CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Missouri Medicaid

Rules and instructions for requesting prior authorization of inpatient and outpatient services for UnitedHealthcare Community Plan members in Missouri; applies to participating providers, hospitals, facilities and out-of-network providers except for emergency/urgent care.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Missouri Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionProviders must obtain prior authorization for listed services via the Provider Portal Prior Authorization and Notification tool or by phone at 866-815-5334; emergency and urgent care are exempt.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-07-01effective date

866-815-5334phone (PA requests)

Provider Portalonline

Emergency/Urgentexempt

$500DME cost threshold

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Services and Conditions That Require Prior Authorization

Codes and Code Groups Referenced for Prior Authorization

Selected surgical CPT codes requiring prior authorization (non-exhaustive)CPTCovered

43644	Bariatric procedure (laparoscopic adjustable gastric banding or related)
43770	Laparoscopic gastric bypass
43846	Bariatric surgery code (example)

Cardiology CPT codes requiring prior authorization (selected)CPTCovered

37220	Transcatheter therapy, peripheral vascular
93580	Intravascular imaging during cardiac catheterization

ICD-10 diagnosis codes referenced in the listICD-10

M86.0xx

Osteomyelitis diagnosis codes (many specific subcodes listed)

Selected ICD-10 diagnosis codes referenced for PAICD-10

M86.472	Chronic osteomyelitis code listed
M86.479	Chronic osteomyelitis code listed
M86.48	Chronic osteomyelitis code listed
M86.49	Chronic osteomyelitis code listed
C44.01	Skin cancer / reconstructive related diagnosis codes listed

Cosmetic/reconstructive CPT codesCPTCovered

11960	Cosmetic & reconstructive procedure
14020	Cosmetic & reconstructive procedure
15820	Reconstructive procedure
21175	Reconstructive/appearance procedure

ICD-10 example codesICD-10

D04.0	Listed ICD-10 code (partial list) appearing in this segment
D04.10	Listed ICD-10 code
D04.111	Listed ICD-10 code
D04.112	Listed ICD-10 code

DME / Orthotics & Prosthetics HCPCS codes (sample)HCPCS

E0784	DME/HCPCS code listed
K0854	DME/HCPCS code listed
K0885	DME/HCPCS code listed

Genetic and molecular testing codesCPTExperimental

81162	Genetic/molecular testing CPT code requiring prior authorization
81163	Genetic/molecular testing CPT code requiring prior authorization
81403	Molecular testing CPT code requiring prior authorization / prior notification

Selected U-codes (partial)CPT

0277U
0278U
0282U

Orthotics/prosthetics L-codes (partial)HCPCSCovered

L0112	Orthotic/prosthetic HCPCS codes (many listed)
L0482
L5726

Air ambulance codesHCPCSCovered

A0430

Non-emergent air ambulance

Air ambulance codes (additional)HCPCSCovered

A0431	Non-emergent air ambulance
A0435	Non-emergent air ambulance
A0436	Non-emergent air ambulance

Sample L-codes (many more listed)HCPCSCovered

L5795	Orthotics/prosthetics HCPCS L-code listed in document segment
L5811	Orthotics/prosthetics HCPCS L-code listed in document segment

Selected CPT/HCPCS examplesmixedCovered

64490	Pain management injection CPT code
T1001	Personal care assistance HCPCS code

Examples of listed CPT/HCPCS codesmixed

10121	CPT listed (integumentary examples)
11440	CPT listed
15100	CPT listed
20680	Miscellaneous musculoskeletal code
20552	Injection procedure code
64561	Nervous system injection/implantation code
43235	Upper GI endoscopy
22300	Placeholder - multiple spinal codes listed in section
32851	Transplant-related CPT listed

Example HCPCS codes listedHCPCSCovered

E0747	Bone growth stimulator
E0748	Bone growth stimulator
E0760	Bone growth stimulator
E2402	Negative pressure wound therapy system, disposable canister
Q2041	Home oxygen equipment or related (Q-code)
Q2042	Home oxygen equipment or related (Q-code)

Code with special authorization conditionCPTCovered

38232

Bone marrow or stem cell harvesting (authorization required for oncology diagnosis only)

DME retail cost threshold

Threshold amount$500 retail purchase

Applies toDurable medical equipment (DME) codes listed in the document

Trigger for PAPrior authorization required when retail cost of listed DME exceeds $500

Exclusion noteProsthetics are explicitly not considered DME

DME cost threshold

Threshold rulePrior authorization applies when DME cost is more than $500

Supporting detailApplies to the DME codes enumerated (examples: E0194, E0265, E0270, E0277, E0300, E0328, E0329, E0445, E0457, E0465, E0466, E0470)

Action requiredProviders must obtain prior authorization for listed DME items exceeding the cost threshold

Orthotics/prosthetics prior auth threshold

Threshold amountRetail purchase or cumulative rental cost greater than $500

Applies toOrthotics and prosthetic HCPCS L-series codes listed in the document (examples: L0112, L0170, L0456, L0462, L0464, L0480, L0482)

Trigger for PAPrior authorization required only when retail purchase or cumulative rental cost exceeds $500

How to Request Prior Authorization and Provider Responsibilities

Prior Authorization

How to request prior authorization and provider responsibilities

To request prior authorization, submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com -> Sign In -> Prior Authorization and Notification tile). Telephone support is also available. Physicians, health care professionals and ancillary providers are responsible for obtaining prior authorization for services included on this list. Hospitals and facilities are responsible for admission notification per the Missouri Provider Manual. Prior authorization is not required for emergency or urgent care.

Submit prior authorization requests online via the Provider Portal Prior Authorization and Notification tool
If calling, use the phone numbers printed on the member's health plan ID card for service-specific programs when indicated

Prior Authorization

Cardiology prior authorization codes and contact

Cardiology services (advanced outpatient cardiac diagnostic and interventional procedures) require prior authorization. Submit requests online via the Provider Portal Prior Authorization and Notification tool or call 866-889-8054. Cardiology-specific CPT codes listed in this section require authorization.

Key Definitions and Scope Notes

Definition of prior authorization and emergency/urgent care exemption

DefinitionPrior authorization is the process by which providers request approval from UnitedHealthcare before delivering certain non-emergent services to Missouri Medicaid members; emergency and urgent care are exempt.

Who must requestPhysicians, health care professionals and ancillary care providers are responsible for obtaining prior authorization for services included on this list; out-of-network providers must request authorization for all non-emergent services.

Submission methodsOnline via Prior Authorization and Notification tool on UnitedHealthcare Provider Portal or by phone at 866-815-5334; PCN authorizations: 877-347-9367.

Carved-out services governed by state rules

MeaningCarved out to state indicates certain services and their authorization processes are governed by state rules rather than by this payer document.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Missouri Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2025

Next Review DateN/A

SourceLink

On This Page

Cardiology CPT codes requiring prior authorization (partial list): 37220, 37221, 37224, 37225, 37229, 37231, 93580
Providers ordering outpatient diagnostic cardiac procedures (catheterization, echocardiograms, electrophysiology implants, stress echoes) must obtain prior authorization

Prior Authorization

Bariatric surgery and breast reconstruction prior authorization

Bariatric surgery and non-mastectomy breast reconstruction procedures require prior authorization. Use the Provider Portal Prior Authorization and Notification tool to submit requests.

Bariatric surgery: prior authorization required for listed CPT codes
Breast reconstruction (non-mastectomy): prior authorization required for listed CPT codes

Prior Authorization

Enteral services

Enteral (in-home nutritional) services, including gastrostomy tube nutrition, require prior authorization. Submit requests via the Provider Portal Prior Authorization and Notification tool.

Enteral services (in-home nutritional therapy) require prior authorization
HCPCS codes of note: B9002, B9998

Prior Authorization

Arthroscopy prior authorization

Many arthroscopy and related musculoskeletal procedures require prior authorization. Confirm authorization via the Provider Portal Prior Authorization and Notification tool before scheduling.

Arthroscopy and shoulder surgery CPT codes listed above require prior authorization
Site-of-service rules (SOS) may apply to certain arthroscopy codes (see SOS rules block)

Prior Authorization

U-code prior authorization

Certain temporary (U-) codes require prior authorization. Review the procedure list and submit requests through the Provider Portal.

U-codes shown in this list require prior authorization
Submit authorization requests online via the Provider Portal

Prior Authorization

Injectable medications (state carve-out)

Injectable medications are carved out to the state for prior authorization; follow state-specific processes. Providers should use the authorization/process identified on the member's plan or call the number on the member's ID card for guidance.

Injectable medications prior authorization is managed per state carve-out rules
Check the member ID card or state plan guidance for contact and submission instructions

Prior Authorization

Radiology prior authorization submission instructions

Advanced outpatient radiology (selected CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology) requires prior authorization. Submit outpatient imaging prior authorization requests online via the Provider Portal Prior Authorization and Notification tool or call 866-889-8054. Ordering providers are responsible for notifying scheduling of authorization status before the appointment.

Prior authorization required for advanced outpatient imaging: selected CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures
Ordering provider must notify scheduling and obtain authorization prior to outpatient advanced imaging

Prior Authorization

Selected CPT/HCPCS codes requiring prior authorization

Selected CPT and HCPCS codes across specialties require prior authorization. Providers must verify authorization via the Provider Portal or call the appropriate program number. Below are representative examples from the policy (partial lists).

Sleep studies: 95805, 95807, 95808, 95810, 95811 (attended) and 95800, 95801, 95806 (unattended) require prior authorization
Proton beam therapy: 77520, 77522, 77523, 77525 require prior authorization
Non-emergent air ambulance: A0430, A0431, A0435, A0436 require prior authorization

Prior Authorization

Surgical and specialty CPT codes requiring prior authorization (partial)

Many surgical and specialty procedures require prior authorization. Use the Provider Portal to submit requests and reference the code lists in this document. The list includes, but is not limited to, major abdominal, thoracic, cardiac, transplant, and complex ENT/ocular procedures.

Examples of surgical/specialty CPT codes listed (partial): 22100-22220 (spinal surgery range), 32851-32854 (thoracic), 33935, 33945 (cardiac), 44135, 44137 (colorectal), 47135-47147 (hepatic), 50360-50370 (renal), various ENT/ocular codes (see policy)
Code 38232 requires authorization only for oncology diagnoses

Prior Authorization

Site of service prior authorization rule

Site-of-service (SOS) rules: prior authorization is required when services are requested in an outpatient hospital setting for specified procedures. Prior authorization is not required if the same procedure is performed at a participating ambulatory surgery center (ASC). Verify SOS requirements before scheduling.

If requesting services in an outpatient hospital setting for codes flagged with SOS, obtain prior authorization
ASC site may not require authorization for the same codes—confirm via Provider Portal

Prior Authorization

Transplant and CAR T-cell therapy notification

Transplant and CAR T-cell therapy (e.g., Kymriah, Yescarta) require special notification and case management. For these services, 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 prior to the service.

All transplant and CAR T-cell therapy services require prior authorization/notification and coordination with the Transplant Case Management team
Common transplant CPT examples in this policy: 32851-32854, 33935, 33945, 38208-38242, others listed

Documentation Required

Code-specific rules

Code-specific operational rules and exceptions are noted throughout the policy. Providers should review code-level notes (such as oncology-only authorizations, SOS flags, carve-outs to state programs, and device/program-specific submission instructions) before submitting authorization requests.

Check code-specific notes in the policy for special conditions (e.g., oncology-only, SOS, state carve-outs)
When a program (e.g., VAD, transplant) provides a unique fax or intake process, follow that program's instruction rather than the general portal flow

Prior Authorization

VAD and wound vac codes

Ventricular assist device (VAD) services and wound VACs require program-specific notification and authorization. For VAD services, call the notification number on the member's health plan ID card and then fax the form provided by the nurse to the Optum VAD Case Management Team at 855-282-8929. Wound VAC devices (E2402) require prior authorization via the Provider Portal.

VAD program: call the member ID card notification number, then fax the completed form to Optum VAD Case Management at 855-282-8929
Wound vac (E2402) requires prior authorization

Abortion is explicitly noted as carved out to state in the document.

ImplicationProviders should follow state-specific authorization procedures for carved-out services rather than the payer's standard PA process.

Cochlear implants and auditory implants definition

DefinitionCochlear implants and other auditory implants: a medical device within the inner ear (may have an external portion) used for profound sensorineural deafness.

PA requirementPrior authorization required for cochlear implants and related auditory implant procedures/codes (examples: CPT 69714; HCPCS L8692, L8614, L8619, 69930).

Device noteMay include internal and external components; specific CPT/HCPCS codes are listed for authorization purposes.

Durable Medical Equipment (DME)

DefinitionDurable Medical Equipment (DME): equipment items listed in the document (examples: HCPCS E0194, E0265, E0270, E0277, E0300, E0328, E0329, E0445, E0457, E0465, E0466).

PA triggerPrior authorization required for listed DME codes when retail cost exceeds $500.

ExclusionProsthetics are explicitly noted as not considered DME.

Prosthetics vs DME

Key distinctionProsthetics are not considered DME per the document's explicit note.

Related PA rulesProsthetics have separate treatment from DME; DME PA thresholds do not apply to prosthetics.

Orthotics/prosthetics listMany HCPCS L-codes are listed separately for orthotics and prosthetics with their own PA conditions.

Genetic/molecular testing notification/prior authorization

Program requirementGenetic and molecular tests must be registered with the Genetic and Molecular Testing Prior Authorization/Notification program.

Required informationRegistration must include laboratory identification and test-specific information as part of the notification/prior authorization process.

Examples of codesDocument lists numerous CPT/HCPCS codes requiring notification/PA (examples: 81439–81465 range, 81518–81599, other molecular test codes).

Orthotics/prosthetics prior authorization threshold

Threshold amountRetail purchase or cumulative rental cost greater than $500

Applies toOrthotics and prosthetic HCPCS L-series codes listed (examples: L0112, L0170, L0456, L0462, L0464, L0480, L0482)

PA conditionPrior authorization required only for L-code items when retail purchase or cumulative rental cost exceeds $500

Home health prior authorization scope

ScopeHome health care prior authorization required only in outpatient settings, including the member's home.

Relevant codesExamples include G0299, G0300, G0493, G0494, G0495, G0496 listed in the document.

Provider responsibilityPrior authorization must be obtained by ordering providers for home health services delivered in outpatient/home settings.

Site-of-service outpatient hospital definition

DefinitionSite-of-service (SOS) outpatient hospital: outpatient hospital setting where prior authorization rules may differ based on site of service.

SOS rulePrior authorization is required only when requesting the service in an outpatient hospital; it is not required if performed at a participating ambulatory surgery center (ASC).

ExamplesSOS notation appears with procedures such as shoulder surgery and certain ENT codes listed in the document.

UHC Provider Portal PA tool

Tool namePrior Authorization and Notification tool on the UnitedHealthcare Provider Portal

How to accessGo to UHCprovider.com, Sign In, then select the Prior Authorization and Notification tile on the provider portal dashboard.

PurposePrimary online method for submitting prior authorization and notification requests, including advanced outpatient imaging procedures.

Transplants / CAR T-cell therapy carve-out and notification

Carve-out and PA requirementTransplant and CAR T-cell therapy services are carved out to state and require prior authorization; providers must contact UnitedHealthcare Community and State Transplant Case Management.

ContactCall the UnitedHealthcare Community and State Transplant Case Management team at 888-936-7246 or use the notification number on the member's ID card.

ExamplesCAR T-cell therapies noted include Kymriah (tisagenlecleucel) and Yescarta (axicabtagene ciloleucel).

Sleep studies definition for PA

DefinitionSleep studies include both attended (polysomnography) and unattended sleep studies and require prior authorization per listed CPT codes.

Example CPT codesAttended: 95805, 95807, 95808, 95810, 95811; Unattended: 95800, 95801, 95806

PA requirementProviders must obtain prior authorization for sleep study services listed in the document before scheduling.

General prior authorization term

General termPrior authorization: approval from UnitedHealthcare before providing certain non-emergent services to Missouri Medicaid members.

Emergency/urgent careEmergency and urgent care are exempt from prior authorization requirements.

Provider responsibilityProviders and facilities are responsible for obtaining authorizations or providing admission notification as appropriate.

VAD definition

DefinitionVentricular assist device (VAD): a mechanical pump that takes over the function of the damaged ventricle.

PA requirementVAD services require prior authorization; providers should call the notification number on the member's ID card and fax the form provided by the nurse to the Optum VAD Case Management Team at 855-282-8929.

Example CPT codesDocument lists VAD-related CPT codes (examples: 33975, 33976, 33979, 33981) and wound vac code E2402 also requires PA.