UnitedHealthcare Missouri Medicaid Prior Auth Policy Update

Cardiology prior authorization criteria

Covered when ALL of the following are met:

ALL of the following

Prior authorization is required for outpatient and office-based diagnostic catheterizations, echocardiograms, electrophysiology implants and stress echoes prior to performance.
Submit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-889-8054.
Refer to the Cardiology Prior Authorization and Notification Program on UHCprovider.com/MOcommunityplan for the full CPT code list that requires prior authorization.

Prior authorization is not required for emergency or urgent care (see General prior authorization rules).

Other services requiring prior authorization

Covered when the specified service or code meets the listed requirement:

Bariatric surgery and specific obesity‑related services require prior authorization (example CPT codes: 43644, 43645, 43770, 43775, 43845, 43846, 43848, 43860).

Behavioral health services: prior authorization required for specific codes; providers should call the number on the member's health plan ID card for details and referral requirements.

Bone growth stimulator (electronic stimulation or ultrasound) requires prior authorization (CPT 20979).

Breast reconstruction (non‑mastectomy) procedures require prior authorization (multiple CPT codes listed in the coding section, e.g., 11971, 19316, 19318, 19325, 19328, 19330, etc.).

Partial coverage criteria (codes segment)

Covered when the following code‑specific notes apply:

Circumcision requires prior authorization only when there is documented medical necessity (example CPTs: 54161, 54162, 54163, 54164).

Cochlear implants and other auditory implants require prior authorization (example CPTs/HCPCS: 69714, 69930, L8614, L8619).

Cosmetic procedures that change or improve physical appearance without significantly improving or restoring physiological function require prior authorization (examples include 11960, 14020, 14021, 14041, 14061, 15820–15823, 15830, 15847, 17106).

Reconstructive procedures that treat a medical condition or improve physiological function are listed separately and may have different prior authorization notes (see reconstructive code lines).

Prior authorization coverage criteria (partial)

Covered when the code or service listed below is associated with prior authorization and any stated conditions:

Gastrostomy tube services — listed codes include 33477, 65767, E1831, 36514, 66180, 64722, A6000 and related codes; prior authorization is required (noted as experimental/investigational in the excerpt).

Femoroacetabular impingement syndrome (FAI) procedures require prior authorization (example CPT 29915; associated codes include 65767, E1831).

Functional endoscopic sinus surgery (FESS) procedures require prior authorization (example CPTs: 29914; endoscopic nasal/sinus codes: 31240, 31253, 31256, 31257, 31287).

Genetic and molecular testing performed in an outpatient setting requires prior authorization and completion of required documentation; numerous CPT/HCPCS codes listed (examples include 81162–81164, 81228, 81400–81405, 81410–81417, 81425–81427, 81431–81435, 81437–81448).

Durable Medical Equipment (DME) items listed require prior authorization when they meet retail purchase or cumulative rental cost thresholds; sample DME HCPCS include A9900, E0194, E0265, E0270, E0277, E0300, E0328–E0329, E0445, E0457, E0460–E0486.

Partial prior authorization requirements

Covered when the following conditions and code lists are met:

Genetic and molecular testing: authorization/notification process is required; providers must indicate the laboratory and test name. Payment is authorized for CPT codes registered with Genetic and Molecular lists (example codes: 81457, 81449, 81450, 81455, 81462, 81458–81460, 81518, 81463–81465).

Home health care (outpatient settings, including member's home) requires prior authorization for listed codes (examples: G0299, G0300, G0493, G0494, S3870).

Hysterectomy procedures require prior authorization for listed CPT codes (examples: 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58290, 58291, 58292, 58542–58544, 58550, 58552, 58553, 58570–58573).

Joint replacement (total hip and knee) procedures require prior authorization for listed codes (examples include 24360–24371 series, 27120, 27125, 27130, 27132, 27134, 27137–27138, 27412, 27446–27447, 27486–27487, 29866–29868, J7330).

Orthognathic surgery procedures require prior authorization for listed CPT codes (examples: 21121, 21123, 21125, 21127, 21141–21151, 21154–21160, 21188, 21193–21196, 21198–21199, 21206, 21208–21210, 21215, 21240–21249, 21255, 21296, 21299).

Prior authorization criteria (partial)

Covered when the following rules and code‑specific notes apply:

Orthotics and prosthetics: prior authorization required only for items with a retail purchase or cumulative rental cost greater than $500 (see HCPCS L‑codes listed).

Radiology: care providers ordering advanced outpatient imaging (certain CT, MRI, MRA, PET, nuclear medicine, nuclear cardiology) must provide notification prior to scheduling and submit prior authorization requests via the Provider Portal or call 866-889-8054.

Proton beam therapy: CPT codes 77520, 77522, 77523, 77525 require prior authorization.

Pain management injection procedures (examples: CPT 64490, 64493) require prior authorization.

Prior Authorization and Site-of-Service Rules

Covered when the following site‑of‑service and procedure rules apply:

Proton beam therapy (CPT 77520, 77522, 77523, 77525) requires prior authorization.

Advanced outpatient imaging (certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology) requires notification prior to scheduling and prior authorization submission via the Provider Portal or by calling 866-889-8054.

ALL of the following

ONE of: Sinuplasty procedures require prior authorization (CPTs 31295–31298).
ONE of: Septoplasty and rhinoplasty for nasal functional impairment and septal deviation require prior authorization (example CPTs 30460, 30462, 30465).

Prior authorization-required procedures (excerpt)

Covered when the listed surgical and diagnostic procedures meet the code‑specific prior authorization requirement:

Maxillomandibular advancement and oral‑pharyngeal tissue reduction for treatment require prior authorization (example CPTs: 21685, 41599, 42145).

Sleep studies — attended (CPTs 95805, 95807, 95808, 95810) and unattended (CPTs 95800, 95801, 95806) — require prior authorization.

Spinal surgery procedures require prior authorization (sample CPTs include 22100, 22101, 22102, 22112, 22114, 22206, 22207, 22210, 22212, 22214, 22220 and additional spinal surgery codes listed).

Prior authorization and special instructions

Covered when the following special instructions and service‑specific contacts are followed:

Stimulator implantation (including bone growth stimulators and neurostimulators) requires prior authorization (see coding module for applicable CPT/HCPCS codes, e.g., bone growth stimulator).

Transplants and CAR T‑cell therapy require prior authorization. Contact UnitedHealthcare Community and State Transplant Case Management at 888-936-7246 or use the notification number on the member's health plan ID card. Note: some inpatient transplant procedures may be carved out to the state.

Ventricular assist device (VAD) services require prior authorization. Call the notification number on the member's health plan ID card and fax the nurse‑provided form to Optum at 855-282-8929.

Vein procedures require prior authorization (example CPTs: 36473, 36475, 36478, 37700).

NOTE: Code 38232: prior authorization is conditional — code 38232 will only require prior authorization for specified cases per the policy notes.

Code Lists and Coding Details

Selected bariatric surgery CPT codes requiring prior authorizationCPTCovered

43644	Bariatric surgery CPT code listed as requiring prior authorization
43645	Bariatric surgery CPT code listed as requiring prior authorization
43770	Bariatric surgery CPT code listed as requiring prior authorization
43775	Bariatric surgery CPT code listed as requiring prior authorization
43845	Bariatric surgery CPT code listed as requiring prior authorization
43846	Bariatric surgery CPT code listed as requiring prior authorization
43848	Bariatric surgery CPT code listed as requiring prior authorization
43860	Bariatric surgery CPT code listed as requiring prior authorization

Breast reconstruction (non-mastectomy) CPT codesCPTCovered

11971	Breast reconstruction (non-mastectomy) code listed
19316	Breast reconstruction (non-mastectomy) code listed
19318	Breast reconstruction (non-mastectomy) code listed
19325	Breast reconstruction (non-mastectomy) code listed
19328	Breast reconstruction (non-mastectomy) code listed
19330	Breast reconstruction (non-mastectomy) code listed
19340	Breast reconstruction (non-mastectomy) code listed
19342	Breast reconstruction (non-mastectomy) code listed
19350	Breast reconstruction (non-mastectomy) code listed
19357	Breast reconstruction (non-mastectomy) code listed

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Bone growth stimulatorCPTCovered

20979

Bone growth stimulator (electronic stimulation or ultrasound) CPT/HCPCS code requiring prior authorization

Extracted codes (partial list)mixed

M86.571
M86.572
M86.579
M86.58
M86.59
M86.60
M86.651
M86.652
M86.659
M86.661

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ICD-10 excerpts (partial)ICD-10

C44.82	ICD-10 code referenced for prior authorization mapping
C44.89	ICD-10 code referenced for prior authorization mapping
C44.90	ICD-10 code referenced for prior authorization mapping
C4A.0	ICD-10 code fragments listed

DME HCPCS codes (partial)HCPCSCovered

E0194	DME HCPCS code
E0270	DME HCPCS code
A9900	DME HCPCS code

Genetic/molecular testing codes (partial)CPTCovered

81162	Genetic/molecular testing CPT/HCPCS
81415	Genetic/molecular testing CPT
81431	Genetic/molecular testing CPT

Genetic/molecular testing CPT codes (partial list)CPTCovered

81431	Molecular pathology or related genetic test (listed as requiring prior or to obtain prior authorization)
81425	Genetic test code referenced in sequence with other 814xx codes
81432	Genetic test code referenced
81426	Genetic test code referenced
81435	Genetic test code referenced
81427	Genetic test code referenced
81439	Genetic test code referenced
81448	Genetic test code referenced
81440	Genetic test code referenced
81443	Genetic test code referenced

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Genetic/molecular U-codes (partial)HCPCSCovered

0007M	Misc/genetic test U-code listed
0006M	Misc/genetic test U-code listed
0026U	Misc/genetic test U-code listed
0018U	Misc/genetic test U-code listed
0022U	Misc/genetic test U-code listed
0023U	Misc/genetic test U-code listed

Sample listed CPT/HCPCS codes (partial list)mixedCovered

21198	Orthognathic surgery
21215	Orthognathic surgery
L0112	Orthotics/prosthetics
L0710	Orthotics/prosthetics

Procedural codes requiring prior authorizationmixedCovered

64490	Injection procedure
77520	Proton beam therapy

Upper GI/Endoscopy related CPT codes (excerpt)CPT

43237
43238
43242
43245
43246
43247
43248
43251

Specialty-specific CPT codesCPT

21320	ENT procedures (example)
30140
65710	Eye and ocular adnexa example
67010

Sample musculoskeletal/related procedure codes extracted from segmentCPT | HCPCS | mixed

20552
20553
29845
29893
G0260
64561
65426
67028
43235

Musculoskeletal procedure and device codesCPT | HCPCS

63064
63075
63077
63081
63085
63087
63090
63101
63102
63170

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Cardiology program codes/details

Cardiology prior authorization detailsSee UHCprovider.com/MOcommunityplan > Prior Authorization and Notification Resources > Cardiology Prior Authorization and Notification Program for full CPT list; requests may be submitted via the Provider Portal or by calling 866-889-8054.

Services requiring cardiology PAOutpatient and office-based diagnostic catheterizations, echocardiograms, electrophysiology implants and stress echoes require prior authorization.

How to submit cardiology PASubmit via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 866-889-8054.

DME cost/rental threshold

DME rental/purchase thresholdPrior authorization required for DME items with retail purchase or cumulative rental cost of $500 or more.

Example DME HCPCS codesA9900, E0194, E0265 (see DME code list for full details).

Prosthetics noteProsthetics are not considered DME (documented in list).

Orthotics/prosthetics prior-authorization threshold

Orthotics/prosthetics PA thresholdPrior authorization required only for orthotics and prosthetic items with a retail purchase or cumulative rental cost greater than $500.

Sample orthotics HCPCS codesL0112, L0170, L0456 (additional L-codes listed in document).

ScopeApplies to orthotics and prosthetic codes listed in the policy; see coding sections for full code list.

Orthotics/prosthetics prior authorization threshold

Retail/cumulative rental thresholdRetail purchase or cumulative rental cost greater than $500 triggers prior authorization requirement for orthotics and prosthetics.

Examples of affected codesL0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631, L0632 (see policy for full list).

ClarificationThreshold applies only to items listed with retail purchase or cumulative rental cost information in the document.

Site-of-service prior auth threshold

Site-of-service PA rulePrior authorization is required only when the service is requested in an outpatient hospital setting (SOS applies); no PA required if performed at a participating ambulatory surgery center when specified.

Example procedures with SOS ruleSinuplasty (31295-31298) subject to SOS prior authorization rule as noted in the policy.

Provider responsibilityCare providers ordering advanced outpatient imaging or other specified procedures must notify prior to scheduling and submit PA via the Provider Portal or phone per policy instructions.

Submission Process, Notifications, and Provider Requirements

Prior Authorization

How to submit prior authorization requests and exceptions

Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by fax to 866-968-7582, or by phone at 888-702-2202. 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.

Online: Sign in at UHCprovider.com, select Prior Authorization and Notification on the provider portal dashboard.
Fax: 866-968-7582 (use Prior Authorization Forms).
Phone: 888-702-2202.

Prior Authorization

Cardiology prior authorization process

For cardiology prior authorization, submit requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 866-889-8054. Prior authorization is required for outpatient and office-based diagnostic catheterizations, echocardiograms, electrophysiology implants and stress echoes prior to performance.

For CPT details and full cardiology prior authorization list, visit UHCprovider.com/MOcommunityplan > Prior Authorization and Notification Resources > Cardiology Prior Authorization and Notification Program.

Prior Authorization

Prior authorization notes: circumcision, cochlear implants, cosmetic procedures

Prior authorization is required for circumcision only when there is documented medical necessity; cochlear implants and other auditory implants require prior authorization; cosmetic procedures require prior authorization.

Circumcision CPT codes listed include 54161, 54162, 54163, 54164 (PA required only with documented medical necessity).
Cochlear implant CPT/HCPCS codes listed include 69714, 69930, L8614, L8619 (PA required).
Cosmetic procedures (e.g., 11960) — prior authorization required.

Prior Authorization

Prior authorization required for gastrostomy, FAI, and FESS

Prior authorization is required for gastrostomy tube procedures and for femoroacetabular impingement syndrome (FAI) and functional endoscopic sinus surgery (FESS) as listed by CPT/HCPCS codes.

Gastrostomy tube codes listed include 33477, 65767, E1831, 36514, 66180, 64722, A6000 (PA required).
FAI codes listed include 29915, 65767, E1831 (PA required).
FESS codes listed include 29914, 31240, 31256, 31253, 31257, 31287 (PA required).

Billing Rule

DME prior authorization and cost threshold

Durable Medical Equipment (DME) items listed require prior authorization; some DME items require prior authorization only when retail purchase or cumulative rental cost exceeds the specified threshold.

DME HCPCS codes listed include A9900, E0194, E0265, E0270, E0277, E0300, E0328, E0329, E0445, etc. (PA required).
PA required only when retail purchase or cumulative rental cost is more than $500.

Prior Authorization

Genetic and molecular testing prior authorization and notification

Genetic and molecular testing performed in an outpatient setting requires prior authorization; care providers requesting laboratory testing must complete the prior authorization and indicate the laboratory and test name.

Extensive list of CPT/HCPCS genetic/molecular testing codes (e.g., 81162, 81163, 81164, 81228, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81425, 81426, 81427, 81431, 81432, 81435, 81437, 81439, 81440, 81443, 81445, 81448) require PA when performed outpatient.
Authorization/notification must include laboratory and test name; payment will be authorized for CPT codes registered with Genetic and Molecular.

Documentation Required

Genetic/molecular testing: include lab and test name on PA

When requesting genetic and molecular testing, indicate the laboratory and test name as part of the authorization/notification process; payment will be authorized for CPT codes registered with the Genetic and Molecular registry.

Examples of additional CPT codes referenced for this process include 81457, 81449, 81450, 81455, 81462, 81458, 81459, 81460, 81518, 81463, 81464, 81465.

Prior Authorization

Home health care prior authorization (outpatient/home)

Home health care requires prior authorization only when services are provided in an outpatient setting that includes the member's home.

Home health care CPT/HCPCS codes listed include S3870, G0299, G0300, G0493, G0494 (PA required in outpatient/home settings).

Prior Authorization

Hysterectomy prior authorization

Hysterectomy procedures require prior authorization for the listed CPT codes.

Hysterectomy CPT codes listed include 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58290, 58291, 58292, 58542, 58543, 58544, 58550, 58552, 58553, 58570, 58571, 58572, 58573.

Prior Authorization

Joint replacement prior authorization

Joint replacement (total hip and knee replacement) procedures require prior authorization for the listed CPT/HCPCS codes.

Codes include 24360–24371 series and hip/knee replacement codes such as 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27412, 27446, 27447, 27486, 27487, 29866–29868, J7330.

Prior Authorization

Air ambulance prior authorization

Non-emergent air ambulance transport requires prior authorization.

Examples of codes: A0430, A0431, A0435, A0436.

Prior Authorization

Orthognathic surgery prior authorization

Orthognathic surgery (maxillofacial/jaw functional treatment) requires prior authorization for the listed CPT codes.

Orthognathic CPT codes include 21121, 21123, 21125, 21127, 21141–21151, 21154–21160, 21188, 21193–21196, 21198, 21199, 21206, 21208–21210, 21215, 21240–21249, 21255, 21296, 21299.

Billing Rule

Orthotics & prosthetics prior authorization threshold

Orthotics and prosthetics require prior authorization only for items with a retail purchase or cumulative rental cost of more than $500.

Sample HCPCS codes include L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631, L0632, L0634, L0636, L0637, L0638, L0640, L0700, L0710.
Threshold: retail purchase or cumulative rental cost greater than $500 triggers PA.

Prior Authorization

Orthognathic surgery CPT/HCPCS codes require PA

Orthognathic surgery CPT/HCPCS codes listed in the policy require prior authorization.

See orthognathic code list (e.g., 21121, 21123, 21125, 21127, 21141–21151, 21154–21160, 21188, 21193–21196, 21198, 21199, 21206, 21208–21210, 21215, 21240–21249, 21255, 21296, 21299).

Prior Authorization

Pain management and injection prior authorization

Pain management injection procedures require prior authorization.

Examples include injection codes 64490 and 64493.

Prior Authorization

Personal care and private duty nursing prior authorization

Personal care assistance and private duty nursing services require prior authorization (private duty nursing prior authorization required as noted).

Personal care codes include T1001, T1019, T1028; private duty nursing codes include T1000, T1002, T1003.

Prior Authorization

Prostate procedures prior authorization

Prostate procedures listed require prior authorization.

Prostate procedure codes include 37243, 52441, 52442, 53850, 53852, 55873, 55874.

Prior Authorization

Proton beam therapy prior authorization

Proton beam therapy (codes 77520, 77522, 77523, 77525) requires prior authorization.

For details and CPT lists, providers should visit UHCprovider.com/MOcommunityplan Prior Authorization and Notification Resources or call 866-889-8054.

Prior Authorization

Radiology prior authorization and notification process

Advanced outpatient imaging procedures (certain CT, MRI, MRA, PET, nuclear medicine, nuclear cardiology) require prior authorization; care providers ordering these procedures must notify prior to scheduling and submit requests via the Provider Portal or call 866-889-8054.

Submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 866-889-8054.

Documentation Required

Prior authorization process for proton therapy and advanced imaging

Prior authorization is required for proton therapy codes listed; providers ordering advanced outpatient imaging must notify prior to scheduling and submit prior authorization requests via the Provider Portal or call the provided number.

Proton codes: 77520, 77522, 77523, 77525.

Step Therapy

Sinuplasty and site-of-service (SOS) prior authorization

Sinuplasty procedures (CPT 31295–31298) require prior authorization; site-of-service prior authorization applies when requested in an outpatient hospital setting (SOS applies).

Sinuplasty CPT codes: 31295, 31296, 31297, 31298.
Site-of-service rule: PA required only when requested in an outpatient hospital; not required if performed at a participating ambulatory surgery center (ASC) where specified.

Prior Authorization

Septoplasty and rhinoplasty prior authorization

Septoplasty and rhinoplasty for treatment of nasal functional impairment and septal deviation require prior authorization for the listed CPT codes.

Septoplasty/rhinoplasty CPT codes include 30460, 30462, 30465.

Prior Authorization

Maxillomandibular advancement and oral-pharyngeal tissue reduction PA

Maxillomandibular advancement and oral-pharyngeal tissue reduction procedures require prior authorization for the listed CPT codes.

Codes include 21685, 41599, 42145 (PA required).

Prior Authorization

Sleep studies (attended and unattended) prior authorization

Sleep studies, both attended (e.g., 95805, 95807, 95808, 95810) and unattended (e.g., 95800, 95801, 95806), require prior authorization.

Submit prior authorization before scheduling sleep studies as listed.

Prior Authorization

Spinal surgery prior authorization

Spinal surgery procedures require prior authorization for the listed CPT codes.

Examples of spinal surgery CPT codes listed include 22100, 22101, 22102, 22112, 22114, 22206, 22207, 22210, 22212, 22214, 22220, 22510–22515, 22532, 22533, 22548, 22551, 22554, 22556, 22558, 22586, 22590, 22595, 22600.

Prior Authorization

Stimulator implantation prior authorization

Implantation of stimulators (including bone growth stimulators and neurostimulators) requires prior authorization.

Bone growth stimulator is listed as requiring prior authorization (see coding list for specific codes such as 20979 and device implantation codes).

Prior Authorization

Transplant and CAR T-cell prior authorization and contact

Transplant and CAR T-cell therapy services require prior authorization; contact the UnitedHealthcare Community and State Transplant Case Management team at 888-936-7246 or the notification number on the member's health plan ID card.

Some inpatient transplant procedures are carved out to the state; follow the contact instructions for transplant and CAR T-cell services (e.g., Kymriah, Yescarta).
Code 38232 will only require prior authorization for specified cases (conditional per note).

Prior Authorization

VAD prior authorization and notification

Ventricular assist device (VAD) services require prior authorization; call the notification number on the member's health plan ID card and fax the form provided by the nurse to Optum at 855-282-8929.

Follow the notification phone number on the member's ID card before faxing required forms to Optum 855-282-8929.

Prior Authorization

Vein procedures prior authorization

Vein procedures require prior authorization for the listed CPT codes.

Vein procedure codes listed include 36473, 36475, 36478, 37700.

Note

Definitions and Policy Terms

Prior authorization (definition & submission)

Definition of prior authorizationPrior authorization is the process requiring providers to obtain approval from UnitedHealthcare before performing certain procedures or services; it is not required for emergency or urgent care.

Submission methodsRequests may be submitted online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by fax to 866-968-7582, or by phone at 888-702-2202.

Out-of-network providersOut-of-network providers must request prior authorization for all procedures and services, excluding emergent or urgent care.

State-carved services

State-carved servicesCertain services (example: abortion) are carved out to the state and follow state-level authorization rules.

ImplicationFor carved-out services, CPT/HCPCS codes and PA processes are governed by state-specific procedures rather than this policy.

ReferenceSee policy entry labelled 'Abortion' for additional carved-out notes and instructions.

Prior authorization (circumcision)

Circumcision PA requirementPrior authorization required only for circumcision cases with documented medical necessity.

Circumcision CPT codes listed54161, 54162, 54163, 54164 (codes listed in policy).

Documentation expectationMedical necessity must be documented to justify PA for circumcision.

Cochlear implants (summary)

Cochlear implant PACochlear implants and other auditory implants require prior authorization.

Representative codes69714, 69930, L8614, L8619 are listed for cochlear and auditory implants.

Device descriptionDescribed as a medical device within the inner ear with an external portion to assist persons with profound sensorineural deafness.

Durable Medical Equipment (DME)

DME prior authorization ruleDurable Medical Equipment (DME) items require prior authorization; some items are subject to PA based on retail purchase or cumulative rental cost thresholds.

Sample DME HCPCS codesA9900, E0194, E0265, E0652 (codes listed in the DME section).

Prosthetics notePolicy distinguishes prosthetics from DME (prosthetics are not DME).

Genetic and molecular testing (outpatient)

Outpatient genetic/molecular testing PAGenetic and molecular testing performed in an outpatient setting requires prior authorization and completion of provider prior authorization documentation, including indicating the laboratory and test name.

Representative CPT/HCPCS codes81162, 81163, 81164, 81228, 81401–81417, 81425–81427, 81431–81465 (extensive list in policy).

Payment notePayment will be authorized for CPT codes registered with Genetic and Molecular per the policy's authorization/notification process.

Authorization/notification process

Authorization & notification processProviders must submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by phone using the numbers provided for specific programs (e.g., cardiology 866-889-8054), or by fax where specified.

Portal instructionGo to UHCprovider.com, sign in with One Healthcare ID, then select the Prior Authorization and Notification tile on the provider portal dashboard.

Radiology/advanced imaging requirementCare providers ordering advanced outpatient imaging must provide notification prior to scheduling and submit PA via the Provider Portal or call 866-889-8054 as noted.

Orthotics and prosthetics prior authorization threshold

Orthotics/prosthetics PA threshold (definition)Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500.

Policy scopeApplies to orthotics and prosthetics codes enumerated in the orthotics/prosthetics sections of the policy.

Action requiredSubmit PA when cumulative rental or retail purchase exceeds the $500 threshold as indicated in the policy.

Proton beam therapy

Proton beam therapy definition & PAProton beam therapy uses focused radiation with proton beams; CPT codes 77520, 77522, 77523 and 77525 require prior authorization.

Clinical contextProtons are described as tiny particles with a positive charge in the policy's explanatory notes.

Submission instructionSubmit PA via the Provider Portal or call the provided number per radiology/proton instructions.

Site of service (SOS) - outpatient hospital

SOS — outpatient hospital ruleSite of service (SOS) - outpatient hospital: prior authorization is required only when the service is requested in an outpatient hospital setting; no PA required if performed at a participating ambulatory surgery center where specified.

Examples notedPolicy cites auditory system procedures and other listed CPTs where SOS applies; see specific code lines for details.

Provider responsibilityWhen SOS applies, providers must request PA for the outpatient hospital setting; otherwise verify if ASC or ambulatory setting exempts PA.

Proton (definition)

Proton (context)Protons are tiny particles with a positive charge (contextual description related to proton beam therapy).

Relation to therapyThis contextual definition supports the policy's proton beam therapy entry and code-based PA requirements.

ReferenceSee Proton beam therapy section for CPT codes and PA instructions.

Site of service (SOS)

Site of service (SOS) referencePolicy frequently references site of service (SOS) - outpatient hospital when indicating when prior authorization applies.

Implementation noteReview SOS notes in each specialty section to determine whether PA is required based on facility setting.

ExamplesMusculoskeletal procedure sections include multiple SOS-noted CPT lines; see the coding sections for specifics.

Prior authorization (procedures overview)

Prior authorization — general rulePrior authorization is required for specified procedures such as sleep studies (attended and unattended) and certain surgical procedures listed in the policy.

Sleep studies examplesAttended sleep study CPTs: 95805, 95807, 95808, 95810; Unattended: 95800, 95801, 95806 (PA required).

Surgical proceduresMaxillomandibular advancement and oral-pharyngeal tissue reduction (CPTs 21685, 41599, 42145) and spinal surgery codes require prior authorization per the policy.

VAD, stimulators & transplant (summary)

VAD — definition & PAVentricular assist device (VAD) services: a mechanical pump that takes over the function of the damaged ventricle; prior authorization required. Call the notification number on the member's health plan ID card and fax the nurse-provided form to Optum at 855-282-8929.

Stimulator implantationImplantation of stimulators (bone growth stimulators, neurostimulators) requires prior authorization per the policy.

Transplant/CAR T-cell noteTransplants and CAR T-cell therapy require prior authorization; contact UnitedHealthcare Community and State Transplant Case Management (see policy for contact number).

OpenPayer

Prior authorization requirements for Missouri Medicaid

Coverage Criteria and Prior Authorization Requirements

Code Lists and Coding Details

Submission Process, Notifications, and Provider Requirements

Definitions and Policy Terms