UnitedHealthcare Kansas Medicaid Prior Auth Policy Update

Services and Coverage Rules Requiring Prior Authorization

Coverage criteria by service category

The document identifies categories of services and specific codes that require prior authorization for Kansas Medicaid members.

Behavioral health services: Prior authorization required; for specific codes call the number on the member's health plan ID card. For applied behavior analysis (ABA) therapy, submit via fax or Provider Express.

Bariatric surgery and obesity-related services: Prior authorization required for listed CPT codes (examples include 43644, 43645, 43659, 43770, 43842, 43845, 43846, 43847, 43848, 43860).

Genetic testing (BRCA): Prior authorization required for listed CPT codes (examples: 81162, 81163, 81164, 81165, 81166, 81212, 81432, 81433).

Breast reconstruction (non-mastectomy): Prior authorization required for multiple CPT codes (examples: 11971, 19316, 19318, 19325, 19368–19371, 19380, 19396, L8600).

Injectable oncology/supportive drugs: Colony-stimulating factor drugs and bone-modifying agents administered in an outpatient setting for a cancer diagnosis require prior authorization; specific J/Q codes listed (e.g., J1442, J2506, J2820, J0897, Q5101, Q5120, Q5122, Q5110).

Prior authorization coverage criteria

Services and items requiring prior authorization and associated conditions

Injectable chemotherapy drugs (including J9000-J9999, J0640, J0641, J0642, J1950 and Q-coded chemotherapy injectables): Prior authorization required when administered in an outpatient setting (including intravenous, intravesical, intrathecal) for a cancer diagnosis.

Durable medical equipment (listed HCPCS/E/A codes): Prior authorization required only for the listed DME codes when retail purchase or cumulative rental cost exceeds $500. (Prosthetics are not considered DME for this requirement.)

Cosmetic and reconstructive procedures: Prior authorization required for the many listed cosmetic/reconstructive CPT codes unless an applicable exception (for example related to skin cancer diagnoses) applies.

Prior authorization coverage criteria (codes listed)

Coverage requires prior authorization for listed services and codes.

Enteral and in‑home nutritional therapy: Prior authorization required for listed K- and related codes (examples: K0859, K0863, K0870, K0879, K0886, T1999, K0860, K0864, K0871, K0880, K0890, V2786, etc.).

Genetic and molecular testing (including BRCA) performed in outpatient settings (including member's home): Prior authorization required; multiple CPT codes enumerated and laboratories must notify UnitedHealthcare when sequencing is performed.

Home health services: Prior authorization required in outpatient settings (including member's home) for listed home health procedure codes (examples: 97535, 99383, 99392, 99600, G0152, G0300, S0315, S5135, S9131, T1000, etc.).

Injectable medications (numerous J-codes and HCPCS): Prior authorization required for the long enumerated list of injectable medications (examples include J0401, J0402 and many others).

Selected coverage criteria and instructions

Coverage actions and criteria (selected) described in this section

Outpatient genetic/molecular testing: Prior authorization is required in outpatient settings (including member's home) for certain genetic and molecular tests; the ordering provider and laboratory must notify UnitedHealthcare when sequencing is performed.

Orthognathic surgery and treatment of maxillofacial/jaw functional impairment: Prior authorization required for orthognathic procedures and related CPT mappings (examples mapped in document).

Orthotics and prosthetics: Prior authorization required only when the retail purchase or cumulative rental cost exceeds $500 (prosthetics generally treated separately from DME).

Prior authorization submission instructions (selected): Submit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call the listed phone numbers; certain specialty prior-notification requirements (for example OptumRx notifications for specific products) are specified in the document.

PA and coverage nodes from extract

Partial extract lists services with PA requirements and some coverage notes.

PET scans: Not a covered benefit unless medically necessary and prior authorization is obtained; listed PET CPT codes include 78459, 78609, 78814, 78491, 78811, 78815, 78492, 78812, 78608, 78813.

Private duty nursing: Prior authorization required (example code T1000).

Prostate procedures: Prior authorization required for listed procedure codes (examples enumerated in the extract).

Proton beam therapy: Prior authorization required (examples: 77520, 77522, 77523, 77525).

Rhinoplasty and sinuplasty: Prior authorization required for listed CPT codes (examples: rhinoplasty 30400, 30435, 30410, etc.; sinuplasty 31295–31298).

Special authorization and handling criteria

Special coverage and authorization notes for unclassified codes, VADs, wound vacs, and vein procedures.

Unclassified codes (J3490, J3590, C9399): Prior authorization required when used for specified high‑cost products (examples called out include Casgevy and Omisirge; specific mapped CPT/HCPCS entries are shown in the extract).

Ventricular assist devices (VADs): Special handling—providers must call the notification number on the member's health plan ID card and fax the form provided by the nurse to Optum VAD Case Management at 855-282-8929; VAD device and supplies may not be covered or require special authorization and case management.

CAR‑T and transplant services: Transplant and CAR‑T services require contacting UnitedHealthcare Community and State Transplant Case Management for authorization (listed CAR‑T products are provided in the document).

Wound vacuum therapy (Wound vac): Prior authorization required.

Vein procedures and ablation/removal: Removal or ablation of saphenous and named branches for venous disease/varicose veins require prior authorization; unclassified codes used for vein procedures also require prior authorization for specified products as indicated in the extract.

CPT / HCPCS / ICD-10 Codes and Code Groups

Genetic testing (BRCA) codes requiring prior authorizationCPTCovered

81162	BRCA-related genetic testing
81163	BRCA-related genetic testing / related codes 81212
81164	BRCA-related genetic testing / related codes 81432
81165	BRCA-related genetic testing / related codes 81433
81166	BRCA-related genetic testing

Bariatric surgery and obesity-related service codesCPTCovered

43644	Bariatric surgery
43645	Bariatric surgery
43659	Bariatric surgery
43770	Bariatric/obesity-related procedures
43775	Bariatric surgery
43842	Bariatric surgery
43845	Bariatric surgery
43846	Bariatric surgery
43847	Bariatric surgery
43848	Bariatric surgery

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Selected musculoskeletal and breast reconstruction codesCPTCovered

20975	Bone growth stimulator (electrical)
20979	Bone growth stimulator (ultrasound)
11971	Breast reconstruction (non-mastectomy) - example code
19316	Breast reconstruction (non-mastectomy)
19318	Breast reconstruction (non-mastectomy)
19325	Breast reconstruction (non-mastectomy)

Injectable oncology/supportive medication HCPCS/J-codesHCPCSCovered

J1442	Filgrastim (Neupogen) — PA required
Q5101	Biosimilar Zarxio — PA may be required
J2506	Pegfilgrastim (Neulasta) — PA required
J2820	Sargramostim (Leukine) — PA required
J0897	Denosumab (Xgeva) — bone-modifying agent, PA required
J1456	Antiemetic drugs
J1449	Colony stimulating factors
J0885	Erythropoiesis-stimulating agents

Selected ICD-10 codes appearing in listICD-10

M86.369	Osteomyelitis unspecified site
M86.371	Acute osteomyelitis, other
M86.372	Chronic osteomyelitis, other
M86.379	Osteomyelitis unspecified
M86.38	Other osteomyelitis
M86.39	Osteomyelitis, other
I96	Gangrene, not elsewhere classified
L03.115	Cellulitis of right lower limb
L03.116	Cellulitis of left lower limb
Q27.30	Congenital malformation of pulmonary artery

Chemotherapy injectable HCPCS/J-codesHCPCSCovered

J9000-J9999	Chemotherapy injectable drugs range
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin
J1950	Leuprolide acetate (Lupron Depot) injectable

Selected DME/HCPCS codesHCPCSCovered

A4604	Disposable suction catheter
A4618	Oxygen conserving device
A7027	Custom fabricated knee orthosis
E0601	Powered wheelchair
E0787	External ambulatory glucose monitor (E0787 referenced in CGM context)

Selected cosmetic and reconstructive CPT codes (examples from list)CPTCovered

11960	Skin grafting, other
14060	Adjunctive procedures (example cosmetic/reconstructive) — sample codes listed
21172	Reconstruction of mandible/maxilla
55970	Vasectomy reversal? (example reconstructive codes listed)

Sample E-codesHCPCSCovered

E0601	Durable medical equipment HCPCS code listed for prior authorization
E0620	Durable medical equipment HCPCS code listed for prior authorization

Sample J-codesHCPCSCovered

J0402	Abilify Asimtufii (listed J-code) requiring prior authorization
J0401	Abilify Maintena (listed J-code) requiring prior authorization

Genetic testing codesCPTCovered

81162	BRCA genetic/molecular testing code requiring prior authorization in outpatient setting
81400	Genetic testing code requiring prior authorization in outpatient setting

Injectable medication HCPCS/J-codes (selected examples)HCPCSCovered

J0401	Abilify Maintena (example from injectable list)
J9305	Pemetrexed (Alimta) (example from injectable list)
J2326	Spinraza (example from injectable list)
J3399	Zolgensma (example from injectable list)

Orthotics and prosthetics HCPCS L-codes (selected examples)HCPCSCovered

L0112	Orthotic/prosthetic HCPCS L-code (example)
L0638	Orthotic/prosthetic HCPCS L-code (example)
L4000	Orthotic/prosthetic HCPCS L-code (example)

Maxillofacial / orthognathic procedure CPT-to-other-code mappings (selected)CPTCovered

21121	Orthognathic surgery / maxillofacial procedure mapping (example)
21123	Orthognathic surgery / maxillofacial procedure mapping (example)

Sample L-code mappings (orthotics/prosthetics and other devices)HCPCS

L5220	L-code listed in mapping lines
L5230	L-code listed in mapping lines

Selected CPT-to-L-code mappings and PA-required CPTsmixed

78459	PET scan CPT code mapped to L8045/L8609
77520	Proton beam therapy CPT code mapped to L8045/L8609
31295	Sinuplasty CPT code mapped to L8045/L8609
22100	Spinal surgery CPT code listed as requiring prior authorization

Code mapping cross-referencesCPT | HCPCS | mixed

32854	Associated code group mappings (e.g., 32855, 32856, 33930)
33933	Associated mappings to 33935, 33940, 33944
38232	Mapping entries to 38240-38242 (note: marked with *)
50370	May map to J3394 or S2060/S2061 entries

Unclassified codes requiring PA for specified productsHCPCSExperimental

J3490	Unclassified drug code — prior authorization required for specific therapies (e.g., Casgevy, Omisirge)
J3590	Unclassified drug code — prior authorization required for specific therapies
C9399	Unclassified miscellaneous code — prior authorization required for specific therapies

Outpatient administration requirement — colony-stimulating factors and bone-modifying agents administered in an outpatient setting for a cancer diagnosis require prior authorization

Policy requirementColony-stimulating factors and bone-modifying agents administered in an outpatient setting for a cancer diagnosis require prior authorization.

Example drugs/codesJ1442, J1447, J1448, J2506, J2820, J0897, Q5101, Q5108, Q5110, Q5120, Q5122, Q5125 (also require PA when used for non-oncology diagnoses).

Setting

How Providers Request Prior Authorization and Required Notifications

Prior Authorization

Prior Authorization Required — Enteral / In‑home Nutritional Therapy

For enteral services and in‑home nutritional therapy (including enteral formulas and related supplies), prior authorization is required.

Affected HCPCS/K-codes include: K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0889, K0890, K0891, T1999, S1040, V2786 (and associated B‑codes such as B4160, B9002, B9998)

Prior Authorization

Transplant and CAR T‑cell Therapy — Call Transplant Case Management

For transplant and CAR T‑cell therapy services (including but not limited to Abecma, Breyanzi, Carvykti, Kymriah, Lyfgenia, Tecartus and Yescarta), providers must contact UnitedHealthcare Community and State Transplant Case Management to obtain prior authorization. Do not submit these requests through the general portal; call the transplant team for case management and prior authorization routing.

Includes transplant procedures and all CAR T‑cell therapies listed above
Follow UnitedHealthcare Community and State Transplant Case Management instructions for submission and documentation requirements

Key Terms and Thresholds

Definition of Prior Authorization

DefinitionPrior authorization is the process by which providers must obtain approval from the plan before performing certain procedures or services.

Emergency care exceptionPrior authorization is not required for emergency or urgent care.

Out-of-network requirementOut-of-network clinicians must request prior authorization for all non-emergent services.

Behavioral health network

Network arrangementMany behavioral health benefits are provided through a designated behavioral health network.

How to obtain PA for behavioral healthFor specific codes requiring prior authorization, call the number on the member's health plan ID card.

OpenPayer

Prior authorization requirements for Kansas Medicaid

Services and Coverage Rules Requiring Prior Authorization

CPT / HCPCS / ICD-10 Codes and Code Groups

How Providers Request Prior Authorization and Required Notifications

Key Terms and Thresholds