CurrentUnitedHealthcarePolicy PCA-5-23-01819-POE-WEB_07132023

Prior authorization requirements for Minnesota Medicaid

Lists services, codes, and submission methods that require prior authorization for UnitedHealthcare Community Plan of Minnesota providers (including Senior Care Options, Senior Care Plus, Special Needs Basic Care, Long Term Services and Support). It details how to submit requests and notes exceptions for emergency/urgent care and out-of-network rules.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Minnesota Medicaid

Policy CodePolicy PCA-5-23-01819-POE-WEB_07132023

Change TypeNo material changes

Effective DateJul 1, 2024

Next Review Date

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone at 877-440-9946.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Portal & Phoneways to submit prior authorization requests

2024-07-01policy effective date shown on header

$500DME prior authorization threshold noted

EnteralEnteral services flagged

Gender dysphoria

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.

Gender-affirming procedures listed

Services and Coverage Criteria Requiring Prior Authorization

inv-01: Services requiring prior authorization

Covered services that require prior authorization include (but are not limited to):

Bariatric surgery (Centers of Excellence requirement) — examples: CPT 43644, 43775, 43645, 43842, 43659, 43845, 43770, 43846.

Behavioral health services — refer to the member's plan ID card for the specific referral/prior authorization contact information.

Bone growth stimulators — examples: CPT 20975, 20979; HCPCS E0760.

Breast cancer (BRCA) genetic testing — examples: CPT 81162, 81432, 81163, 81433, 81164, 81212.

Cancer supportive care injectables (colony-stimulating factors) — examples: J1442, Q5101, Q5110, Q5122, J2506, Q5120, Q5111, Q5108, J1447.

Chemotherapy injectable drugs administered outpatient — examples: J9000-J9999, J0640, J0641, J0642, J1950 and related Q-code oncology injectables.

Cardiovascular/cardiology procedures — examples: CPT 37225, 37229, 37231 (see cardiology-specific submission details).

Cochlear and other auditory implants — examples: CPT 69710, 69714, 69930; HCPCS L8614, L8691, L8692, H2012.

Chiropractic and cognitive rehabilitation services — prior authorization required for listed codes and settings.

Cosmetic and reconstructive procedures — numerous CPT/HCPCS and some ICD-10-coded procedures require prior authorization (examples in policy excerpt).

inv-02: Prior authorization coverage criteria (partial)

Partial list of additional services requiring prior authorization:

Durable medical equipment (DME) — listed HCPCS items require prior authorization; some items only require authorization when rental or retail purchase cost thresholds are met (see DME cost threshold).

See HCPCS examples and cost-threshold rules in policy.

Enteral services — prior authorization required (examples: HCPCS B9002, B9998).

Experimental / investigational procedures — marked procedures require prior authorization (examples: CPT 33477, 36514, 64722, 65765, 65767, 66180).

Gender dysphoria treatments and related reconstructive procedures — prior authorization required for multiple CPT codes (examples include 14000, 14001, 14040, 14302, 15734, 15738, 15750, 15757, 19303).

inv-03: Prior authorization / notification criteria (partial)

Listed services require prior authorization or prior notification; follow UnitedHealthcare submission instructions when submitting requests:

Injectable medications and specialty drugs — numerous injectable medications require prior authorization; providers should submit requests via the Prior Authorization and Notification tool or the phone number specified for injectable prior auths (policy lists many J-/C-/G-codes).

See injectable medication code examples in the policy.

Genetic and molecular testing — prior authorization or prior notification required for molecular and genetic tests (examples: CPT 81228, 81400, 81401–81417, temporary codes in 0250U–0300U range).

Ordering provider must follow BRCA notification process for DNA sequencing; laboratory notifies UnitedHealthcare as required.

Home health care, hysterectomy, joint replacement, orthognathic and other musculoskeletal procedures — prior authorization required for listed procedures (examples: G0299, G0495 for home health; hysterectomy CPTs such as 58150, 58152, 58180; orthognathic and musculoskeletal codes listed elsewhere in policy).

Non-emergent air ambulance transport — prior authorization required (examples: A0430, A0431, A0435, A0436, S9960, S9961).

inv-04: Code-based prior authorization requirements

Code-based prior authorization requirements by category (examples):

Orthognathic surgery codes — prior authorization required for enumerated CPTs including 21151, 21154, 21155, 21159, 21160, 21188, 21193–21196 and many additional 211xx–212xx codes.

Orthopedic surgery codes — prior authorization required for listed orthopedic CPTs such as 24365, 25441–25449, 27700, 29834–29899 (policy lists many specific codes).

Orthotics and prosthetics (HCPCS L-codes) — many L-codes are listed; prior authorization is required only when retail purchase or cumulative rental cost exceeds $500 (examples: L0112, L0170, L0456, L0462, L0464, L0480, L0482, etc.).> $500

See full L-code list in policy.

inv-05: Primary coverage criteria

Primary coverage categories and representative codes requiring prior authorization:

Pain management procedures — prior authorization required for intrathecal/epidural and related codes (examples: CPT 62350, 62351, 62360, 62361, 62362).

Radiation therapy / advanced outpatient imaging — prior authorization/notification required for radiation therapy codes (examples: 77520, 77522, 77523, 77525) and for certain advanced outpatient imaging procedures (CT, MRI, MRA, PET, nuclear medicine).

Ordering clinicians responsible for prior notification before scheduling; use the Prior Authorization and Notification tool or call the portal number.

Spinal surgery — prior authorization required for many spinal surgery CPTs (examples include 20930, 20931, 20939, 22100, 22510 and numerous additional spinal procedure codes).

Stimulators and implantable devices — implantation of devices that send electrical impulses requires prior authorization (examples: HCPCS E0749; CPTs such as 61863–61868, 63650, 63655, 63685, 64553, 64555, 64568, 64570; HCPCS L8680, L8682–L8688).

Codes and Coding Rules

Cosmetic / Reconstructive CPT codes (prior authorization)CPT

11960	Subcutaneous injection; with implant of filler material (e.g., collagen)
11971	Removal of implanted material from subcutaneous tissue
14020	Adjacent tissue transfer or rearrangement, forehead (eg, for repair of defect)
14021	Adjacent tissue transfer or rearrangement, eyelid
14041	Adjacent tissue transfer or rearrangement, cheek
14060	Adj tissue transfer, nose
14061	Adj tissue transfer, nose (complex)
14301	Reconstruction of full-thickness burn defect
15820	Revision of reconstructed breast
15821	Revision of breast reconstruction, periareolar approach

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BRCA genetic testing CPT codes (prior authorization required)CPTCovered

81162	BRCA1 and BRCA2 full sequence analysis (may be panel)
81432	BRCA1/BRCA2 comprehensive analysis (multigene)
81163	BRCA1 duplication/deletion analysis
81433	BRCA1/BRCA2 duplication/deletion
81164	BRCA1/BRCA2 targeted mutation analysis
81212	BRCA1/BRCA2 single site testing

Cancer supportive care — colony stimulating factors (prior authorization)HCPCSCovered

J1442	Filgrastim (Neupogen)
J1447	Tbo-filgrastim (Granix)
Q5101	Filgrastim biosimilar (Zarxio)
Q5110	Filgrastim-aafi (Nivestym)
Q5108	Pegfilgrastim-jmdb (Fulphila)
Q5111	Pegfilgrastim-cbqv (UDENYCA)
Q5120	Pegfilgrastim-bmez (Ziextenzo)
Q5122	Pegfilgrastim-apgf (Nyvepria)
J2506	Pegfilgrastim (Neulasta)
J1447	Tbo-filgrastim (Granix) duplicate

Chemotherapy injectables (prior authorization required)HCPCSCovered

J9000-J9999	Chemotherapy injectable drug range
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin, other
J1950	Leuprolide acetate (Lupron Depot)
Q codes	Chemotherapy drugs with Q-codes (as listed)
Miscellaneous HCPCS (e.g., J3490/J3590)	Drugs not yet assigned a specific code billed under miscellaneous HCPCS

Auditory and cochlear implant codes (prior authorization)CPTCovered

69710	Cochlear implant or auditory brainstem implant procedure
69714	Removal or revision of cochlear implant
69930	Implantation of auditory brainstem implant
L8614	Cochlear device prosthesis
L8691	Internal component auditory implant
L8692	External component auditory implant
H2012	Behavioral health related code referenced for related services

ICD-10 diagnosis codes referenced (partial list)ICD-10

C43.0	Melanoma of lip
C43.10	Melanoma of eyelid
C43.111	Melanoma of right eyelid
C43.112	Melanoma of left eyelid
C44.01	Basal cell carcinoma of lip
C44.02	Squamous cell carcinoma of lip
C44.101	Malignant neoplasm of skin of unspecified eyelid
D04.9	Carcinoma in situ of skin, unspecified

DME HCPCS codes that may require prior authorizationHCPCSCovered

A9279	Orthopedic/other procedure code (DME)
A9280	DME supply code
A9900	Miscellaneous DME supply
E0194	DME: wheelchair accessory
E0265	DME: lower extremity prosthesis
E0266	DME: lower extremity prosthesis
E0270	DME: prosthetic accessory
E0277	DME: knee orthosis
E0300	DME miscellaneous
E0328	DME: power wheelchair component

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Sample CPT/HCPCS codes requiring prior authorization (examples)mixed

33477	Cardiac procedure (example investigational)
36514	Infusion catheter placement (example)
64722	Neurostimulator implantation (example)
65765	Corneal transplant (example)
65767	Corneal transplant, other
66180	Eye surgery (example)
A4638	Medical device (investigational)
A6000	Device supply code

Genetic and molecular testing codes (prior authorization)CPTCovered

81401	Molecular pathology procedure level 1
81402	Molecular pathology procedure level 2
81403	Molecular pathology procedure level 3
81404	Molecular pathology procedure level 4
81405	Molecular pathology procedure level 5
81406	Molecular pathology procedure level 6
81407	Molecular pathology procedure level 7
81408	Molecular pathology procedure level 8
81410	Targeted genomic sequence analysis panel
81411	Targeted genomic sequence analysis

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Listed CPT/HCPCS codes requiring prior authorization — examplesmixed

58542	Laparoscopy with removal of uterus (example)
58543	Laparoscopic hysterectomy
58544	Laparoscopic hysterectomy, radical
58550	Hysteroscopy
58552	Diagnostic hysteroscopy

Orthotics/Prosthetics L-codes (prior authorization threshold applies)HCPCSCovered

L0112	Ankle-foot orthosis, prefabricated
L0170	Ankle-foot orthosis, custom
L0456	Trunk orthosis
L0462	Thoracic-lumbar-sacral orthosis (TLSO)
L0464	Cervical orthosis
L0480	Lower limb prosthetic, preparatory
L0482	Lower limb prosthetic, preparatory, other
L0484	Lower limb prosthetic, definitive
L0486	Lower limb prosthetic, definitive, other
L0624	Foot orthosis

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Procedure CPT ranges often requiring authorization (examples)CPT

62350-62362	Epidural injection series for pain management (range includes 62350, 62351, 62360, 62361, 62362)
29914-29916	Arthroscopy procedures for femoroacetabular impingement (FAI)
31240-31288	Endoscopic sinus surgery and related functional procedures

How to Submit Requests, Notifications, and Provider Responsibilities

Prior Authorization

Experimental / Investigational — Prior Authorization Required

For services or procedures that are considered experimental or investigational, providers must obtain prior authorization before rendering the service. Prior authorization is required for all listed experimental/investigational CPT and HCPCS codes.

Prior authorization required for experimental/investigational services including (but not limited to): 33477, 36514, 64722, 65765, 65767, 66180, A4638, A6000, A9274, E0231, E1831, S0810, S1030, S1031, S2102, S9988

Prior Authorization

How to Obtain Prior Authorization / Notification

Submit prior authorization requests and required notifications through the UnitedHealthcare Provider Portal using the Prior Authorization and Notification tool (UHCprovider.com -> Sign In -> Prior Authorization and Notification). If you do not have a One Healthcare ID, visit UHCprovider.com/access. Phone submission options are available for certain programs (see specific program numbers below). 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 or urgent care. Advance notification is required for certain advanced outpatient imaging and laboratory/genetic testing per program guidance.

Definitions and Terms

inv-41: Prior authorization — definition/reference for prior authorization term

DefinitionPrior authorization: Request approval before rendering a service, as required by UnitedHealthcare policy; it is required under the direction of UnitedHealthcare Health Services and supports prospective, concurrent and retrospective care review.

When requiredRequired for many listed services and codes in this policy; not required for emergency or urgent care.

How to submitSubmit requests via the Prior Authorization and Notification tool on UHCprovider.com or by phone (877-440-9946) unless otherwise specified.

inv-42: Durable medical equipment (DME) — definition and notes about DME authorization conditions

DefinitionDurable medical equipment (DME): Equipment items identified by HCPCS codes (e.g., A9279, A9280, A9900, E0194, E0265, E0470) that may require prior authorization.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Minnesota Medicaid

Policy CodePolicy PCA-5-23-01819-POE-WEB_07132023

Change TypeNo material changes

Effective DateJul 1, 2024

Next Review Date

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone at 877-440-9946.

SourceLink

On This Page

Submission and notification process — submit prior authorization requests online via the Prior Authorization and Notification tool on UHCprovider.com or call the plan-specific number provided in the policy; specific services (e.g., BRCA testing) have defined notification workflows.

Transplant and CAR-T-cell therapy services — prior authorization required for transplant procedures and CAR-T-cell therapy services as specified in the policy.

Online: Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com).
Phone general prior authorization: 877-440-9946.
Program-specific phone numbers: Cardiology/electrophysiology implants: 866-889-8054; Advanced outpatient imaging and other program lines may also use 866-889-8054 or program-specific numbers as noted in topic sections.
For certain laboratory/genetic tests (eg, BRCA/DNA sequencing) the ordering provider must notify the laboratory, and the laboratory will notify UnitedHealthcare per program requirements.

Prior Authorization

Orthognathic Surgery — Prior Authorization Required

Orthognathic (maxillofacial/jaw) surgical procedures require prior authorization. Providers must request approval before performing these procedures.

Prior authorization required for orthognathic CPT codes including: 21151, 21154, 21155, 21159, 21160, 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21208, 21209, 21210, 21215, 21240, 21242, 21244, 21245, 21246, 21247, 21248, 21249, 21255, 21296, 21299

Prior Authorization

Orthognathic Surgery — Additional Codes / Notes

Additional orthognathic procedure codes are also subject to prior authorization; confirm and obtain approval prior to scheduling or performing surgery.

Additional orthognathic CPT codes that require prior authorization: 21198, 21199, 21206, 21208–21210, 21215, 21240–21249, 21255, 21296, 21299 (see full orthognathic list in policy).
Obtain prior authorization via the Provider Portal or applicable program phone line before treatment.

Prior Authorization

Orthopedic Surgery — Prior Authorization Required

Many orthopedic surgical procedures require prior authorization. Providers must obtain approval before performing the listed orthopedic surgeries.

Prior authorization required for orthopedic CPT codes including (but not limited to): 24365, 25441, 25442, 25444, 25446, 25449, 27700, 29834, 29837, 29838, 29840, 29844, 29845, 29846, 29847, 29891, 29892, 29894, 29895, 29897, 29898, 29899.
Submit prior authorization requests via the Provider Portal or applicable phone number prior to scheduling surgery.

Prior Authorization

Orthotics & Prosthetics — Prior Authorization and Cost Threshold

Orthotics and prosthetics require prior authorization only when the item is a retail purchase or when cumulative rental cost exceeds $500. Obtain authorization before providing such orthotics or prosthetics.

Prior authorization required for L-code orthotics/prosthetics when retail purchase or cumulative rental cost > $500. Examples of affected L-codes include: L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631, L0632, L0634, L0636, L0637, L0638, L0640, L0700, L0710, L0810, L0820, L0830, L0859, L1000, L1005, L1200, L1300, L1310, L1499, L1680, L1685, L1700, L1710, L1720, L1730, L1755, L1820, L1830, L1831, L8044–L8047, L8499, L8609, L8610, L8612, L8631, L8659, L8680–L8688 (see full list in policy).
When prior authorization is required, submit via the Provider Portal or applicable phone number before furnishing the item.

Authorization conditions

Some DME items always require prior authorization; others require authorization only when retail purchase or cumulative rental cost thresholds (e.g., $500) are met.

ExamplesListed DME HCPCS codes include A9279, A9280, A9900, E0194, E0265, E0300, E0328, E0445, E0470 and others.

Provider actionObtain prior authorization via the Provider Portal tool or phone before furnishing DME when required by code or cost threshold.

inv-43: Experimental and investigational — definition and note about requirement for prior authorization

DefinitionExperimental and investigational: Procedures or services identified in the policy as experimental/investigational are subject to prior authorization.

ExamplesListed examples include CPT codes 33477, 36514, 64722, 65765, 65767, 66180 and certain HCPCS codes (e.g., A4638, A6000).

RequirementProviders must obtain prior authorization for procedures designated investigational before providing the service.

inv-44: Prior notification — definition and context where notification (not full authorization) is required

DefinitionPrior notification: Advance notification to UnitedHealthcare that certain services (rather than full prior authorization) require notification before scheduling or testing (examples include BRCA testing and advanced outpatient imaging).

BRCA testingNotification/prior authorization required before DNA sequencing; the ordering provider must notify the laboratory and the laboratory will notify UnitedHealthcare.

Advanced imagingHealth care professionals ordering advanced outpatient imaging are responsible for providing notification prior to scheduling; use the Prior Authorization and Notification tool or call 866-889-8054.

inv-45: Prior authorization — secondary reference to term (duplicate inventory entry)

Definition (duplicate)Prior authorization: Request approval before rendering a service as required by UnitedHealthcare; supports prospective, concurrent and retrospective review. Not required for emergency/urgent care.

SubmissionUse the Prior Authorization and Notification tool on UHCprovider.com or call 877-440-9946 to submit prior authorization requests.

ApplicabilityApplies to participating providers across listed Minnesota plan lines; out-of-network providers must request prior authorization except for emergent/urgent care.

inv-46: Orthotics and prosthetics prior authorization threshold — threshold definition for orthotics/prosthetics (> $500)

Threshold (restated)Prior authorization required only for orthotics and prosthetics with a retail purchase or cumulative rental cost of more than $500.

Codes referencedPolicy enumerates many HCPCS L-codes (e.g., L0112, L0624, L0631, L0700, L0810) subject to this threshold rule.

Provider actionObtain prior authorization when the item’s retail purchase or cumulative rental cost exceeds $500 before providing orthotic or prosthetic services.

inv-47: Surgical prior authorization — definition noting listed orthognathic and orthopedic CPT code requirements

DefinitionSurgical prior authorization: Prior authorization is required for listed orthognathic and orthopedic surgery CPT codes included in the policy.

Orthognathic examplesCPT codes listed include 21151, 21154, 21155, 21159, 21160, 21188, 21193-21196, 21246-21255, 21296, 21299.

Orthopedic examplesOrthopedic CPT codes listed include 24365, 25441-25449, 27700, 29834-29899 and others that require prior authorization.

Provider actionSubmit prior authorization for these surgical procedures via the Provider Portal tool or the phone numbers listed before scheduling non-emergent surgeries.

inv-48: Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal — tool name and reference

Tool namePrior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com)

How to accessSign in at UHCprovider.com and select Prior Authorization and Notification on the Provider Portal dashboard; visit UHCprovider.com/access for One Healthcare ID information.

Phone alternativesPrimary phone contact for prior authorization submission is 877-440-9946; alternative numbers for specific programs include 866-889-8054 for advanced imaging and cardiology program contacts as noted.

ContextUse this tool for submitting prior authorization requests and for providing required notifications before scheduling certain services (e.g., advanced outpatient imaging).