CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for UnitedHealthcare Community Plan of Arizona Developmental Disabilities

Defines prior authorization (PA) requirements for participating health care professionals providing inpatient and outpatient services to members of UnitedHealthcare Community Plan of Arizona Developmental Disabilities. Applies to services reimbursable under AHCCCS and includes instructions for submitting PA requests and many service-specific PA code lists and rules (partial document - part 1 of 6).

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Arizona Developmental Disabilities

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 1, 2026

Next Review Date

Key ActionSubmit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) signed in with One Healthcare ID, or call the listed phone numbers and include required clinical documentation.

SourceLink

2026-04-01policy effective date

State-specific (AZ)applies to

Manycode entries present in part 1

Prior authorization requiredMultiple service groups require prior authorization or notification

member age group repeatedly referenced for prior authorization rules

>=50unique CPT/HCPCS codes referenced in this part (approx.)

Policy Snapshot

This document establishes prior authorization (PA) requirements for participating health care professionals and facilities providing inpatient and outpatient services to members of the UnitedHealthcare Community Plan of Arizona Developmental Disabilities. It applies to services reimbursable under the Arizona Health Care Cost Containment System (AHCCCS); PA eligibility and coverage are governed by AHCCCS definitions and medical policy. To submit PA requests use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call the numbers listed in the policy. The policy is effective 2026-04-01.

Key policy facts

Effective dateEffective 2026-04-01

Applies toState-specific (AZ)

Scope summaryDefines prior authorization (PA) requirements for participating health care professionals providing inpatient and outpatient services to members of UnitedHealthcare Community Plan of Arizona Developmental Disabilities; applies to services reimbursable under AHCCCS and includes instructions for submitting PA requests and many service-specific PA code lists and rules (partial document - part 1 of 6).

StatusCURRENT

Policy numberN/A

Prior Authorization Eligibility and Coverage Criteria

General prior authorization eligibility criteria

High-level conditions that must be met for PA requests under this AZ plan.

ALL of the following

Services must be covered benefits as defined by AHCCCS.
Rendering providers, facilities and vendors must be actively registered with AHCCCS.
Only one health care professional may request services on a prior authorization request form.
Services provided by non-network or out-of-state providers require prior authorization and documentation supporting the out-of-network request.

Codes and Billing Categories

Augmentative and alternative communicationCPT|HCPCS|mixedCovered

92607
E2500
E2508
92608
E2502
E2510
92609
E2504
A9901
E2506

1–10 of 11

1/2

Bariatric surgery (codes requiring PA)CPTCovered

43644
43775
43847
43645
43842
43659
43845
43770
43846

Bone growth stimulatorsCPT|HCPCSCovered

20975
20979
E0760

Breast cancer genetic testingCPTCovered

81162
81166
81217
81163
81212
81432
81164
81215
81165
81216

Breast reconstruction (non-mastectomy)CPT|HCPCSCovered

11971
19328
19350
19367
19371
19330
19357
19368
19380
19340

1–10 of 17

1/2

Cancer supportive care (colony-stimulating factors & bone-modifying agents)HCPCS|mixedCovered

J9000-J9999	range: chemotherapy injectables
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin
J1950	Lupron Depot

Cochlear and auditory implantsCPT|HCPCSCovered

69710
L8619
69714
L8690
69930
L8691
L8614
L8692

CircumcisionCPTNot Covered

54150	Routine circumcision not a covered benefit; PA required only for cases with (specific indications)
54160
54161
54162

Cerebral seizure monitoring (inpatient video EEG)CPTCovered

95700
95714
95720
95711
95715
95722
95712
95716
95724
95713

1–10 of 12

1/2

Cardiology / Cardiovascular (examples)CPTCovered

93580

example cardiovascular code listed

Functional endoscopic sinus surgery (FESS)CPTCovered

31240
31253
31254
31255
31267

Genetic/biomarker testing codes (examples)CPTCovered

88299	generic/biomarker testing
81313
88245
88262
88269
88274
88285
81327
81460
81435

1–10 of 11

1/2

Continuous glucose monitor HCPCS examplesHCPCSCovered

A4226
A9277
E2103
A4238
A9278
A4239
E0787
A9276
E2102

DME codes requiring PA regardless of dollar amount (partial list)HCPCS|K-codesCovered

E0194
E0300
E0265
E0266
E0270
E0445
E0457
E0465
E0466
E0483

1–10 of 128

1/13

Biomarker / genetic / pathology testing codes (fragmented)CPT|HCPCS|mixed

88299	Unlisted pathology code (listed in document as biomarker codes)
81313	Molecular pathology (listed among biomarker codes)
88245	Cytogenetic analysis code
88262	Cytogenetic code
88269	Cytogenetic code
88274	Cytogenetic code
88285	Cytogenetic code
81327	Molecular pathology
81460	Molecular pathology code
88248	Cytogenetic code

1–10 of 16

1/2

Hearing aids and hearing evaluation HCPCS codes (for members <21)HCPCS

V5014	Hearing aid related HCPCS
V5248	Hearing aid related HCPCS
V5060	Hearing aid related HCPCS
V5252	Hearing aid related HCPCS
V5030	Hearing aid related HCPCS
V5190	Hearing aid related HCPCS
V5256	Hearing aid related HCPCS
V5095	Hearing aid related HCPCS
V5253	Hearing aid related HCPCS
V5260	Hearing aid related HCPCS

1–10 of 26

1/3

Home health / Home health care codesHCPCS|CPT

V5261	Home health related HCPCS (appears in this section)
V5100	Home health related HCPCS
V5254	Home health related HCPCS
V5242	Home health related HCPCS
V5258	Home health related HCPCS
V5120	Home health related HCPCS
V5010	Home health related HCPCS
V5246	Home health related HCPCS
V5262	Home health related HCPCS
V5040	Home health related HCPCS

1–10 of 19

1/2

Hospice and hysterectomy CPT codes (fragmented inclusion)CPT

58150	Listed under hospice (document appears corrupted)
58152	Listed under hospice/hysterectomy
58240	Hysterectomy group code referenced in multiple lines
58180	Listed
58260	Listed
58200	Listed
58210	Hysterectomy code (explicitly listed as requiring prior authorization)
58263	Hysterectomy code present
58267	Hysterectomy code present
58262	Hysterectomy code present

1–10 of 19

1/2

Incontinence suppliesHCPCS|mixedCovered

58542	Referenced under incontinence supplies routing
58543	Referenced for incontinence supplies routing
58544	Referenced for incontinence supplies routing
58548	Referenced for incontinence supplies routing
58550	Referenced for incontinence supplies routing
58552	Referenced for incontinence supplies routing
58553	Referenced for incontinence supplies routing
58554	Referenced for incontinence supplies routing
58570	Referenced for incontinence supplies routing
58571	Referenced for incontinence supplies routing

1–10 of 14

1/2

In-home infusion services (routing)HCPCS|mixedCovered

58542	Referenced for in-home infusion routing
58543	Referenced for in-home infusion routing
58544	Referenced for in-home infusion routing
58548	Referenced for in-home infusion routing
58550	Referenced for in-home infusion routing
58552	Referenced for in-home infusion routing
58553	Referenced for in-home infusion routing
58554	Referenced for in-home infusion routing
58570	Referenced for in-home infusion routing
58571	Referenced for in-home infusion routing

1–10 of 14

1/2

Injectable medications (vendor-provided list)HCPCS|J-codes|mixed

J3262	Actemra®
J0791	Adakveo®
J7171	Adzynma™
J1426	Amondys® 45
J0225	Amvuttra™
J0256	Aralast® NP / Prolastin-C / Zemaira®
J0585	Botulinum toxin (example code listed)
Q5161	Botulinum toxins (Q-code example)
J0567	Brineura®
J2329	Briumvi™

1–10 of 47

1/5

Selected medication HCPCS/J-codes mentionedHCPCS

J9381	Tzield™
C9094
C9149
C9157
C9166
C9399
J3590
J1823	Uplizna® / Intravitreal Vascular Endothelial Growth Factor (listed as intravitreal VEGF in text)
J0178
J0179

1–10 of 19

1/2

Nonemergent air ambulanceHCPCSCovered

A0430	Nonemergent air ambulance transport
A0431	Nonemergent air ambulance transport
A0435	Nonemergent air ambulance transport
A0436	Nonemergent air ambulance transport

Joint replacement (hip/knee) — CPT codes listedCPT

24360
24370
27130
27138
27486
29868
24361
24371
27132
27412

1–10 of 19

1/2

Orthognathic / maxillofacial surgery — CPT codes listedCPT

21121
21123
21125
21127
21141
21142
21143
21145
21146
21147

1–10 of 39

1/4

Orthotics and prosthetics — HCPCS L- and other codesHCPCSCovered

L0112
L0170
L0456
L0462
L0464
L0480
L0482
L0484
L0486
L0624

1–10 of 257

1/26

Outpatient therapy (prior authorization required)CPTCovered

92507	Speech/hearing/therapy code (as listed)
92523	Speech/hearing/therapy code (as listed)
92508	Speech/hearing/therapy code (as listed)
92524	Speech/hearing/therapy code (as listed)
92521	Speech/hearing/therapy code (as listed)
92526	Speech/hearing/therapy code (as listed)
92522	Speech/hearing/therapy code (as listed)
97014	Physical medicine therapeutic procedure (as listed)
97016	Physical medicine therapeutic procedure (as listed)
97018	Physical medicine therapeutic procedure (as listed)

1–10 of 22

1/3

Pain injections and management (prior authorization required)CPTCovered

64490	Injection procedure, single branch (listed under L8612)
64493	Injection procedure (listed under L8631)

Pharmacy (prior authorization; J-codes listed)HCPCSCovered

90378	Immune/biologic J-code (example; listed under L8612)
J1299	Unclassified drug (listed under L8612)
J1429	Drug J-code (listed under L8612)
J2840	Drug J-code (listed under L8612)
J0224	Vaccine/drug J-code (listed under L8631)
J1290	Drug J-code (listed under other group)
J1428	Drug J-code (listed under other group)
J3399	Unclassified biologic (listed)
J1303	Drug J-code (listed under L8631)
J1786	Drug J-code (listed under L8631)

1–10 of 16

1/2

Selected procedures requiring prior authorization (examples extracted)CPTCovered

33289	Potentially unproven services example
59840	Pregnancy termination (listed)
59852	Pregnancy termination (listed)
59841	Pregnancy termination (listed)
59855	Pregnancy termination (listed)
59850	Pregnancy termination (listed)
59856	Pregnancy termination (listed)
59851	Pregnancy termination (listed)
59857	Pregnancy termination (listed)
T1002	Private duty nursing (listed)

1–10 of 22

1/3

Shoulder arthroscopy codes (SOS applies)CPTCovered

29805	Arthroscopy, shoulder (listed; SOS applies)
29806	Arthroscopy, shoulder (listed; SOS applies)
29807	Arthroscopy, shoulder (listed; SOS applies)
29819	Shoulder arthroscopy (listed; SOS applies)
29820	Shoulder arthroscopy (listed; SOS applies)
29822	Shoulder arthroscopy (listed; SOS applies)
29823	Shoulder arthroscopy (listed; SOS applies)
29824	Shoulder arthroscopy (listed; SOS applies)
29825	Shoulder arthroscopy (listed; SOS applies)
29826	Shoulder arthroscopy (listed; SOS applies)

1–10 of 12

1/2

Radiology — advanced outpatient imaging (prior authorization required)mixedCovered

see online

Visit Radiology Prior Authorization and Notification Program for specific CPT codes

Proton beam therapyCPTCovered

77520	Proton beam therapy (listed)
77522	Proton beam therapy (listed)
77523	Proton beam therapy (listed)
77525	Proton beam therapy (listed)

Spinal surgery (examples)CPTCovered

22100	Spinal surgery (listed)
22101	Spinal surgery (listed)
22102	Spinal surgery (listed)
22110	Spinal surgery (listed)
22112	Spinal surgery (listed)
22206	Spinal surgery (listed)
22207	Spinal surgery (listed)
22210	Spinal surgery (listed)
22510	Spinal surgery (listed)
22511	Spinal surgery (listed)

1–10 of 13

1/2

Durable medical equipment / specialty beds (prior authorization required)HCPCSCovered

E0250	Specialty bed (listed)
E0260	Specialty bed (listed)
E0251	Specialty bed (listed)
E0255	Specialty bed (listed)
E0256	Specialty bed (listed)
E0290	Specialty bed (listed)
E0291	Specialty bed (listed)
E0293	Specialty bed (listed)
E0294	Specialty bed (listed)
E0300	Specialty equipment (listed)

1–10 of 17

1/2

Transplant administrative instructioninformational

phone

For transplant and CAR T-Cell therapy services (Abecma, Breyanzi, Carvykti, Kymriah, Yescarta, etc.) call UnitedHealthcare Community and State Transplant Case Management Team at 800-418-4994 or the notification number on the member's ID card. Clinical documentation must accompany requests.

Other surgical and abdominal procedure codes (selected)CPT

43648	Bariatric/abdominal procedure — listed
44132	Bowel resection — listed
44133	Bowel resection — listed
44135	Bowel resection — listed
44136	Bowel resection — listed
44137	Bowel resection — listed
44715	Abdominal surgery — listed
44720	Abdominal surgery — listed
44721	Abdominal surgery — listed
47133	Hepatic surgery — listed

1–10 of 29

1/3

CAR T‑cell therapy and temporary/unclassified codesHCPCS|CPT

38232	Autologous stem cell harvest — prior authorization only for oncology diagnosis (explicit note repeated in document)
Temporary and Unclassified Codes	Multiple temporary/unclassified codes noted — require prior authorization per policy (generic reference)

Transportation codes / scheduling instructionHCPCS

C9399	Nonemergent transportation — prior authorization required; schedule via Medical Transportation Management at 888-700-6822
J3490	Nonemergent transportation (billing grouping) — schedule via Medical Transportation Management at 888-700-6822
J3590	Nonemergent transportation (billing grouping) — schedule via Medical Transportation Management at 888-700-6822

Venous procedures / saphenous vein ablationCPT

36473	Vein ablation — listed under J-coded supply grouping
37718	Vein procedure — listed
37780	Vein procedure — listed
36475	Vein ablation — listed
37722	Vein procedure — listed
36478	Vein ablation — listed
37765	Vein procedure — listed
37700	Venous procedure — listed
37766	Venous procedure — listed

Ventricular assist devices (VAD) and related codesCPT|HCPCS

C9399	Ventricular assist devices — call notification number on member ID card
J3490	Ventricular assist devices — call notification number on member ID card
J3590	Ventricular assist devices — call notification number on member ID card
33927	VAD procedure/code — listed
33976	VAD procedure/code — listed
33928	VAD procedure/code — listed
33979	VAD procedure/code — listed
33929	VAD procedure/code — listed
33981	VAD procedure/code — listed
33975	VAD procedure/code — listed

1–10 of 11

1/2

Wound VAC / negative pressure wound therapyHCPCS

E2402

Wound VAC — prior authorization required

Drug HCPCS codes referenced (J/Q codes for therapies)HCPCS

J3394	Drug/biologic HCPCS listed
J3391	Drug/biologic HCPCS listed
J3392	Drug/biologic HCPCS listed
J3402	Drug/biologic HCPCS listed
Q2041	CAR T-cell HCPCS listed
Q2042	CAR T-cell HCPCS listed
Q2053	CAR T-cell HCPCS listed
Q2054	CAR T-cell HCPCS listed
Q2055	CAR T-cell HCPCS listed
Q2056	CAR T-cell HCPCS listed

1–10 of 12

1/2

Augmentative and alternative communication (duplicate group from earlier if needed)CPT|HCPCS|mixedCovered

92607
E2500
E2508
92608
E2502
E2510
92609
E2504
A9901
E2506

1–10 of 11

1/2

What Providers Must Do

Prior Authorization

How to submit prior authorization requests

Submit prior authorization (PA) requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal at UHCprovider.com (sign in with One Healthcare ID). You may also call the phone lines listed in the policy. Some requests must be routed to specialized vendors as noted.

Portal: UHCprovider.com — sign in with One Healthcare ID and use the Prior Authorization and Notification tool [[portal instructions referenced]]
Phone: 800-445-1638
Other phone numbers mentioned for PA submission/routing: 866-889-8054, 888-397-8129
Vendor routing: some services require contacting specialized vendors (e.g., LabCorp, Preferred Homecare, Optum Infusion, Nationwide Vision, UnitedHealthcare Dental) per the document

Documentation Required

Key Defined Terms

Definitions

EPSDTEarly and Periodic Screening, Diagnostic and Treatment — Medicaid benefit for members younger than 21 referenced for coverage of some services.

AHCCCSArizona Health Care Cost Containment System — state Medicaid program whose coverage definitions and medical policy govern eligibility for prior authorization under this plan.

Prior authorizationA process by which providers must obtain approval from UnitedHealthcare before certain services, procedures, drugs, or equipment will be covered.

Preferred HomecareVendor designated by UnitedHealthcare for provision of incontinence supplies (phone: 800-636-2123).

Optum InfusionVendor designated by UnitedHealthcare for infusion and in-home injectable medication services (phone: 800-985-3059). Prior authorization routing required for medications/services not covered by Optum Infusion.

Review at Launch for New to Market Medications / Predetermination

Policy Background and Scope

This is part 1 of 6 of the Arizona Developmental Disabilities prior authorization code list and guidance. It defines scope and general rules for PA requests for UnitedHealthcare Community Plan of Arizona Developmental Disabilities, including that services must be AHCCCS-reimbursable, rendering providers and vendors must be actively registered with AHCCCS, and only one practitioner may sign a PA request. The document highlights age-specific rules under EPSDT: for members younger than 21 certain services (for example allergy immunotherapy, hearing aids, select genetic testing and nutritional supplements) are covered when medically necessary; separate vendor routing applies for some benefits (for example Preferred Homecare for incontinence and enteral/DME services and LabCorp for many genetic tests). It also notes PA routing for in-home infusion and many injectable medications through Optum Infusion and provides contact numbers for vendor routing and portal submission.

Policy Effective Date and Changes

Effective date: 2026-04-01. This document is the current PA requirements list for UnitedHealthcare Community Plan of Arizona Developmental Disabilities and includes updates to PA routing, vendor contacts and code listings. Please refer to the Provider Portal for submission and the state-specific AMPM references where noted.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Arizona Developmental Disabilities

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 1, 2026

Next Review Date

SourceLink

On This Page

Experimental and investigational services are not covered benefits (prior authorization is required for such services but they are not covered).

Only medically necessary, cost-effective, federal- and state-reimbursable services are covered as outlined by AHCCCS.

Allergy testing and immunotherapy (age-specific rules)

Rules for allergy testing and immunotherapy coverage by member age.

ANY of the following

Members <21: Allergy immunotherapy and allergy testing covered under EPSDT when medically necessary.
Members >=21: Allergy immunotherapy, including subcutaneous injections and sublingual immunotherapy (SLIT), is not a covered benefit.
Allergy testing (for all ages) is covered only when member has a sustained anaphylactic reaction to an unknown allergen or a severe allergic reaction where further exposure could be life‑threatening; prior authorization is required for allergy testing.

Chemotherapy (injectable outpatient)

PA requirements for outpatient/injectable chemotherapy.

ALL of the following

Prior authorization is required for injectable chemotherapy drugs administered in an outpatient setting (including intravenous, intravesical and intrathecal) for a cancer diagnosis.
Drugs in the J9000–J9999 range, Leucovorin (J0640), Levoleucovorin (J0641, J0642), Lupron Depot (J1950), chemotherapy drugs with a Q‑code, and chemotherapy drugs billed under a miscellaneous HCPCS require prior authorization.

Continuous glucose monitors

PA requirement tied to diagnosis.

ALL of the following

Prior authorization is required for continuous glucose monitors when the member has a type 2 diabetes diagnosis.

DME

PA requirements for durable medical equipment.

ANY of the following

PA is required only for listed HCPCS codes when retail purchase or cumulative rental cost thresholds are met (some items require PA regardless of dollar amount).
Certain DME items require prior authorization regardless of dollar amount (many E‑ and K‑codes are listed).
Prosthetics are not DME; see orthotics and prosthetics guidance for prosthetic requests and rules.

Documentation requirements

Clinical documentation must accompany PA requests; when applicable include a Certificate of Medical Necessity and/or oral supplement certificate. Requests for enteral/parenteral/oral in‑home nutritional therapy must include clinical documentation and the oral supplement certificate of medical necessity.

Include clinical documentation with PA requests
Include Certificate of Medical Necessity and/or oral supplement certificate when applicable
Enteral/parenteral/oral in‑home nutritional therapy: clinical documentation and oral supplement certificate must accompany the request

Prior Authorization

Age-specific rules and vendor routing

Members younger than 21 are subject to EPSDT rules for coverage of certain services; specified lab and service requests must be directed to designated vendors (LabCorp, Preferred Homecare, Nationwide Vision) as noted in the policy.

EPSDT: Members <21 have EPSDT coverage rules for allergy immunotherapy, genetic testing and nutritional supplements
Lab routing: certain genetic/pathology testing requests directed to LabCorp
Preferred Homecare: nutritional/DME services routing; Nationwide Vision: eye care routing

Billing Rule

Out-of-network and experimental services

Out‑of‑network or out‑of‑state providers require prior authorization plus supporting documentation; services considered experimental/investigational require prior authorization but are not covered benefits.

All out‑of‑network services require PA and documentation supporting the out‑of‑network request
Out‑of‑state services are approved only when emergent or unavailable in Arizona (see AMPM references)
Experimental/investigational services require PA but are not covered benefits

Prior Authorization

Prior authorization notes (fragmented)

For members younger than 21, hearing evaluations and hearing aids may not require prior authorization; lab/vendor notes and some service codes (home health, hospice, hysterectomy) require PA. For tests not covered by LabCorp, call LabCorp at 800‑788‑9743 to determine PA requirements.

Hearing aids/services for members <21: Prior authorization is not required
Some home health/hospice/hysterectomy codes listed require prior authorization
LabCorp contact for PA determination for tests: 800-788-9743

Documentation Required

LabCorp prior authorization process reference

LabCorp is the designated vendor for certain genetic and biomarker testing and can determine prior authorization requirements for tests; call LabCorp at 800‑788‑9743.

LabCorp phone for PA/testing routing: 800-788-9743
Breast cancer genetic testing and other biomarker testing are directed to LabCorp per the document

Prior Authorization

Incontinence supplies routing and prior authorization

Incontinence supplies are a benefit only when provided through Preferred Homecare; to request incontinence supplies (codes listed) call Preferred Homecare at 800‑636‑2123.

Relevant codes: 58542, 58543, 58544, 58548, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58951, 58956
Preferred Homecare phone: 800-636-2123

Prior Authorization

Infusion in-home services routing and prior authorization

Prior authorization is required for infusion and in‑home services not covered by Optum Infusion; to request services or supplies call Optum Infusion at 800‑985‑3059. The policy lists specific in‑home codes that require vendor routing.

Optum Infusion phone: 800-985-3059
Referenced in‑home codes include: 58542, 58543, 58544, 58548, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58951, 58956

Prior Authorization

Injectable medications (Optum Infusion vendor routing and prior auth)

Medications not covered by Optum Infusion require prior authorization and must be requested through Optum Infusion. A long list of J‑ and Q‑codes and brand names is provided in the policy; call Optum Infusion at 800‑985‑3059 to route PA requests.

Call Optum Infusion at 800-985-3059 for injectable medications prior authorization and routing
Codes listed in the policy (examples) include: J3262, J0791, J7171, J1426, J0225, J0256, J0585, Q5161, J0567, J2329, Q5128, J2786, Q5158, J3247, J0584, J1551, J0589, J2508, J3403, J1302, J3380, J7170, J1411, J0638, J3245, J9155, Q0138, J1439, J1459, J1555, J1561, J0222, J0129, J1745, J3358, J3241, J2356, J3315, J3316, J9381, Q5133 (see document for full list)

Prior Authorization

Prior authorization required for multiple services

Prior authorization is required for many services including inpatient admissions/post‑acute services, joint replacement, orthognathic/maxillofacial surgery, orthotics/prosthetics, nonemergent air ambulance, and numerous DME/HCPCS/CPT codes. Use the UnitedHealthcare Provider Portal Prior Authorization and Notification tool to submit requests.

Includes inpatient/post‑acute services (acute care hospitals, acute inpatient rehabilitation) and notification requirements
Joint replacement and orthognathic surgery codes listed require PA
Provider Portal is the required submission route (UHCprovider.com Prior Authorization and Notification tool)

Documentation Required

Documentation required for orthotics/prosthetics and other devices

Requests for orthotics/prosthetics must include documentation establishing medical necessity, indication for repairs/adjustments, and evidence a component isn't functioning when replacement is requested. Age‑specific orthotic coverage limits are noted in the policy.

Documentation must establish medical necessity and justify repairs/adjustments
Evidence that a component isn't operating effectively must be provided when requesting replacement
Some orthotic coverage is limited by member age (references to members <21 and >=21)

Prior Authorization

Predetermination recommended for Review at Launch medications

For newly marketed drugs on UnitedHealthcare's Review at Launch list, predetermination (advance review) is highly recommended—check the Review at Launch policy on UHCprovider.com for the current list.

Predetermination is highly recommended for drugs on the Review at Launch Medication List
Review at Launch policy available at UHCprovider.com/policies under For Community Plans

Denial Risk

Notification requirement for inpatient admissions

Notification and prior authorization are required for inpatient admissions and specified facility types; failure to notify or obtain authorization may affect coverage.

Notification required for inpatient admissions/post‑acute services (acute care hospitals and acute inpatient rehabilitation)
Failure to notify/obtain authorization may impact coverage

Prior Authorization

Prior authorization required for many listed services

Providers must obtain prior authorization for numerous radiology, advanced imaging and other listed CPT/HCPCS codes; submit via the Provider Portal or call the radiology line noted in the policy.

Radiology PA submission: use the Prior Authorization and Notification tool on UHCprovider.com or call 866-889-8054
Refer to UHCprovider.com/AZcommunityplan for CPT lists under the Radiology Prior Authorization and Notification Program

Prior Authorization

Out-of-network and out-of-state services

All out‑of‑network services require prior authorization; out‑of‑state services are approved only when the service is emergent or unavailable in Arizona.

Out‑of‑network: PA required for all out‑of‑network services
Out‑of‑state: benefit approved only when emergent or unavailable in Arizona

Documentation Required

Pharmacy prior authorization documentation requirements

Pharmacy prior authorization requests must include J‑codes and NDC numbers for the medication requested. A list of medications requiring PA for the Arizona community plan is available on UHCprovider.com/AZcommunityplan.

Include J‑codes and NDC codes with pharmacy PA requests
Medication PA list available at UHCprovider.com/AZcommunityplan > Pharmacy Resources & Physician Administered Drugs > Pharmacy Prior Authorization

Billing Rule

Site-of-service prior authorization rules

Site‑of‑service rules: prior authorization may be required for certain procedures only when performed in an outpatient hospital setting; the same procedures may not require PA if performed at a participating ambulatory surgery center.

PA required when requesting service in an outpatient hospital setting
No PA required if performed at a participating ambulatory surgery center for specified procedures (e.g., carpal tunnel, cataract)

Prior Authorization

Radiology submission instructions

Radiology PA requests should be submitted online via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by calling 866‑889‑8054. See UHCprovider.com/AZcommunityplan for the CPT codes requiring radiology PA.

Portal: UHCprovider.com Prior Authorization and Notification tool
Phone for radiology PA: 866-889-8054
CPT code lists available at UHCprovider.com/AZcommunityplan > Prior Authorization and Notification Resources > Radiology Prior Authorization and Notification Program

Prior Authorization

Prior authorization required for listed CPT/HCPCS codes

Prior authorization is required for numerous specific CPT/HCPCS codes listed across the policy (spine surgery, transplant/CAR T‑cell, stimulators, sterilization, VAD, wound vac, venous procedures, transportation, etc.). Include clinical documentation where noted (for example, transplants and CAR T‑cell therapies).

Many spine, transplant, stimulator, sterile procedure and device codes require PA (see full code lists in the policy)
Clinical documentation must accompany requests where noted (transplant, CAR T‑cell)
Transportation and venous procedure codes also require PA per the lists

Prior Authorization

Transplant and CAR T‑cell therapy authorization contact

For transplant and CAR T‑cell therapy services, call the UnitedHealthcare Community and State Transplant Case Management Team at 800‑418‑4994 (or use the notification number on the member's ID card). Clinical documentation must accompany authorization requests.

Transplant Case Management phone: 800-418-4994
Clinical documentation must accompany requests to establish medical necessity

Prior Authorization

Transportation prior authorization and scheduling

Nonemergent transportation (taxi, stretcher van) requires prior authorization and must be scheduled through Medical Transportation Management; call 888‑700‑6822. Relevant billing codes include C9399, J3490, J3590.

Transportation scheduling phone: 888-700-6822
Relevant codes: C9399, J3490, J3590

Documentation Required

Sterilization consent requirement (AZ guidance referenced)

For sterilization procedures, an appropriate signed consent for sterilization form is required. The policy references AHCCCS AMPM Chapter 400, Section 420 (Section E Sterilization) for Arizona‑specific guidance and the consent form location.

Signed consent to sterilization form required for any member requesting sterilization
Refer to AMPM Chapter 400, Section 420, Section E Sterilization at azahcccs.gov for form and guidance

Prior Authorization

Code-specific special rule: 38232

CPT 38232 (autologous stem cell harvest) requires prior authorization only when submitted for an oncology diagnosis — this is a code‑specific special rule in the policy.

Code 38232: PA required only if submitted for an oncology diagnosis

UnitedHealthcare process/policy that lists newly FDA-approved drugs that require review; predetermination is highly recommended for drugs on the Review at Launch Medication List.

Prior authorization (PA)A process by which providers must obtain approval from UnitedHealthcare before certain services, procedures, drugs, or equipment will be covered.

Site of service (SOS)Indicates the setting where the service is performed (e.g., outpatient hospital vs ambulatory surgery center) and may change PA requirements.

SOSSpecial authorization process referenced in document ('SOS applies') — no detailed definition provided in this part.

CAR T-Cell therapyChimeric antigen receptor T-cell therapies; prior authorization and clinical documentation required; contact UnitedHealthcare Community and State Transplant Case Management Team at 800-418-4994.