CurrentUnitedHealthcarePolicy N/A

Children's Special Health Care Services — Prior Authorization Quick Reference

Lists prior authorization requirements and submission instructions for participating UnitedHealthcare Community Plan of Michigan, Healthy Michigan Plan (HMP) and Children's Special Health Care Services (CSHCS) providers; includes code-level examples and vendor contact info for certain DME supplies.

Policy Summary

PayerUnitedHealthcare

PolicyChildren's Special Health Care Services — Prior Authorization Quick Reference

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateEffective February 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, 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.

800-903-5253Outpatient therapy PA phone

855-225-9847Outpatient therapy PA fax

800-737-0045DME vendor (J&B)

888-246-7667Respiratory vendor

144PT max / yr

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.

36Speech visits / yr

Coverage and Prior Authorization Criteria

Prior authorization coverage criteria and rules (excerpt)

Prior authorization requirements and notable exceptions/notes referenced in the document segment:

Providers must submit prior authorization requests via one of the following: online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by phone at 800-903-5253, or by fax to 855-225-9847.

Prior authorization is not required for emergency or urgent care.

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

Exceptions where prior authorization is not needed: orthopedic physician services; medically necessary obstetric physician services; 23-hour observation.

Certain DME categories (catheter supplies, diabetic supplies including external insulin pumps, electric breast pumps, incontinence supplies) are benefits only when provided through J&B Medical Supply Company, Inc.; requests for these supplies must be made by calling J&B Medical Supply at 800-737-0045.

Cochlear implants and other auditory implants require prior authorization (example codes: 69710, L8691; 69714, L8692).

Continuous glucose monitors require prior authorization when used with type 2 or gestational diabetes (example HCPCS: A4238, A4239, A9276).

Selected surgical/therapy categories

Abortion procedures require prior authorization (example CPTs: 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857).
Bariatric surgery and specific obesity-related services require prior authorization (example CPTs: 43644, 43645, 43659, 43770, 43775, 43842, 43845, 43846, 43848, 43860).
Bone growth stimulators (electronic stimulation) require prior authorization (example code: 20975).

Prior authorization and vendor-based coverage criteria

Prior authorization and vendor routing requirements shown in this document fragment

DME - Diabetic supplies (including external insulin pumps), electric breast pumps and incontinence supplies: benefit only when provided through J&B Medical Supply Company, Inc.; to request supplies call 800-737-0045; prior authorization as indicated.

DME - Respiratory supplies: benefit only when provided through Binson's Medical Equipment & Supplies; to request call 888-246-7667; prior authorization as indicated.

Enteral services (in-home nutritional therapy, enteral or via gastrostomy tube) require prior authorization; example HCPCS: B4034, B4149, B4155, B4161.

Genetic and molecular testing (including BRCA) performed in an outpatient setting requires prior authorization; ordering provider must notify the laboratory as part of the PA process (example CPT/HCPCS codes: 81162, 81163, 81164, 81228, 81229, 81400, 81401, 81402, 81403).

Functional endoscopic sinus surgery (FESS) requires prior authorization for listed CPT codes (examples include 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288).

Prior authorization requirements (partial)

Services listed in this section require prior authorization as noted.

Joint total hip and knee replacement procedures require prior authorization; submit requests via the Provider Portal Prior Authorization and Notification tool or call 888-397-8129 (example CPTs listed in the source).

Non-emergent air ambulance transport requires prior authorization; submit via the Provider Portal or call 888-397-8129 (example HCPCS: A0430, A0431, A0435).

Orthognathic surgery (treatment of maxillofacial/jaw functional impairment) requires prior authorization; submit via the Provider Portal or call 888-397-8129 (multiple CPT codes listed such as 21121, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21188, 21193–21196).

Prior authorization criteria (partial list)

Prior authorization requirements and submission methods

Orthognathic surgery CPT codes listed in this section require prior authorization; submit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-397-8129.

Orthotics and prosthetics: prior authorization required only for listed HCPCS codes when the retail purchase or cumulative rental cost exceeds $500; submit via Provider Portal or call 888-397-8129.

For the services and codes in this section, submit prior authorization requests via the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal or call 888-397-8129.

Outpatient therapy limits and prior auth

Outpatient therapy coverage limits and exclusions

Prior authorization is required for any outpatient therapy services above the benefit maximums.

Physical therapy: benefit maximum 144 units per calendar year.

Occupational therapy: benefit maximum 144 units per calendar year.

Speech therapy: benefit maximum 36 visits per calendar year.

Speech therapy is not a covered benefit when provided to meet developmental milestones.

Care providers may request prior authorization or assistance by calling 800-903-5253 or faxing 855-225-9847.

Procedure-specific prior authorization

Select procedures requiring prior authorization

Procedures with PA required

Prostate procedures require prior authorization for dates of service on or after April 1, 2022 (example CPTs: 37243, 53852, 52441, 55873, 52442, 55874, 53850).
Proton beam therapy requires prior authorization (example CPTs: 77520, 77522, 77523).
Rhinoplasty/septoplasty and related sinus procedures require prior authorization (examples include 30400, 31295).
Shoulder surgery procedures require prior authorization (examples include CPTs 23470, 29805, 29819, 29825, etc.).

Prior authorization requirements (partial)

Prior authorization requirements and listed CPT/HCPCS codes

Sleep apnea procedures (maxillomandibular advancement and oral-pharyngeal tissue reduction) require prior authorization (example CPTs include 21685, 41599, 42145).

Spinal surgery procedures require prior authorization; multiple spinal CPT codes are listed in the source (examples include 22100, 22101, 22102, 22110, 22510–22514, 22206–22224).

Note: For dates of service on or after April 1, 2022, prior authorization is required in all places of service as indicated in the source.

Prior authorization criteria (partial list)

Prior authorization requirements and contacts for selected services:

Implantation of electrical stimulation devices (including bone growth stimulators) requires prior authorization (example HCPCS: E0760).

Transplant and CAR T-cell therapy services require prior authorization; contact Optum Transplant Case Management at 888-936-7246 or the number on the member's ID card (transplant services carved out to state as noted).

Ventricular assist device (VAD) services require prior authorization; call the notification number on the back of the member's health plan ID card and fax the nurse-provided form to the Optum VAD Case Management team at 855-282-8929 (example CPT/HCPCS codes: 33927, 33928, 33929, 33975, 33983, Q0507–Q0509).

Wound VAC supplies/services require prior authorization (example HCPCS: E2402).

Vein procedures for removal/ablation of saphenous veins require prior authorization (example CPTs: 36473, 36475, 36478, 37700).

Code Lists and Coding Notes

Example CPT/HCPCS codes mentionedmixed

59840	Abortion, CPT/HCPCS example
43644	Bariatric surgery example
20975	Bone growth stimulator
69710	Cochlear implant
L8691	Cochlear implant device HCPCS
A4238	Continuous glucose monitor supply HCPCS

Genetic/molecular testing (BRCA) codesCPTCovered

81162	BRCA1/BRCA2 testing (example listed)
81163	BRCA testing
81164	BRCA testing
81228	BRCA-related testing
81229	BRCA-related testing
81400	Genetic testing (listed)

Enteral services codesHCPCSCovered

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

Functional endoscopic sinus surgery codesCPTCovered

31240	FESS CPT example
31253	FESS CPT example

Referenced HCPCS/CPT codes (partial list)mixed

J1299	Drug HCPCS code referenced
J1930	Somatuline Depot (example listed)
J1747	Spevigo (example listed)
J3358	Stelara (example listed)
Q5099	Steqeyma IV (example listed)
J2781	Syfovre (example listed)
90378	Synagis (example listed)
J3241	Tepezza (example listed)
J9381	Tzield (example listed)
J1303	Ultomiris (example listed)

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Examples of codes requiring prior authorizationCPT | HCPCS | mixed

21151	Orthognathic surgery code listed as requiring prior authorization
21206	Orthognathic surgery code listed
L0112	Orthotics/prosthetics HCPCS code listed
L0480	Orthotics/prosthetics HCPCS code listed
L4000	Orthotics/prosthetics HCPCS code listed
L5100	Orthotics/prosthetics HCPCS code listed

Orthotics/Prosthetics HCPCS L-codes (partial list)HCPCS

L4000	Orthotics and prosthetics code reference
L4010	Orthotics and prosthetics code reference
L4020	Orthotics and prosthetics code reference
L5100	Orthotics and prosthetics code reference
L5150	Orthotics and prosthetics code reference
L5200	Orthotics and prosthetics code reference
L5312	Orthotics and prosthetics code reference
L5644	Orthotics and prosthetics code reference
L5990	Orthotics and prosthetics code reference
L7186	Orthotics and prosthetics code reference

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Procedure CPT codes referenced in outpatient therapy section (partial list)CPT

33289	Potentially unproven service (example)
C2624	Potentially unproven service (example)
77520	Proton beam therapy
77522	Proton beam therapy
77523	Proton beam therapy
30400	Rhinoplasty/septoplasty
31295	Sinuplasty
23470	Shoulder surgery (example)
45378	Colonoscopy (example)
38500	Hemic and lymphatic systems (example)

Integumentary system codes (sample)CPT

10121	CPT code listed in integumentary system section
11440	CPT code listed in integumentary system section
11450	CPT code listed in integumentary system section

Spinal surgery codes (sample)CPT

22100	Spinal surgery CPT code
22514	Spinal surgery CPT code
63001	Spinal/neurosurgical CPT code
63200	Spinal surgery CPT code

ENT/Respiratory/GI codes (sample)CPT

31525	Respiratory system procedure code
42820	Tonsillectomy/adenoidectomy code
43235	Upper gastrointestinal endoscopy code

Selected CPT/HCPCS codes referencedmixed

63016	Spine procedure code listed
63017	Spine procedure code listed
63020	Spine procedure code listed
63030	Spine procedure code listed
63040	Spine procedure code listed
63042	Spine procedure code listed
63650	Spinal cord stimulation related code listed
63655	Spinal cord stimulation related code listed
64555	Neuromodulation lead/implant code listed
64568	Neuromodulation code listed

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Additional procedural and drug codesmixed

38232	Hematopoietic cell transplantation related code (asterisked)
44132	Bowel surgery codes
50300	Kidney related procedure code
J3394	Drug J-code listed
J3402	Drug J-code listed

Orthotics/Prosthetics prior authorization threshold

ThresholdPrior authorization required only for orthotics/prosthetic items with a retail purchase or cumulative rental cost greater than $500.

SubmissionSubmit PA requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-397-8129.

Example HCPCSExamples of listed HCPCS L-codes subject to this threshold include L0112, L0170, L0456, L0462.

How Providers Should Submit Requests and Vendor Routing

Prior Authorization

How to submit prior authorization requests

This list contains prior authorization requirements for participating UnitedHealthcare Community Plan of Michigan, Healthy Michigan Plan (HMP) and Children's Special Health Care Services (CSHCS) health care professionals providing inpatient and outpatient services. Please submit your requests in one of the following ways: Online: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) — sign in with your One Healthcare ID; Phone: 800-903-5253; Fax: 855-225-9847 (a fax form is available at Prior Authorization Paper Fax Forms). Prior authorization is not required for emergency or urgent care. Out‑of‑network providers must request prior authorization for all procedures and services (excluding emergent or urgent care). Note: Exceptions — orthopedic physician services, medically necessary obstetric physician services and 23‑hour observation do not need prior authorization.

Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (preferred).
If you do not have a One Healthcare ID, visit UHCprovider.com/access to register.

Note

DME vendor and supply request instructions

Key Terms and Vendor Contacts

Continuous glucose monitor

DefinitionContinuous glucose monitor (CGM): device requiring prior authorization for members with type 2 and gestational diabetes; example HCPCS: A4238.

Additional example codesOther example HCPCS codes listed: A4239, A9276.

PA notePA required as specified in device entry; follow Provider Portal or PA contact methods.

Cochlear implant

DefinitionCochlear implant: a medical device within the inner ear with an external portion that helps persons with profound sensorineural deafness achieve conversational hearing.

Example codesExample CPT/HCPCS listed: 69710, 69714, L8691, L8692.

Policy Summary

PayerUnitedHealthcare

PolicyChildren's Special Health Care Services — Prior Authorization Quick Reference

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateEffective February 1, 2026

Next Review DateN/A

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

SourceLink

On This Page

Injectable medications: numerous listed injectable J-/Q-codes require prior authorization; providers must follow the specified PA process for these drugs.

Home health care: prior authorization required for services rendered by a home health agency (bill type 03xx); example codes include G0299, G0300, G0493, G0494.

Physical therapy units per calendar year

Physical therapy maximum144 units per calendar year.

Contact for PACare providers may call 800-903-5253 or fax 855-225-9847 for outpatient therapy prior authorization requests.

When PA requiredPrior authorization is required for any outpatient therapy services above the benefit maximums.

Occupational therapy units per calendar year

Occupational therapy maximum144 units per calendar year.

Contact for PACare providers may call 800-903-5253 or fax 855-225-9847 for outpatient therapy prior authorization requests.

When PA requiredPrior authorization is required for any outpatient therapy services above the benefit maximums.

Speech therapy visits per calendar year

Speech therapy maximum36 visits per calendar year.

Coverage exclusionSpeech therapy is not a covered benefit if provided to meet developmental milestones.

Contact for PACare providers may call 800-903-5253 or fax 855-225-9847 for outpatient therapy prior authorization requests.

Prior authorization effective date

Effective dateFor dates of service on or after April 1, 2022, prior authorization is required in all places of service as noted.

ScopeApplies to specified procedures referenced in the document (see procedure-specific sections).

ActionProviders should follow PA submission requirements for services on/after this date (portal/phone/fax).

Durable medical equipment (DME) — catheter, diabetic, electric breast pump and incontinence supplies are a benefit only when provided through J&B Medical Supply Company, Inc. To request catheter, diabetic supplies, electric breast pumps or incontinence supplies, call J&B Medical Supply at 800-737-0045.

Affected HCPCS/K-codes include multiple catheter/diabetic/breast pump/incontinence codes (see DME section for full list).
J&B Medical Supply is the preferred vendor for these categories and handles ordering/prior authorization routing.

Note

Respiratory and enteral services prior authorization and vendor

Respiratory supplies are a benefit only when provided through Binson's Hospital Supplies / Binson's Medical Equipment, Inc. To request respiratory supplies, call Binson's at 888-246-7667. Enteral (in‑home nutritional) services require prior authorization and are routed according to the enteral codes listed in the DME/enteral section.

Respiratory supply requests: Binson's Medical Equipment & Supplies — 888-246-7667.
Enteral services (in‑home nutritional therapy) require prior authorization; refer to listed enteral HCPCS (e.g., B4034, B4149, B4155, B4161) for routing.

Prior Authorization

Joint replacement prior authorization instructions

Prior authorization is required for injectable medications listed below. Submit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or follow any additional prior‑notification instructions (for certain products) through Optum Rx prior notification services when noted.

Prior authorization required for the following (partial list — refer to full policy for complete list): Actemra (J3262); Adakveo (J0791); Acthar (J0801); Aldurazyme (J1931); Amvuttra (J0225); Avsola (Q5121); Benlysta (J0490); Berinert (J0597); Botulinum toxins (J0585, J0586, J0587); Brineura (J0567); Cimerli (Q5128); Cimzia (J0717) — prior notification for Cimzia and Synagis through Optum Rx at 800-310-6826; Crysvita (J0584); Daxxify (J0589); Eylea HD (J0177); Fasenra (J0517); Gamifant (J9210); Givlaari (J0223); Hemlibra (J7170); Ilaris (J0638); Inflectra (Q5103); Injectafer (J1439); IVIG products (multiple codes including 90283, 90284 and many J-codes such as J1459, J1552–J1575, etc.); Leqembi (J0174); Leqvio (J1306); Lumizyme (J0221); Nplate (J2802); Ocrevus (J2350); Orencia (J0129); Prolia (J0897); Remicade (J1745); Rituxan (J9312); Skyrizi (J2327); and many others listed in the injectable medications section.
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Prior Authorization

Joint replacement prior authorization instructions

Joint, total hip and knee replacement procedures require prior authorization. For prior authorization submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-397-8129. Affected CPT/HCPCS examples include codes for hip and knee arthroplasty and related procedures (see full list in policy).

Prior authorization required for total hip and knee replacement procedures (examples: 27130 and related codes listed in policy).
Submit online via the Prior Authorization and Notification tool or call 888-397-8129.

Prior Authorization

Orthognathic surgery prior authorization

Orthognathic surgery (treatment of maxillofacial/jaw functional impairment) requires prior authorization. Submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-397-8129. Affected CPT codes include (but are not limited to) 21121, 21123, 21125, 21127, 21141, 21142, 21151, 21154, 21155, 21159, 21160, 21188, 21193, 21194, 21195, 21196 — refer to the policy for the complete list.

Prior authorization required for orthognathic procedures addressing maxillofacial/jaw functional impairment.
Submit via the Prior Authorization and Notification tool on the Provider Portal or call 888-397-8129.
Include supporting documentation demonstrating functional impairment and medical necessity as part of the submission.

PA requirementCochlear implants require prior authorization per the document.

Prior authorization — definition and when required

DefinitionPrior authorization: a requirement to obtain approval before rendering specified services; submit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by phone or by fax.

Submission methodsOnline via Provider Portal tool, phone (e.g., 800-903-5253 or 888-397-8129 depending on service), or fax (e.g., 855-225-9847).

ExceptionsEmergency and urgent care do not require prior authorization; some physician services (orthopedic, medically necessary obstetric) and 23-hour observation are exceptions.

J&B Medical Supply — preferred vendor

VendorJ&B Medical Supply Company, Inc. is the preferred vendor for diabetic supplies (including external insulin pumps), electric breast pumps, and incontinence supplies.

ContactTo request these supplies call J&B Medical Supply at 800-737-0045.

PA noteDME items listed require prior authorization when applicable and must be provided through the vendor for benefit eligibility.

Binson's Medical Equipment & Supplies — respiratory vendor

VendorBinson's Medical Equipment & Supplies (Binson's Hospital Supplies) is the required provider for respiratory supplies to be a benefit.

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

PA noteRespiratory supplies are a benefit only when provided through this vendor; enteral services also require prior authorization.

Prior authorization — portal/phone/fax submission

DefinitionPrior authorization submissions: requests submitted via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, by phone, or by fax.

ExamplesJoint replacement and other procedure PAs referenced instruct providers to submit via the Provider Portal or call 888-397-8129.

Redundancy noteThis block repeats the submission definition for clarity—use portal/phone/fax depending on service instructions.

Prior notification (Optum Rx)

DefinitionPrior notification (Optum Rx): certain medications (e.g., Cimzia and Synagis) require prior notification through Optum Rx prior notifications services.

ContactOptum Rx prior notifications phone: 800-310-6826.

ScopeObtain prior notification for specified drugs as directed rather than standard PA channels.

Provider Portal — Prior Authorization and Notification tool

ToolProvider Portal — the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal is the primary online submission channel for PAs.

When to useUse the Provider Portal tool for a wide range of services requiring PA including joint replacement, orthognathic surgery, air ambulance, and orthotics/prosthetics.

Alternate contactsWhere specified, phone numbers (e.g., 888-397-8129) are provided as alternatives to portal submission.

Authorization threshold for O&P items

Authorization thresholdPrior authorization is required only when an orthotics/prosthetic item's retail purchase price or cumulative rental cost exceeds $500.

SubmissionSubmit PA requests via the Provider Portal or call 888-397-8129 as noted in orthotics/prosthetics entries.

ExamplesListed HCPCS L-codes in the orthotics/prosthetics section are subject to this threshold (see L0112, L0170, etc.).

Prior authorization for services above outpatient therapy maximums

PA requirementPrior authorization is required for any outpatient therapy services above the benefit maximums.

ContextThis applies to physical therapy, occupational therapy and speech therapy when annual limits are exceeded.

ContactCare providers may call 800-903-5253 or fax 855-225-9847 to request prior authorization for outpatient therapy services above the maximums.

Prior Authorization and Notification tool — submission channel

DefinitionThe Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal is the designated submission channel for prior authorization requests.

Alternate methodsProviders may also call the phone numbers provided for specific service types (e.g., 888-397-8129 for joint replacement).

Use-caseUse this tool for procedure, device, DME and therapy authorization submissions as indicated in the document.

Sleep apnea procedures — definition and examples

DefinitionSleep apnea procedures: procedures such as maxillomandibular advancement and oral-pharyngeal tissue reduction that require prior authorization.

Example codesExample CPT/HCPCS codes listed include 21685, 41599, 42145.

PA notePrior authorization required for these sleep apnea procedures per the outpatient therapy section.

Spinal surgery — definition

DefinitionSpinal surgery: a group of listed CPT codes representing spinal surgery procedures that require prior authorization.

Example codesSample CPT codes listed include 22100, 22101, 22102, 22110 (and many others in the spinal surgery section).

PA notePrior authorization is required for spinal surgery procedures as listed in the document.

Ventricular assist services (VAD)

DefinitionVentricular assist device (VAD) services: mechanical pump therapy that takes over the function of a damaged ventricle and restores blood flow; these services require prior authorization.

ContactCall the notification number on the member's health plan ID card and fax the nurse-provided form to Optum VAD Case Management at 855-282-8929.

Example codesExample CPT/HCPCS codes listed include 33927, 33928, 33929, 33975, 33983, Q0507, Q0508, Q0509.

Stimulators / implantable electrical devices

DefinitionStimulators / implantable electrical devices: devices that send electrical impulses, including bone growth stimulators (HCPCS example E0760).

Example HCPCSBone growth stimulator code example: E0760.

PA requirementPrior authorization is required for implantation of electrical stimulation devices.

CAR T-cell therapy / transplant services

DefinitionCAR T-cell therapy / transplant services: chimeric antigen receptor T-cell therapies and transplant services requiring prior authorization (examples: Carvykti, Kymriah, Lyfgenia, Ryoncil, Yescarta).

ContactFor transplant and CAR T-cell therapy services call Optum Transplant Case Management at 888-936-7246 or the number on the back of the member's ID card.

PA noteThese services require prior authorization and are managed through Optum transplant case management per the document.