CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements and submission instructions — UnitedHealthcare Community Plan of Tennessee (excerpt)

Lists services and procedures requiring prior authorization for participating providers in the UnitedHealthcare Community Plan of Tennessee; includes submission methods, vendor contacts, cost thresholds, and behavioral health special rules.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements and submission instructions — UnitedHealthcare Community Plan of Tennessee (excerpt)

Policy CodePolicy N/A

Change TypeNo material changes noted in this revision

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by phone at 866-604-3267; behavioral health requests via Member Services at 800-690-1606.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Portalonline submission

866-604-3267phone contact

No auth requiredemergency/urgent rule

$500DME cost threshold

800-690-1606

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.

20+codes listed (partial)

Services and Items Requiring Prior Authorization

Coverage criteria overview

Services and items listed in this document require prior authorization or notification as specified below. Submit requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by phone; behavioral health and HCBS have separate contacts. Prior authorization is not required for emergency or urgent care. For involuntary psychiatric admissions, documentation must be submitted the next business day and medical necessity is applied after the first 24 hours per the Contractor Risk Agreement (CRA).

ALL of the following

Submit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by phone at 866-604-3267 (behavioral health via Member Services 800-690-1606).
Prior authorization not required for emergency or urgent care; out-of-network providers must request prior authorization for all procedures/services.
For involuntary psychiatric hospitalizations, documentation supporting the inpatient stay must be submitted the next business day; medical necessity criteria are applied after the first 24 hours per the Contractor Risk Agreement (CRA).

ALL of the following

Inpatient/residential behavioral health services requiring prior authorization include: inpatient detoxification; inpatient psychiatric; psychiatric residential treatment; substance abuse residential detoxification; substance abuse residential treatment; residential rehabilitation.
Ambulatory/outpatient behavioral services requiring prior authorization include: ABA; electroconvulsive therapy (ECT); Family Support Services; Enhanced Supported Housing; Intensive Community-Based Treatment; outpatient detoxification and rehabilitation; psychological testing; supported housing; Suboxone; transcranial magnetic stimulation.

ALL of the following

Durable medical equipment (DME) prior authorization is required only for DME codes listed with a retail purchase or cumulative rental cost greater than $500; prosthetics are not DME for this purpose.
Incontinence supplies are a benefit only when provided through Edgepark Medical Supplies; to request supplies call 844-564-1008.

ALL of the following

Home- and Community-Based Services (HCBS) CHOICES and Employment and Community First (ECF CHOICES) require prior authorization.
Authorization for HCBS services (description, amount, frequency, duration) is determined by a full assessment of the individual’s physical, mental and social needs and coordinated via the CHOICES Care Coordinator or ECF CHOICES Support Coordinator; call UnitedHealthcare Community Plan at 800-690-1606 for HCBS assistance.

Prior authorization criteria (excerpt)

Selected services and codes require prior authorization or have specific submission/vendor instructions.

ALL of the following

Prior authorization required for inpatient services.
Relevant CPT codes: 95700, 95711, 95712, 95713, 95714, 95715, 95716, 95718, 95724.

ALL of the following

Prior authorization required for injectable chemotherapy administered outpatient (including IV, intravesical, intrathecal).
Relevant HCPCS/CPT examples or ranges: J9000-J9999; Leucovorin J0640; Levoleucovorin J0641/J0642; Lupron Depot J1950. Submit via Provider Portal or call 888-397-8129.

ALL of the following

BRCA/genetic testing notification/prior auth

Genetic and molecular testing (including BRCA)

ALL of the following

Notification/prior authorization is required before DNA sequencing for BRCA testing: the ordering provider must notify the laboratory conducting the test and the laboratory will notify UnitedHealthcare.
Extensive lists of CPT/HCPCS/U-codes and proprietary lab codes require notification/prior authorization (see code list).

Procedures prior authorization

Procedural services

ALL of the following

Prior authorization required for listed FESS CPT codes.
Representative CPT codes: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288.

ALL of the following

Prior authorization required for listed arthroscopic CPT codes 29914, 29915, 29916.

Code listing (partial)

Partial listing of codes and product names referenced for authorization. This excerpt presents codes and medication names but does not provide additional coverage criteria beyond listing.

Representative drug/product entries listed in this excerpt include Ultomiris (J1303), Veopoz (J9376), Viltepso (J1427), Vimizim (J1322), Vyepti (J3032), Vyjuvek (J3401), Vyondys 53 (J1429), Vyvgart (J9332), Vyvgart Hytrulo (J9334) and many other J-/C-/Q-codes.

The document contains numerous placeholder and repeated code entries; refer to the full code lists in the source for the complete set of HCPCS/CPT/ proprietary codes requiring authorization/notification.

Prior authorization and notification criteria (partial)

Services and procedures requiring prior authorization or notification as listed below.

ALL of the following

Prior authorization is required for inpatient hospital services including acute medical, nursery level 4, maternity, rehabilitation and skilled nursing facility levels of care.
For post-acute inpatient facilities (acute care hospitals, acute inpatient rehabilitation, critical access hospitals, LTAC), prior authorization and notification of admission date are required.

ALL of the following

Prior authorization required for joint replacement (total hip and knee) and other musculoskeletal procedures including shoulder surgery.
Representative CPT examples for joint replacement include 27130 (total hip), 27486 (total knee) and related codes (see full list in source).

Prior authorization coverage requirements

Services in the following categories require prior authorization as indicated:

ALL of the following

Prior authorization required for musculoskeletal services including joint replacement and shoulder surgery (representative codes and details provided in the source).

ALL of the following

Non-emergent air ambulance transport requires prior authorization (sample codes A0430, A0431, A0435, A0436, S9960, S9961).

ALL of the following

Orthognathic/maxillofacial surgery for jaw functional impairment requires prior authorization; multiple CPT codes are provided in the source.

Orthotics and Prosthetics Authorization Criteria

Authorization and coding guidance for orthotics and prosthetics in this document segment.

ALL of the following

Prior authorization is required only for orthotic and prosthetic items when the retail purchase or cumulative rental cost exceeds $500.
Representative HCPCS L-codes referenced for orthotics/prosthetics include: L0112, L0170, L0456, L0464, L0480, L0482, L0486, L0624, L0629, L0631, L0632, L0634, L0636, L0637 (partial list).

Prosthetics authorization criteria (fragmentary)

Fragmented guidance about authorization for prosthetics referencing specific HCPCS codes and a cost threshold for rental/purchase.

ALL of the following

A rental cost or cumulative rental/purchase cost greater than $500 triggers the requirement for additional information and/or prior authorization for prosthetic devices.
HCPCS examples repeatedly associated with this threshold include L0464, L0486, L0624, L0629, L0631, L0632, L0634, L0636, L0637 (partial and repeated listings).

ALL of the following

The document contains repeated/fragmented entries referencing prosthetics codes and reiterates the purchase/cumulative rental cost > $500 threshold as the trigger for authorization review.

Administrative/billing notes

Administrative and billing notes present; no clinical coverage criteria in these pages.

These pages contain administrative coding and billing references (including repeated lists of HCPCS/L-codes) and a recurring note that purchase or cumulative rental cost over $500 requires additional information or prior authorization; they do not add new clinical coverage criteria.

Zolgensma — authorization and cost notes

Fragmented entries referencing authorization codes and a repeated cost threshold related to high-cost products and associated supplies.

ALL of the following

Multiple HCPCS/L-codes are listed in association with Zolgensma and related items; representative codes include L0486, L0624, L0629, L0631, L0632, L0634, L0636, L0637.
Additional information: purchase or a cumulative rental cost of more than $500 is repeatedly noted as triggering the need for additional information or authorization for associated supplies/items.

ALL of the following

The Zolgensma sections are fragmented and repeat the cost-threshold guidance; consult the full authorization process and billing instructions in the broader policy for submission details.

Relevant CPT, HCPCS, and Other Codes

DME / Orthotics / Prosthetics HCPCSHCPCS

E0194	Custom molded seat insert
E0265	Decorator (unspecified)
E0266	Seat elevator
E0270	Accessory, wheelchair
E0277	Accessory, wheelchair
E0300	Power wheelchair component
E0328	Power chair component
E0329	Power chair component
E0445	Pressure reducing support surface
E0457	Wheelchair accessory

1–10 of 133

1/14

Cardiology CPT/HCPCS Codes Requiring Prior AuthorizationCPTCovered

33207	Transvenous lead implantation
33208	Insertion or replacement of pacing lead
33212	Insertion or replacement of ICD pulse generator
33213	Insertion or replacement of ICD lead
33214	Removal/replacement of pacemaker/defibrillator
33221	Revision or replacement of pacemaker/defibrillator
33224	Insertion of transvenous pacing electrode
33225	Insertion of subcutaneous implantable defibrillator
33227	Insertion of ventricular assist device
33228	Leadless pacemaker insertion

1–10 of 32

1/4

Ambulatory / Service HCPCS and Misc CodesHCPCS

99503	Home visit, nursing
G0494	Care management
S9123	Home infusion
S9131	Home infusion
J3262	Actemra
J0801	Acthar
J0791	Adakveo
G0159	Therapy service
G0495	Care management
S9124	Home infusion

1–10 of 12

1/2

Selected Injectable Medication HCPCS/J-codesHCPCS

J1447	Tbo-filgrastim - authorization may be required
J1448	Trilaciclib (Cosela)
J1454	Palonosetron/fosnetupitant
J0185	Cinvanti (aprepitant)
J1453	Fosaprepitant (Emend)
J1627	Sustole (granisetron ER)
J0897	Denosumab (Xgeva/Prolia)
J2820	Sargramostim (Leukine)

HCPCS V-codes for Prosthetics / DMEHCPCS

V2786	External prosthetic device
V5274	Seat cushion, lumbar support or positioning (V5274)
V5281	Supportive equipment, seat pad (V5281)
V5282	Supportive seating accessory (V5282)
V5290	Cushion, lateral support (V5290)

Relevant CPT, HCPCS, and Other Codes

DME/Orthotics Authorization Note

How to Request Authorization and Provider Responsibilities

Prior Authorization

How to request prior authorization

Submit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (sign in at UHCprovider.com with your One Healthcare ID) or by phone at 866-604-3267 (or the specialty numbers listed below for some services). Prior authorization is not required for emergency or urgent care. Out-of-network providers must request prior authorization for all procedures and services.

Online: Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com).
Phone: 866-604-3267 (use specialty numbers where noted in specific service entries).

Prior Authorization

Behavioral health — inpatient/residential prior authorization

Inpatient and residential behavioral health services require prior authorization. This includes inpatient detoxification, inpatient psychiatric hospitalization, psychiatric residential treatment, substance abuse residential detoxification and residential rehabilitation. For involuntary psychiatric admissions, providers must submit supporting documentation the next business day; UnitedHealthcare applies medical necessity criteria after the first 24 hours per the contractor risk agreement.

Key Terms and Vendor References

Prior authorization submission channels and exceptions — Prior authorization requests must be submitted via the Provider Portal, phone, or other specified channels and are required for listed services except emergency and urgent care.

Submission channelsOnline via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal; Phone: 866-604-3267

Behavioral health exceptionsBehavioral health requests via Member Services at 800-690-1606; ABA via fax or Provider Express as noted

Emergency/Urgent carePrior authorization is not required for emergency or urgent care

Out-of-network ruleOut-of-network providers must request prior authorization for all procedures/services

Contractor Risk Agreement (CRA) note — Under the CRA, medical necessity criteria are applied after the first 24 hours of an involuntary psychiatric admission.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements and submission instructions — UnitedHealthcare Community Plan of Tennessee (excerpt)

Policy CodePolicy N/A

Change TypeNo material changes noted in this revision

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Prior authorization required for auditory (inner ear) implants and associated external components for profound sensorineural deafness.
Relevant CPT/HCPCS examples: 69710, 69714, 69930, L8619, L8690, L8691, L8614, L8692.

ALL of the following

DME codes listed (examples: A9279, A9280, A9900, E0194, E0265) require prior authorization when retail purchase or cumulative rental cost exceeds $500.
Incontinence supplies must be obtained through Edgepark Medical Supplies (call 844-564-1008).

ALL of the following

Non-emergent air ambulance transport requires prior authorization.
Representative codes: A0430, A0431, A0435, A0436, S9960, S9961.

ALL of the following

Prior authorization required for orthognathic/maxillofacial surgery to treat jaw functional impairment; multiple CPT codes are listed in the document.

Inpatient detoxification

Inpatient psychiatric

Psychiatric residential treatment

Substance abuse residential detoxification

Substance abuse residential treatment / residential rehabilitation

Documentation for involuntary admissions must be submitted the next business day

Prior Authorization

Behavioral health — outpatient prior authorization

Certain ambulatory and outpatient behavioral health services require prior authorization. Prior authorization is required for services such as applied behavior analysis (ABA), electroconvulsive therapy (ECT), family support services, enhanced supported housing, intensive community-based treatment, outpatient detox/rehabilitation, psychological testing, supported housing, suboxone treatment, and transcranial magnetic stimulation.

ABA
Electroconvulsive therapy (ECT)
Family Support Services
Enhanced Supported Housing
Intensive Community-Based Treatment (ICT/ICFT/PACT)
Outpatient detoxification and rehabilitation
Psychological testing
Supported housing
Suboxone
Transcranial magnetic stimulation

Prior Authorization

Cancer supportive care medications — prior authorization

Prior authorization is required for cancer supportive care medications administered in the outpatient setting, including selected colony-stimulating factors, pegfilgrastim biosimilars, sargramostim, trilaciclib, certain anti-emetics, and the bone-modifying agent denosumab (Xgeva). Submit requests via the UnitedHealthcare Provider Portal.

Colony-stimulating factors and biosimilars: e.g., J1442, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, J1447, J2506, J1449, J0885
Filgrastim products (Zarxio Q5101; Releuko Q5125; others)
Pegfilgrastim products (Neulasta J2506; biosimilars Q5122, Q5120, Q5108, etc.)
Sargramostim (J2820)
Tbo-filgrastim (J1447)
Trilaciclib (J1448)
Anti-emetic agents: palonosetron/fosnetupitant (J1454), aprepitant (J0185), fosaprepitant (J1453), granisetron ER (J1627/J1456)
Bone-modifying agent: Denosumab (Xgeva) J0897

Prior Authorization

Outpatient injectable chemotherapy — prior authorization

Outpatient injectable chemotherapy drugs (including IV, intravesical and intrathecal agents) require prior authorization for a cancer diagnosis. This includes chemotherapy HCPCS range J9000–J9999, leucovorin (J0640), levoleucovorin (J0641/J0642), Lupron Depot (J1950), Q‑codes for chemotherapy products, and miscellaneous HCPCS (J-codes or Q-codes) billed for unassigned products. Submit authorization requests online via the Provider Portal or by calling the chemotherapy prior authorization line.

Chemotherapy injectable drugs: J9000–J9999
Leucovorin: J0640; Levoleucovorin: J0641, J0642
Lupron Depot: J1950
Q‑codes for chemotherapy products and miscellaneous HCPCS for products without assigned codes
Submit via Provider Portal or call 888-397-8129

Prior Authorization

Gender dysphoria services — prior authorization

Gender dysphoria treatment and related procedures require prior authorization. Surgeries and other interventions billed with the gender dysphoria diagnosis codes (e.g., F64.x series) must be authorized in advance. Specific CPT codes commonly associated with gender-affirming procedures are listed in the plan and must be submitted along with the applicable diagnosis codes.

Diagnosis codes: F64.0, F64.1, F64.2, F64.8, F64.9 (as applicable)
Example procedure CPT codes referenced in the policy: 14000, 14001, 14041, 15734, 15738, 15750, 15757, 15758, 19303, 53410, 53430, 54125, 54520, 19303 and others in the section — submit procedure code(s) with supporting documentation for authorization

Prior Authorization

FAI (femoroacetabular impingement) surgery — prior authorization

Femoroacetabular impingement (FAI) procedures — arthroscopic hip procedures — require prior authorization for the listed CPT codes. Submit procedure codes (for example 29914, 29915, 29916) with clinical documentation demonstrating medical necessity.

FAI arthroscopic CPT codes: 29914, 29915, 29916
Provide clinical documentation supporting diagnosis and indication for surgery

Prior Authorization

Additional HCPCS / J‑codes / C‑series codes — authorization note

The policy includes many additional HCPCS/CPT/J- and C-series HCPCS codes that require prior authorization across drug, device and procedure categories. Examples include C-series codes (C9149, C9151, C9161, C9166, C9167, C9168, C9172, C9399, C9090, C9094), miscellaneous drug codes (J3490, J3590), and high-cost drug HCPCS such as J1303 (Ultomiris) and other J-codes. Review the specific code listings in the plan when preparing authorization requests and include clinical documentation and diagnosis codes.

Examples of C-series HCPCS: C9149, C9151, C9157, C9161, C9166, C9167, C9168, C9172, C9090, C9094, C9399
Examples of J-/misc drug codes: J1303 (Ultomiris), J3399 (Zolgensma listing), J3490, J3590
When requesting authorization, include the exact CPT/HCPCS code(s), diagnosis, supporting clinical notes, and any relevant lab or imaging results

Prior Authorization

Surgical / device procedures — prior authorization

Certain surgical procedures and device/implant categories require prior authorization. Examples in the policy include bone growth stimulators (CPT 20975, 20979), breast reconstruction and mastectomy-related reconstruction codes (e.g., 11971, 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19367–19370, 19371, 19380, 19396), auditory implants (CPT 69710, 69714, 69930 and HCPCS L86xx series), and many cosmetic/reconstructive CPT codes listed in the surgical section. Verify the exact CPT/HCPCS code(s) and submit the required documentation for prior authorization.

Bone growth stimulator: CPT 20975, 20979 (prior authorization required)
Breast reconstruction / mastectomy-related reconstruction: CPT examples 11971, 19303, 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19367–19371, 19380, 19396
Auditory implants: CPT 69710, 69714, 69930; HCPCS L8619, L8690, L8691, L8614, L8692 (prior authorization required)
Cosmetic/reconstructive examples: 11960, 14020, 14021, 14041, 14061, 15734, 15738, 15750, 15757, 15758, 15820, 15821, 15822, 15823, 15830, 15847, 17107–17108, 21137–21139, 21172–21184, 21230, 21235, 21249, 21256, 21275, 21280, 21282, 21295, 21740

Prior Authorization

Orthotics / prosthetics — cost threshold and authorization

Orthotics and prosthetics require prior authorization only when the retail purchase price or cumulative rental cost exceeds $500. The policy lists multiple example HCPCS L‑codes for orthotics/prosthetics and for items related to high-cost gene therapy supports (e.g., Zolgensma-related L‑codes). When the cost threshold is met, include itemized pricing, justification and supplier information with your authorization request.

Prior authorization threshold: retail purchase or cumulative rental cost > $500 triggers authorization requirement
Example HCPCS L‑codes referenced: L0112, L0170, L0456, L0464, L0480, L0482, L0486, L0624, L0629, L0631, L0632, L0634, L0636, L0637 (and others listed in the prosthetics section)
Provide itemized cost, supplier, and medical justification when requesting authorization if threshold exceeded

Prior Authorization

Zolgensma and associated coding — authorization and cost notes

Zolgensma and related high-cost items: the document lists Zolgensma (often billed under J3399 or related HCPCS) and numerous associated L‑codes for supportive equipment or prosthetics where prior authorization is required when applicable. Predetermination is highly recommended for new-to-market and high-cost drugs. For Zolgensma-related items and other high-cost therapies, submit full clinical documentation and itemized cost information via the Provider Portal; follow the Review at Launch/New-to-Market medication guidance as applicable.

Zolgensma drug code reference: J3399 (and related coding as documented)
Associated HCPCS/L‑codes referenced for Zolgensma-related items and prosthetics: L0486, L0624, L0629, L0631, L0632, L0634, L0636, L0637, L0464, L0482 (see policy for full list)
Predetermination recommended for new-to-market medications; include clinical documentation and itemized costs
When supportive device/prosthetic purchase or cumulative rental exceeds $500 prior authorization is required

Under the Contractor Risk Agreement (CRA), medical necessity criteria are applied after the first 24 hours of an involuntary psychiatric admission

Provider responsibilityDocumentation supporting involuntary inpatient psychiatric hospitalization must be submitted the next business day

ScopeApplies to involuntary psychiatric hospitalizations only

Chemotherapy injectable drugs definition — Chemotherapy injectable drugs listed (J9000-J9999 and examples).

Definition/example codesChemotherapy injectable drugs defined as J9000-J9999; examples include Leucovorin J0640 and Levoleucovorin J0641/J0642; Lupron Depot J1950

Billing notesSome chemotherapy injectables have Q-codes or may be billed under miscellaneous HCPCS if no assigned code exists

SubmissionPrior authorization requests for these drugs should be submitted online via the Provider Portal or by calling 888-397-8129

Incontinence supplies vendor — Edgepark Medical Supplies is the designated vendor for incontinence supplies; contact information provided.

Designated vendorEdgepark Medical Supplies is the designated vendor for incontinence supplies

ContactTo request incontinence supplies call Edgepark Medical Supplies at 844-564-1008

Benefit noteIncontinence supplies are a benefit only when provided through Edgepark Medical Supplies

BRCA testing notification process — Ordering provider must notify the laboratory conducting the BRCA test and the laboratory will notify UnitedHealthcare prior to DNA sequencing.

Notification requirementOrdering provider must notify the laboratory conducting the BRCA test; the laboratory will notify UnitedHealthcare prior to DNA sequencing

ScopeApplies to BRCA and genetic/molecular testing where DNA sequencing is performed

Codes referencedExtensive list of CPT/HCPCS/U-codes accompany the notification/prior authorization requirement (see code list)

HCBS prior authorization definition — Prior authorization for Home- and Community-Based Services CHOICES and ECF CHOICES is required and is determined by a full assessment.

DefinitionPrior authorization is required for Home- and Community-Based Services (HCBS) CHOICES and ECF CHOICES

DeterminationAuthorization for each service (description, amount, frequency, duration) is determined by a full assessment of the individual's physical, mental and social needs

CoordinationAssessment process is facilitated by the CHOICES Care Coordinator or ECF CHOICES Support Coordinator; call UnitedHealthcare Community Plan at 800-690-1606 for HCBS

authorization prior — Prior authorization (term reference).

TermPrior authorization

Definition summaryAuthorization required before certain services; see submission channels for how to request

ExclusionsNot required for emergency or urgent care

CPT or HCPCS code mapping — HCPCS/J-code corresponding to an injectable medication (term reference).

MappingHCPCS/J-code corresponding to an injectable medication is used to identify the drug for authorization (e.g., many J-codes listed)

ExamplesExamples of injectable medication codes appear throughout the document (see J3262, J0801, J1303, etc.)

Submission guidancePrior authorization for injectable medications should follow the Provider Portal/phone submission instructions

Ultomiris — Product mention (term reference).

Product mentionUltomiris (J1303) is referenced multiple times in the injectable medication listings

ContextAppears among repeated HCPCS/J-code entries for injectable/specialty drugs

Authorization implicationListed drugs generally require prior authorization as indicated elsewhere in the policy

Uplizna — Product mention (term reference).

Product mentionUplizna is listed among medications with HCPCS/CPT code references in the document

ContextAppears alongside other specialty injectables and HCPCS/L codes

AuthorizationDrugs listed require prior authorization per injectable medications section

Review at Launch for New to Market Medications — Policy reference for new medications (term reference).

Policy referenceReview at Launch for New to Market Medications policy referenced for newly FDA-approved drugs; predetermination highly recommended

ActionCheck the Review at Launch policy and submit predetermination for new-to-market medications where advised

SubmissionUse Prior Authorization and Notification tool or call provided phone number for drug requests

Non-emergent air ambulance transport — Definition and sample codes for air ambulance transport requiring prior authorization.

DefinitionNon-emergent air ambulance transport requires prior authorization

Example codesSample HCPCS/CPT codes listed: A0430, A0431, A0435, A0436, S9960, S9961

ContextListed under ambulance transport entries with prior authorization requirement

Orthognathic surgery definition — Orthognathic surgery: surgical treatment of maxillofacial/jaw functional impairment requiring prior authorization; multiple CPT codes referenced.

DefinitionOrthognathic surgery: surgical treatment of maxillofacial/jaw functional impairment requiring prior authorization

CodingMultiple CPT codes referenced for orthognathic/maxillofacial procedures (e.g., 21121, 21141, 21142, 21143, 21145, 21154, 21193, 21194)

ActionPrior authorization required for procedures treating jaw functional impairment

Prior authorization threshold for orthotics/prosthetics — Prior authorization is required only for orthotic and prosthetics with a retail purchase or a cumulative rental cost of more than $500.

Threshold for orthotics/prostheticsPrior authorization is required only for orthotics and prosthetics with a retail purchase or a cumulative rental cost of more than $500

Related HCPCS codesExamples of L-codes referenced include L0112, L0464, L0486, L0624, L0632

NoteThe $500 threshold is repeated across multiple prosthetics/orthotics entries in the document

rental cost threshold — Indicates that a rental cost or cumulative rental cost exceeding $500 is relevant for authorization decisions; document fragment contains repeated mention.

Rental/cumulative rental cost thresholdRental cost or cumulative rental cost greater than $500 triggers requirement for additional information or authorization

Repeated usageUsed repeatedly in entries related to prosthetics, Zolgensma billing notes, and HCPCS L-code references

Associated codesOften shown alongside HCPCS L-codes such as L0632, L0634, L0636, L0637

Additional information / cost threshold — Additional information = purchase or a cumulative rental cost of more than $500.

Additional information triggerAdditional information is required when purchase or a cumulative rental cost is more than $500

ContextThis trigger is used in administrative/billing guidance for Zolgensma and other HCPCS/L-code items

Sample codesAssociated HCPCS/L-codes include L0486, L0624, L0632, L0634, L0636, L0637

Cost threshold for additional information/authorization — purchase or a cumulative rental cost of more than $500.

Cost threshold for additional information/authorizationPurchase or a cumulative rental cost of more than $500

ApplicationAppears in authorization and coding references for Zolgensma-related items and prosthetics

Associated HCPCS codesExamples listed with the threshold include L0486, L0624, L0629, L0631, L0632, L0634, L0636, L0637