CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements and submission instructions — UnitedHealthcare Community Plan of Arizona (ACC) Medicaid

Lists prior authorization requirements, submission methods, code-level guidance, vendor contacts, and age/site-of-service distinctions for providers participating in the UnitedHealthcare Community Plan of Arizona Complete Care (ACC) Medicaid program; affects in-network and out-of-network participating professionals and facilities delivering inpatient and outpatient services in Arizona.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements and submission instructions — UnitedHealthcare Community Plan of Arizona (ACC) Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on UHCprovider.com (sign in with One Healthcare ID) or call 800-445-1638.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

UHCprovider.comportal submission

800-445-1638main PA phone

888-397-8129alternate drug PA phone

<21EPSDT (<21)

J9000-J9999

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Manyservices flagged require PA

Coverage Criteria and Medical Necessity

Allergy immunotherapy/testing criteria

Covered when ALL of the following are met:

Member is younger than 21 (EPSDT applies) and service is medically necessary.

Allergy immunotherapy/testing specifics

Allergy immunotherapy and allergy testing are covered under EPSDT for members younger than 21 when medically necessary.
For members 21 and older, allergy immunotherapy (including subcutaneous injections and sublingual immunotherapy) is not a covered benefit.
When allergy testing prior authorization is required
- Member has sustained an anaphylactic reaction to an unknown allergen (examples: severe facial swelling, breathing difficulties, epiglottal swelling, extensive urticaria).
- Member exhibited such a severe allergic reaction that further exposure to the unknown allergen may be life-threatening; prior authorization is required in these cases.

Operational: Requests must meet AHCCCS coverage definitions and only one health care professional may request services on a PA form.

Oncology supportive drug coverage

Covered when ALL of the following are met:

Injectable colony-stimulating factors, pegfilgrastim products, erythropoiesis-stimulating agents and specified bone-modifying agents are administered in an outpatient setting for a cancer diagnosis and require prior authorization.

Prior authorization requests should be submitted online via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (sign in with One Healthcare ID) or by calling 888-397-8129.

Cardiology prior authorization criteria

Covered when ALL of the following are met:

Outpatient and office-based diagnostic catheterizations, electrophysiology implants and stress echocardiography procedures performed by participating physicians require prior authorization.

Providers must submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 866-889-8054; see UHCprovider.com/AZcommunityplan for the full CPT code lists.

Chemotherapy prior authorization criteria

Covered when ALL of the following are met:

Injectable chemotherapy drugs administered in an outpatient setting (including IV, intravesical and intrathecal routes) for a diagnosed cancer require prior authorization.

Included drug codes: Includes chemotherapy injectable drugs J9000-J9999, leucovorin (J0640), levoleucovorin (J0641/J0642), Lupron Depot (J1950), Q-coded chemotherapy injectables, and miscellaneous HCPCS-billed injectables.

Submit prior authorization requests online using the Prior Authorization and Notification tool on UHCprovider.com (sign in with One Healthcare ID) or call 888-397-8129.

Seizure monitoring authorization guidance

Covered when ALL of the following are met:

Certain cerebral seizure monitoring CPT codes (95700, 95711, 95712, 95713) require prior authorization for outpatient monitoring.

Inpatient video monitoring CPT codes (e.g., 95714–95718) do not require prior authorization.

Operational: EEG and monitoring performed in outpatient hospital or ASC settings may be subject to site-of-service PA rules; follow portal submission guidance for PA requests.

Cochlear implants and CGM prior authorization

Covered when ALL of the following are met:

Cochlear implants - pediatric: For members younger than 21, cochlear and other auditory implant procedure/device codes listed require prior authorization.

Cochlear implants - adult: For members 21 and older, prior authorization is required for supplies, equipment maintenance and repair for cochlear/inner-ear devices (listed L-codes).

Continuous glucose monitor (CGM): Continuous glucose monitor supplies (e.g., A4226, A9277) require prior authorization and are authorized only with an appropriate Type 2 diabetes diagnosis.

Operational: Contact via Provider Portal/One Healthcare ID or call 888-397-8129 for prior authorization submission or questions.

Cosmetic vs reconstructive procedures and pediatric EPSDT

Coverage limited or excluded when ANY of the following apply:

ANY of the following

Services or items furnished solely for cosmetic purposes are excluded from AHCCCS coverage.
Reconstructive procedures that treat a medical condition or improve/restore physiologic function may be covered and typically require prior authorization (see listed CPT/HCPCS codes).
For members younger than 21, EPSDT procedures may be covered when medically necessary; refer to AHCCCS AMPM Chapter 400, Section 430 for EPSDT authorization procedures.

Operational: Providers should submit PA requests via the Provider Portal or call 888-397-8129 as instructed in the code lists.

DME and nutrition coverage criteria

Covered when ALL of the following are met:

Durable medical equipment (DME) codes listed require prior authorization when retail purchase or cumulative rental cost exceeds the applicable threshold; Preferred Homecare is the vendor contact for many DME items.

Requests for enteral/parenteral nutrition or oral nutritional supplements must include clinical documentation and a Certificate of Medical Necessity as applicable.

Diabetic supplies are provided through the local pharmacy; continuous glucose monitor supplies require prior authorization with the specified diagnosis.

Operational: Providers should contact Preferred Homecare (vendor) per the Provider Manual and use the UHC provider portal for PA submission when required.

Experimental/investigational coverage requirement

Covered when ALL of the following are met:

Prior authorization is required for all services considered experimental and/or investigational; examples of CPT/HCPCS codes are listed in the document and refer to AHCCCS AMPM Chapter 300, Section 320 policy guidance.

Operational: See AMPM Chapter 300 Section 320 and submit supporting clinical documentation with the PA request.

Coverage criteria and prior authorization rules

Service-specific prior authorization rules — key rules summarized:

Enteral/Parenteral nutrition: Follow AHCCCS AMPM guidance for members 21 and older (Chapter 300, Policy 310-GG); clinical documentation and Certificate of Medical Necessity must accompany PA requests.

Experimental/Investigational services: All experimental/investigational services require prior authorization per AMPM Chapter 300 Section 320; examples and code lists are provided.

Infusion and injectable medications: Prior authorization is required for in-home infusion services not covered by Optum Infusion; contact Optum Infusion (888-705-4470) for medications they manage. Injectable medications not covered by vendor-default require prior authorization.

Hearing services: Hearing evaluations and hearing aids: prior authorization is not required for members younger than 21; for members 21 and older prior authorization is required for hearing aids and related codes.

Coverage stance — not specified

Document enumerates many injectable medications and associated codes. Coverage determination:

The document lists injectable medications and HCPCS/CPT codes for reference; specific clinical prerequisites or inclusion/exclusion criteria for each listed injectable are not specified in this excerpt.

Prior authorization and notification rules (excerpt)

Administrative PA / notification requirements (excerpt):

For prior authorization, submit requests online using the UnitedHealthcare Provider Portal (UHCprovider.com) Prior Authorization and Notification tool; notification/PA of admission date is required for acute care hospitals, acute inpatient rehabilitation and long-term acute care hospitals.

Operational: Review the 'Review at Launch for New to Market Medications' policy on UHCprovider.com/policies for medications referenced on the drug lists.

Administrative prior authorization instructions

Administrative submission guidance and instructions:

Submit prior authorization requests online via the UnitedHealthcare Provider Portal at UHCprovider.com (click Sign In and use the Prior Authorization and Notification tool).

Certain services and listed CPT/HCPCS codes require prior authorization; providers should consult the Provider Portal resources and code lists for PA submission specifics.

Operational: The Provider Portal and the Review at Launch policy are primary references for administrative PA procedures and current drug lists.

Administrative coverage notes (partial)

Administrative coverage notes and conditions (partial):

Prior authorization is required for the codes listed throughout the document; providers should use the UHC provider portal to request authorization.

Orthotics and prosthetics coverage applies when the orthotic is medically necessary, is the preferred treatment option consistent with Medicare or AHCCCS orthotics rules, and providers should follow AHCCCS guidance for purchase/repair/replace considerations.

Age-based applicability: some codes and device/supply rules vary for members younger than 21 versus members 21 and older; check the specific code entries and AMPM references.

Outpatient therapy coverage rules (partial)

Therapy coverage and PA rules (age-dependent):

For members younger than 21: outpatient occupational and physical therapy and speech therapy are covered when medically necessary; prior authorization is required after the initial evaluation and before the initial therapy visit and for ongoing therapy visits; requests are reviewed for medical necessity and no annual benefit limits apply.

For members 21 and older: prior authorization is not required for occupational and physical therapy; outpatient speech therapy is not a covered benefit except for QMB members as noted.

Imaging and network geography rules

Advanced imaging and geographic/site rules:

Advanced outpatient imaging (certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures) requires prior authorization; the ordering clinician is responsible for notification prior to scheduling and must submit PA via the Provider Portal.

Out-of-state services are a limited benefit and are only approved when the service is emergent or unavailable in Arizona; prior authorization is required for out-of-state requests.

Prior authorization and site-of-service rules (excerpt)

Site-of-service and procedure-specific PA rules:

Prior authorization is required for listed procedures such as shoulder surgery and sinuplasty (codes shown) when performed in an outpatient hospital setting; prior authorization is not required if the procedure is performed at a participating ambulatory surgery center (ASC).

Prior authorization is required for skilled nursing facility services, sleep apnea procedures/surgeries, and spinal surgery codes listed in the document.

Operational: Check the specific code entries and site-of-service notes on the Provider Portal for ASC participation exceptions.

Authorization and documentation requirements (part 11)

Authorization and documentation expectations (administrative):

Prior authorization is required for spinal surgery, sterilization, stimulator implantation and transplant/CAR T-cell therapy services as listed; clinical documentation establishing medical necessity must accompany PA requests.

Sterilization specific: For members younger than 21, prior authorization is required for sterilization codes and an appropriate Consent to Sterilization form must be signed and provided per AHCCCS guidance.

Transplant/CAR T: Transplant and CAR T-cell therapy requests require prior authorization, detailed clinical documentation, and coordination with the UnitedHealthcare Community and State Transplant Case Management Team.

Prior authorization statements in excerpt

Operational PA instructions and clarifications:

Transportation: Prior authorization is required for non-emergent taxi and stretcher van; schedule via Medical Transportation Management (MTM) at 888-700-6822.

Ventricular assist device (VAD) procedures and related codes require prior authorization; notify using the number on the member ID card then fax required forms to the Optum VAD Case Management Team at 855-282-8929.

Code-specific clarification: CPT code 38232 requires prior authorization only when billed for oncology indications.

Code Lists and Coding Notes

Chemotherapy & supportive injectable HCPCS/J-codesHCPCSCovered

J9000-J9999	Chemotherapy injectable drugs range (requires prior authorization)
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin (additional)
J1950	Lupron Depot
J1442	Filgrastim (Neupogen)
Q5110	Filgrastim-aafi (Nivestym)
Q5125	Filgrastim-ayow (Releuko)
Q5101	Filgrastim-sndz (Zarxio)
J2506	Pegfilgrastim (Neulasta)

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Augmentative & alternative communication (AAC) codesCPTCovered

92607	Evaluation of oral and pharyngeal function for feeding
92608	Diagnostic analysis of speech
92609	Therapeutic services for AAC
A9901	Durable medical equipment miscellaneous - AAC (unlisted)

AAC DME/HCPCS codesHCPCSCovered

E2500	High technology communication device (example)
E2502	Speech generating device (example)
E2504	AAC accessory (example)
E2506	AAC accessory (example)
E2508	AAC accessory (example)
E2510	AAC accessory (example)
E2511	AAC accessory (example)
E2512	AAC accessory (example)
E2599	Miscellaneous AAC supply
V5336	Vehicle modification for AAC device (example)

ICD-10 diagnosis codes referenced for authorizationICD-10

I70.448	Atherosclerosis of other extremity arteries with ulceration, left leg
I70.449	Atherosclerosis of other extremity arteries with ulceration, unspecified leg
I70.461	Atherosclerosis of native arteries of right leg
I70.462	Atherosclerosis of native arteries of left leg
I70.463	Atherosclerosis of native arteries of bilateral legs
I70.468	Atherosclerosis of other extremity arteries with other complications
I70.469	Atherosclerosis of other extremity arteries with unspecified complications
I70.521	Atherosclerosis of bypass graft of right leg
I70.522	Atherosclerosis of bypass graft of left leg
I70.523	Atherosclerosis of bypass graft of bilateral legs

Chemotherapy HCPCS/J-codes requiring prior authorizationHCPCSCovered

Leucovorin	May be billed J0640/J0641/J0642 depending on product
Lupron Depot	J1950
Miscellaneous chemotherapy	Chemotherapy drugs billed under J9000-J9999 or miscellaneous HCPCS

Representative CPT examples for procedures requiring prior authorizationCPT

21121	Maxillofacial procedure example
21150	Orthognathic/jaw procedure example
21151	Maxillofacial functional procedure
21154	Maxillofacial functional procedure
21155	Maxillofacial functional procedure

Common DME HCPCS examples (prior authorization may apply)HCPCSCovered

E0265	Patient elevator/transfer equipment (example)
E0266	Patient elevator/transfer equipment (example)
E0270	Patient lift (example)
E0300	Powered vehicle seat (not covered example)
E0445	Oxygen contents (example)
E0457	Oxygen contents (example)

Genetic testing / biomarker CPT codes (sample)CPT

81323	Genetic test (sample)
81325	Genetic test (sample)
81401	Molecular pathology procedure (sample)
81403	Molecular pathology procedure (sample)
81404	Molecular pathology procedure (sample)
81405	Molecular pathology procedure (sample)
81406	Molecular pathology procedure (sample)
81407	Molecular pathology procedure (sample)
81408	Molecular pathology procedure (sample)

Injectable medication HCPCS/J-codes (sample list)HCPCSCovered

J2508	Elfabrio
J3380	Entyvio
J1302	Enjaymo
J7204	Esperoct
J3111	Evenity
J1305	Evkeeza
J0177	Eylea HD (intravitreal)
J0517	Fasenra
Q5130	Fylnetra (Q-code)
J9210	Gamifant

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Additional injectable HCPCS/CPT codes listedHCPCSCovered

J1439	Injectafer
J1459	IVIG (multiple rates - see policy)
J1558	Xembify
J0218	Xenpozyme
J9202	Zoladex
J1575	Injectable medication example

Visible mixed CPT/HCPCS/Q codes called out in document segmentmixed

J2350	Drug administration code referenced multiple times
J2356	Tezepelumab (example J-code)
90378	Vaccine/immune globulin example
A9513	Therapeutic radiopharmaceutical example
A9590	Therapeutic radiopharmaceutical example
A9607	Therapeutic radiopharmaceutical example

Non-emergent air ambulance HCPCS codes (examples)HCPCSCovered

A0430	Basic life support, non-emergent air ambulance
A0431	Advanced life support, non-emergent air ambulance
A0435	Air ambulance service, transport and treatment (example)
A0436	Air ambulance service, transport and treatment (example)

Example orthognathic/maxillofacial CPT codesCPTCovered

21121	Maxillofacial osteotomy
21150	Maxillofacial reconstruction
21151	Maxillofacial functional reconstruction
21154	Maxillofacial functional reconstruction
21159	Maxillofacial procedure example

Sample HCPCS L-codes (orthotics/prosthetics)HCPCSCovered

L0112	Lower extremity orthosis (example)
L0170	Cervical orthosis (example)
L0456	Custom trunk orthosis (example)
L0462	Prosthetic component (example)
L0464	Prosthetic component (example)
L0480	Prosthetic component (example)

Additional HCPCS L-codesHCPCSCovered

L0624	Orthotic/prosthetic supply (example)
L0629	Orthotic/prosthetic supply (example)
L0631	Orthotic/prosthetic supply (example)
L0861	Orthotic/prosthetic supply (example)
L1000	Orthotic/prosthetic supply (example)
L1005	Orthotic/prosthetic supply (example)
L1200	Orthotic/prosthetic supply (example)

Intravitreal / implantable related L-codesHCPCSCovered

L5321	Ocular prosthetic/implant example
L5331	Ocular prosthetic/implant example
L5341	Ocular prosthetic/implant example
L5400	Ocular prosthetic/implant example
L5420	Ocular prosthetic/implant example

Therapy and speech CPT codes (members <21)CPTCovered

97012	Gait training (example)
97014	Physical therapy (example)
97016	Therapeutic exercise (example)
97018	Hot/cold therapy (example)
97113	Therapeutic exercises
97530	Therapeutic activities
92507	Speech therapy evaluation
92508	Speech therapy individual
92526	Treatment of swallowing

Selected procedures requiring prior authorization (examples)CPT

64490	Injection(s), anesthetic agent; paravertebral facet
64493	Injection(s), therapeutic, paravertebral
92507	Speech-language therapy evaluation
33289	Cardiac device procedure example
59840	Obstetric procedure example
59852	Obstetric procedure example

Selected musculoskeletal CPT/HCPCSCPT

20552	Injection(s) for trigger point
20553	Injection(s) for trigger point, multiple
21012	Facial fracture repair (example)
21336	Mandibular fracture repair (example)
22902	Spinal reconstructive procedure (example)

Selected HCPCS E-codes (examples)HCPCSCovered

E0250	Patient lift/transfer (example)
E0251	Patient lift/transfer (example)
E0255	Enclosed bed (example)
E0260	Patient aid (example)
E0261	Patient aid (example)

Spinal surgery CPT mappings (examples)CPTCovered

22100	Spinal surgery code example
22101	Spinal surgery code example
22102	Spinal surgery code example
22110	Spinal surgery code example
22206	Spinal fusion example
22633	Spinal fusion with instrumentation (example)

Sterilization CPT codes (consent required)CPTCovered

52601	Vasectomy (example)
52630	Vasectomy (example)
52647	Sterilization procedure
52648	Sterilization procedure
52649	Sterilization procedure
55250	Sterilization related (example)
55801	Sterilization related (example)

Implantable stimulator device HCPCS/L-codesHCPCSCovered

L8685	Implantable neurostimulator lead, single
L8686	Implantable neurostimulator lead, multiple
L8687	Implantable neurostimulator pulse generator
L8688	Implantable neurostimulator accessory

Mixed CPT/HCPCS/Q codes and J-codes listedmixedCovered

J3490	Unclassified drug (requires coding detail)
J3590	Unclassified biologic (requires coding detail)
C9301	Drug/biologic code example
C9399	Drug/biologic code example
J0217	Lamzede (example J-code)

Cardiac/VAD and wound VAC related codesmixedCovered

33975	Ventricular assist device procedure example
33982	VAD procedure example
E2402	Wound vac code example
C9301	Wound vac drug-related HCPCS example
C9399	Wound vac drug-related HCPCS example

Provider Actions — Submission, Contacts, and Operational Steps

Prior Authorization

Cardiology prior authorization overview

Prior authorization is required for participating physicians for outpatient and office-based diagnostic catheterizations, electrophysiology implants, and stress echocardiograms prior to performance. Submit requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-889-8054. For the full CPT/HCPCS code list and program details, visit UHCprovider.com/AZcommunityplan > Prior Authorization and Notification Resources > Cardiology Prior Authorization.

Outpatient and office-based diagnostic catheterizations require prior authorization
Electrophysiology implants require prior authorization
Stress echocardiograms require prior authorization
Submit via Provider Portal Prior Authorization and Notification tool or call 866-889-8054
See UHCprovider.com/AZcommunityplan > Prior Authorization and Notification Resources > Cardiology Prior Authorization for full code list

Definitions and Reference Notes

EPSDT — Early and Periodic Screening, Diagnostic and Treatment program for members younger than 21

Definition — EPSDTEarly and Periodic Screening, Diagnostic and Treatment (EPSDT): AHCCCS program providing coverage for medically necessary services for members younger than 21.

AHCCCS referenceEPSDT coverage and authorization procedures are detailed in the AHCCCS Medical Policy Manual (AMPM) Chapter 400, Section 430; see AMPM for procedures and Certificate of Medical Necessity guidance.

Program scope for pediatricsFor members younger than 21, certain services (e.g., allergy immunotherapy/testing, hearing and eye care, enteral nutrition) are covered under EPSDT when medically necessary.

AHCCCS — Arizona Health Care Cost Containment System definition and role

AHCCCS definitionArizona Health Care Cost Containment System (AHCCCS): State program that defines covered benefits and eligibility for prior authorization under this policy.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements and submission instructions — UnitedHealthcare Community Plan of Arizona (ACC) Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on UHCprovider.com (sign in with One Healthcare ID) or call 800-445-1638.

SourceLink

On This Page

Incontinence supplies are provided through Preferred Homecare; contact the vendor to request supplies per the Provider Manual.

Genetic/biomarker testing: Many genetic/biomarker CPT codes are listed and require prior authorization; Labcorp contact information and guidance are referenced for PA determinations.

Documentation Required

Enteral/parenteral documentation requirement

Clinical documentation and, where applicable, the Certificate of Medical Necessity (CMN) for commercial oral nutritional supplements must accompany prior authorization requests for enteral and parenteral nutrition services (including total parenteral nutrition, lipids, and oral supplements). In-home nutritional therapy delivered enterally or via gastrostomy tube requires supporting clinical evidence of medical necessity. For members younger than 21, refer to AHCCCS AMPM Chapter 400, Section 430 (Policy 430-10). For members 21 and older, refer to AMPM Chapter 300, Policy 310-GG. To request services and supplies, call Preferred Homecare at 800-636-2123.

Clinical documentation and CMN must accompany PA requests for enteral/parenteral nutrition
In-home enteral/TPN therapy requires documentation of medical necessity
Members <21: see AMPM Chapter 400, Section 430, Policy 430-10
Members ≥21: see AMPM Chapter 300, Policy 310-GG
To request services/supplies call Preferred Homecare: 800-636-2123

Prior Authorization

Prior Authorization / Coding Reference

A comprehensive prior-authorization coding reference and injectable medication list is available through the Provider Portal. Many injectable chemotherapies, colony-stimulating factors, erythropoiesis-stimulating agents, and other specialty J/Q-coded medications require prior authorization. Use the Portal to submit PA requests and review the specific HCPCS/J-codes that require prior authorization.

Colony-stimulating factors and related agents (e.g., J1442, J2506, J2820) require PA
Many injectable chemotherapy drugs (J9000-J9999 and Q-codes) require PA
A long list of specialty injectables (see Portal lists such as J0129, J1745, J9312, etc.) require PA
Submit injectable medication PA requests via the Provider Portal or call 888-397-8129 (alternate numbers appear in specialty sections)
Refer to the Provider Portal for the most current Prior Authorization / Coding Reference and code groupings

Note

Prior authorization recommendation and reference

When new medications are launched, the 'Review at Launch for New to Market Medications' process may recommend prior authorization. Providers should consult UnitedHealthcare's Review at Launch policy for Community Plans (available at UHCprovider.com/policies > For Community Plans > Medical & Drug Policies and Coverage Determination Guidelines for Community Plan) to determine if newly marketed drugs are subject to initial review and PA requirements.

Review at Launch may recommend PA for new-to-market medications
See UHCprovider.com/policies > For Community Plans > Medical & Drug Policies and Coverage Determination Guidelines for Community Plan

Prior Authorization

Code listing and prior authorization/site-of-service notes

The policy contains extensive code listings and site-of-service notes indicating when prior authorization is required and when site-of-service (e.g., outpatient hospital vs ASC) affects PA requirements. Providers ordering advanced imaging, certain outpatient hospital procedures, or services listed under specialty sections must verify site-of-service PA rules and the specific CPT/HCPCS codes before scheduling.

Advanced outpatient imaging (select CT/MRI/MRA/PET, nuclear medicine) requires PA and prior notification
Site-of-service PA applies: some codes require PA only if performed in an outpatient hospital (not at a participating ASC)
Code lists within the document include site-of-service annotations—confirm code-level SOS requirements prior to scheduling
Out-of-network and out-of-state services require PA and supporting documentation

Prior Authorization

Spinal surgery prior authorization

Spinal surgery codes require prior authorization. Providers must submit PA requests with supporting clinical documentation establishing medical necessity for the specific spinal procedure codes listed (examples include 22100, 22101, 22102, 22110, 22112 and others). Verify the full spine code list in the Provider Portal and include relevant imaging, operative planning, and prior conservative therapy documentation as part of the PA submission.

Prior authorization is required for listed spinal surgery CPT codes (e.g., 22100, 22101, 22102, 22110, 22112)
Include imaging, prior conservative treatment, and clinical justification with the PA request
Check Provider Portal for the complete spinal code list and submission requirements

Prior Authorization

Transplant and CAR T-cell therapy prior authorization and case management

Transplant and CAR T-cell therapy services require prior authorization and case management. Clinical documentation to support medical necessity must accompany PA requests. For CAR T-cell therapies (examples: Yescarta®/axicabtagene ciloleucel, Kymriah®/tisagenlecleucel, Tecartus®, Carvykti™, Lyfgenia™, others), providers must contact the UnitedHealthcare Community and State Transplant Case Management Team for authorization coordination. Call the UnitedHealthcare Community and State Transplant Case Management Team at the number listed in the transplant section of the Provider Portal (refer to the transplant section for the specific phone/fax contact and instructions).

Prior authorization and case management required for transplants and CAR T-cell therapies
Clinical documentation must establish medical necessity and accompany PA requests
For CAR T-cell therapies (e.g., axicabtagene ciloleucel, tisagenlecleucel, ciltacabtagene autoleucel, etc.) contact the UnitedHealthcare Community and State Transplant Case Management Team for authorization
Refer to the Provider Portal transplant section for the specific telephone and fax contact details

Provider registration requirementAll rendering health care professionals, facilities and vendors must be actively registered with AHCCCS to request prior authorization.

Reference to AMPMCoverage and authorization follow AHCCCS Medical Policy Manual (AMPM) chapters referenced throughout the document.

UHC provider portal — Prior Authorization and Notification tool definition

UHC Prior Authorization toolPrior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) is the primary submission method for prior authorization requests.

Sign‑in methodAccess the portal at UHCprovider.com and click Sign In in the top‑right corner; use One Healthcare ID to sign in.

Alternative contactFor certain services or questions, phone contacts are provided in the document (e.g., specific phone numbers for drug or vendor workflows).

Circumcision coverage — routine circumcision not covered

Circumcision coverage stanceRoutine circumcision is not a covered benefit.

Relevant CPT codesCircumcision procedure codes referenced include 54161 and 54162 in the document.

Contact for PA questionsHealthcare ID portal or phone (888‑397‑8129) referenced for related authorization inquiries.

Certificate of Medical Necessity — requirement for commercial oral nutritional supplements per AHCCCS AMPM Chapter 400

Certificate of Medical NecessityThe Certificate of Medical Necessity for Commercial Oral Nutritional Supplements is required and can be found in AHCCCS AMPM Chapter 400 (Policy 430-2).

Enteral/parenteral documentationClinical documentation must accompany requests for enteral/parenteral nutrition (TPN/lipids/oral supplements) as described in AMPM Chapter 400/430 guidance.

Vendor contact for suppliesTo request related services/supplies, call Preferred Homecare at the phone number listed in the provider guidance.

Experimental/investigational services — definition and PA requirement

Definition — Experimental/InvestigationalServices considered experimental and/or investigational require prior authorization and are not covered benefits without approval.

AMPM cross‑referenceRefer to AHCCCS AMPM Chapter 300, Section 320, Policy 320-B for details on experimental/investigational services and examples.

Examples listedThe document lists example CPT/HCPCS codes (e.g., 33477, A4638, G0293) that are considered experimental/investigational and require prior authorization.

Prior authorization — general definition and cross-references to external AMPM and contact numbers

Prior authorization — general definitionPrior authorization is a requirement to obtain approval before certain services are provided; requests must be submitted via the UnitedHealthcare Provider Portal or by specified contact methods.

Provider registration ruleOnly one health care professional may request services on a prior authorization request form; rendering providers must be registered with AHCCCS.

External references and contactsThe policy references AHCCCS AMPM chapters and provides phone contacts and portal navigation instructions for submitting prior authorization requests.

Injectable medications — definition note for injectable medication listings

Injectable medications — noteThe document enumerates numerous injectable medications with associated HCPCS/J codes; many entries reference prior authorization requirements.

Code examplesExamples of J/Q codes are listed throughout the document (see medication code tables and prior authorization / coding reference sections).

Submission instructionPrior authorization requests for injectable medications should be submitted via the UHC provider portal or by the phone numbers provided for specific drug categories.

Review at Launch — policy referenced for new-to-market medications

Review at Launch policy'Review at Launch for New to Market Medications' is the referenced policy for new medications and is available at UHCprovider.com/policies > For Community Plans > Medical & Drug Policies and Coverage Determination Guidelines for Community Plan.

Use for new drugsProviders should consult Review at Launch for up‑to‑date prior authorization expectations for new‑to‑market medications listed in this document.

Portal referencePolicy access and prior authorization submission instructions are provided on the UnitedHealthcare Provider Portal.

UHCprovider.com — UnitedHealthcare Provider Portal definition for submission

Provider Portal definitionUnitedHealthcare Provider Portal (UHCprovider.com) is the designated online tool for submitting prior authorization requests via the Prior Authorization and Notification tool.

How to accessGo to UHCprovider.com and click Sign In in the top‑right corner; sign in using One Healthcare ID to submit requests.

Primary submission routeThe portal is the primary and recommended method for prior authorization submission throughout the document.

Member age applicability — age-based applicability notes for orthotics/prosthetics

Member age applicability — orthotics/prostheticsSome orthotics and prosthetics codes have age‑based applicability; certain orthotic/prosthetic items are specifically noted for members younger than 21.

Pediatric rulesFor members younger than 21, orthotics/prosthetics follow EPSDT and AMPM guidance; prior authorization instructions reference UHC provider portal submission.

Adult applicabilityWhere specified, codes and coverage rules apply to members 21 and older under AMPM Chapter 300 policies.

Proton beam therapy — definition/reference

Proton beam therapy — definitionProton beam therapy: focused radiation therapy using beams of protons; prior authorization is required for the listed codes (e.g., 77520, 77522, 77523, 77525).

Codes referencedProcedure codes associated with proton beam therapy include 77520, 77522, 77523 and 77525 in the document.

SOS - outpatient hospital — site-of-service definition

SOS - outpatient hospitalSite of service (SOS) — outpatient hospital: prior authorization is required when requesting services in an outpatient hospital setting for listed procedures.

ASC exceptionPrior authorization is not required if the same procedure is performed at a participating ambulatory surgery center (ASC).

ExamplesExamples include ENT and sinuplasty codes where SOS determines PA requirement (e.g., 31295–31298).

Participating ASC — definition and PA implication

Participating ASC definitionParticipating ambulatory surgery center (ASC): if a procedure is performed at a participating ASC, prior authorization is not required for services that would otherwise require PA in an outpatient hospital.

Implication for schedulingProviders should confirm ASC participation to determine whether prior authorization is necessary before scheduling.

Reference in code listsThe document notes specific CPT/HCPCS codes where the ASC exception applies.

Consent for Sterilization — consent form location reference

Consent for Sterilization formThe Consent to Sterilization form is located at azahcccs.gov > Resources > Guides‑Manuals‑Policies > AHCCCS Medical Policy Manual (AMPM) > Chapter 400 > 420, Family Planning > Attachment A.

Sterilization PA requirementPrior authorization is required for sterilization codes; members younger than 21 require PA and a signed sterilization consent form.

Transplant Case Management Team — UnitedHealthcare contact for transplant/CAR T-cell services

Transplant Case Management TeamUnitedHealthcare Community and State Transplant Case Management Team: contact for prior authorization and case management for transplant and CAR T‑cell therapy services (phone listed in document).

Clinical documentationPrior authorization for transplant and CAR T‑cell therapies requires clinical documentation to support the need for the service.

Examples of therapiesCAR T‑cell products referenced include tisagenlecleucel, axicabtagene ciloleucel, and others; contact the Transplant Case Management Team to obtain authorization.

Ventricular assist devices (VAD) — definition of VAD

VAD definitionVentricular assist devices (VAD): a mechanical pump that takes over the function of the heart and restores normal blood flow.

PA requirementPrior authorization is required for VAD procedures and associated codes; notification via member ID and fax to Optum VAD Case Management Team is referenced elsewhere in the document.

Transportation prior authorization — MTM scheduling and PA requirement for non-emergent transport

Transportation PA requirementTransportation prior authorization is required for non‑emergent taxi and stretcher van services.

Scheduling contactTo schedule transportation, call Medical Transportation Management (MTM) at 888‑700‑6822 as provided in the document.

Applicable codesExamples of related CPT/HCPCS codes (e.g., C9301, C9399, J3490, J3590) are listed in the transportation section.