CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Nebraska Medicaid

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

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Nebraska Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-397-8129.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

May 1, 2024effective date stated

888-397-8129authorization phone

Provider Portalsubmission tool

$750DME threshold

50+code lists

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Prior authorization criteria by category

Category-based prior authorization requirements shown; specific clinical criteria and full code lists appear elsewhere in the full document.

Behavioral health: Prior authorization required; for specific codes call the number on the member's health plan ID card. ABA therapy submissions via fax or Provider Express.

Abortion: Prior authorization required for listed CPT codes (examples include CPT 59840–59866 series).

Bariatric surgery: Prior authorization required for listed bariatric CPT codes (examples include 43644, 43645, 43659, 43770, 43775, 43842–43848, 43860).

BRCA genetic testing: Prior authorization required for BRCA CPT codes (examples include 81162–81164, 81432–81433).

Bone growth stimulator: Prior authorization required for bone growth stimulator CPT code 20975.

Cancer supportive services: Prior authorization required for colony-stimulating factor drugs and certain bone‑modifying agents administered in the outpatient setting for a cancer diagnosis (specific J/Q codes listed).

Extracted coverage requirements (partial)

Examples of coverage stance and criteria from this document segment:

Inpatient cerebral seizure video EEG: Prior authorization required for inpatient video EEG CPT codes 95700, 95711, 95712, 95713; outpatient/ambulatory video EEG rules differ.

Outpatient injectable chemotherapy (for cancer diagnoses): Prior authorization required for chemotherapy injectable J‑code range J9000–J9999 and specified supportive J‑codes (e.g., J0640, J0641, J0642, J1950, J1952).

Cochlear and other auditory implants: Prior authorization required (examples: CPT 69710, 69714, 69930 and HCPCS device codes L8619, L8690, L8691, L8692); request via Prior Authorization and Notification tool or call 888‑397‑8129.

Continuous glucose monitoring devices/supplies: Prior authorization required for listed HCPCS (examples A4238, A4239, A9274, E0787); request via Provider Portal or phone 888‑397‑8129.

Prior authorization and coverage nodes

Coverage requirements noted in this segment

Durable Medical Equipment (DME): Prior authorization required for listed DME HCPCS codes (examples E0194, E0265, E0266, etc.).

DME cost threshold: Prior authorization required for DME items with a retail purchase or cumulative rental cost greater than $750.

Enteral services / In‑home nutritional therapy: Prior authorization required for enteral services delivered enterally or via gastrostomy tube (examples B4155, B9002, B9998).

Experimental and investigational (and/or linked services): Prior authorization required for CPT codes flagged as experimental/investigational (examples include 33477, 36514, 64722).

Prior authorization requirements (by category)

Services and codes listed below require prior authorization before provision to Nebraska Medicaid members:

Enteral services (in‑home nutritional therapy): Prior authorization required (HCPCS B4155, B9002, B9998).

Experimental/investigational services and linked services: Prior authorization required for listed CPT/HCPCS codes flagged as experimental/investigational (examples: CPT 33477, 36514, 64722, 65767, 66180).

Selected surgical procedures and genetic testing: Prior authorization required for listed procedures (e.g., femoroacetabular impingement CPT 29914–29916; FESS CPT 31240, 31253–31255) and for many genetic testing CPT/HCPCS codes (examples 81228, 81229, 81277, 81400–81417).

Home health and hospice: Prior authorization required in outpatient settings (including member's home) for listed home health codes (G0156, G0162, G0299, G0300, G0493–G0496) and for hospice codes (T2042–T2045).

Injectable medications: Numerous J‑ and Q‑codes for injectable/biologic medications and therapeutic radiopharmaceuticals require prior authorization (see injectable medication lists).

Prior authorization requirements — enumerated items

Listed items and codes that require prior authorization in Nebraska Medicaid:

Non‑emergent air ambulance transport: Prior authorization required for HCPCS codes A0430, A0431, A0435, A0436.

Orthognathic surgery (treatment of maxillofacial/jaw functional impairment): Prior authorization required for listed CPT codes (examples include 21121, 21123, 21125, 21127, 21141–21147, 21150–21151, 21154–21160, 21188, 21193–21196, 21198–21199, 21206, 21208–21210, 21215, 21240, 21242, 21245–21249, 21255, 21296, 21299).

Orthotics and prosthetics: Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost greater than $750 (many L‑codes listed).

Prior authorization required — listed services

Services and codes in this list that are explicitly marked 'Prior authorization required' must be authorized before provision:

Outpatient therapy: Prior authorization required for listed CPT codes (examples include 92507, 92508, 92526, 92607–92609, 92700, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032–97034).

Private duty nursing: Prior authorization required for listed HCPCS codes (examples T1003, T1022).

Stimulators and neurostimulators: Prior authorization required for listed stimulator implantation and device codes (examples E0748, E0749, E0760 and device/CPT ranges for neurostimulators and bone growth stimulators).

Ventricular assist devices (VAD): Prior authorization required; providers should call the notification number on the back of the member's health plan ID card and fax the form to the Optum VAD Case Management Team at 855‑282‑8929.

How Providers Request Authorization and Operational Notes

Note

Submission methods and exceptions

For prior authorization, submit requests using one of the following methods: • Online: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com). Sign in with a One Healthcare ID and select the Prior Authorization and Notification tab. If you do not have a One Healthcare ID, follow the portal instructions to register. • Phone: Call 877-842-3210. Note: Prior authorization is not required for emergency or urgent care. Out-of-network providers must request prior authorization for all non-emergent procedures and services.

Prior Authorization

Behavioral health prior authorization

Behavioral health services may require prior authorization depending on the member's plan and whether services are managed through a designated behavioral health network. To determine prior authorization requirements and to refer for mental health or substance use services, call the number on the member's health plan ID card. ABA therapy authorization may require submission via fax or Provider Express per plan instructions.

Prior Authorization

Category-level prior authorization requirements

Certain categories of services require prior authorization at the category level. Providers should confirm authorization requirements for specific procedures or codes before providing services. Examples of categories requiring prior authorization include (but are not limited to): bariatric surgery; bone growth stimulators; BRCA and other genetic testing; cochlear and auditory implants; continuous glucose monitoring; home health and hospice (outpatient settings); enteral services; orthognathic surgery; orthotics and prosthetics when retail purchase or cumulative rental cost exceeds $750; outpatient therapy and private duty nursing; DME codes listed in the DME section; transplants and CAR T-Cell therapies; ventricular assist devices; stimulators and neurostimulators; injectable chemotherapy and many injectable medications. Always verify the member's benefit plan and follow the specific submission instructions for each category.

Prior Authorization

Cancer supportive services prior authorization

Colony-stimulating factor drugs and outpatient bone-modifying agents administered for a cancer diagnosis require prior authorization. Examples of injectable colony-stimulating factor drugs that require prior authorization include eflapegrastim (Rolvedon J1449), filgrastim (Neupogen J1442), filgrastim biosimilars (Q5101, Q5125, etc.), pegfilgrastim (Neulasta), and others. These agents may also be listed in the Injectable Medications section; follow the prior authorization process for injectable medications when requesting approval for cancer supportive services.

Note

How to obtain prior authorization and sample codes

How to obtain prior authorization and sample codes: • Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 888-397-8129 or 877-842-3210 where noted for specific services. • Many categories list representative CPT/HCPCS codes in this document; for example: A0430, A0431, A0435 (air ambulance); selected J‑codes for chemotherapy and supportive drugs (see Injectable medications and Chemotherapy sections); numerous L‑codes for orthotics/prosthetics; CPT codes for outpatient therapy (92507, 92508, 97012, etc.); T1003 (outpatient therapy)/T1022 (private duty nursing). • For transplant and CAR T-Cell therapy, and other services that require specialized case management, use the transplant contact information below. • If a code is not listed or is billed as miscellaneous (J9000–J9999 or A9699, etc.), contact the prior authorization phone number or submit via the portal to confirm whether authorization is required.

Note

How to request prior authorization

How to request prior authorization: • Preferred method: Submit requests through the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal. • Alternate method: Call the applicable prior authorization phone number listed for the service or on the member's ID card. • Include supporting clinical documentation, relevant diagnosis codes, procedure codes, member information, and treating provider details. • For services that require case management (for example, transplants, VADs, or complex high-cost therapies), follow the specialized notification and fax instructions provided in the applicable service entry.

Prior Authorization

Non-emergent air ambulance transport

Non-emergent air ambulance transport requires prior authorization. Representative HCPCS codes include A0430, A0431 and A0435. Prior authorization must be obtained before scheduling or providing non-emergent air ambulance services.

Prior Authorization

Transplant / CAR T-Cell prior authorization contact

Transplant and CAR T-Cell therapy contact: Prior authorization is required for transplant services and CAR T-Cell therapies (including Abecma, Breyanzi, Kymriah, Tecartus, Yescarta, and similar products). For prior authorization and case management assistance, call the UnitedHealthcare Community and State Transplant Case Management team at 888-936-7246 or use the notification number listed on the back of the member's health plan ID card.

Prior Authorization

Outpatient therapy / Private duty nursing

Outpatient therapy and private duty nursing require prior authorization. Representative codes include outpatient therapy CPT codes such as 92507, 92508, 92526, 92607–92609, 92700 and physical/occupational therapy codes 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032–97034, and T1003 for therapy services. Private duty nursing is represented by T1022. Submit authorization requests via the Provider Portal or call the prior authorization phone number. Include therapy plans, frequency/duration, and clinical justification.

Key Terms and Definitions

Prior authorization

DefinitionA required approval that providers must request from UnitedHealthcare before providing non-emergent services; not required for emergency or urgent care.

Submission methodsOnline via Provider Portal Prior Authorization and Notification tool or by phone (877-842-3210).

Who must requestParticipating and out-of-network providers must request PA for listed services (out-of-network providers must request PA for all services except emergent/urgent care).

Effective datePolicy effective May 1, 2024 (see document header).

Prior authorization is a required approval obtained via the Provider Portal Prior Authorization and Notification tool or by calling 888-397-8129 before performing or billing certain listed services.

Required approval methodObtain approval via the Provider Portal Prior Authorization and Notification tool or by calling 888-397-8129 before performing or billing listed services.

IncludesCochlear implants, continuous glucose monitoring supplies/devices, reconstructive/cosmetic procedures and other listed services requiring PA.

NotePrior authorization not required for emergency or urgent care; see member ID card for behavioral health phone contact where applicable.

Reconstructive vs cosmetic procedures

Reconstructive proceduresTreat or improve physiologic function and may require prior authorization.

Cosmetic proceduresProcedures that solely change appearance are listed with CPT codes and may also require prior authorization.

ExamplesCPT examples shown include 14060, 15821, 15847, 14061, 15822, 15877, 17107, etc., with PA instructions to use Provider Portal or call 888-397-8129.

Durable medical equipment (DME)

DME definition in policyDurable medical equipment (DME) items listed in the table require prior authorization.

Examples of DME HCPCS codesE0194, E0265, E0266, E0300, E0328, E0329, E0445, E0457, E0465, E0466, etc.

Threshold notePA applies when retail purchase or cumulative rental cost exceeds $750 (see DME threshold).

ExclusionsProsthetics are handled under orthotics/prosthetics guidance rather than DME list.

Enteral services / In-home nutritional therapy

DefinitionIn-home enteral nutritional therapy delivered enterally or via gastrostomy tube requires prior authorization.

Example HCPCS codesB4155, B9002, B9998

ScopeApplies to enteral services for in-home nutritional therapy as listed in the document.

Home health services (outpatient)

Prior authorization scopeHome health services require prior authorization only in outpatient settings, including the member's home.

Example codesG0156, G0162, G0299, G0300, G0493–G0496

HospiceHospice services listed (T2042–T2045) also require prior authorization per document.

Enteral services (in-home nutritional therapy)

Enteral services PAPrior authorization required for in-home enteral nutritional therapy (enteral or via gastrostomy tube).

Relevant codesB4155, B9002, B9998

How to requestSubmit via Provider Portal Prior Authorization tool or call 888-397-8129 as instructed in the document.

Orthotics and prosthetics prior authorization threshold

Orthotics/prosthetics PA thresholdPrior authorization required only for orthotics and prosthetic codes with a retail purchase or cumulative rental cost over $750.

Examples of L-codesL0112, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0629, L0631, etc. (many L-codes listed)

ConditionIf item cost is at or below $750, PA is not required per this policy language.

Prior authorization requirement

Primary PA requirementPrior authorization is required for the services and codes listed in this document before provision or billing (non-emergent).

How to submitUse the Prior Authorization and Notification tool on the Provider Portal or call the listed phone numbers (877-842-3210 for general PA; 888-397-8129 appears for many listed services).

ExceptionsEmergency or urgent care services do not require prior authorization.

Stimulators / Neurostimulators

Stimulators includedIncludes bone growth stimulators and neurostimulators; listed device HCPCS/CPT include E0748, E0749, E0760 and multiple CPT codes for implantation.

Prior authorizationPA required for certain stimulator and neurostimulator services as listed in the document.

Example CPT/HCPCSCPT examples in stimulators section and codes such as 63650, 63655, 63685; HCPCS L8680–L8688 for implantable components.

Transplants / CAR T-Cell therapy

Transplant and CAR T-Cell requirementTransplants and CAR T-Cell therapy services require prior authorization and case management contact before provision.

Contact for authorizationCall UnitedHealthcare Community and State Transplant Case Management at 888-936-7246 or use the notification number on the back of the member's ID card.

Products referencedDocument lists CAR T products including Abecma (idecabtagene cifleucel), Breyanzi (lisocabtagene), Kymriah (tisagenlecleucel), Tecartus (brexucabtagene autoleucel), and Yescarta (axicabtagene ciloleucel).

11971	Injection of filling material for reconstruction
19316	Mastopexy, augmentation
19318	Reduction mammoplasty
19325	Augmentation mammoplasty, with prosthetic implant
19328	Removal of intact mammary implant
19330	Mastectomy, simple
19340	Immediate insertion of breast prosthesis following mastectomy
19341	Delayed insertion of breast prosthesis following mastectomy
19342	Breast reconstruction with implant
19350	Nipple/areola reconstruction

OpenPayer

Prior authorization requirements for Nebraska Medicaid

Prior Authorization — Coverage Criteria by Category

Codes (CPT/HCPCS/ICD-10) and Status

How Providers Request Authorization and Operational Notes

Key Terms and Definitions