CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Hawaii Medicaid

Lists services, CPT/HCPCS/ICD-10 codes, and instructions for submitting prior authorization requests for UnitedHealthcare Community Plan in Hawaii participating providers; applies to inpatient and outpatient services and out-of-network providers except emergency/urgent care.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Hawaii Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-980-8728.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Online & phoneRequest methods

No PA requiredEmergency/urgent care

Multiple servicesExamples requiring PA

$500DME threshold

2024-08-01Effective date

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.

Services Requiring Prior Authorization and Coverage Stance

DME, Incontinence, Hearing, and Home Health — Prior Authorization and Routing

Durable medical equipment (DME), incontinence supplies, hearing aids, and home health services have specific prior authorization, vendor, or routing requirements. Consolidated guidance and applicable codes are listed below.

Durable Medical Equipment (DME) — Prior authorization required only for DME codes listed with a retail purchase or cumulative rental cost over $500. Examples of listed HCPCS/CPT codes requiring prior authorization include: A9279, A9280, A9900, E0194, E0265, E0266, E0270, E0277, E0300, E0328, E0329, E0445, E0457, E0460, E0465, E0466, E0470, E0471, E0483, E0486, E0620, E0636, E0637, E0652, E0656, T1999, T5999, V2786, V5269, V5270, V5271, V5272, V5274. Note: prosthetics are not DME; orthotics/prosthetics follow separate prior authorization rules and cost threshold.

Durable medical equipment — Incontinence supplies are a covered benefit only when provided through Medline®. To request incontinence supplies, providers or members must call Medline at 877-816-5587. Applicable supply codes noted: V5287, V5282, V5283, V5286, V5287 (repeated in source).

Enteral / In-home nutritional therapy — Prior authorization required for in-home enteral nutrition and gastrostomy tube supplies and formula. Example HCPCS/CPT codes: B4034, B4035, B4036, B4100, B4102, B4103.

Hearing aids and hearing aid services — Prior authorization required. Submit prior authorization requests for hearing aid devices through the UnitedHealthcare Provider Portal at UHCprovider.com, by calling 888-980-8728, or by fax to 800-267-8328.

Home health care — Prior authorization required only in outpatient settings, including the patient's home. Prior authorization is not required for members residing in a skilled nursing facility. Representative codes requiring prior authorization include: G0151, G0152, G0153, G0155, G0156, G0157, G0158, G0159, G0160, G0161, G0299, G0300, G0493, G0494, G0495, G0496, G0493, S5180, S5181, S9122, S9124, S9128, S9129, S9131, S9474, T2045, T2044. Requests should include pertinent clinical information and may be submitted following the standard prior authorization routing instructions on page 1 of this document.

Auditory implants — Prior authorization required for implantable auditory devices. Example HCPCS codes: L8614, L8619, L8690, L8691, L8692.

Operational note: DME/orthotics/prosthetics threshold — Prior authorization is required for orthotics and prosthetic codes with a retail purchase or cumulative rental cost exceeding $500; some home health services may qualify but are not subject to the cost threshold.

Provider action note: For all items above, confirm member-specific benefit coverage and submit prior authorization requests via the UnitedHealthcare Provider Portal or the phone/fax numbers listed on the member's ID card when applicable.

CPT, HCPCS and ICD-10 Codes Referenced

Selected ICD-10 diagnosis codes tied to authorization guidanceICD-10

I70.221	Atherosclerosis of native arteries of other extremity with gangrene
I70.569	Atherosclerosis of nonautologous biological bypass graft of unspecified extremity, other
I70.621	Atherosclerosis of autologous vein bypass graft of right leg
I70.622	... autologous vein bypass graft of left leg
I70.623	... autologous vein bypass graft of bilateral legs
I70.628	... autologous vein bypass graft of other extremity
I70.629	... autologous vein bypass graft of unspecified extremity

How to Request Prior Authorization and Operational Requirements

Prior Authorization

How to request prior authorization and exceptions

Submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 888-980-8728. 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. For inpatient admissions, fax the member's registration/admission document with pertinent information to UnitedHealthcare Community Plan of Hawaii at 800-267-8328.

Online: Prior Authorization and Notification tile on UHCprovider.com (sign in and select tile).
Phone: 888-980-8728.
Inpatient requests: fax registration/admission document to 800-267-8328.
PA not required for emergency/urgent care; out-of-network providers must request PA except for emergent/urgent care.

Prior Authorization

Bariatric surgery requires prior authorization

Prior authorization is required for bariatric surgery and specified obesity-related services; example CPT codes listed include 43644, 43645, 43659 and 43770.

Key Definitions and Contact Information

inv-76: Definition of Prior authorization — process note, exceptions for emergency/urgent care

DefinitionPrior authorization is the process by which providers submit requests (online or by phone) to obtain approval before performing non-emergent services

How to requestOnline via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone at 888-980-8728

ExceptionsPrior authorization is not required for emergency or urgent care; out-of-network providers must request PA for all procedures/services except emergent/urgent care

inv-77: Cochlear and other auditory implants — device definition

Device definitionA medical device within the inner ear with an external portion to help persons with profound sensorineural deafness achieve hearing

Example codes

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Hawaii Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-980-8728.

SourceLink

On This Page

Example CPT codes requiring PA: 43644, 43645, 43659, 43770

Prior Authorization

Selected surgical/device services require prior authorization

Prior authorization is required for selected surgical/device services such as bone growth stimulators and non-mastectomy breast reconstruction; example codes include 20975, 20979, 11971, 19328, 19350 and L8600.

Bone growth stimulator example codes: 20975, 20979
Breast reconstruction (non-mastectomy) example codes: 11971, 19328, 19350, 19367, 19316, 19330, 19357, 19368, 19318, 19340, 19361, 19369, 19396, 19325, 19342, 19364, 19370, L8600

Prior Authorization

EEG / seizure monitoring: inpatient PA required; outpatient video EEG exceptions

Prior authorization is required for inpatient cerebral seizure monitoring. Inpatient video EEG prior authorization is not required when performed in an outpatient hospital or ambulatory surgical center.

Inpatient EEG/seizure monitoring codes referenced (examples): 95700–95718 series listed in policy.
Outpatient hospital/ASC inpatient video EEG codes (e.g., 95720, 95722, 95724, 95726) do not require PA.

Prior Authorization

Outpatient injectable chemotherapy requires prior authorization

Prior authorization is required for injectable chemotherapy drugs administered in an outpatient setting (including intravenous, intravesical and intrathecal) for a cancer diagnosis; multiple A- and J-codes are listed for PA (examples shown).

Example chemotherapy codes requiring PA: A9590, A9607, A9699, J0640, J0641, J0642, J0897, J1442, J1447, J1448, J1449, J1456, J1932, J1950, J1952, J1954, J2506, J2820, J9000, J9021, J9022, J9025, J9029, J9033, J9035, J9036, J9037, J9040

Prior Authorization

Auditory implants (e.g., cochlear) require prior authorization

Prior authorization is required for cochlear and other auditory implants; listed auditory implant HCPCS codes include L8614, L8619, L8690, L8691 and L8692.

Auditory implant HCPCS codes requiring PA: L8614, L8619, L8690, L8691, L8692

Prior Authorization

Continuous glucose monitors require prior authorization

Prior authorization is required for continuous glucose monitors; example codes listed include A4226, A4239, A9276, A9277, A9278, E0787, E2102 and E2103.

Example CGM HCPCS/CPT codes requiring PA: A4226, A4239, A9276, A9277, A9278, E0787, E2102, E2103

Prior Authorization

Cosmetic and reconstructive procedures require prior authorization

Prior authorization is required for many cosmetic and reconstructive procedures; the policy lists numerous CPT codes (examples include 11960, 14020, 14021, 14041, 14060, 14061, 14301, 15820–15823, 15830) that are subject to PA.

Example cosmetic/reconstructive CPT codes requiring PA: 11960, 14020, 14021, 14041, 14060, 14061, 14301, 15820, 15821, 15822, 15823, 15830

Prior Authorization

PA required for auditory implants and glucose monitors (combined)

Prior authorization is required for the listed auditory implant and continuous glucose monitor codes; the document groups these device codes together for PA and references additional glucose monitor codes in the policy.

Auditory implant codes: L8614, L8619, L8690, L8691, L8692
Glucose monitor codes: A4226, A4239, A9276, A9277, A9278, E0787, E2102, E2103

Prior Authorization

Prior authorization for cosmetic and reconstructive procedures — code list

Cosmetic and reconstructive procedure codes are listed in the policy and many are identified as requiring prior authorization; providers should reference the code list when submitting PA requests.

Examples of codes listed: 11960, 14020*, 14021*, 14041, 14060, 14061*, 14301, 15820–15823, 15830
Some codes are marked with an asterisk in the policy indicating additional notes—use the code list when requesting PA.

Billing Rule

DME prior authorization rules and $500 cost threshold

Prior authorization is required only for the DME codes listed in the policy and applies when the retail purchase or cumulative rental cost exceeds $500; some home health services and certain items are exempt from the cost threshold.

PA applies when retail purchase or cumulative rental cost is more than $500.
Examples of DME codes listed: A9279, A9280, A9900, E0194, E0265, E0266, E0270, E0277, E0300, E0328, E0329, E0445.
Prosthetics are not considered DME for the cost threshold—see orthotics/prosthetics section.

Billing Rule

DME and incontinence supplies: procurement and PA notes

DME entries include incontinence supplies and specify that incontinence supplies are a benefit only when provided through Medline; to request incontinence supplies, contact Medline at 877-816-5587.

Incontinence supplies benefit only when provided through Medline.
Medline contact for incontinence supplies: 877-816-5587.
DME codes for incontinence supplies examples: V5287, V5282, V5283, V5286.

Prior Authorization

Enteral and in-home nutritional therapy require prior authorization

Enteral/in-home nutritional therapy and gastrostomy tube services require prior authorization; example HCPCS codes include B4034, B4035, B4036, B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4155, B4158, B4159, B4160 and B4161.

Enteral/in-home nutritional therapy codes requiring PA: B4034, B4035, B4036, B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4155.
Gastrostomy tube codes requiring PA: B4158, B4159, B4160, B4161.

Documentation Required

Genetic and molecular testing (including BRCA) — PA/notification requirements

Genetic and molecular testing (including BRCA-related tests) require prior authorization or notification; providers must indicate the performing laboratory and test name and, for some tests, notify UnitedHealthcare or the lab prior to sequencing.

Example genetic/molecular CPT codes: 81162–81465 series and U-codes (e.g., 0252U–0269U).
Providers must include the laboratory name and test name when requesting PA; some tests require notification prior to sequencing.

Documentation Required

Hearing aid PA submission instructions (portal, phone, fax)

Submit hearing aid device prior authorization requests through the UnitedHealthcare Provider Portal at UHCprovider.com, by phone at 888-980-8728, or by fax to 800-267-8328.

Portal submission: UHCprovider.com (Prior Authorization and Notification tile).
Phone: 888-980-8728.
Fax: 800-267-8328.

Prior Authorization

Home health care: PA required for outpatient/home settings

Home health care prior authorization is required only in outpatient settings, including the patient's home; PA is not required for members residing in skilled nursing facilities. Selected home health codes requiring PA are listed (G- and S- codes).

PA required only in outpatient settings (includes patient's home); not required for members in skilled nursing facilities.
Example home health PA codes: G0151, G0152, G0153, G0155, G0156, G0157, G0158, G0159, G0160, G0161, G0299, G0300, G0493–G0496, S5180–S5181, S9122, S9124, S9131, S9474.

Prior Authorization

Experimental/Investigational services require prior authorization

Experimental and investigational services and certain linked services are identified in the policy and require prior authorization; numerous CPT/HCPCS codes are flagged under this category.

Examples of investigational codes listed: 33477, 36514, 64722, 65765, 65767, 66180, A4638, A6000, A9274, E0231, E1831, S0810, S1030, S1031, S2102, S9988.
Providers should submit PA requests for services flagged as experimental/investigational per the code list.

Prior Authorization

BRCA and genetic/molecular testing — PA references and requirements

BRCA and other genetic/molecular tests are included in the genetic testing code lists (e.g., 0252U–0269U and 81162–81465); prior authorization references for these codes are provided and providers must include lab/test identification.

BRCA-related U-codes example: 0252U, 0253U, 0254U, 0260U, 0262U, 0264U, 0265U, 0269U.
Genetic test CPT examples: 81162–81465; include lab and test name with PA request.

Prior Authorization

Hearing aids and hearing aid services require prior authorization

Hearing aids and related hearing aid services require prior authorization; submit requests via the UnitedHealthcare Provider Portal, phone 888-980-8728, or fax 800-267-8328.

Hearing aid services: PA required.
Submission methods: UHCprovider.com, phone 888-980-8728, fax 800-267-8328.

Prior Authorization

Home health care — PA required only for outpatient/home settings (reiteration)

Home health care PA requirement is reiterated: prior authorization is required only in outpatient settings, including the patient's home; selected codes are listed for PA.

See home health codes: G0151–G0161 series, G0299–G0300, G0493–G0496, and S- series codes listed in the policy.
PA not required for members in skilled nursing facilities.

Prior Authorization

Injectable medications — prior authorization required (extensive list)

Numerous injectable medications require prior authorization; the policy includes an extensive list of J- and Q-codes and brand references (examples include J2326, Q5127, J1747, J0218, J2357).

Providers should reference the policy's injectable medication code lists when submitting PA.
Examples of listed injectable medication codes/brands: J2326 (Spinraza™/Stimufend®), Q5127 (Stimufend® variant), J1747, J0218, J2357 and many additional J-/Q-codes in chunks 75–78 and 117–119.

Documentation Required

HCPCS codes (e.g., J2326, Q5127) and PA notes for specialty drugs

HCPCS drug-to-code entries for select specialty products (notably J2326 and Q5127) are listed in the policy tied to product names such as Spinraza™ and Stimufend®; these entries are included for prior authorization processing.

Spinraza™ associated code: J2326.
Stimufend® associated codes: J2326 and Q5127 (listed repeatedly in policy).

Prior Authorization

Joint replacement and inpatient services require prior authorization

Prior authorization is required for joint replacement procedures (total hip and knee); example CPT/HCPCS codes listed include 23470, 27130, 27412, 27487 and J7330.

Example joint replacement codes requiring PA: 23470, 27130, 27412, 27487, J7330
Inpatient admissions: notify UnitedHealthcare within 48 hours for emergency admissions; routine OB/deliveries require notification only.

Documentation Required

Inpatient notification requirements (emergency admissions within 48 hours)

For emergency inpatient admissions, notify UnitedHealthcare within 48 hours of admission; routine obstetrics and deliveries require notification only.

Emergency admissions: notify within 48 hours.
Routine OB/deliveries: notification only (no PA required for standard notification).
Inpatient PA submission: fax registration/admission document to 800-267-8328.

Prior Authorization

Non-emergent air ambulance requires prior authorization

Non-emergent air ambulance transport requires prior authorization; example HCPCS codes include S9960 and S9961.

Non-emergent air ambulance HCPCS codes: S9960, S9961
Request PA online or by phone using the portal/phone instructions on page 1.

Prior Authorization

Off-island travel requires prior authorization

Off-island (including out-of-state) travel requires prior authorization; requests should be submitted online or by phone using the instructions at the top of page 1 (UHCprovider.com or 888-980-8728).

Submit off-island travel PA requests via the Prior Authorization and Notification tool on UHCprovider.com or by phone at 888-980-8728.

Billing Rule

Orthotics and prosthetics — PA required when cost exceeds $500

Orthotics and prosthetics codes listed require prior authorization when the retail purchase or cumulative rental cost exceeds $500; many L-codes are enumerated across the policy.

PA threshold: retail purchase or cumulative rental cost > $500 triggers PA.
Example L-codes: L0112, L0464, L0480, L1000, L2030, L3265 and many additional L-code entries throughout the policy.

Prior Authorization

Injectable medications — PA required (brand and J/Q codes listed)

Numerous injectable medications (including brand and specific J/Q codes such as Stimufend Q5127 and Spinraza J2326/J1747) are listed and require prior authorization; providers should reference the policy's code lists for each medication when submitting PA requests.

Examples of referenced codes/brands: J2326 (Spinraza™/Stimufend®), Q5127 (Stimufend®), J1747 (Spinraza™), plus an extensive list of J-/Q-codes in chunks 75–78 and 117–119.
Providers should include relevant documentation per PA submission requirements for each injectable medication.

Documentation Required

New-to-market medications — check Review at Launch and consider pre-determination

For new-to-market medications, providers are advised to consult the 'Review at Launch for New to Market Medications' policy on UHCprovider.com and consider pre-determination for drugs on that list.

Review at Launch policy location: UHCprovider.com/policies > Menu > Policies and Protocols > Community Plan Policies > Medical & Drug Policies and Coverage Determination Guidelines for Community Plan.
Pre-determination is highly recommended for drugs on the Review at Launch list.

Prior Authorization

Private duty nursing — PA required for T1000/T1002/T1003

Private duty nursing prior authorization is required only for codes T1000, T1002 and T1003.

PA required for private duty nursing codes: T1000, T1002, T1003

Prior Authorization

Proton beam therapy requires prior authorization

Proton beam therapy requires prior authorization for listed CPT codes; examples provided include 77520, 77522, 77523 and 77525.

Proton beam CPT codes requiring PA: 77520, 77522, 77523, 77525

Prior Authorization

Prostate procedures require prior authorization

Prostate procedures require prior authorization; example CPT codes listed include 37243, 52441, 52442, 53850, 53852, 55873 and 55874.

Example prostate procedure CPT codes requiring PA: 37243, 52441, 52442, 53850, 53852, 55873, 55874

Prior Authorization

ENT surgeries (rhinoplasty/septoplasty/sinuplasty) require prior authorization

ENT surgeries such as rhinoplasty, septoplasty and sinuplasty require prior authorization for the listed CPT codes; sinuplasty codes 31295–31298 are specifically noted as prior authorization required.

Rhinoplasty CPT examples: 30400, 30410, 30420, 30430
Septoplasty CPT examples: 30435, 30450, 30460, 30462
Sinuplasty CPT examples requiring PA: 31295, 31296, 31297, 31298

Prior Authorization

Sleep apnea procedures — PA only for listed codes

Sleep apnea procedures require prior authorization only for the specific CPT/HCPCS codes listed (examples include 21685, 41599, 42145).

Sleep apnea procedure codes: 21685, 41599 (unlisted), 42145 — PA required only for listed codes

Prior Authorization

Orthotics & prosthetics L-codes — PA guidance applies

A large series of L-codes for orthotics and prosthetics are listed with guidance indicating how to obtain prior authorization; these L-codes are subject to the orthotics/prosthetics PA processes described in the policy.

Extensive L-code listings (examples: L6010, L6020, L6050, L6100, L6200, L6360, L6370, L6400, L6550, L6621, L6646, L6692, L6704, L6713).
Follow orthotics/prosthetics PA process and cost threshold guidance in the policy.

Prior Authorization

Potentially unproven services — PA required

Potentially unproven services listed in the policy are flagged as prior authorization required; example codes include 33289 and C2624.

Example potentially unproven service codes requiring PA: 33289, C2624

Prior Authorization

Spine and related surgeries — PA required per code mappings

Spine and related surgery CPT code mappings in the policy indicate prior authorization is required for the listed code pairs and ranges; providers should reference the mapping series when submitting PA.

Spine surgery mapping examples include series such as 22100→22112, 22101→22114, 22102→22206, 22110→22207 and extended mappings shown in the policy.
Submit PA referencing the specific CPT mappings listed.

Prior Authorization

Stimulators (implantable) require prior authorization

Stimulator implantation devices (implantable stimulators and related devices) require prior authorization; the policy lists CPT/HCPCS codes including 0098T and multiple E- and L-codes (e.g., E0747, E0748, E0749, E0760, L8680–L8688).

Example stimulator/implantation codes requiring PA: 0098T, E0747, E0748, E0749, E0760, L8680, L8682, L8685, L8686, L8687, L8688

Prior Authorization

Transplants and CAR T-cell therapies — PA routing via Transplant Case Management / Optum

Transplant and CAR T-cell therapy services require prior authorization and routing through UnitedHealthcare Community and State Transplant Case Management (call 888-936-7246); for certain gene therapies and specified products, PA is required through Optum Transplant per the policy.

Contact UnitedHealthcare Community and State Transplant Case Management at 888-936-7246 for transplant and CAR T-cell therapy PA.
Certain gene therapies/products (e.g., Amtagvi, Casgevy, Skysona, Lantidra, Lenmeldy) require PA routed through Optum Transplant.
UnitedHealthcare Community Plan of Hawaii manages referrals to the SHOTT program for organ transplants.

Prior Authorization

Vision services — PA required with age-based exceptions

Vision services require prior authorization with age-based exceptions; the policy notes PA is not required for members 40 years of age or older for certain vision codes and that PA is required for many vision codes for members 21 and older.

Example vision HCPCS codes listed: S0500, V2200–V2219 series and others.
PA exceptions: some vision services are not subject to PA for members 40+; other age-based rules (e.g., PA required for members 21 and older) are noted—refer to the vision code list.

Prior Authorization

Vein procedures require prior authorization; select products routed via Optum Transplant

Vein procedures (removal and ablation) require prior authorization; example CPT codes include 36473, 36475, 36478, 37700 and 37766. Certain gene therapies and specified products will require PA through Optum Transplant.

Vein procedure codes requiring PA: 36473, 36475, 36478, 37700, 37766
Products such as Amtagvi, Casgevy, Skysona, Lantidra and Lenmeldy require PA through Optum Transplant.

Prior Authorization

Wound VAC therapy requires prior authorization

Wound VAC therapy requires prior authorization; the HCPCS code listed in the policy is E2402.

Wound VAC HCPCS code requiring PA: E2402

L8614, L8619, L8690, L8691, L8692 (auditory implant L-codes)

Prior authorizationPrior authorization required for cochlear and other auditory implants (per listed codes)

inv-78: Chemotherapy (injectable outpatient) definition

DefinitionInjectable chemotherapy drugs administered in an outpatient setting including intravenous, intravesical and intrathecal for a cancer diagnosis

Prior authorizationPrior authorization required for outpatient injectable chemotherapy agents

Example HCPCS/CPT entriesA9590, A9607, A9699, J0640, J0641, J0642, J0897, etc. (see chemotherapy code listings)

inv-79: Auditory implants (alternate entry)

Definition (alternate entry)Auditory implants: A medical device within the inner ear with an external portion to help persons with profound sensorineural deafness achieve improved hearing

Associated codesL8614, L8619, L8690, L8691, L8692

Authorization notePrior authorization required for listed auditory implant codes

inv-80: Durable Medical Equipment (DME) definition and when PA applies

DefinitionDurable Medical Equipment (DME): Equipment for which prior authorization is required only for the DME codes listed and when retail purchase or cumulative rental costs exceed the specified threshold

When PA appliesPA applies to listed DME codes when retail purchase or cumulative rental cost exceeds $500; some home health services and certain items are exempt

ProstheticsProsthetics are not considered DME and have separate guidance

inv-81: Incontinence supplies — Medline contact note

Benefit restrictionIncontinence supplies are a benefit only when provided through Medline

Medline contactTo request incontinence supplies, call Medline at 877-816-5587

Affected codesIncontinence supply HCPCS/CPT entries listed (e.g., V5287, V5282, V5283, V5286)

inv-82: Genetic/molecular testing prior authorization summary

SummaryGenetic and molecular testing (including BRCA) requires prior authorization or notification; providers must identify the performing laboratory and test name

Notification requirementFor some tests, the provider or laboratory must notify UnitedHealthcare prior to sequencing (per listed U-codes and instructions)

Representative codesExamples include ranges 81162–81465 and U-codes such as 0252U–0269U and other specified CPT/HCPCS molecular test codes

inv-83: Hearing aid prior authorization submission methods (portal/phone/fax)

Submission methodsSubmit hearing aid device prior authorization requests via UnitedHealthcare Provider Portal (UHCprovider.com), by phone at 888-980-8728, or by fax to 800-267-8328

PA requirementHearing aids and hearing aid services require prior authorization

Portal referenceUse the Prior Authorization and Notification tile on the UHCprovider.com portal dashboard (Sign In required)

inv-84: Home health care PA rules — outpatient/home settings and exceptions

PA setting ruleHome health care prior authorization is required only in outpatient settings, including the patient's home

ScopeApplies to listed G- and S- home health care codes (examples: G0151–G0161, G0299–G0300, G0493–G0496, S5180–S5181, S9122–S9131)

ExceptionPrior authorization is not required for members residing in a skilled nursing facility

inv-85: Hearing aid PA submission methods (duplicate/reference)

Submission methods (duplicate)Submit hearing aid device prior authorization requests via UHCprovider.com, phone 888-980-8728, or fax 800-267-8328

PA requiredHearing aids and hearing aid services require prior authorization per the policy

Reference chunksSee hearing aid instructions repeated in chunks 72–73 for portal/phone/fax details

inv-86: Drug-to-HCPCS mapping — Spinraza™ and Stimufend® code associations

Spinraza™ mappingSpinraza™ is associated with HCPCS code J2326 in the policy listings

Stimufend® mappingStimufend® is referenced with HCPCS code Q5127 (and also J2326 appears in related entries)

Usage noteThese HCPCS/drug name associations are listed in multiple code entries for prior authorization reference

inv-87: Emergency admission — notification requirement definition

DefinitionEmergency admission: inpatient admission that requires notification to UnitedHealthcare within 48 hours of admission

Notification methodFax the member's registration/admission document with pertinent information to UnitedHealthcare Community Plan of Hawaii at 800-267-8328

ExceptionsRoutine obstetrics/deliveries require notification only (not full prior authorization in some cases)

inv-88: Prior authorization threshold for orthotics/prosthetics — $500 rule

Orthotics/prosthetics PA threshold (restated)Prior authorization required when retail purchase or cumulative rental cost exceeds $500

Applicable itemsL-series orthotics and prosthetics codes listed across the policy (examples include L0112, L0464, L0480, L0484, L0624, L0632, etc.)

Repeated guidanceText in multiple chunks reiterates the $500 cumulative rental/purchase threshold for listed orthotics/prosthetics codes

inv-89: Proton beam therapy definition

DefinitionProton beam therapy: focused radiation therapy using beams of protons (tiny particles with a positive charge)

PA requirementPrior authorization required for listed proton beam therapy CPT codes (e.g., 77520, 77522, 77523, 77525)

Representative codes77520, 77522, 77523, 77525

inv-90: Orthotics and prosthetics (L-codes) definition/reference

DefinitionOrthotics and prosthetics: L-code series used for devices and related services; many L-codes are enumerated in the policy

PA guidanceLarge series of L-codes are listed with guidance on how to obtain prior authorization where applicable

ExamplesSample L-codes listed include L6010, L6020, L6050, L6100, L6200, L0112, L0464, L0480, L0484

inv-91: SHOTT — State of Hawaii Organ and Tissue Transplant program note

ProgramState of Hawaii Organ and Tissue Transplant program (SHOTT) is the carve-out program responsible for organ transplant benefits

Referral managementUnitedHealthcare Community Plan of Hawaii manages referrals to SHOTT and the transplant referral process

ContactTransplant Case Management team phone: 888-936-7246 (or notification number on member ID card)

inv-92: Routing mechanism for certain gene therapies/products (Optum Transplant) — definition/note

Routing mechanismCertain gene therapies and specified products require prior authorization through Optum Transplant (per policy note)

ExamplesProducts noted include Amtagvi, Casgevy, Skysona, Lantidra, Lenmeldy which will require PA through Optum Transplant

ContextOptum Transplant routing is referenced alongside transplant/CAR-T routing in the policy