CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for developmentally disabled Arizona members

Lists prior authorization requirements, submission methods, and coverage notes for providers participating with UnitedHealthcare Community Plan of Arizona Developmental Disabled Program. Affects participating health care professionals, facilities, and vendors serving Arizona Developmentally Disabled members.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for developmentally disabled Arizona members

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone at 800-445-1638.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Multipleservice types listed requiring prior authorization

Portal & phonemethods to request prior authorization

Age-basedage-differentiated rules

Requiredout-of-network requirement

Applies

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Coverage criteria and service rules

inv-01: General prior authorization and coverage conditions

General coverage and prior authorization rules

Services must be AHCCCS-covered, medically necessary, cost-effective, and federally/state reimbursable to be eligible for prior authorization.

Experimental and investigational services are not covered benefits.

Rendering health care professionals, facilities, and vendors must be actively registered with AHCCCS.

Only one health care professional may request services on an authorization request form.

MSIC exception: Services delivered inside Multi‑Specialty Interdisciplinary Clinics (MSIC) to CRS‑designated members do not require prior authorization.

Services provided by non‑network or out‑of‑state providers require prior authorization and supporting documentation for the out‑of‑network request.

inv-02: Service-specific requirements

Service‑specific prior authorization requirements (examples)

Augmentative and alternative communication (AAC) codes listed (e.g., 92607, 92608, 92609, A9901, E2500–E2512, E2599, V5336) require prior authorization.

Allergy testing and immunotherapy: covered for members <21 under EPSDT when medically necessary; for members ≥21, allergy immunotherapy (including shots and SLIT) is not a covered benefit. Prior authorization required when testing meets specified severe/allergic reaction criteria.

Behavioral health: prior authorization is required for inpatient admissions.

Chemotherapy and injectable oncology/supportive drugs (e.g., J9000–J9999, J0640–J0642, J1950, Q‑codes, miscellaneous HCPCS) require prior authorization for outpatient administration; submit requests via the Provider Portal or by phone per portal instructions.

Cardiology examples: Selected cardiovascular outpatient procedures (e.g., 93580) and other specified cardiac services require prior authorization.

inv-03: Sample coverage criteria

Examples of coverage criteria and requirements:

Routine circumcision is not a covered benefit; prior authorization is required only when medical necessity is documented (CPT 54150, 54160, 54161, 54162).

Cochlear and other auditory implants: for members <21, prior authorization is required for listed implant procedure and device codes; for members ≥21, prior authorization is required for supplies, equipment maintenance and repairs and clinical documentation must establish medical necessity.

Femoroacetabular impingement (FAI) and functional endoscopic sinus surgery (FESS) procedure codes listed (e.g., 29914–29916, 31240, 31253–31259, 31267, 31276, 31287–31288) require prior authorization for members 21 and older.

Experimental or investigational services require prior authorization per AHCCCS AMPM Chapter 300 Section 320.

Enteral and parenteral nutrition and related DME (specialty beds, wound vacs, etc.) require clinical documentation and prior authorization; certificate of medical necessity may be required, with EPSDT/AMPM guidance for members <21.

inv-04: Extracted authorization criteria fragments

Selected coverage and authorization rules extracted from document fragments:

Eye care (members 21 and older): prior authorization is required when medically necessary to diagnose or treat diseases and conditions of the eye.

Surgical procedures: prior authorization is required for listed CPT codes for femoroacetabular impingement (FAI) and functional endoscopic sinus surgery (FESS).

Genetic testing: prior authorization is required for all services not covered by LabCorp; call LabCorp at 800‑788‑9743 to determine prior authorization requirements.

Infusion and in‑home injectable medications: prior authorization is required for services/medications not covered by Optum Infusion; contact Optum Infusion at 800‑985‑3059 to request services/medications.

Eye care contact: for member eye care services call Nationwide Vision at 480‑961‑1702.

inv-05: Injectable medications

Injectable medications and intravitreal agents listed require prior authorization.

Numerous injectable medications and intravitreal VEGF agents require prior authorization; the document lists many J‑codes and related HCPCS (examples include J7204, J3111, J1305, J0177, J1951, J9155, J0223, J2507, J0897 and many others).

inv-06: Admissions, laboratory, and transport

Facility admissions, laboratory services, and transport have specified authorization/notification requirements.

Inpatient admissions: notification is required for admissions; prior authorization and notification of admission date are required for acute care hospitals, acute inpatient rehabilitation, and long‑term acute care hospitals for specified products/procedures.

Laboratory services: prior authorization is required; providers must call to determine specific prior authorization requirements.

Non‑emergent air ambulance transport (A0430, A0431, A0435, A0436) requires prior authorization.

inv-07: Maxillofacial and orthognathic procedures

Orthognathic and maxillofacial procedures require prior authorization for listed CPT codes.

Orthognathic surgery and treatment of maxillofacial/jaw procedures require prior authorization for the listed CPT codes (examples include 21121, 21123, 21125, 21127, 21141–21147, 21150–21160, 21188, 21193–21199, 21206–21215, 21240–21249, 21255, 21296, 21299).

inv-08: Orthotics and prosthetics coverage rules

Orthotics and prosthetics prior authorization rules and repair coverage notes.

Orthotics and prosthetics codes listed require prior authorization when the retail purchase or cumulative rental cost is more than $500.

Reasonable repairs or adjustments of purchased orthotics are covered to make the orthotic serviceable or when the repair cost is less than purchasing a replacement unit.

Age‑based notes: Certain L‑codes include member age restrictions or orthotic limitations for members 21 and older; some L‑codes require documentation at time of authorization to establish condition or that a component isn't operating.

inv-09: Orthotics/Prosthetics coverage notes

Orthotics and prosthetics coding notes and coverage conditions

Repairs/adjustments of purchased orthotics are covered when they make the orthotic serviceable or when repair cost is less than replacement.

Certain L‑codes require documentation at the time of authorization to establish the condition or that a component is not operating (examples appear in the listed L‑code sections).

Member age exceptions: Some L‑codes include member age restrictions or orthotic limitations for members 21 and older; authorization requirements may differ by age.

inv-10: Therapy, pain management, and pharmacy coverage notes

Therapy and other service coverage and authorization notes

Prior authorization is required for the listed outpatient therapy CPT codes (occupational, physical, and where applicable speech); outpatient speech therapy is noted as not a covered benefit.

Outpatient occupational and physical therapy are covered but limited to 15 visits per benefit year to restore/maintain function and 15 visits per benefit year to acquire a new skill, with EPSDT and QMB exceptions where applicable.

For Qualified Medicare Beneficiaries (QMB), visits are covered for unlimited visits when medically necessary.

Pain injections and management (e.g., CPT 64490, 64493) require prior authorization; selected pharmacy and physician‑administered J‑codes also require prior authorization.

inv-11: Coverage criteria and requirements (partial)

Coverage rules and required documentation or limits included in these sections

Outpatient speech therapy is explicitly stated as not a covered benefit.

Outpatient occupational and physical therapy visit limits: 15 visits per benefit year to restore or maintain a skill/function and 15 visits per benefit year to acquire a new skill and then maintain it.

Qualified Medicare Beneficiaries (QMB): unlimited visits when medically necessary.

Pregnancy termination procedures require prior authorization and must be accompanied by clinical documentation and a certificate of medical necessity per AHCCCS guidance.

Pharmacy prior authorization: service requests must include the medication requested; UnitedHealthcare Pharmacy Prior Authorization contact information is provided (phone/fax) and specific forms are on the provider site.

inv-12: Extracted coverage requirements (partial)

Selected service‑level coverage/authorization notes from the document:

Skilled and custodial nursing facility services require prior authorization.

Spinal surgery, sleep apnea procedures, specialty/enclosed beds, and related device codes require prior authorization; sterilization requests require prior authorization and a signed consent form per AHCCCS AMPM Chapter 400 Section 420.

Transplant and CAR‑T cell therapy services require prior authorization; clinical documentation is required and specific CAR‑T temporary codes are listed.

Non‑emergent transportation (taxi, stretcher van) requires prior authorization and must be scheduled via Medical Transportation Management (MTM) at 888‑700‑6822; certain temporary/unclassified drug codes are noted for transportation exceptions.

Vein procedures (removal/ablation of saphenous trunks/branches) and ventricular assist devices require prior authorization for the listed procedure/device codes.

inv-13: Prior authorization and transportation criteria (partial)

Prior authorization and transportation statements extracted from this section:

Prior authorization is required for the listed CPT/HCPCS/Q‑codes and services; service requests must include the medication requested when applicable.

To schedule non‑emergent transportation, call Medical Transportation Management (MTM) at 888‑700‑6822 or use the notification number on the member's ID card and fax the form provided by the nurse.

Selected procedural and device codes (examples include ventricular assist device codes 33927–33983, Q0507–Q0509, and wound VAC E2402) are identified as requiring prior authorization.

Codes referenced and coding notes

Augmentative and alternative communication (AAC)CPT | HCPCSCovered

92607	Augmentative and alternative communication evaluation
92608	AAC subsequent evaluation
92609	AAC additional related code
A9901	Augmentative communication device, miscellaneous
E2500	AAC device code
E2502	AAC device code
E2504	AAC device code
E2506	AAC device code

Bariatric surgeryCPTCovered

43644	Laparoscopic gastric bypass
43645	Laparoscopic gastric bypass with other procedures
43659	Unlisted laparoscopic procedure, stomach
43770	Laparoscopic revision of gastric restrictive procedure
43775	Revision of gastric bypass
43842	Gastric restrictive procedure
43845	Revision gastric restrictive
43846	Gastrointestinal surgery code

Injectable chemotherapy and related drugsHCPCSCovered

J9000-J9999	Injectable chemotherapy drugs
J0640	Leucovorin
J0641	Levoleucovorin
J1950	Leuprolide depot (Lupron Depot)

Cancer supportive care (bone-modifying, CSFs, ESAs)HCPCSCovered

J0897	Denosumab (Xgeva) / bone-modifying agent
J1449	Colony stimulating factors or related
J0885	Erythropoiesis-stimulating agents
J2820	Sargramostim (Leukine)

Cardiovascular procedureCPTCovered

93580

Transcatheter placement of right or left heart catheter

CircumcisionCPT

54150	Neonatal circumcision
54160	Circumcision removal of foreskin older child
54161	Circumcision with special technique
54162	Circumcision procedure code

Selected DME/diabetic supply HCPCS examplesHCPCSCovered

E0194	DME item (example listed)
E0445	DME item (not covered by Preferred Homecare listed)
E0694	Diabetic supplies

K-series DME codesHCPCSCovered

K0800-K0891	Various complex rehab and seat/positioning codes listed (K* series)
K0836-K0891	Additional K-series codes requiring authorization

Chemotherapy injectable codesHCPCSCovered

J9000-J9999	Chemotherapy injectable drugs
J0640	Leucovorin

Selected surgery CPT codes requiring prior authorizationCPTCovered

29914	Arthroscopic hip procedure (FAI-related)
29915	Arthroscopic hip procedure (FAI-related)
29916	Arthroscopic hip procedure (FAI-related)
31240	Nasal/sinus endoscopy code
31253	FESS code
31254	FESS code
31255	FESS code

Selected injectable or J-code medications referencedHCPCSCovered

J3262	Actemra
J0791	Adakveo
J0172	Aduhelm
J1426	Amondys 45
J0225	Amvuttra
J0739	Apretude
J0256	Aralast NP / Prolastin-C / Zemaira

Selected injectable HCPCS codesHCPCSCovered

J0588	Listed injectable medication (see document list)
J2329	Listed injectable medication (see document list)
J2786	Cinqair
J0802	Cortrophin Gel
J0584	Crysvita
J1551	Cutaquig

Selected L-codes for orthotics/prostheticsHCPCSCovered

L0112	Orthotics/prosthetics code
L0484	Prosthetic/orthotic component
L2000	Orthotics/prosthetics code

Selected CPT procedure codesCPTCovered

21121	Orthognathic surgery CPT
27120	Joint replacement related CPT

Selected L-codes and notesHCPCS

L1720	Orthotics/prosthetics L-code listed effective 5/1/2024
L1830	Orthotics/prosthetics L-code — additional information about repairs/adjustments
L2106	L-code with note: For members 21 and older
L2627	L-code with conditional applicability
L3977	L-code with note: The orthotic is less expensive
L5312	L-code with orthotic limitation for members 21 and older
L5505	L-code with note: Reasonable repairs or adjustments of purchased orthotics
L5610	Orthotics and prosthetics L-code
L5700	Orthotics and prosthetics L-code with documentation requirement at time of authorization
L5824	Orthotics and prosthetics L-code

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Selected CPT and J-codes referencedmixed

92507	Speech-language therapy
97110	Therapeutic exercises
64490	Injection for pain management
J1290	Pharmacy/j-code listed

Prostate proceduresCPT

37243

Prostate procedure code listed for prior authorization

Proton beam therapy / advanced radiologyCPT

77520	Proton beam therapy code listed for prior authorization
77522	Proton beam therapy code listed for prior authorization
77523	Proton beam therapy code listed for prior authorization
77525	Proton beam therapy code listed for prior authorization

Various CPT/HCPCS codes requiring prior authorizationCPT

30400-30465	Rhinoplasty/septoplasty codes listed for prior authorization
29805-29879	Shoulder and arthroscopy-related codes listed for prior authorization
45378-45390	Colonoscopy and related GI procedure codes listed for prior authorization
38500-38525	Hemic and lymphatic system procedure codes listed
10121-15120	Integumentary system / dermatologic procedure codes listed
47000	Liver biopsy code listed
20680	Site of service outpatient code listed
64561-64640	Nervous system procedure codes listed
65426-67036	Ophthalmologic procedure codes listed

Arthroscopy / related CPT/HCPCS codes (partial list)CPT

29835
29840
29845
29846
29861
29875
29876
29879
29880
29881

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Device / CAR-T / temporary codesmixed

E0747	Bone growth stimulator
E0748	Bone growth stimulator
E0749	Bone growth stimulator
0537T	CAR T-cell therapy temporary code
0538T	CAR T-cell therapy temporary code
0539T	CAR T-cell therapy temporary code
0540T	CAR T-cell therapy temporary code

Vascular / vein procedure codesCPT

36473	Endovenous ablation
36475	Endovenous ablation
36478	Endovenous ablation
37700	Vein stripping/ligation

Examples of codes referencedmixed

33927	Ventricular assist device (example listed)
33928	Ventricular assist device (example listed)
33929	Ventricular assist device (example listed)
33975	Related procedural code (listed)
33976	Related procedural code (listed)
33979	Related procedural code (listed)
33981	Related procedural code (listed)
33982	Related procedural code (listed)
33983	Related procedural code (listed)
Q0507	Example Q-code listed

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Age-based coverage rule example

Age-based coverage ruleAllergy immunotherapy and testing: covered under EPSDT for members younger than 21 when medically necessary; for members 21 and older allergy immunotherapy (including allergy shots and SLIT) is not a covered benefit.

MSIC exceptionServices delivered inside Multi-Specialty Interdisciplinary Clinics (MSIC) to CRS-designated children do not require prior authorization.

What providers must do and who to contact

Prior Authorization

How to request prior authorization

Submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone at 800-445-1638.

Prior Authorization

Specialty-specific submission channels

Some specialties have dedicated submission channels and phone numbers; for cardiology use the Provider Portal or call 866-889-8054, and for many chemotherapy/injectable drug requests use the Provider Portal or call 888-397-8129 (and Optum Infusion for in-home injectable meds at 800-985-3059).

Documentation Required

Eligibility and coverage requirement

Prior authorization is required only for services that are AHCCCS-covered, medically necessary, cost‑effective, and federally/state reimbursable; experimental and investigational services are not covered.

Key definitions and thresholds

AHCCCS-covered benefits must be medically necessary, cost-effective, and federally/state reimbursable per Arizona Health Care Cost Containment System rules

AHCCCS coverage requirementTo be eligible for prior authorization, services must be AHCCCS-covered, medically necessary, cost-effective, and federally/state reimbursable.

Experimental exclusionExperimental and investigational services are not covered benefits.

Single-request ruleOnly one health care professional may request services on an authorization request form.

Multi-specialty interdisciplinary clinics — services delivered inside MSIC to CRS-designated children do not require prior authorization

MSIC exceptionServices delivered inside Multi-Specialty Interdisciplinary Clinics (MSIC) to CRS-designated members do not require prior authorization.

Scope

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for developmentally disabled Arizona members

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone at 800-445-1638.

SourceLink

On This Page

Circumcision: routine circumcision is not covered; prior authorization is required only when medical necessity is documented (CPTs 54150–54162 listed).

Advanced outpatient imaging: ordering professionals must provide notification prior to scheduling and submit prior authorization requests via the Provider Portal.

Provider enrollmentRendering professionals, facilities and vendors must be actively registered with AHCCCS to be eligible for prior authorization.

DME prior authorization cost threshold

DME PA dollar thresholdPrior authorization required for DME items with a retail purchase or cumulative rental cost of more than $500.

Preferred Homecare contactTo request DME items contact Preferred Homecare at 800-636-2123.

Examples of affected HCPCSDocument lists multiple E-codes as DME examples (e.g., E0194, E0445, E0694).

Orthotics/prosthetics purchase/rental cost threshold

Orthotics/prosthetics PA thresholdPrior authorization required when retail purchase or cumulative rental cost exceeds $500.

Repairs/adjustments coverageReasonable repairs or adjustments of purchased orthotics are covered to make the orthotic serviceable or when repair cost is less than replacement.

Example L-codesNumerous L-codes listed for authorization (e.g., L0112, L0484, L1720, L5610).

OT/PT visit limits

OT/PT visit limitOutpatient occupational and physical therapy are limited to 15 visits per benefit year to restore/maintain function or to acquire a new skill and then maintain it.

Speech therapyOutpatient speech therapy is not a covered benefit.

Prior authorization for listed therapy codesPrior authorization is required for listed outpatient therapy CPT codes for members (examples shown in document).

Prior Authorization

Services commonly requiring prior authorization

Prior authorization is required for many listed CPT/HCPCS codes and service categories (examples include AAC devices, allergy testing when criteria met, bariatric surgery, behavioral health inpatient admissions, chemotherapy and other injectable therapies).

Documentation Required

Authorization request rules

Only one health care professional may request services on an authorization request form.

Documentation Required

Provider enrollment and out-of-network rules

All rendering professionals, facilities and vendors must be actively registered with AHCCCS; services by non-network or out-of-state providers require prior authorization plus documentation supporting the out‑of‑network request.

Prior Authorization

Chemotherapy prior authorization and submission

Injectable chemotherapy drugs (J9000–J9999), leucovorin/levoleucovorin (J0640, J0641, J0642) and Lupron Depot (J1950) require prior authorization; submit via the Prior Authorization and Notification tool or call 888-397-8129.

Prior Authorization

Circumcision prior authorization

Routine circumcision is not a covered benefit; prior authorization is required only when medical necessity is documented (relevant CPT codes include 54150, 54160, 54161, 54162).

Prior Authorization

Implants, auditory devices, and select surgical procedures

Cochlear and other auditory implants require prior authorization for members younger than 21 for the listed codes; for members 21 and older prior authorization is required for supplies, equipment maintenance and repairs and clinical documentation must establish medical necessity.

Documentation Required

Dental and DME authorization notes

Dental services have a separate contact (UnitedHealthcare Dental at 855-812-9208). DME prior authorization is required for listed codes and for items with retail purchase or cumulative rental cost over $500; Preferred Homecare handles many DME requests at 800-636-2123.

Prior Authorization

Enteral/parenteral nutrition and related DME

Enteral and parenteral nutrition, specialty beds, wound vacs and related DME require prior authorization; requests and clinical documentation (including certificate of medical necessity when applicable) should be submitted to Preferred Homecare at 800-636-2123.

Prior Authorization

Experimental/investigational services

All services considered experimental or investigational require prior authorization per AHCCCS AMPM Chapter 300, Section 320.

Prior Authorization

Eye care prior authorization for adults

For members 21 and older, prior authorization is required when medically necessary to diagnose or treat diseases and conditions of the eye.

Prior Authorization

Surgical procedure prior authorization (FAI, FESS)

Prior authorization is required for listed surgical procedure codes for femoroacetabular impingement (29914–29916) and many FESS codes (e.g., 31240, 31253–31259, 31276, 31287–31288).

Prior Authorization

Genetic testing prior authorization / LabCorp routing

Genetic testing requires prior authorization for services not covered by LabCorp; call LabCorp at 800-788-9743 to determine prior authorization requirements.

Prior Authorization

Infusion and injectable meds prior authorization / Optum Infusion

In‑home infusion services and many injectable medications require prior authorization; for services or medications not covered by Optum Infusion contact Optum Infusion at 800-985-3059.

Note

Eye care authorization contact

For member eye care services contact Nationwide Vision at 480-961-1702.

Prior Authorization

Inpatient admission notification/authorization

Notification is required for inpatient admissions; prior authorization and notification of the admission date are required for acute care hospitals, acute inpatient rehabilitation and long‑term acute care hospitals for certain products and services.

Prior Authorization

Non-emergent air ambulance

Non‑emergent air ambulance transport (A0430, A0431, A0435, A0436) requires prior authorization.

Prior Authorization

Orthognathic and maxillofacial procedures

Orthognathic surgery and treatment of maxillofacial/jaw procedures require prior authorization for the listed CPT codes (examples include 21121, 21123, 21125, 21141–21147, 21150–21160, 21188, 21193–21199, 21206–21215, 21240–21249, 21255, 21296, 21299).

Billing Rule

Orthotics and prosthetics prior authorization rules

Orthotics and prosthetics codes listed require prior authorization when retail purchase or cumulative rental cost is more than $500; repairs/adjustments of purchased orthotics are covered when they make the device serviceable or when repair cost is less than replacement.

Prior Authorization

Injectable medications and intravitreal agents

Numerous injectable medications and intravitreal VEGF agents listed (see J‑code lists in the document) require prior authorization.

Prior Authorization

Laboratory services

Laboratory services require prior authorization; providers must call to determine specific prior authorization requirements.

Prior Authorization

Out-of-network prior authorization

Prior authorization is required for all out‑of‑network services.

Prior Authorization

Out-of-state prior authorization limitation

Out‑of‑state services are a benefit only when emergent or when the service is unavailable in Arizona.

Prior Authorization

Outpatient therapy codes requiring prior authorization

Prior authorization is required for the listed outpatient therapy codes (occupational, physical and, where applicable, speech therapy codes) and related therapy services; note outpatient speech therapy is not a covered benefit.

Prior Authorization

Pain injections prior authorization

Pain injections and management procedures (examples include 64490, 64493) require prior authorization.

Prior Authorization

Pharmacy/physician-administered drug prior authorization

Selected pharmacy and physician‑administered drug HCPCS/J‑codes are listed as requiring prior authorization or are included in pharmacy prior authorization lists; service requests must include the medication requested.

Prior Authorization

Advanced outpatient imaging prior authorization

Health care professionals ordering advanced outpatient imaging procedures must provide notification prior to scheduling and submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

Prior Authorization

Site of service prior authorization rules

Prior authorization is required when requesting certain services in an outpatient hospital setting for listed CPT/HCPCS codes; prior authorization is not required if the service is performed at a participating ambulatory surgery center for some services.

Documentation Required

Pharmacy prior authorization contact

For pharmacy prior authorization contact UnitedHealthcare Pharmacy Prior Authorization Service by phone at 800-310-6826 or fax at 866-940-7328; a list of medications requiring prior authorization is available on the UHC provider site.

Billing Rule

Therapy coverage and limits

Outpatient speech therapy is not a covered benefit; outpatient occupational and physical therapy are covered but limited to specified visit counts per benefit year (15 visits per benefit year for restoring/maintaining or acquiring new skills).

Prior Authorization

Pregnancy termination prior authorization

Prior authorization is required for pregnancy termination and specific related codes; clinical documentation and a certificate of medical necessity must accompany the authorization request.

Prior Authorization

Nursing facility services

Skilled and custodial nursing facility services require prior authorization.

Prior Authorization

Spinal surgery / Sterilization / Sleep apnea / Specialty beds

Spinal surgery, sterilization, sleep apnea procedures and specialty/enclosed beds require prior authorization for the listed codes; sterilization requests must include a signed consent to sterilization form per AHCCCS guidance.

Prior Authorization

Stimulators / Implantable devices

Implantable stimulators and bone growth stimulators and associated HCPCS/L‑codes listed (e.g., E0747–E0749, L8680, L8682, L8685–L8688) require prior authorization.

Prior Authorization

Transplant and CAR T-Cell therapy

Transplant and CAR T‑Cell therapy services require prior authorization; clinical documentation is required and specific CAR‑T and transplant procedure codes are listed in the document.

Prior Authorization

Transportation (non-emergent)

Non‑emergent transportation (taxi, stretcher van) requires prior authorization and must be scheduled via Medical Transportation Management (MTM) at 888-700-6822; certain drug/unclassified codes and oncology exceptions are noted.

Prior Authorization

Vein procedures

Vein procedures (removal/ablation of saphenous trunks/branches) require prior authorization for the listed CPT codes (e.g., 36473, 36475, 36478, 37700, 37718, 37722, 37765, 37766).

Prior Authorization

Ventricular assist devices

Ventricular assist devices require prior authorization for the listed codes (examples include 33927–33983 and Q‑codes shown in the document).

Prior Authorization

Prior authorization and transportation scheduling

Service requests for certain codes must include the medication requested when applicable; to schedule transportation call MTM at 888-700-6822 or use the notification number on the member's ID card and fax the form provided by the nurse.

Prior Authorization

Procedural and device codes requiring prior authorization

Selected procedural and HCPCS/Q‑codes (including ventricular assist device and wound VAC related codes such as 33927–33983, Q0507–Q0509, E2402) are identified as requiring prior authorization.

Applies specifically to CRS-designated/CRS-formerly designated children receiving services inside MSIC.

DocumentationStandard eligibility and medical necessity requirements still apply for coverage determinations outside MSIC.

Cosmetic procedures

DefinitionCosmetic procedures: services or items furnished solely to improve physical appearance without improving or restoring physiologic function; such services are excluded from AHCCCS coverage.

Examples (codes)Document lists example CPT/HCPCS codes associated with cosmetic procedures (e.g., 11960, 14020, 14021, 14041).

Coverage ruleReconstructive procedures that treat, improve or restore physiologic function remain eligible when medically necessary.

Reconstructive vs Cosmetic

Reconstructive vs cosmeticReconstructive procedures treat or improve/restore physiologic function; cosmetic procedures change appearance and are excluded when furnished solely for cosmetic purposes.

Coverage implicationReconstructive procedures remain covered when medically necessary; cosmetic-only purposes are excluded from AHCCCS coverage.

Code referencesDocument provides representative CPT/HCPCS codes for both categories to guide determinations.

LabCorp routing for genetic testing

LabCorp routingGenetic testing: prior authorization is required for services not covered by LabCorp; to determine prior authorization requirements call LabCorp at 800-788-9743.

ScopeApplies to multiple genetic test CPT codes listed in the document (examples include 81265, 81302, 81404, 81415).

Member age noteThese genetic testing routing instructions are indicated in the section for members 21 and older.

Optum Infusion routing

Optum Infusion contactInfusion in-home services and injectable medications: prior authorization is required for services/medications not covered by Optum Infusion; call Optum Infusion at 800-985-3059 to request services or supplies.

ScopeApplies to in-home infusion services and many injectable medications listed in the document (codes effective 5/1/2024).

Request instructionsRequests for Optum-covered items should be made via the Optum Infusion contact number provided in the document.

Notification is required for inpatient admissions (date of admission must be provided).

Inpatient admission notificationNotification is required for admissions; prior authorization and notification of admission date are required for acute care hospitals, acute inpatient rehabilitation, and long-term acute care hospitals for certain products.

Products requiring authorizationAuthorization is specifically required for certain products (examples: Adzynma; Cosentyx IV; Nulibry; Omvoh; Revcovi; Vabysmo; Vyjuvek).

ProcedureProvide admission date when submitting the required notification.

Orthotics and prosthetics with retail purchase or cumulative rental cost over $500 require prior authorization.

PA threshold for O&POrthotics and prosthetics with retail purchase or cumulative rental cost over $500 require prior authorization.

Repair coverageReasonable repairs/adjustments of purchased orthotics are covered when they make the device serviceable or when repair cost is less than replacement.

Supporting codesMultiple L-codes are listed for authorization and repair guidance (e.g., L0112, L0484, L1720, L5610).

Repairs/adjustments coverage

Repairs/adjustments coverageReasonable repairs or adjustments of purchased orthotics are covered to make the orthotic serviceable and/or when repair cost is less than purchasing another unit.

Component replacementSome components will be replaced per code-specific notes; documentation requirements may apply at time of authorization.

Representative L-codesDocument lists numerous L-codes associated with repairs and components (examples include L1720, L1830, L5610, L5648).

Out-of-state services limitation

Out-of-state services limitationOut-of-state services are covered only when emergent or the service is unavailable in Arizona.

Outpatient therapy codes PAPrior authorization is required for listed outpatient therapy CPT codes; outpatient speech therapy is not a covered benefit.

QMB exceptionQualified Medicare Beneficiaries (QMB) are covered for unlimited visits when medically necessary.

QMB

QMB coverage noteQualified Medicare Beneficiaries (QMB): covered for unlimited visits when medically necessary.

Sterilization consent requirementSterilization requests must include an appropriate signed Consent to Sterilization form per AHCCCS AMPM Chapter 400 Section 420.

Service request medication requirementService requests for certain procedures/devices must include the medication requested where applicable.

Sterilization consent

Sterilization consentSterilization requests require a signed Consent to Sterilization form as referenced in AHCCCS Medical Policy Manual (AMPM) Chapter 400, Section 420.

Reference locationThe Consent to Sterilization form is available via the AHCCCS AMPM resources and policies webpages.

Prior authorizationPrior authorization is required for sterilization procedures as listed in the document.

MTM (transportation scheduling)

MTM schedulingTo schedule non-emergent transportation (taxi, stretcher van) call Medical Transportation Management (MTM) at 888-700-6822.

Authorization requirementNon-emergent transportation requires prior authorization; certain temporary/unclassified codes and oncology exceptions are noted.

Notification alternativeAlternatively, call the notification number on the back of the member's health plan ID card and fax the nurse-provided form when instructed.

Ventricular assist device (VAD) definition

Ventricular assist device (VAD) definitionA mechanical pump that takes over the function of the damaged ventricle of the heart and restores normal blood flow.

Associated codesVAD-related procedural codes listed in the document include examples such as 33927, 33928, 33929 and related Q-codes.

Prior authorizationVentricular assist devices require prior authorization for the listed codes; scheduling/notification instructions reference member ID contact methods.