CurrentUnitedHealthcarePolicy N/A

Children's Special Health Care Services prior authorization requirements

This document lists prior authorization requirements and submission methods for participating UnitedHealthcare Community Plan of Michigan, Healthy Michigan Plan (HMP) and Children's Special Health Care Services (CSHCS) providers for inpatient and outpatient services in Michigan.

Policy Summary

PayerUnitedHealthcare

PolicyChildren's Special Health Care Services prior authorization requirements

Policy CodePolicy N/A

Change TypeAdministrative — no material changes

Effective DateApr 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal, or by calling 800-903-5253 or faxing 855-225-9847.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Apr 1, 2025policy effective date shown

800-903-5253prior auth phone

855-225-9847prior auth fax

$500DME cost threshold

20+codes listed

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.

J&B Medical Supplypreferred DME vendor

Coverage Criteria and Prior Authorization Requirements

Prior authorization coverage criteria (partial)

Covered when the following prior authorization rules apply:

Prior authorization is required for many listed procedural services and associated CPT/HCPCS codes (examples include abortion procedures, bariatric surgery, bone growth stimulators, breast reconstruction and related codes).

Exceptions (no prior authorization required)

Emergency or urgent care.
Orthopedic physician services.
Medically necessary obstetric physician services.
23-hour observation.

Some supportive cancer care items are noted as not requiring prior authorization.

Partial coverage criteria and rules

Coverage-related rules and criteria (partial):

Chemotherapy: No prior authorization required.

Cochlear and auditory implants: Prior authorization required (examples: 69710, 69714, 69930, L8691, L8692, L8619).

Continuous glucose monitors: Prior authorization required when billed for type 2 or gestational diabetes (examples: A4238, A4239, A9276, E2103).

DME cost threshold: Durable medical equipment requires prior authorization when retail purchase or cumulative rental cost is more than $500 (examples: E0277, E0328, E0329, E0457, E0465, E0466, E0470, E0471, E0483, E0636, E0637, E0638).

Coverage criteria — supplies, services, and procedures (partial)

Coverage and access rules for supplies, enteral services, genetic testing, home health, and selected procedures:

J&B Medical Supply — DME supplies: Catheter, diabetic (including external insulin pumps), incontinence supplies, and electric breast pumps are benefits only when provided through J&B Medical Supply Company, Inc.; to request supplies call 800-737-0045.

Respiratory supplies vendor: Respiratory supplies are a benefit only when provided through Binson's Hospital Supplies or Binson's Medical Equipment, Inc.; to request respiratory supplies call 888-246-7667.

Enteral services: In-home enteral nutritional therapy (enteral or via gastrostomy tube) requires prior authorization; applicable HCPCS examples include B4034, B4149, B4155, B4161, B4150, B4158, B4036, B4152, B4159, B4102, B4153, B4160.

Experimental/investigational procedures: Experimental, investigational and/or linked services require prior authorization (examples: 33477, S2102, 36514, 64722, 66180).

Prior authorization requirements for procedures, orthotics/prosthetics, and specified services (partial)

Prior authorization required for many procedures, orthotics/prosthetics and specified L-codes when thresholds apply (partial list):

Joint replacement (total hip and knee) — prior authorization required (examples of listed codes provided in source).

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

Orthognathic and maxillofacial surgical procedures — prior authorization required; orthotics and prosthetic codes require prior authorization when retail purchase or cumulative rental cost exceeds $500 (many L-codes listed).

Orthotics and prosthetics — prior authorization required only for codes listed with a retail purchase or cumulative rental cost over $500; extensive L-code list applies.

Outpatient therapy — prior authorization required for services above the benefit maximum.

Outpatient therapy limits

Outpatient therapy visit/unit limits (prior authorization required when exceeded):

Physical therapy: 144 units per calendar year.

Occupational therapy: 144 units per calendar year.

Speech therapy: 36 visits per calendar year.

Coverage criteria (partial)

Coverage limits and prior authorization rules (partial):

Therapy limits: Physical and occupational therapy unit limits (144 units/year) and speech therapy visit limits (36 visits/year) apply; prior authorization is required for services beyond these benefit maximums.

Selected services requiring prior authorization: Certain service categories and codes require prior authorization (examples include proton beam therapy codes 77520/77522/77523/77525; rhinoplasty/septoplasty codes 30400–30465 series; sinuplasty 31295–31298; potentially unproven service code 33289).

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

Provider contact: Providers may submit prior authorization requests by phone at 800-903-5253 or by fax to 855-225-9847; online submission via the Provider Portal is also available.

Prior authorization and contact requirements (partial)

Prior authorization requirements and contact instructions for specific procedure categories:

Spinal surgery: For dates of service on or after April 1, 2022, prior authorization is required in all places of service under the spinal surgery service category; site of service restrictions apply.

Sleep apnea procedures: Prior authorization is required for sleep apnea procedures and related surgeries such as maxillomandibular advancement and oral–pharyngeal tissue reduction (examples: 21685, 41599, 42145).

Stimulator implantation: Prior authorization is required for implantation of stimulators and related devices including bone growth stimulators and implantable neurostimulators (examples: E0760, CPT codes for implantation and lead placement).

Transplant and CAR T-cell therapy: Prior authorization is required for transplant and CAR T-cell therapy services; contact Optum Transplant Case Management at 888-936-7246 or the number on the member's ID card for authorization support.

Prior authorization requirements

Procedures explicitly noted as requiring prior authorization include (partial list):

Vein procedures (removal and ablation of main trunks and named branches of the saphenous veins) — prior authorization required (examples: S2060, S2061, S5152; related CPT/HCPCS codes listed).

Ventricular assist device (VAD) services — prior authorization required; contact the VAD Case Management team at 855-282-8929 for authorizations.

Wound VAC devices — prior authorization required (example HCPCS: E2402).

Codes and Coding Notes

Specified CPT/HCPCS codes requiring prior authorization (partial list)CPTCovered

59840	Abortion procedure code (prior authorization required)
43644	Bariatric surgery related code (prior authorization required)
20975	Bone growth stimulator (prior authorization required)
11971	Breast procedure (prior authorization required)
19316	Breast reconstruction related code (prior authorization may be required)

ICD-10 diagnosis codes referenced in cardiovascular sectionICD-10

I70.221	Cardiovascular-related ICD-10 code (listed for prior authorization context)
I70.222	Cardiovascular-related ICD-10 code

ICD-10 codes (excerpt)ICD-10

I77.77
I77.79
I74.3
I74.4
I74.5
I74.8
I74.9
I75.021
I75.022
I75.023

1–10 of 14

1/2

DME/HCPCS examples (excerpt)HCPCS

E0784	Preferred vendor J&B Medical Supply noted
E1002
E1239
K0849

DME / HCPCS codes (preferred-vendor noted)HCPCSCovered

E0784	Disposable or consumable DME item with preferred vendor noted
E1239
E2100
E2230
E2298
E2301
E2310
E2311
E2325
E2327

1–10 of 64

1/7

Injectable medication J/Q codes (partial list)mixedCovered

J3262	Actemra
J0791	Adakveo
J0172	Aduhelm
J7171	Adzynma
J0801	Acthar
J1931	Aldurazyme
J0225	Amvuttra
J0256	Aralast NP/Prolastin-C/Zemaira
Q5121	Avsola
J0490	Benlysta

1–10 of 50

1/5

Injectable medications and unclassified codesHCPCS

J7320	Sodium hyaluronate
J7321	Sodium hyaluronate
J7322	Sodium hyaluronate
J7324	Sodium hyaluronate
J7325	Sodium hyaluronate
J7326	Sodium hyaluronate
J7327	Sodium hyaluronate
J7329	Sodium hyaluronate
J7331	Sodium hyaluronate
J7332	Sodium hyaluronate

1–10 of 32

1/4

Intravitreal VEGF codesHCPCS

J0178	Intravitreal VEGF
J0179	Intravitreal VEGF
J2777	Intravitreal VEGF
J2778	Intravitreal VEGF
J2779	Intravitreal VEGF
Q5124	Intravitreal VEGF (Q-code shown)

Additional IV biologics and colony-stimulating factorsHCPCS

J9332	Vyvgart
Q5138	Wezlana IV (effective 5/1/2025)
J1442	White blood cell colony-stimulating factor
J1447	White blood cell colony-stimulating factor
J2506	White blood cell colony-stimulating factor
Q5101	White blood cell colony-stimulating factor
Q5108	White blood cell colony-stimulating factor
Q5110	White blood cell colony-stimulating factor
Q5111	White blood cell colony-stimulating factor
Q5120	White blood cell colony-stimulating factor

1–10 of 11

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Additional injectable medicationsHCPCS

J1558	Xembify
J0218	Xenpozyme
J2357	Xolair
J9202	Zoladex

Selected CPT/HCPCS codes requiring prior authorization (partial)CPT | HCPCSCovered

77520	Proton beam therapy treatment planning or delivery
77522	Proton beam therapy
77523	Proton beam therapy
77525	Proton beam therapy
30400	Rhinoplasty
30410	Rhinoplasty
31295	Sinuplasty
31296	Sinuplasty
33289	Potentially unproven service code listed

Additional procedure codes listed (partial)CPT | HCPCSCovered

69205	Auditory system procedure
66821	Cataract surgery
45378	Colonoscopy
13101	Repair of superficial wound (example cosmetic/reconstructive)
10121	Skin lesion removal/injection example

Sample spinal surgery CPT codes (partial list)CPTCovered

22100	Spinal surgery procedure (listed)
22513	Spinal surgery procedure (listed)
22600	Spinal surgery procedure (listed)
22800	Spinal instrumentation procedure (listed)
63001	Spinal decompression/laminectomy codes (listed)

Sleep apnea related surgical CPT codes (partial)CPTCovered

21685	Maxillomandibular advancement (listed)
41599	Unlisted procedure, face (listed)
42145	Oral-pharyngeal tissue reduction (listed)

Stimulator and neurostimulator codes (partial)mixedCovered

E0760	Bone growth stimulator (HCPCS)
63650	Neurostimulator implantation (listed)
63685	Lead implantation for neurostimulator (listed)

Transplant and related procedure codes (partial)CPTCovered

38232	Hematopoietic progenitor cell transplantation (listed) - flagged with * in source
33930	Cardiac transplant-related procedure (listed)

Sample listed CPT/HCPCS codes (not exhaustive)mixed

32850	Listed procedural code in section
33930	Listed procedural code in section
38232	Listed procedural code in section (marked with *)
J3394	Drug/biologic HCPCS code referenced
E2402	Wound VAC HCPCS code referenced

DME prior authorization cost threshold

ThresholdDurable medical equipment (DME) that is a retail purchase or has a cumulative rental cost of more than $500 requires prior authorization for the listed DME codes.

Examples (codes shown)E0277, E0328, E0329, E0457, E0465, E0466, E0470, E0471, E0483, E0636, E0637, E0638 (see policy for full list).

NoteProsthetics are not considered DME; see orthotics and prosthetics section for prior authorization rules.

Provider Submission Instructions and Action Items

Prior Authorization

Prior authorization submission methods and exceptions

Providers must obtain prior authorization for many services and supplies. Submit requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com — sign in with One Healthcare ID), by phone at 800-903-5253 (or 888-397-8129 for certain radiopharmaceutical/drug requests), or by fax to 855-225-9847. Prior authorization is not required for emergency or urgent care. Out-of-network providers must request prior authorization for all procedures and services except emergent/urgent care. Exceptions: orthopedic physician services, medically necessary obstetric physician services and 23-hour observation do not require prior authorization.

Online: Prior Authorization and Notification tool on UnitedHealthcare Provider Portal (UHCprovider.com)
Phone: 800-903-5253 (general); 888-397-8129 (procedures/services/radiopharmaceuticals submissions per guidance)
Fax: 855-225-9847 (fax form available at Prior Authorization Paper Fax Forms)

Prior Authorization

Examples of services and CPT/HCPCS codes requiring prior authorization

Examples of services and CPT/HCPCS codes that require prior authorization include (partial list): Abortion (59840, 59841, 59850–59857, 59866), Bariatric surgery (43644, 43645, 43659, 43770, 43775, 43842–43848, 43860), Bone growth stimulator (20975), Breast reconstruction and related breast procedures (11971, 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19367–19371, 19380, 19396), Cardiovascular/vascular procedures (37220–37231 series), Cochlear and auditory implants (69710, 69714, 69930, L8619, L8691, L8692), Cosmetic and reconstructive procedures (11960, 14020*, 14021*, 14041, 14061*, 15820–15823, 15830, 15847, 15877–15879, 17106), Functional endoscopic sinus surgery (31240, 31253–31259, 31267, 31288), Femoroacetabular impingement procedures (29914–29916), Genetic and molecular testing (BRCA and others: 81162, 81163, 81164, 81228, 81229, 81277, 81400–81408, 81415, 81417, 81479, 81518), Home health care (G0299, G0300, G0493, G0494). This list is not exhaustive; refer to the full code lists for complete requirements.

Definitions, Vendors, and Contact Information

Emergency or urgent care

DefinitionEmergency or urgent care: prior authorization is not required for emergency or urgent care services.

Out-of-networkOut-of-network providers must request prior authorization for all procedures and services except emergent or urgent care.

Submission methodsPrior authorization requests may be submitted online, by phone (800-903-5253), or by fax (855-225-9847).

Authorization exceptions

Exceptions (no prior auth needed)Orthopedic physician services; medically necessary obstetric physician services; 23-hour observation.

General rulePrior authorization is required for listed services except where explicit exceptions are stated in the policy.

Policy Summary

PayerUnitedHealthcare

PolicyChildren's Special Health Care Services prior authorization requirements

Policy CodePolicy N/A

Change TypeAdministrative — no material changes

Effective DateApr 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal, or by calling 800-903-5253 or faxing 855-225-9847.

SourceLink

On This Page

CMS inpatient-only procedures:

CMS-designated inpatient-only procedures must be requested as inpatient; outpatient performance is not payable per CMS OPPS guidance.

Preferred vendor note: J&B Medical Supply Company, Inc. is identified as a preferred vendor for certain DME items (example: E0784).

Femoroacetabular impingement and FESS: Femoroacetabular impingement (FAI) and functional endoscopic sinus surgery (FESS) require prior authorization with listed CPT codes (FAI examples: 29914–29916; FESS examples: 31240, 31256, 31253, 31257, 31254, 31259, 31288, 31255, 31267).

Genetic/molecular testing and home health: Outpatient genetic and molecular testing (including BRCA) and home health care services require prior authorization; examples include genetic testing CPT/HCPCS: 81162, 81229, 81402, 81406, 81163, 81277, 81403, 81407, 81417, 81164, 81400, 81404, 81408, 81479 and home health G-codes: G0299, G0300, G0493–G0496.

IVIG code mapping examples

Mapping examples90283,1 → 90284; 90283,2 → J1459; 90283,3 → J1552; J1554,1 → J1555; J1554,2 → J1556; J1554,3 → J1557.

Additional mappingsJ1559,1 → J1561; J1559,2 → J1566; J1559,3 → J1568; J1569,1 → J1572; J1569,2 → J1575; J1569,3 → J1599.

SectionIntravenous immunoglobulin (IVIG) code mapping examples provided in policy for billing and authorization consistency.

Physical therapy unit limit

LimitPhysical therapy: 144 units per calendar year.

Applies toOutpatient physical therapy services as listed in the policy.

ReviewRefer to the policy for coding and unit definitions applicable to the 144-unit limit.

Occupational therapy unit limit

LimitOccupational therapy: 144 units per calendar year.

Applies toOutpatient occupational therapy services as listed in the policy.

ReviewRefer to the policy for coding and unit definitions applicable to the 144-unit limit.

Speech therapy visit limit

LimitSpeech therapy: 36 visits per calendar year.

Applies toOutpatient speech therapy services as listed in the policy.

ReviewRefer to the policy for visit definitions and exceptions affecting the 36-visit limit.

PT/OT units per calendar year

PT/OT combined units144 units per calendar year (applies separately to physical therapy and occupational therapy as indicated in the policy).

Calendar year basisLimits are measured per calendar year; see policy for billing and unit conversion guidance.

Exceptions/authorizationServices exceeding limits may require prior authorization per policy rules.

Speech therapy visits per calendar year

Speech therapy visits per year36 visits per calendar year.

MeasurementCounted as visits per calendar year; refer to policy for visit definitions and applicable CPT/HCPCS codes.

AuthorizationRequests that exceed the annual visit limit may require prior authorization as noted in the policy.

Abortion: 59840, 59841, 59850–59857, 59866
Bariatric surgery: 43644, 43645, 43659, 43770, 43775, 43842–43848, 43860
Bone growth stimulator: 20975
Breast reconstruction and related: 11971, 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19367–19371, 19380, 19396
Cardiovascular: 37220–37231 (select codes)
Cochlear/auditory implants: 69710, 69714, 69930, L8619, L8691, L8692
Cosmetic/reconstructive: 11960, 14020*, 14021*, 14041, 14061*, 15820–15823, 15830, 15847, 15877–15879, 17106
FESS: 31240, 31253–31259, 31267, 31288
FAI: 29914–29916
Genetic/molecular testing (outpatient): 81162, 81163, 81164, 81228, 81229, 81277, 81400–81408, 81415, 81417, 81479, 81518
Home health agency services: G0299, G0300, G0493, G0494

Prior Authorization

Implants requiring prior authorization (examples)

Certain implants and prosthetic devices require prior authorization. Examples include cochlear and auditory implants (69710, 69714, 69930, L8619, L8691, L8692) and other implantable medical devices as listed in the full code set. Prosthetics (orthotics/prosthetics) are noted separately from DME.

Cochlear/auditory implants: 69710, 69714, 69930, L8619, L8691, L8692
Implantable neurostimulators and related device implant codes (see stimulator section)

Prior Authorization

Continuous glucose monitor prior authorization

Continuous glucose monitors (CGMs) require prior authorization when billed for members with type 2 diabetes or gestational diabetes. Applicable HCPCS codes include A4238, A4239, A9276, E2103, A9277.

CGM codes: A4238, A4239, A9276, A9277, E2103
Prior authorization required with diagnosis of type 2 diabetes or gestational diabetes

Prior Authorization

Enteral services prior authorization

Enteral (in‑home nutritional) therapy administered enterally or via gastrostomy tube requires prior authorization. Representative HCPCS codes include B4034, B4036, B4102, B4149, B4150–B4153, B4155–B4159, B4160–B4161.

Enteral product codes: B4034, B4036, B4102
Formula/feeding product codes: B4149, B4150, B4152, B4153, B4155–B4159, B4160, B4161
Prior authorization required for in-home enteral nutritional therapy

Prior Authorization

Procedures requiring prior authorization

Procedures across multiple service categories require prior authorization — examples include spinal surgery (22100–22224, 22510–22512, 22110–22220 series, 63303–63308), shoulder surgery and arthroscopy (23470–23474, 29805–29888 series), sinus/sinuplasty (31295–31298), prostate procedures (37243, 53852, 52441, 55873, 52442, 55874, 53850), rhinoplasty/septoplasty (30400–30462 series), proton beam therapy (77520, 77522–77525), sleep apnea surgical procedures (21685, 41599, 42145), and many others listed in the code appendices. Site-of-service rules may add prior authorization requirements when services are performed in an outpatient hospital setting versus an ASC.

Spinal surgery codes: 22100–22224, 22510–22512, 22206–22220, 63303–63308
Shoulder/arthroscopy series: 23470–23474, 29805, 29806–29888 (select codes)
Sinuplasty: 31295–31298
Prostate procedures: 37243, 53852, 52441, 55873, 52442, 55874, 53850
Rhinoplasty/septoplasty: 30400–30462 series
Proton beam therapy: 77520, 77522–77525
Site of service (SOS) rule: prior authorization required when performed in outpatient hospital; not required if in participating ASC

Prior Authorization

How to obtain prior authorization (radiopharmaceuticals and others)

How to obtain prior authorization for radiopharmaceuticals, specialty drugs, and other procedures: submit online via the Provider Portal Prior Authorization and Notification tool or call the numbers below. For radiopharmaceuticals and many drugs, call 888-397-8129 to submit prior authorization requests. For some medications and prior notifications (Cimzia, Synagis), use Optum Rx prior notification at 800-310-6826. For transplants and CAR T-cell therapies contact the Optum Transplant Case Management team.

Radiopharmaceuticals / certain drug prior auth: submit online or call 888-397-8129
Cimzia and Synagis prior notification: Optum Rx prior notifications 800-310-6826
Transplant and CAR T-cell therapy: Optum Transplant Case Management 888-936-7246

Prior Authorization

Provider contact for prior authorization

Provider contacts and specific prior authorization phone/fax resources: general prior authorization phone 800-903-5253 and fax 855-225-9847; for procedure/radiopharmaceutical prior auth submissions use 888-397-8129. For transplants and CAR T-cell therapies call Optum Transplant Case Management at 888-936-7246 (or the number on the member ID). For ventricular assist device (VAD) case management call 855-282-8929. For wound VAC, DME, and other device prior authorization follow the listed HCPCS and DME rules.

General prior authorization phone: 800-903-5253
General prior authorization fax: 855-225-9847
Procedures/radiopharmaceuticals prior auth: 888-397-8129
Transplant / CAR T: Optum Transplant Case Management 888-936-7246
VAD Case Management team: 855-282-8929

Prior Authorization

Prior authorization contact

Prior authorization contact guidance and carve-outs: inpatient transplant procedures are carved out to state programs — still call Optum Transplant Case Management (888-936-7246) or the number on the member's ID for coordination. Some drugs require Review at Launch or pre-determination; follow the Review at Launch Medication List. For certain unclassified/temporary J/C codes (C9157, C9166, C9399, J3490, J3590) prior authorization is required only for specific products.

Optum Transplant Case Management: 888-936-7246 for transplant and CAR T coordination
Review at Launch / pre-determination recommended for new-to-market FDA drugs (see Review at Launch Medication List)
Unclassified/temporary J/C codes: prior auth applies only for specific products noted (e.g., Elfabrio, Qalsody)

Prior Authorization

Codes requiring prior authorization (partial list)

The document includes an extensive partial code list that requires prior authorization across categories — examples from the partial list include: DME/medical equipment codes (A9900, E0194, E0265, E0266, E0277, E0328, E0329, E0457, E0465–E0471, E0483, E0636–E0652), stimulator and neurostimulation implantation and related procedure codes (E0760, 61863–61886, 63650, 63655, 63685, 64555, 64568, 64570, 64590), wound VAC (E2402), vein procedure codes (S2061, S2060, S5152, S2061 variants, and CPT S-codes where applicable), and numerous CPT surgical codes across transplant, cardiac, abdominal, thoracic and other specialties (see full appendices).

DME codes with prior auth when retail purchase/cumulative rental > $500: A9900, E0194, E0265, E0266, E0277, E0328, E0329, E0457, E0465–E0471, E0483, E0636–E0652
Stimulator/neurostimulator implant codes: E0760, 61863–61886, 63650, 63655, 63685, 64555, 64568, 64570, 64590
Wound VAC: E2402
Vein procedures and related codes: S2061, S2060, S5152 and related CPT vein codes
Extensive CPT lists for transplants, cardiac, abdominal, thoracic, spinal and other surgeries (see code appendices)

Prior Authorization

Prior authorization for specific service categories

Prior authorization is required for multiple specific service categories; examples consolidated here: DME over cost thresholds (retail purchase or cumulative rental > $500), enteral nutrition and supplies, implantable devices and stimulators, genetic/molecular outpatient testing, home health agency services, experimental/investigational services, proton beam therapy, CAR T-cell and transplant coordination, spinal surgery (all places of service as of effective dates noted), vein procedures, wound VACs, ventricular assist device (VAD) services, and many elective/ cosmetic/reconstructive procedures. Always review the service-specific code lists and clinical criteria when requesting prior authorization.

DME cost-threshold rule: prior auth when retail purchase or cumulative rental > $500
Enteral nutrition: B4034, B4036, B4102, B4149, B4150–B4159, B4160–B4161
Implants/stimulators: cochlear, neurostimulators, cardiac devices (see codes)
Genetic/molecular outpatient testing: BRCA and other sequencing panels (codes listed)
Home health agency services: G0299, G0300, G0493, G0494
Experimental/investigational services: e.g., 33477, S2102, 36514, 64722, 66180

Prior Authorization

Procedure codes requiring prior authorization

Procedure codes that require prior authorization (partial/pro representative list) include numerous CPT/HCPCS across specialties — examples: major abdominal and transplant surgeries (32850–32856, 33930–33945 series; 38208–38215; 38232*, 38240–38242; 44132–44137; 44715–44721; 47133–47147; 48551–48554), select urology/renal procedures (50300, 50320, 50323, 50325, 50340, 50360, 50365, 50370, 50547), and many more listed in the procedure appendices. Verify code-level requirements in the full policy before scheduling.

Transplant/major surgery examples: 32850–32856, 33930–33945, 38208–38215, 38232*, 38240–38242
Abdominal/colorectal: 44132–44137, 44715–44721, 47133–47147, 48551–48554
Renal/urology examples: 50300, 50320, 50323, 50325, 50340, 50360, 50365, 50370, 50547

Prior Authorization

Vein procedures, CAR T, wound VAC and VAD prior authorization

Vein procedures (removal/ablation of saphenous trunks/branches), CAR T-cell therapy coordination, wound VACs, and VAD services require prior authorization and in some cases specialized case management contacts. Examples include vein procedure codes (S2061, S2060, S5152 and related CPT vein codes), CAR T-cell therapy and related codes (e.g., 36473, 36475, 36478, 37700), wound VAC (E2402), and VAD codes (33927, 33928, 33975, 33982). For VAD case management contact 855-282-8929. For transplant/CAR T coordination contact Optum Transplant Case Management at 888-936-7246.

Vein procedure example codes: S2061, S2060, S5152 and related CPT vein codes
CAR T-cell therapy examples: 36473, 36475, 36478, 37700 (coordination required)
Wound VAC: E2402
VAD example codes: 33927, 33928, 33975, 33982
VAD Case Management: 855-282-8929
Transplant / CAR T coordination: Optum Transplant Case Management 888-936-7246

Provider actionIf unclear, use the Provider Portal or contact prior authorization phone/fax listed in the policy for clarification.

CMS inpatient-only procedures must be requested as inpatient; outpatient performance is not payable per CMS OPPS guidance.

CMS inpatient-only requirementCMS-designated inpatient-only procedures must be requested as inpatient; outpatient performance is not payable per CMS OPPS guidance.

ReferenceSee CMS Addendum B Status Indicator C for the inpatient-only list (cms.gov link noted in policy).

Provider actionSubmit authorization requests as inpatient for CMS inpatient-only procedures to ensure appropriate payment consideration.

Durable medical equipment requiring prior authorization when retail purchase or cumulative rental cost exceeds $500.

RuleDurable medical equipment (DME) that is a retail purchase or has a cumulative rental cost of more than $500 requires prior authorization for the listed codes.

Example codesE0277, E0328, E0329, E0457, E0465, E0466, E0470, E0471, E0483, E0636, E0637, E0638 (see policy for full list).

Prosthetics noteProsthetics are not DME; orthotics and prosthetics follow separate prior authorization rules.

J&B Medical Supply preferred vendor and contact

Preferred vendorJ&B Medical Supply Company, Inc. is identified as the preferred vendor for multiple DME categories (including catheter, diabetic supplies and electric breast pumps).

ContactTo request catheter, diabetic or electric breast pump supplies from J&B Medical Supply call 800-737-0045.

Benefit conditionCertain supplies are benefits only when provided through J&B Medical Supply as specified in the policy.

Binson's Medical Equipment respiratory supplier and contact

Respiratory supplierBinson's Medical Equipment & Supplies (Binson's Hospital Supplies) is the designated supplier for respiratory supplies.

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

Benefit conditionRespiratory supplies are a benefit only when provided through the designated supplier(s) listed in the policy.

Unclassified/temporary codes prior auth note

Unclassified/temporary codes noteUnclassified and temporary codes C9157, C9166, C9399, J3490 and J3590 require prior authorization only for Elfabrio and Qalsody.

Review guidanceCheck the policy's drug and code listings to determine when unclassified/temporary codes trigger prior authorization.

Provider actionObtain prior authorization for the specific drugs noted when billed with these unclassified/temporary codes.

Review at Launch guidance

Review at Launch guidanceRefer to the Review at Launch for New to Market Medications policy and its Medication List; pre-determination is highly recommended for drugs on that list.

Prior notificationObtain prior notification for Cimzia and Synagis through Optum Rx prior notification services at 800-310-6826.

Up-to-date infoPolicy instructs checking Review at Launch for the most current new-drug inclusions and authorization expectations.

Site of service (SOS) - outpatient hospital vs ASC

SOS rule (outpatient hospital vs ASC)Prior authorization is required only when requesting a service in an outpatient hospital setting; it is not required if performed at a participating ambulatory surgery center (ASC).

ExamplesPolicy lists site-of-service applicability with numerous CPT codes; confirm setting when requesting authorization.

Provider actionWhen submitting, indicate place of service to determine if prior authorization is required per site-of-service rule.

Site of service

DefinitionSite of service (SOS): policy applies site-of-service rules (e.g., outpatient hospital vs ASC) to determine prior authorization requirement.

EffectSome services require prior authorization only in certain sites of service; see policy listings for specifics.

Provider actionConfirm and document the intended site of service when requesting prior authorization.

Optum Transplant Case Management

ProgramOptum Transplant Case Management handles authorization for transplant and CAR T-cell therapy services.

ContactCall the Optum Transplant Case Management team at 888-936-7246 or the number on the back of the member's health plan ID card for authorization inquiries.

ScopeIncludes authorization for CAR T-cell therapies (e.g., Carvykti, Kymriah, Lyfgenia, Yescarta) and transplant procedures as listed.

Transplant/CAR T authorization contact

Contact for transplant/CAR TFor transplant and CAR T-cell therapy services (including Carvykti, Kymriah, Lyfgenia, Yescarta), call Optum Transplant Case Management at 888-936-7246 or the number on the member's ID card.

Prior auth requirementPrior authorization is required for transplant and CAR T-cell therapy services; inpatient transplant procedures may be carved out to state rules.

Provider actionUse the specified Optum contact to initiate authorization and coordination of care for these services.

VAD authorization contact

VAD authorization contactVentricular assist device (VAD) services require prior authorization and reference the VAD Case Management team at 855-282-8929.

ScopeApplies to VAD services and related mechanical circulatory support as listed in the policy.

Provider actionContact the VAD Case Management team at 855-282-8929 to initiate prior authorization and case management for VAD services.