesion (example listed)
43200	Upper GI endoscopy (example listed)

ENT, respiratory, urology examplesCPT

31525	Laryngoscopy, direct
42820	Tonsillectomy/adenoidectomy codes
52276	Cystourethroscopy

Integumentary and biopsy examplesCPT

10121	Injection procedure (integumentary)
47000	Liver biopsy

Spinal surgery codes (sample from list)CPT

22112	Listed spinal surgery/related procedure code
22114	Listed spinal surgery/related procedure code
22206	Listed spinal surgery/related procedure code
22207	Listed spinal surgery/related procedure code
22210	Listed spinal surgery/related procedure code
22212	Listed spinal surgery/related procedure code
22214	Listed spinal surgery/related procedure code
22220	Listed spinal surgery/related procedure code
22224	Listed spinal surgery/related procedure code
22510	Listed spinal surgery/related procedure code

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Transplant/major surgery and misc codesmixed

38232	Listed hematopoietic progenitor cell transplantation code (noted with asterisk in list)
44132	Listed abdominal/intestinal procedure code
44133	Listed abdominal/intestinal procedure code
47133	Listed hepatic procedure code
47135	Listed hepatic procedure code
50300	Listed renal procedure code
J3394	Drug J-code listed in section
S2060	Service code listed in section

CAR T-cell, VAD, wound vac and vein procedure codesmixed

36473	Apheresis / CAR T-cell related code listed
36475	Apheresis / CAR T-cell related code listed
36478	Apheresis / CAR T-cell related code listed
37700	Extremity procedure code listed
E2402	Wound vac device code listed
33927	Ventricular assist device related code listed
33928	Ventricular assist device related code listed
33975	VAD procedure code listed
33982	VAD procedure code listed

DME purchase/rental cost threshold - $500

ThresholdRetail purchase or cumulative rental cost greater than $500 triggers prior authorization for DME

Applies toDurable Medical Equipment (DME) items listed with E- and related HCPCS codes (examples: E0277, E0328, E0329, E0457, E0465, E0466, E0470, E0471, E0483, E0636, E0637, E0638)

Exclusions/NotesProsthetics are not considered DME for this threshold; some home health care services may qualify but are not subject to the cost threshold

Provider Actions, Submission Methods, and Vendor Steps

Prior Authorization

How to obtain prior authorization

For prior authorization, submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com — sign in with One Healthcare ID). You may also call 800-903-5253 or fax 855-225-9847. For some services UnitedHealthcare directs providers to specialty intake lines (see transplant/CAR T-cell and VAD contacts below). Prior authorization is not required for emergency or urgent care. Out-of-network providers must request prior authorization for all non-emergent procedures and services.

Online: Prior Authorization and Notification tool on UnitedHealthcare Provider Portal (UHCprovider.com).
Phone: 800-903-5253.
Fax: 855-225-9847.
Exceptions: orthopedic physician services, medically necessary obstetric physician services, and 23-hour observation — prior authorization not required.

Note

Chemotherapy prior authorization note

Chemotherapy and cancer supportive care administered in the appropriate setting do not require prior authorization.

Definitions and Key Terms

Prior authorization (definition)

DefinitionA requirement to submit a request and receive approval before certain procedures or services are provided (prior authorization)

ExceptionsNot required for emergency or urgent care; exceptions include orthopedic physician services, medically necessary obstetric physician services, and 23‑hour observation

How to requestOnline via the Prior Authorization and Notification tool on UHCprovider.com, by phone 800‑903‑5253, or by fax 855‑225‑9847

CMS inpatient‑only procedures

Definition/NoteCMS inpatient‑only procedures must be requested as inpatient; if performed outpatient they are not payable per CMS OPPS guidance

ReferenceSee CMS Addendum A/B (Status Indicator C) on cms.gov for the inpatient‑only code list

Policy Revision History

2025-05-01effective_dateLatest

Policy content marked ‘Wezlana IV’ indicates multiple site-of-service prior authorization requirements became effective 5/1/2025.

2022-04-01policy_change

Prior authorization requirement for the spinal surgery service category applied for dates of service on or after April 1, 2022.

note

Policy Summary

PayerUnitedHealthcare

PolicyChildren's Special Health Care Services - Prior Authorization Requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by phone at 800-903-5253, or by fax to 855-225-9847.

SourceLink

On This Page

Unclassified/temporary codes (C9157, C9166, C9399, J3490, J3590) require prior authorization only for specified products (examples: Elfabrio, Qalsody).

Site-of-service rule: prior authorization is required when requesting services in an outpatient hospital setting; not required if performed at a participating ambulatory surgery center (ASC).

Outpatient therapy prior authorization thresholds apply for services above benefit maxima: Physical therapy 144 units/year; Occupational therapy 144 units/year; Speech therapy 36 visits/year.

Enteral prior authorization

RequirementPrior authorization is required for in‑home enteral nutritional therapy (enteral or via gastrostomy)

Example HCPCS/B‑codesB4034, B4149, B4155, B4161, B4035, B4150, B4158, B4036, B4152, B4159, B9998, B4102, B4153

SettingApplies to enteral services provided in the home setting

Outpatient therapy benefit maxima

Physical therapy144 units per calendar year

Occupational therapy144 units per calendar year

Speech therapy36 visits per calendar year

Chemotherapy — No prior authorization required.
Cancer supportive care — No prior authorization required.

Prior Authorization

DME — Preferred vendor and catheter supplies requirement

Certain durable medical equipment (DME) categories require use of preferred vendors; catheter, diabetic, incontinence and electric breast pump supplies are benefits only when provided through the designated vendor. To request supplies from the preferred vendor, call the number shown.

Catheter supplies — benefit only when provided through J&B Medical Supply Company, Inc.; to request catheter supplies call J&B Medical Supply at 800-737-0045.
Diabetic supplies and external insulin pumps — J&B Medical Supply Company, Inc. is the preferred vendor; to request diabetic supplies call 800-737-0045.
Incontinence supplies and electric breast pumps — J&B Medical Supply Company, Inc. is the preferred vendor; call 800-737-0045 to request.
Respiratory supplies — benefit only when provided through Binson's Medical Equipment & Supplies; call 888-246-7667 to request respiratory supplies.

Prior Authorization

Site of service prior authorization rule

Site-of-service prior authorization is required only when the service is requested to be performed in an outpatient hospital setting. The same procedure performed at a participating ambulatory surgery center (ASC) does not require prior authorization. Verify site of service at time of request.

Prior authorization required when requesting services in an outpatient hospital.
Prior authorization not required if the procedure is performed at a participating ASC.
Site-of-service rule applies to many procedure categories (examples listed elsewhere in this policy).

Prior Authorization

Stimulators / Neurostimulator prior authorization

Implantation of stimulators and neurostimulators (including spinal cord stimulators and other neurostimulation devices) requires prior authorization. This includes device implantation and associated CPT/HCPCS codes — obtain authorization before scheduling the procedure.

Stimulator and neurostimulator implant procedures — prior authorization required.
Includes procedures and codes listed under Nervous system / Neurostimulator and related CPT/HCPCS codes in this policy.
Bone growth stimulators and E0760 are included where indicated.

Prior Authorization

Transplant and CAR T‑cell therapy prior authorization

Transplant procedures and CAR T-cell therapies require prior authorization and coordinated case management. Inpatient transplant procedures may be carved out to the state — contact the Optum Transplant Case Management team to initiate authorization and care coordination.

For transplant and CAR T-cell therapy services (examples: Carvykti™, Kymriah, Lyfgenia™, Yescarta®) call the Optum Transplant Case Management team at 888-936-7246 or the number on the back of the member's ID card.
Inpatient transplant procedures may be carved out to state programs; verify enrollment and routing at the time of request.
Pre-authorization and case management are required before scheduling transplant or CAR T-cell therapy services.

Prior Authorization

Vein procedures / VAD / Wound vac prior authorization

Vein procedures (saphenous vein removal/ablation), ventricular assist device (VAD) services, and negative pressure wound therapy (wound vac) require prior authorization. VAD services have a dedicated case management contact for authorization and coordination.

Vein procedures for venous disease/varicose veins (removal/ablation of saphenous trunks/branches) — prior authorization required; listed codes and modifiers apply.
Ventricular assist device (VAD) services — prior authorization required; contact the VAD Case Management team at 855-282-8929 for authorization and coordination (codes such as 33927, 33928, 33975, 33982 noted).
Wound vacuum (wound vac) therapy — prior authorization required (examples: E2402 and other related codes).

DME cost‑threshold

DefinitionDurable medical equipment (DME) requires prior authorization when retail purchase or cumulative rental cost exceeds $500

ExamplesApplies to many E‑series HCPCS codes (examples in document include E0277, E0328, E0329, E0457, E0465, E0466, E0470, E0471, E0483, E0636, E0637)

Preferred vendor — J&B Medical Supply Company, Inc.

RequirementCertain DME categories (catheter supplies, diabetic supplies, incontinence, electric breast pumps) are a benefit only when provided through J&B Medical Supply Company, Inc.

ContactTo request catheter, diabetic or incontinence supplies from J&B Medical Supply call 800‑737‑0045

Example codeE0784 noted with preferred vendor designation

Preferred vendor — Binson's Medical Equipment & Supplies

RequirementRespiratory supplies are a benefit only when provided through Binson's Medical Equipment & Supplies

ContactTo request respiratory supplies call Binson's Medical Equipment & Supplies at 888‑246‑7667

Prior authorization — scope and examples

DefinitionPrior authorization (pre‑approval) is required before service is provided for enteral services, genetic/molecular testing (including BRCA) performed outpatient, experimental/investigational services, and specified procedures/therapies

Genetic testing examplesCPT/HCPCS codes listed include 81162, 81163, 81164, 81228, 81229, 81277, 81400, 81401, 81402, 81403, 81404

Drug notificationPre‑determination is recommended for new‑to‑market drugs; prior notification for Cimzia and Synagis via Optum Rx at 800‑310‑6826

Site of service (SOS) — outpatient hospital

DefinitionSite of service (SOS) — outpatient hospital: prior authorization is required only when requesting service in an outpatient hospital setting; not required if performed at a participating ambulatory surgery center (ASC)

ExamplesApplies to many CPT/HCPCS codes listed under SOS entries (examples include 31297, 45378, 45380, 43246–43259 series)

Pre‑determination / prior notification

DefinitionPre‑determination / prior notification: recommended review for new‑to‑market medications on the Review at Launch Medication List; separate prior notification processes exist for specific drugs

How to obtainPre‑determination requests via UnitedHealthcare Prior Authorization and Notification tool; drug prior notifications for certain products through Optum Rx (800‑310‑6826)

Site of service (general)

DefinitionSite of service (SOS) — general reference to the place where services are performed (outpatient hospital, ASC, etc.) and its impact on prior authorization

Policy impactSome services require prior authorization only in specific sites of service (e.g., outpatient hospital) while exempt at participating ASCs

Prior authorization (general)

DefinitionPrior authorization: a requirement to obtain approval before a service is provided to ensure coverage

Common applicationsUsed for enteral services, genetic/molecular testing, DME above cost threshold, specialty drugs and many procedures listed in this document

Submission channelsRequests may be submitted online, by phone or fax (see contact details) depending on service type

Optum Transplant Case Management

TeamOptum Transplant Case Management team

ContactCall 888‑936‑7246 or the number on the member's ID card for transplant and CAR T‑cell therapy prior authorization coordination

Prior authorization — summary

RequirementPrior authorization is required for the services and codes listed throughout this document unless an exception is specified

Common exceptionsEmergency/urgent care and specified physician services (orthopedic, obstetric) and 23‑hour observation are not subject to prior authorization

How to requestOnline via UHCprovider Prior Authorization and Notification tool, by phone 800‑903‑5253, or fax 855‑225‑9847

VAD Case Management

ProgramVAD Case Management

ContactVAD Case Management team phone line referenced as 855‑282‑8929 for coordination of ventricular assist services

Site-of-service prior authorization applies when services are requested in an outpatient hospital setting; not required if performed at a participating ASC.