CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Kansas Medicaid

Lists services, CPT/HCPCS/ICD-10 codes, and submission instructions for prior authorization for UnitedHealthcare Community Plan of Kansas providers; applies to participating providers and facilities for Kansas Medicaid members.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Kansas Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID or by phone at 877-842-3210.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleservice types listed

phone & onlinesubmission methods

2026-03-01effective date

$500DME PA threshold

J9000–J9999chemo injectables require PA

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 and Coverage Criteria Requiring Prior Authorization

Prior authorization and coverage stance (partial)

The following services and items require prior authorization or predetermination across UnitedHealthcare plans. Use the Provider Portal Prior Authorization and Notification tool or call the number on the member's ID card (or 888-397-8129 for outpatient chemotherapy) as noted.

General requirement
- Prior authorization is required for many procedural, imaging, surgical and durable medical equipment services listed below; specific CPT/HCPCS codes are included with each service listing.
- Predetermination (review before performing service) is highly recommended for certain medical benefit drugs, including new-to-market oncology and other specialty medications included on UnitedHealthcare Market/Community Plan drug lists.
Drug and injectable medication requirements
- Prior authorization is required for outpatient injectable chemotherapy drugs (including IV, intravesical, intrathecal) for a cancer diagnosis. This includes chemotherapy injectable drugs billed J9000-J9999, J0640-J0642 (leucovorin/levoleucovorin), J1950 (Lupron Depot), drugs with Q-codes, and drugs billed under miscellaneous HCPCS when an assigned code is not yet available.
  Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-397-8129.
- Prior authorization is required for colony-stimulating factor drugs and certain bone-modifying agents administered in the outpatient setting for oncology and, for some J- and Q- codes, for non-oncology diagnoses as noted (J1442, J1447, J1448, J2506, J2820, J0897, Q5101, Q5108, Q5110, Q5120, Q5122, Q5125).
  See the injectable medications section and the Medical Benefit Drug Policy for specific clinical criteria.
- Predetermination is highly recommended for drugs on the Market Medications / Review at Launch lists (new-to-market medications) and for Community Plan Medical Benefit Drug Policy medications. Follow the Drug Policies and Coverage Determination Guidelines for details.
  Check UnitedHealthcare Market Medications and Medical Benefit Drug Policy pages.
Genetic and molecular testing
- Prior authorization is required for outpatient genetic and molecular testing, including BRCA testing and related panels; multiple CPT/HCPCS and proprietary codes are identified in the plan lists (for example CPT codes 81162-81166, 81163, 81164, 81165 and a broader range of molecular testing codes such as 81400-81432 and various G-/U- codes).
Durable medical equipment and orthotics
- Prior authorization is required for DME items that have a retail purchase or cumulative rental cost exceeding $500; specific HCPCS codes listed in the DME section require prior authorization (examples include A4618, A7027, A7044, A7045, A9900 and numerous L- and E- codes).
Selected procedures and services
- Prior authorization is required for a range of surgical and procedural services including but not limited to bariatric surgery, breast reconstruction (non-mastectomy), proton beam therapy, joint replacement, spinal surgery, sinus procedures (sinuplasty), rhinoplasty for functional impairment, sleep apnea procedures, femoroacetabular impingement surgery, vein procedures, ventricular assist devices, and neurostimulator implantation; CPT/HCPCS codes for these services are enumerated in the service lists.
Home health and personal care services
- Prior authorization is required for home health services in outpatient settings and for personal care services; selected CPT/HCPCS codes (for example 97535, 97537, 99381-99382, T1000-T1005, T1019, T1021-T1031 and others) may require prior authorization and documentation such as a face-to-face visit within specified timeframes.
Imaging and diagnostics
- Prior authorization is required for many advanced imaging studies when not otherwise excluded; positron emission tomography (PET) scans are not covered unless medically necessary and prior authorization is obtained (example codes 78459, 78491, 78492, 78811).
Experimental, investigational or unclassified codes
- Prior authorization is required for services and items determined experimental or investigational and for certain unclassified (J3490/J3590/C9399) codes when they are used for specific high-cost or new therapies (examples and effective dates may be noted in the service listings).
  Some prior authorization effective dates (e.g., 12/22/2025) are called out for specific products; check plan updates for current effective dates.
Operational notes
- Providers should submit authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool; sign in with One Healthcare ID. Contact numbers and portal navigation are provided in the plan guidance.
- For chemotherapy and many injectable medications, call 888-397-8129 if not using the portal.
- Always verify member-specific benefit coverage and referral or network requirements — some services require referral to designated behavioral health networks or other contracted providers.

CPT, HCPCS, ICD-10 and Other Codes Referenced

Selected bariatric surgery CPT codesCPTCovered

43644	Bariatric surgery CPT code listed requiring prior authorization
43645	Bariatric surgery CPT code listed requiring prior authorization
43770	Bariatric surgery CPT code listed requiring prior authorization
43775	Bariatric surgery CPT code listed requiring prior authorization
43842	Bariatric surgery CPT code listed requiring prior authorization
43845	Bariatric surgery CPT code listed requiring prior authorization
43847	Bariatric/obesity-related surgery CPT code listed requiring prior authorization
43848	Bariatric/obesity-related surgery CPT code listed requiring prior authorization

BRCA genetic testing codesCPTCovered

81162	BRCA genetic testing code
81166	BRCA genetic testing code
81163	BRCA genetic testing code
81212	BRCA genetic testing code
81164	BRCA genetic testing code
81432	BRCA genetic testing code
81165	BRCA genetic testing code

Selected injectable/supportive care J- and Q-codesHCPCSCovered

J1448	Injectable colony-stimulating factor drug (requires prior authorization)
Q5101	Colony-stimulating factor drug code (requires prior authorization)
Q5122	Colony-stimulating factor drug code (requires prior authorization)
J1434	Injectable medication code listed
J2468	Injectable medication code listed
J1442	Colony-stimulating factor (also requires PA for non-oncology DX)

Selected cardiovascular ICD-10 codesICD-10

I70.221	ICD-10 peripheral vascular disease code listed in cardiovascular section
I70.222	ICD-10 peripheral vascular disease code listed in cardiovascular section
I70.231	ICD-10 peripheral vascular disease code listed in cardiovascular section

Osteomyelitis-related ICD-10 codes (partial)ICD-10

M86.40	Diagnosis code referenced
M86.451	Diagnosis code referenced
M86.452	Diagnosis code referenced
M86.459	Diagnosis code referenced

Cosmetic and reconstructive procedure CPT codes (partial)CPT

19303	Breast reconstruction/reduction related CPT shown
58541	Hysterectomy/reproductive CPT shown

DME/monitor HCPCS codes (partial)HCPCS

E0787	Continuous glucose monitor HCPCS
E0465	DME HCPCS
E2310	DME HCPCS

Chemotherapy-related E- and K- codes listedHCPCS

E1130
E1161
E1229
E1231
E2310
K0005
K0812
K0884

Genetic/molecular testing CPT and U-codesmixedCovered

81162	Genetic/molecular testing codes (BRCA and others)
81229
81401
81414
81520
81595
0037U	U-code genetic/molecular testing examples
0211U
0274U
0379U

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Sample U-codes (chemotherapy/testing)HCPCS

0293U	U-code listed for chemotherapy-related prior authorization
0294U	U-code listed for chemotherapy-related prior authorization
0306U	U-code listed for chemotherapy-related prior authorization
0307U	U-code listed for chemotherapy-related prior authorization

Representative J-codes for injectable medicationsHCPCSCovered

J9041	Bortezomib (Velcade) - injectable medication
J2506	Neulasta - injectable medication
J9312	Rituxan - injectable medication
J9271	Keytruda - injectable medication

Chemotherapy and specialty drug HCPCS/J-codesHCPCS

J9334	Vyxeos
J9153
J0218	Xenpozyme
J0775	Xiaflex
J9228	Yervoy
J9352	Yondelis
J9400	Zaltrap
J3399	Zolgensma
J3393	Zynteglo
J1558	Xembify

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Chemotherapy CPT/HCPCS coding referencesmixed

No codes listed

Procedure and device codes (partial)HCPCS

J7330

Example HCPCS code listed in joint/hip section

Sample CPT/HCPCS codes referencedmixed

27120	Joint, total hip (example listed)
27130	Joint, total hip (example listed)
21121	Orthognathic/maxillofacial surgery example code
L0112	Orthotic supply example code

Orthotics/Prosthetics L-codes (examples)HCPCSCovered

L0112	Orthotic/prosthetic supply code listed
L0464	Orthotic/prosthetic supply code listed
L0631	Orthotic/prosthetic supply code listed
L1945	Orthotic/prosthetic supply code listed
L4000	Orthotic/prosthetic supply code listed

PET scan CPT codesCPTCovered

78459	PET scan
78491	PET scan

Spinal surgery CPT codes (examples)CPTCovered

22100	Spinal surgery code
22532	Spinal fusion/related surgery

Selected CPT/HCPCS codes requiring prior authorization (partial listing from part 9)mixedCovered

31297	Sinuplasty
31298	Sinuplasty
21685	Sleep apnea procedures
95782	Sleep apnea related code listed
22100	Spinal surgery (example)
22551	Spinal surgery list (examples)
22899	Spinal/other surgery codes
63047	Spine surgery codes
64553	Neurostimulator related codes
L8680	Implantable device supply codes

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Non-oncology PA requirement (selected J-/Q-codes)

Codes listedJ1442, J1447, J1448, J2506, J2820, J0897, Q5101, Q5108, Q5110, Q5120, Q5122, Q5125 (these J- and Q-codes require prior authorization; some also require PA when billed for non-oncology diagnoses)

ScopeApplies to injectable colony-stimulating factor and other supportive care drugs administered in an outpatient setting

How to request PA

Submission Instructions and Provider Requirements

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal at UHCprovider.com using your One Healthcare ID, or by phone at 877-842-3210. For Pediatric Care Network (PCN) prior auth requests call 833-802-6427 (8 a.m. - 5 p.m. CT weekdays). Prior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all procedures/services except emergent/urgent care.

Online: UHCprovider.com -> Sign In with One Healthcare ID -> Prior Authorization and Notification tool
Phone: 877-842-3210
PCN prior auth phone: 833-802-6427 (8 a.m. - 5 p.m. CT weekdays)

Prior Authorization

Behavioral health prior authorization instructions

Behavioral health services and applied behavior analysis (ABA) therapy require prior authorization; for specific behavioral health codes call the number on the member's health plan ID card. ABA submissions may be sent via fax or Provider Express.

Definitions and Reference Terms

Prior authorization

DefinitionPrior authorization: approval required from the plan before performing certain services to be eligible for reimbursement

Submission methodsOnline via Prior Authorization and Notification tool on UHCprovider.com (One Healthcare ID) or by phone at 877-842-3210; PCN PA by phone at 833-802-6427

ExceptionsNot required for emergency or urgent care; out-of-network providers must request PA for all non-emergent services

DME

DefinitionDME: Durable medical equipment requiring prior authorization when retail purchase or cumulative rental cost is more than $500

Sample HCPCSA4618, A7027, E0194 (document lists multiple DME HCPCS examples)

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Kansas Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID or by phone at 877-842-3210.

SourceLink

On This Page

Submit via Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or see injectable medications section for instructions

DME prior authorization threshold

ThresholdPrior authorization required when retail purchase or cumulative rental cost exceeds $500

Examples of DME codes listedA4618, A7027 (document includes many E-/A- HCPCS DME codes)

ExclusionsProsthetics are not considered DME for this threshold

Unclassified-code prior auth effective date

Effective datePrior authorization effective 12/22/2025 for Aucatzyl (applies to specified unclassified codes)

Affected unclassified codesJ3490, J3590, C9399 (prior authorization required for specified products billed under these codes)

Provider actionFor some unclassified-code items, call the notification number on the back of the member's ID and fax forms provided by the nurse

Call the number on the member's health plan ID card for specific behavioral health prior authorization requirements

Submit ABA therapy via fax or Provider Express

Prior Authorization

Cancer supportive care prior authorization

Prior authorization is required for cancer supportive care, including colony-stimulating factor drugs and certain injectable supportive-care medications; specified J- and Q-codes (for example J1448, Q5101, Q5122, J1434, J2468, J1442, J2506, J1447, J2820) are listed and some codes also require PA when billed for non-oncology diagnoses.

Colony-stimulating factor and bone‑modifying agents administered outpatient for a cancer diagnosis require prior authorization
Codes J1442, J1447, J1448, J2506, J2820, J0897, Q5101, Q5108, Q5110, Q5120, Q5122, Q5125 also require PA for non‑oncology diagnoses

Prior Authorization

Prior authorization for injectable chemotherapy

Prior authorization is required for injectable chemotherapy drugs administered in an outpatient setting for a cancer diagnosis. Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-397-8129 to submit requests.

Includes chemotherapy injectable drugs billed J9000–J9999, leucovorin (J0640/J0641/J0642), Lupron Depot (J1950), Q‑coded chemotherapy, and miscellaneous HCPCS for drugs without assigned codes
Submit via Provider Portal Prior Authorization and Notification tile or call 888-397-8129

Prior Authorization

Cochlear and auditory implants prior authorization

Cochlear and other auditory implants require prior authorization.

Example codes listed include 69710, 69930, L8614, L8619

Prior Authorization

DME prior authorization threshold

Prior authorization is required for the DME codes listed when the retail purchase or cumulative rental cost exceeds $500; note that prosthetics are not considered DME.

Threshold that triggers PA: retail purchase or cumulative rental cost > $500
Example DME codes referenced: A4618, A7027

Prior Authorization

Enteral services prior authorization

Enteral/in‑home nutritional therapy delivered enterally or via gastrostomy tube requires prior authorization.

Example mapping codes: S1040, T1999, V2786

Prior Authorization

Genetic and molecular testing prior authorization/notification

Genetic and molecular testing performed in an outpatient setting (including BRCA and numerous U‑codes/CPT codes) requires prior authorization/notification; providers must complete the prior authorization/notification process and indicate the laboratory and test name for payment authorization of registered CPT codes.

Prior authorization required for numerous CPT and U‑codes (examples: 81162, 81414, 81520, 0037U, 0211U)
Authorization/notification process must include laboratory and test name

Prior Authorization

Home health prior authorization (outpatient/home)

Home health services provided in outpatient settings, including the member's home, require prior authorization.

Example CPT/HCPCS codes listed: 97535, 97537, 99381, 99382

Prior Authorization

Experimental/investigational items

Items designated experimental and investigational require prior authorization.

Some items are explicitly marked experimental/investigational in the listing and thus need PA

Prior Authorization

Injectable medications prior authorization

Prior authorization is required for injectable medications.

The document lists numerous injectable medication HCPCS/J‑codes that require prior authorization

Documentation Required

Face-to-face documentation requirement

Documentation of a face‑to‑face visit within 90 days prior to certain services is required for prior authorization.

Face‑to‑face visit documentation requirement applies to listed services and codes; timing specified as within 90 days before the service

Documentation Required

Chemo drug codes and prior authorization

Chemotherapy and related drug entries list numerous HCPCS/J‑codes that require prior authorization or reference how to obtain prior authorization; providers should follow the listed submission instructions for those codes.

Examples of listed chemo/supportive codes: J9334 (Vyxeos), J1442, J1447, J1448, J2506, Q5101, Q5122

Prior Authorization

Additional chemo codes

Additional chemotherapy‑related HCPCS codes (including named drugs) are listed with prior authorization indicated.

Examples: J0218 (Xenpozyme), J0775 (Xiaflex), J1737 (Xifyrm)

Prior Authorization

Specialty oncology drug codes

Multiple specialty oncology HCPCS/J‑codes are listed and referenced as requiring prior authorization; providers must follow the PA process for these specialty drugs.

Examples include J9228 (Yervoy), J9352 (Yondelis), J9400 (Zaltrap), Q5101 (Zarxio)

Documentation Required

Policy reference and predetermination recommendation

Providers should consult the Community Plan Medical Benefit Drug Policy and the 'Market Medications – Review at Launch for New to Market Medications' guidance for up‑to‑date prior authorization and predetermination requirements; predetermination is highly recommended for drugs on the Market Medications list.

Check Community Plan Medical Benefit Drug Policy and Market Medications Review at Launch guidance for current PA/predetermination rules
Predetermination is highly recommended for drugs on the Market Medications list

Prior Authorization

Predetermination and prior authorization guidance

Predetermination (advance review) is highly recommended for drugs included on the Market Medications list; prior authorization for chemotherapy drugs is handled per the Community Plan Medical Benefit Drug Policy.

Predetermination helps establish coverage/authorization before administration
Follow Community Plan Medical Benefit Drug Policy for chemotherapy PA handling

Documentation Required

Where to find codes and submission instructions

CPT, HCPCS and U‑codes used for chemotherapy and other listed services and instructions for obtaining prior authorization are specified in the Community Plan listings; follow those entries for code‑specific submission guidance.

The document references specific CPT/HCPCS/U codes and indicates how to obtain prior authorization via the Community Plan listings

Prior Authorization

Drug prior notification / prior authorization instructions

Obtain prior notification for Cimzia and Synagis through OptumRx prior notification services at 800-310-6826. For prior authorization, submit requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-397-8129.

OptumRx prior notification phone for Cimzia and Synagis: 800-310-6826
Prior authorization via Provider Portal Prior Authorization and Notification tool or phone 888-397-8129

Prior Authorization

Procedure prior authorization requirements (partial list)

Many procedures and device categories (for example joint replacement, orthognathic surgery, orthotics) are marked 'Prior authorization required' in their category entries and list associated CPT/HCPCS codes; obtain prior authorization before scheduling these services.

Examples: joint replacement and total hip/knee procedure codes in the listing require PA
Orthotics/prosthetics L‑codes listed require PA

Documentation Required

Predetermination recommendation for Market Medications

Predetermination is highly recommended for drugs on the Market Medications list; consult the Review at Launch for New to Market Medications policy for guidance.

Predetermination recommended to establish coverage/authorization before administration
See Community Plan Medical Benefit Drug Policy guidance

Prior Authorization

Orthotics/Prosthetics prior authorization (codes excerpt)

Orthotics and prosthetics L‑codes enumerated in the document require prior authorization.

Examples of listed L‑codes: L0112, L0464, L0631, L1945, L4000 (and many others enumerated)

Denial Risk

PET scans (coverage and PA requirement)

Positron emission tomography (PET) scans are not a covered benefit unless medically necessary and require prior authorization; CPT examples listed include 78459, 78491, 78811, 78492, 78608.

PET CPT codes listed: 78459, 78491, 78811, 78492, 78608
Coverage only when medical necessity is demonstrated and PA is obtained

Prior Authorization

Personal care services prior authorization

Personal care services require prior authorization.

Example code: T1019

Prior Authorization

Private duty nursing prior authorization

Private duty nursing requires prior authorization.

Example code: T1000

Prior Authorization

Prostate procedures prior authorization

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

Obtain PA prior to prostate procedures identified in the listing

Prior Authorization

Proton beam therapy prior authorization

Proton beam therapy requires prior authorization.

Example CPT codes: 77520, 77522, 77523, 77525

Prior Authorization

Rhinoplasty / septal procedures prior authorization

Rhinoplasty for nasal functional impairment and septal procedures require prior authorization; example CPT codes include 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462.

Obtain PA for rhinoplasty/septal procedures listed

Prior Authorization

Sinuplasty prior authorization

Sinuplasty procedures have entries marked as requiring prior authorization for listed CPT codes (31295–31298).

Sinuplasty CPT codes listed: 31295, 31296, 31297, 31298

Prior Authorization

Sleep apnea procedures prior authorization

Sleep apnea procedures and related sleep study codes require prior authorization.

Example codes: 21685, 41599, 42145, 95782, 95800, 95801, 95805, 95806

Prior Authorization

Spinal surgery prior authorization

Spinal surgery requires prior authorization; numerous spinal procedure CPT codes are listed in the document and must have PA prior to service.

Examples of listed spinal codes: 22100, 22101, 22102, 22110, 22112, 22532, 22533

Prior Authorization

Transplant and CAR T-cell therapy notification

For transplant and CAR T‑cell therapy services (including Abecma, Breyanzi, Carvykti, Kymriah, Lenmeldy, Lyfgenia, Ryoncil, Tecartus, Yescarta), call the UnitedHealthcare Community and State Transplant Case Management team at 888-936-7246 or use the notification number on the back of the member's health plan ID card.

Transplant/CAR‑T services: contact Transplant Case Management at 888-936-7246
Or call the notification number on the back of the member's health plan ID card

Prior Authorization

Unclassified drug code prior auth instructions

For unclassified drug codes (e.g., J3490, J3590, C9399) prior authorization is required for specified products (examples: Casgevy, Omisirge, Aucatzyl); prior authorization for Aucatzyl is effective 12/22/2025. For some unclassified‑code items providers should call the notification number on the back of the member's ID and fax forms provided by the nurse.

Unclassified codes J3490, J3590, C9399 require PA for specified products
PA effective date for Aucatzyl: 12/22/2025
For some items, call the notification number on the back of the member's ID card and fax nurse‑provided forms

Prior Authorization

Device and procedure prior authorization notes (wound vac, vein procedures, VAD, implants)

Wound vacs, vein procedures (saphenous vein ablation/removal), ventricular assist devices (VAD) and many device implantations are listed as requiring prior authorization; some VAD device supplies may be noted as not covered.

Wound vacs require prior authorization
Vein procedures and VADs require prior authorization; some VAD supplies may be non‑covered

NoteProsthetics are not classified as DME for this threshold; see orthotics/prosthetics section for L-codes

Injectable chemotherapy

DefinitionInjectable chemotherapy: chemotherapy injectable drugs (J9000–J9999), select leucovorin codes (J0640, J0641, J0642), Lupron Depot (J1950), Q-coded chemotherapy, and miscellaneous HCPCS for unassigned products

SettingPrior authorization required for outpatient administration for a cancer diagnosis (intravenous, intravesical, intrathecal)

How to request PAUse the Prior Authorization and Notification tool on UHCprovider.com or call 888-397-8129

prior authorization/notification process

How to submitSubmit PA requests via the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal (UHCprovider.com) or call 888-397-8129 / 877-842-3210 as applicable

PCN requestsPediatric Care Network (PCN) prior authorization by phone at 833-802-6427 (8 a.m. - 5 p.m. CT weekdays)

OptumRx prior notificationCertain drugs (e.g., Cimzia, Synagis) require prior notification through OptumRx at 800-310-6826

Enteral services

DefinitionEnteral services: in‑home nutritional therapy delivered enterally or via gastrostomy tube

RequirementPrior authorization required for enteral/in‑home nutritional therapy

Sample mapping codesS1040, T1999, V2786 (used to map testing/ordering and PA workflows)

Home health services

DefinitionHome health services: services provided in outpatient settings including the member's home

RequirementPrior authorization required only when home health services are provided in outpatient settings (including the home)

Sample CPTs97535, 97537, 99381, 99382 (listed examples)

Injectable medications

DefinitionInjectable medications: multiple injectable drugs listed throughout the document require prior authorization

ExamplesJ9041 (bortezomib), J2506 (Neulasta), J9312 (rituximab), J9271 (pembrolizumab) appear as representative J‑codes requiring PA

Related noteSome injectable colony‑stimulating factor codes also require PA for non‑oncology diagnoses (see non‑oncology PA requirement)

Review at Launch for New to Market Medications

PurposeReview at Launch for New to Market Medications: policy for handling newly FDA‑approved drugs included on the Market Medications list

RecommendationPredetermination is highly recommended for drugs on the Market Medications list (use Community Plan Medical Benefit Drug Policy guidance)

Where to find detailsSee the Community Plan Medical Benefit Drug Policy and Review at Launch guidance in Drug Policies and Coverage Determination Guidelines

Predetermination recommended

DefinitionPredetermination: recommended advance review process to establish coverage/authorization before drug administration for items on the Market Medications list

RecommendationPredetermination is highly recommended for drugs on the Market Medications list

ReferenceGuidance available via the Community Plan Medical Benefit Drug Policy and Review at Launch materials

Predetermination (definition)

DefinitionPredetermination: an advance review process to determine coverage/authorization for Market Medications prior to administration

When usedApplied to drugs newly approved by the FDA and included on the Market Medications list

Action for providersSubmit predetermination requests per Community Plan Medical Benefit Drug Policy procedures

Community Plan Medical Benefit Drug Policy (definition/reference)

DefinitionCommunity Plan Medical Benefit Drug Policy: payer policy containing drug‑specific prior authorization rules, coding guidance, and Review at Launch procedures

UseReferenced for guidance on Market Medications, predetermination, and PA submission requirements

AccessPolicy is available in the Community Plan Drug Policies and Coverage Determination Guidelines (document references location)

Market Medications / Review at Launch (definition)

DefinitionMarket Medications / Review at Launch: drugs newly approved by the FDA included on the payer's Market Medications list evaluated under the Review at Launch process

ImplicationDrugs on this list are candidates for predetermination and special handling per the Review at Launch policy

Guidance sourceSee Community Plan Medical Benefit Drug Policy for procedures and predetermination recommendations

Prior notification (OptumRx) contact/process

Contact for OptumRx prior notification800-310-6826 (use for Cimzia and Synagis prior notification)

When to useRequired prior notification for specific drugs (Cimzia, Synagis) routed through OptumRx prior notification services

PA submissionFor prior authorization, submit online via Provider Portal Prior Authorization and Notification tool or call 888-397-8129

Not a covered benefit unless medically necessary (example: PET)

DefinitionNot a covered benefit unless medically necessary: service (example PET scans) is not covered unless medical necessity is demonstrated and prior authorization is obtained

ExamplePET scans listed with CPTs 78459, 78491, 78492, 78608 — not covered unless medically necessary and PA obtained

Provider implicationObtain prior authorization and document medical necessity to secure coverage for such services

Prior authorization required (definition/expectation)

DefinitionPrior authorization required: providers must obtain approval before delivering listed services to be eligible for reimbursement

Examples of services requiring PAPersonal care (T1019), Private duty nursing (T1000), Proton beam therapy (77520, 77522, 77523, 77525), Spinal surgery (multiple CPTs)

How to requestSubmit requests via Provider Portal Prior Authorization and Notification tool or call 888-397-8129 as directed in code entries

Transplant/CAR-T notification (contact reference)

Notification contactUnitedHealthcare Community and State Transplant Case Management team: 888-936-7246 (call for transplant and CAR T-cell therapy services)

When to callFor transplant and CAR T-cell services including Abecma, Breyanzi, Carvykti, Kymriah, Lenmeldy, Lyfgenia, Ryoncil, Tecartus, Yescarta

Alternate methodOr use the notification number on the back of the member's health plan ID card