CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for UnitedHealthcare Connected (Medicare‑Medicaid Plan) Texas

A list of services, codes, and instructions for submitting prior authorization requests for participating UnitedHealthcare Connected (Medicare‑Medicaid Plan) providers in Texas; includes methods to submit requests and special notes for certain services and suppliers.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Connected (Medicare‑Medicaid Plan) Texas

Policy CodePolicy N/A

Change TypeAdministrative update (no material coverage changes)

Effective DateApril 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, chat 24/7, or fax to 877-940-1972.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

TexasJurisdiction

Apr 1, 2025Effective

>$1,000DME threshold

24/7Chat

877-940-1972Fax

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

Prior Authorization and Coverage Criteria

Notable prior authorization criteria and rules

Selected coverage notes and prior authorization caveats included in this portion of the document.

Prior authorization is required for prosthetics and many DME items regardless of billed amount.

Prior authorization is not required for emergency or urgent care.

Behavioral health services may be covered through a designated behavioral health network; call 888-887-9003 for referrals.

Incontinence supplies require prior authorization through the service coordinator when not provided by Tenderheart Health Outcomes; to obtain from Tenderheart call 866-295-2319; to obtain from another provider call the service coordinator at 800-349-0550.

Device / implant notes: Certain device implants and monitors (e.g., cochlear implants, bone growth stimulators, other listed devices) have prior authorization effective dates noted per code; refer to specific code entries for dates.

Prior authorization criteria (summarized)

Prior authorization requirements and notes for specific codes/subcategories as listed in the document excerpts.

Prior authorization is required regardless of billed amount for many listed codes and services.

Durable medical equipment rentals require prior authorization when cumulative rental cost exceeds $1,000.

Injectable / specialty medications: Specific J‑codes and named specialty medications are listed with individual prior authorization effective dates (examples include PiaSky J1307 effective Apr. 1, 2025; Leqvio J1306; Tepezza J3241 with prior auth notes). Providers should refer to the full policy for exact dates and applicability.

Experimental / investigational: Certain procedure codes are listed as Experimental & Investigational (examples: 28446, 31634, 29880); review linked entries for prior authorization instructions.

Post-acute services and device prior authorization criteria

Prior authorization/notification requirements for listed services and codes

Joint replacement post-acute admissions (examples: 23470, 27120, 27412): notification required; prior authorization and notification of admission date is required for listed post-acute facilities. Submit prior authorization requests through naviHealth as part of the Continued Care program (Phone: 855-851-1127; Fax: 844-244-9482).

Therapy services: prior authorization is required for all re-evaluations and the listed therapy codes (examples: 97112, 97139, 97164, 97530, 97535, G0152); initial evaluations do not require prior authorization.

Orthotics/Prosthetics: prior authorization is required for listed orthotics/prosthetic codes when retail purchase or cumulative rental cost exceeds $1,000.

Prior authorization notes (partial)

Prior authorization notes and effective dates associated with listed procedure codes (partial):

Psychological testing codes (examples: 96116, 96121): prior authorization effective Oct. 1, 2019 (source text indicates 'Prior authorization will not...' is truncated).

Radiology / advanced outpatient imaging (examples: 78431–78433, 78830–78832): prior authorization effective Jan. 1, 2020; providers ordering advanced outpatient imaging are responsible for providing required information (source text truncated).

Procedure groups with Jan. 1, 2015 effective date: Several procedures (examples: rhinoplasty codes 30400/30410/30430; selected procedures including 76376/76377) list prior authorization effective Jan. 1, 2015.

Observed prior-authorization entries

Prior authorization effective dates and contact instructions where specified for certain code groups (examples below).

Stimulators / Neurostimulators: Stimulators (bone growth stimulators E0747/E0748; implantable neurostimulator components L8682/L8683) have prior authorization effective date Jan. 1, 2015 (per listed entries).

Ventricular Assist Device (VAD): VAD procedures list prior authorization effective Jan. 1, 2018; contact instructions direct callers to the notification number on the back of the member's health plan ID card and to fax the form provided by the nurse to the Optum VAD Case Management team.

Transplant / CAR T: Transplant and CAR T‑Cell therapy services list multiple HCPCS/J‑codes with varied effective dates (examples include April 1, 2024 and July 1, 2024 entries); additional instructions indicate to call the notification number on the back of the member's health plan ID for prior authorization information.

Codes and Coding Notes

Examples of listed CPT/HCPCS codesmixed

20974-20979	Bone growth stimulator related codes
81163-81164	BRCA genetic testing codes
19316,19325,19355,19318,L8600	Breast reconstruction (non-mastectomy) codes

Examples of listed CPT/HCPCS codes (source)mixed

20974-20979	Bone Growth Stimulator, Code = 20974 20979
81163-81164	BRCA Genetic Testing, Code = 81163 81164
19316,19325,19355,19318,L8600	Breast Reconstruction (Non-Mastectomy), Code = 19316 19325 19355; = 19318 L8600

DME and implant codesmixed

69729-69730,69710-69711,69714,69799,69930,92601-92604,L8614,L8619,L8690,L8691,L8692	Cochlear and auditory implant and related device codes (codes listed across cochlear/implant sections)
E0616,A4238,A9276,A9277	Durable medical equipment and monitor codes (monitor and related DME entries)

Durable Medical Equipment (sample)HCPCSCovered

E1825	Durable medical equipment code (listed)
K0007	Durable medical equipment code (listed)
Q0479	Durable medical equipment code (listed)

Experimental & Investigational (sample)CPTExperimental

28446	Experimental & Investigational (listed)
31634	Experimental & Investigational (listed)
29880	Experimental & Investigational (listed)

Named specialty medications (sample)J-codeCovered

J3247	Cosentyx IV (example injectable)
J1306	Leqvio (example injectable)
J2350	Ocrevus (example injectable)
J3241	Tepezza (listed)
J0223	Givlaari (listed)
J3399	Zolgensma (listed)

Select injectable/drug J-codes listed with subcategories and effective datesHCPCS

J1823	Uplizna™ (subcategory entry present)
J3241	Tepezza®
J0223	Givlaari®
J0896	Reblozyl®
J3399	Zolgensma® (J-code listed as J3399)
J0222	Onpattro™
J1303	Ultomiris™
J0584	Crysvita®
J3398	Luxturna™
J1301	Radicava®

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Post-acute service CPT/HCPCS groupmixedCovered

23470	Joint replacement related CPT code
27120	Hip replacement related CPT code
27412	Knee replacement related CPT code
A0422	Ground ambulance code (TX mandate section)
S9128	Revenue/HCPCS series used for therapy/post-acute listings

HCPCS/L-codes (partial list)HCPCS

L5781
L5780
L5814
L5822

Psychological Testing (CPT)CPTCovered

96116	Psychological testing
96121

Spinal/Neurosurgery CPT codes (partial list)CPT

22100	Spinal surgery codes (various)
22526
22600
22804
63001	Neurosurgery/craniotomy related codes (examples)
63250

Stimulators / NeurostimulatorsHCPCS

E0747	Bone growth stimulator (electrical)
E0748	Bone growth stimulator (electrical)
L8682	Implantable neurostimulator component
L8683	Implantable neurostimulator component

Transplant / CAR T-Cell related drug HCPCS/J-codesmixed

C9301	Temporary/unclassified (listed under transplants)
C9399	Unclassified drugs and biologicals
J3590	Unclassified drug
J3392	Specific drug entries referenced (CAR-T related)
J3393	Specific drug entries referenced

Ventricular Assist Device (VAD) proceduresCPT

33927	Ventricular assist device (VAD) procedure grouping
33928	Ventricular assist device (VAD)
33975	VAD device code grouping
33976	VAD device code

Vein procedures / saphenous ablationCPT

36473	Removal/ablation of main trunks (vein procedures)
36475	Removal/ablation for saphenous veins
36476	Ablation for extremities / varicose veins
36479	Related vein procedure code

DME/prosthetics prior authorization threshold — prior authorization required regardless of billed amount for many prosthetics and home health items

RulePrior authorization is required regardless of billed amount for many prosthetics and certain home health items (multiple prosthetic code mappings referenced).

Examples (source codes)Prosthetic code mappings and references appear throughout (see chunks 17-19 for specific HCPCS/K mappings).

Effective dates notedVarious effective dates referenced for prosthetics entries (examples include July 1, 2017; July 1, 2021; Jan. 1, 2015 in source).

How Providers Submit Requests and Required Actions

Prior Authorization

Durable Medical Equipment (DME) Prior Authorization

Prior authorization is required for Durable Medical Equipment (DME) items listed when the cumulative rental cost is more than $1,000. Submit prior authorization requests using one of the methods described in this document: the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (sign in with One Healthcare ID), chat via the Contact Us page (24/7), phone (see plan contact numbers) or fax to 877-940-1972. Prior authorization is required regardless of billed amount for certain DME codes as noted elsewhere in this policy. Out-of-network requests must be made by a network care provider. Emergency and urgent care are not subject to prior authorization requirements.

Affected HCPCS: E0328, E0329, E0373, E0462, E0618, E0635, E0636, E0639, E0640, E0740, E0970, E0988, E1020, E1035, E1037, E1070, E1085, E1087, E1100, E1170, E1172, E1190, E1200, E1224, E1228, E1231, E1280, E1296
Prior authorization requirement: cumulative rental cost of more than $1,000
Some DME codes may be subject to prior authorization regardless of billed amount (see policy code-specific entries)
How to submit: UnitedHealthcare Provider Portal > Prior Authorization and Notification; Chat via Contact Us (24/7); Fax 877-940-1972; or phone per plan contact information

Key Terms and Thresholds

Prior authorization — definition

DefinitionPrior authorization: A review requirement that must be obtained before certain services are provided; submission channels include the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, 24/7 chat, or fax to 877-940-1972.

ExceptionsPrior authorization is not required for emergency or urgent care.

Submission noteOut-of-network requests must be made by a network care provider per the policy.

Service coordinator — definition / role reference

RoleService coordinator: Entity to contact for prior authorization of incontinence supplies when not provided by Tenderheart Health Outcomes; call 800-349-0550 to obtain supplies from another provider.

Designated supplier

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Connected (Medicare‑Medicaid Plan) Texas

Policy CodePolicy N/A

Change TypeAdministrative update (no material coverage changes)

Effective DateApril 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, chat 24/7, or fax to 877-940-1972.

SourceLink

On This Page

DME cumulative rental cost threshold — more than $1,000

ThresholdPrior authorization required when cumulative rental cost of DME rentals is more than $1,000.

Relevant codesDME codes listed in source include E0328, E0635, E0639 and a longer list (see chunk 22).

ActionSubmit prior authorization per instructions in the policy (portal, chat, or fax).

Orthotics/Prosthetics prior authorization threshold — retail purchase or cumulative rental cost > $1,000 requires prior authorization

ThresholdOrthotics and prosthetics require prior authorization for retail purchase or cumulative rental cost greater than $1,000.

Example HCPCS/L codesOrthotics entries reference codes such as L3020, L1846 and prosthetic examples L5960, L7499, L6895 (see chunks 42 and 50).

Effective datesSome orthotics/prosthetics entries reference prior authorization effective dates (e.g., Jan. 1, 2015; July 1, 2017) in the source.

Tenderheart Health Outcomes can provide incontinence supplies; call 866-295-2319 for supplies from Tenderheart.

ContextUsed in prior authorization instructions for certain durable medical supplies in the policy (see chunk 16).

cumulative rental cost of more than $1,000 — DME threshold definition

DefinitionCumulative rental cost of more than $1,000: The DME rental threshold that triggers a prior authorization requirement (applies to listed DME/orthotics/prosthetics).

Applies toDME rental items and certain prosthetic/orthotic codes referenced in the policy (see chunk 22 and 50).

Provider actionProviders must obtain prior authorization when cumulative DME rental costs exceed this threshold per the policy.

Prior authorization required regardless of billed amount — general rule statement

Policy statementPrior authorization is required regardless of billed amount.

ScopeThis general rule is applied to many prosthetics and selected services as noted throughout the document (see chunk 18).

Provider implicationObtain prior authorization even for low-dollar billed items when those items are identified in the policy as requiring authorization regardless of billed amount.

Continued Care Program (naviHealth) — definition/reference

ProgramContinued Care Program (naviHealth): A program used to submit prior authorization requests and notifications for post-acute inpatient services; submit requests through naviHealth as part of the Continued Care program.

ContactPhone: 855-851-1127; Fax: 844-244-9482 (per source).

PurposeLeverages care coordination services to support members through the post-acute journey, including admission notification and prior authorization for listed joint replacement/post-acute services.

Therapy re-evaluation — definition noting re-evaluations require prior authorization

DefinitionTherapy re-evaluation: Re-evaluations and other listed therapy codes require prior authorization; initial evaluations do not require prior authorization.

Example codesTherapy codes cited include 97112, 97139, 97164, 97530, 97535, 97755, G0152 and others (see chunk 43).

Effective datesSome therapy-related entries include effective dates (e.g., Jan. 1, 2018; July 1, 2017) as noted in the policy text.

advanced outpatient imaging — term reference used with radiology prior auth

TermAdvanced outpatient imaging: Imaging procedures that require prior authorization; providers ordering advanced outpatient imaging are responsible for providing required information (prior authorization effective Jan. 1, 2020).

Example codesReferenced codes include 78431-78433 and 78830-78832 among others in the radiology group (see chunk 63).

Provider responsibilityCare providers ordering these procedures must follow the prior authorization process per the policy.

VAD — Ventricular Assist Device definition

DefinitionVAD (Ventricular Assist Device): A mechanical pump that restores or supports normal blood flow when the ventricle is damaged.

Example procedure codesVAD-related codes referenced include 33975, 33979, 33976 and related device/procedure codes (see chunk 85).

Prior authorization instructionsContact the notification number on the back of the member's health plan ID card and fax the form provided by the nurse to the Optum VAD Case Management team (per source).

Stimulator / Neurostimulator — device definition

DefinitionStimulator / Neurostimulator: Implantation of a device that sends electrical impulses (examples include bone growth stimulators and implantable neurostimulator components L8682/L8683).

Example HCPCS codesBone growth stimulator codes E0747, E0748 and implantable neurostimulator components L8682, L8683 are referenced in the policy (see chunk 74).

Prior authorization noteSome stimulator/neurostimulator entries list prior authorization effective dates (e.g., Jan. 1, 2015).