CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for UnitedHealthcare Community Plan of Hawaii

List of services, CPT/HCPCS codes, diagnosis codes, and instructions describing when prior authorization is required or not for participating UnitedHealthcare Community Plan of Hawaii providers; includes submission methods and contact information.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Hawaii

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateEffective Jan. 1,2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone at 888-980-8728.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-01-01Effective date shown

888-980-8728Prior authorization phone contact

$500DME rental trigger

48 hrsEmergency inpatient notification

888-936-7246Transplant case mgmt contact

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria and Authorization Stance (Partial)

Coverage criteria examples

Examples of coverage rules and authorization stance from the partial document:

Providers must submit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone; emergency and urgent care do not require prior authorization.

Injectable chemotherapy drugs administered in an outpatient setting require prior authorization (examples: A9590, J0640, J1442).

Inpatient video EEG CPT codes (95720, 95722, 95724, 95726) are listed; the document notes prior authorization is not required for outpatient hospital or ambulatory surgical center EEG in some cases.

A long list of ICD-10 diagnosis codes (C43.x and C44.x examples shown) are specified as not requiring prior authorization when billed with certain CPT/HCPCS codes (partial list provided).

Partial code-based coverage stance

Partial extracted criteria from chunks 18–37:

Inpatient video EEG codes: 95720, 95722, 95724, 95726 — prior authorization not required for outpatient hospital or ambulatory surgical center (document notes).

Selected chemotherapy/injectable drug HCPCS/CPT codes listed as prior-authorization required for outpatient injectable chemotherapy: examples include A9590, A9607, A9699, J0640, J0641, J0642, J0897, J1442, J1447, J1448, J1449.

Cochlear and other auditory implants (examples: 69710, 69714, 69930, L8614, L8619) — prior authorization required for implants per document notes.

Cosmetic versus reconstructive procedures: many listed CPT codes (e.g., 11960, 14020-14021, 14041, 15820, 17106, 21137) — cosmetic procedures noted as 'Prior authorization required'; reconstructive procedures that restore physiologic function are listed separately (mixed coverage/notes).

Prior authorization coverage rules (partial)

Lists codes and notes indicating whether prior authorization is required.

Diagnosis codes exempt from prior authorization (examples from ICD-10 C43.x and C44.x series such as C43.39, C43.4, C43.51, C44.01, C44.101, C44.1021) — document indicates prior authorization not required for these diagnosis codes when billed appropriately.

Durable medical equipment (DME) exceptions: many HCPCS K- and V-codes (e.g., A9279, A9280, E0194, E0265, E0266, E0270, E0277, E0300, E0328, E0329, K0870–K0891, V2786, V5269, V5270) are listed as not requiring prior authorization except where noted — prior authorization is required for DME items with retail purchase or cumulative rental cost > $500.

Enteral/in-home nutritional therapy codes (B4034, B4035, B4036 and related B41xx series) — prior authorization required for enteral services per document.

Prior authorization coverage criteria (segment)

Coverage stance and prior authorization requirements for listed services and codes in this document segment.

Durable Medical Equipment (DME): many K- and V-codes are listed as not requiring prior authorization; specific K/V codes enumerated in the document (see source).

Incontinence supplies: benefit only when provided through vendor; to request incontinence supplies call Medline at 877-816-5587 (document note).

Enteral and in‑home nutritional therapy: prior authorization required for enteral services (codes include B4034, B4035, B4036 and additional B41xx entries).

Genetic and molecular testing (including BRCA): prior authorization/notification required; ordering provider and laboratory must follow the Authorization/Notification Program (numerous CPT/HCPCS and U codes listed).

Hearing aids and hearing aid services: prior authorization required; submit via Provider Portal or call 888-980-8728 per document instructions.

Injectable medications not requiring prior authorization (selected examples)

A large set of injectable medications (HCPCS/J-codes) are listed as not requiring prior authorization.

The document lists numerous injectable J- and Q-codes as examples; selected entries include (examples across chunks): J0598 (Cinryze), J0802 (Cortrophin Gel), J3247 (Cosentyx IV), J0584 (Crysvita), J1551 (Cutaquig), J0589 (Daxxify), J1428 (Exondys 51), J0178 (Eylea), J3262 (Actemra), J0801 (Acthar), J0791 (Adakveo), J0172 (Aduhelm), J7171 (Adzynma), J1931 (Aldurazyme), J1426 (Amondys 45), J0225 (Amvuttra), Q5121 (Avsola), J0490 (Benlysta), J0179 (Beovu), J1414 (Beqvez) — document presents many additional examples and indicates prior-authorization status varies by drug/code and context.

Inpatient and facility services prior authorization requirements

Certain inpatient services and procedures require prior authorization or notification.

Emergency inpatient admissions: notify UnitedHealthcare within 48 hours of admission; routine obstetrics and deliveries require notification only.

Joint replacement (total hip/knee) and other inpatient surgical procedures: prior authorization required (document lists example CPT codes such as 27130, 27412 among others).

Non‑emergent air ambulance transport (example codes S9960, S9961) requires prior authorization.

Orthotics and prosthetics prior authorization criteria

Orthotics and prosthetics have cost-based prior authorization requirements.

Prior authorization is required for orthotics and prosthetic codes when the retail purchase or cumulative rental cost exceeds $500. Examples of affected L-codes are listed throughout the document (see L0112, L0480, L0638, etc.).

Special coding and new medication review notes

Special notes on coding and new-to-market medications.

For unclassified and temporary codes C9399, J3490 and J3590, prior authorization is required only for specific products noted (Nulibry and Rivfloza).

For code J0897, prior authorization is required for non-oncology diagnoses (document special rule).

Reference the 'Review at Launch for New to Market Medications' policy; pre-determination is recommended for newly approved drugs on that list.

Partial prior authorization criteria (excerpt)

Prior authorization requirements by service/code (partial list from document).

Selected orthotics/prosthetics L-codes listed as not requiring prior authorization in parts of the document (examples: L5610, L5613, L5614, L5616, L5639, L5640, L5642, L5643, L5644, L5646, L5647, L5648, L5649, L5651, L5653, L5661, L5673, L5682, L5683).

Private duty nursing (codes T1002, T1003): prior authorization only required (document indicates 'Prior authorization only required').

Proton beam therapy (77520, 77522, 77523, 77525): prior authorization required for focused proton beam radiation therapy services.

Transplant and CAR T-cell therapy services: prior authorization required and referral/prior authorization handled via UnitedHealthcare Community and State Transplant Case Management (phone 888-936-7246); transplant services for Hawaii are carved out to the SHOTT program (document notes J9999, Q2054 and related codes).

Vein procedures (removal/ablation of saphenous trunks/branches) — prior authorization required; example CPT codes include 36473, 36475, 36478, 37700, 37718, 37722, 37765, 37766.

Prior authorization coverage criteria (segment)

Prior authorization requirements and contact instructions for specific service types.

Transplant and CAR T-cell therapies: for prior authorization/notification call UnitedHealthcare Community and State Transplant Case Management at 888-936-7246 or the notification number on the back of the member's ID card; listed codes include J9999, Q2054, Q2041, Q2055, Q2042, Q2056, Q2053.

Vein procedures (saphenous removal/ablation): prior authorization required — listed CPT codes include 36473, 36475, 36478, 37700, 37718, 37722, 37765, 37766.

Vision services: numerous V- and S-codes are listed; prior authorization is required for specified ages and codes, with exceptions noted (e.g., prior authorization not required for members 40 years of age or older for certain codes).

Wound VAC therapy (E2402): prior authorization required for negative pressure wound therapy supplies per document note.

CPT / HCPCS / ICD-10 Code Listings (Partial)

Bariatric surgery CPT codesCPTCovered

43644	Bariatric surgery CPT code listed (prior authorization required)
43645	Bariatric surgery CPT code listed (prior authorization required)
43770	Bariatric surgery CPT code listed (prior authorization required)
43860	Bariatric surgery CPT code listed (prior authorization required)

Breast reconstruction CPT codesCPTCovered

19316	Breast reconstruction CPT code (prior authorization required)
19325	Breast reconstruction CPT code (prior authorization required)
19350	Breast reconstruction CPT code (prior authorization required)

Bone growth stimulator CPT codesCPTCovered

20975	Bone growth stimulator CPT code (prior authorization required)
20979	Bone growth stimulator CPT code (prior authorization required)

Chemotherapy HCPCS/J-codesHCPCSCovered

A9590	Injectable chemotherapy HCPCS code (prior authorization required)
J0640	Injectable chemotherapy J-code (prior authorization required)

Chemotherapy / injectable drug codes (partial)HCPCSCovered

J9179	Chemotherapy/injectable HCPCS example listed
J9201	Chemotherapy/injectable HCPCS example listed

Auditory implantsmixedCovered

69710	Cochlear implant CPT code (prior authorization required)
L8614	Auditory implant HCPCS code (prior authorization required)

Selected ICD-10 oncology/skin codesICD-10Covered

C43.0	Malignant melanoma of skin - example ICD-10 code listed
C44.01	Skin cancer ICD-10 code example listed

ICD-10 diagnosis exemptions (partial list)ICD-10Covered

C44.101	ICD-10 diagnosis code listed as not requiring prior authorization
C44.1021	ICD-10 diagnosis code listed as not requiring prior authorization

DME/HCPCS exemptions (partial list)HCPCSCovered

E0466	DME HCPCS code listed
E0470	DME HCPCS code listed

Durable medical equipment and related HCPCSHCPCS

K0870	Durable medical equipment HCPCS code
K0871	Durable medical equipment HCPCS code
K0877	Durable medical equipment HCPCS code
K0878	Durable medical equipment HCPCS code
K0879	Equipment (DME) HCPCS
K0880	Equipment (DME) HCPCS
K0884	Equipment (DME) HCPCS
K0885	Equipment (DME) HCPCS
K0886	Equipment (DME) HCPCS
K0890	Equipment (DME) HCPCS

1–10 of 20

1/2

Selected injectable medication J/Q-codesHCPCS

J3262	Actemra (listed)
J0801	Acthar (listed)
J0791	Adakveo (listed)
J0172	Aduhelm (listed)
J7171	Adzynma (listed)
J1931	Aldurazyme (listed)
J1426	Amondys 45 (listed)
J0225	Amvuttra (listed)
Q5121	Avsola (listed)
J0490	Benlysta (listed)

1–10 of 12

1/2

Selected injectable HCPCS/J-codes listed as not requiring prior authorizationHCPCS

J0598	Cinryze (listed as not requiring prior authorization)
J0802	Cortrophin Gel (listed as not requiring prior authorization)
J3247	Cosentyx IV (listed as not requiring prior authorization)
J0584	Crysvita (listed as not requiring prior authorization)
J1551	Cutaquig (listed as not requiring prior authorization)
J0589	Daxxify (listed as not requiring prior authorization)
J1428	Exondys 51 (listed as not requiring prior authorization)
J0178	Eylea (listed as not requiring prior authorization)

Selected L-codes for orthotics/prosthetics enumeratedHCPCS

L0112	Orthotics/prosthetic code example (listed)
L0480	Orthotics/prosthetic code example (listed)
L0638	Orthotics/prosthetic code example (listed)
L2030	Orthotics/prosthetic code example (listed)
L5230	Orthotics/prosthetic code example (listed)
L5716	Orthotics/prosthetic code example (listed)

Selected L-codes not requiring prior authorization (partial)HCPCSCovered

L6010	Orthotics/prosthetics L6010 (listed as no prior authorization required)
L6120	Prosthetics L6120 (listed as no prior authorization required)
L6200	Prosthetics/orthotics L6200 (listed as no prior authorization required)
L6590	L6590 (listed as no prior authorization required)

Examples of CPT codes requiring prior authorizationCPTCovered

77520	Proton beam therapy CPT code (prior authorization required)
36473	Vein ablation/removal CPT code (prior authorization required)
37243	Prostate procedure CPT code (example listed as prior authorization required)

Transplant/CAR T-cell related codesHCPCS

J9999	Code listed for transplant/CAR T-cell services (case management referral)
Q2054	Code listed for transplant/CAR T-cell services (case management referral)

Vein procedure CPT codesCPTCovered

36473	Vein procedure - removal/ablation (listed)
36475	Vein procedure - removal/ablation (listed)
36478	Vein procedure - removal/ablation (listed)
37700	Vein procedure - removal/ablation (listed)
37718	Vein procedure - removal/ablation (listed)
37722	Vein procedure - removal/ablation (listed)
37765	Vein procedure - removal/ablation (listed)
37766	Vein procedure - removal/ablation (listed)

Wound VAC codeHCPCSCovered

E2402

Negative pressure wound therapy supply (wound VAC) - prior authorization required

Applies to

Applies toApplies to members 18 years of age and older (for the listed entries)

ScopeApplied where noted in diagnosis/code entries for monitoring and related services

Exception noteDoes not change emergency/urgent care authorization rules — PA not required for emergent or urgent care

How to Submit Requests, Notifications, and Provider Responsibilities

Prior Authorization

How to submit prior authorization

Submit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone at 888-980-8728. Prior authorization is not required for emergency or urgent care. For inpatient emergency admissions, notify UnitedHealthcare within 48 hours. Out-of-network providers must request prior authorization for all procedures and services except emergent or urgent care.

Online: UHCprovider.com → Prior Authorization and Notification tool
Phone: 888-980-8728
Inpatient emergency admissions: notify within 48 hours

Prior Authorization

Chemotherapy prior authorization

Certain injectable outpatient chemotherapy drugs require prior authorization when administered in an outpatient setting (including IV). Examples of HCPCS/J-codes that may require prior authorization include A9590, A9607, A9699, J0640–J0642, J0897, J1442, J1447–J1449, J9075, J9118–J9130, J9144–J9155, J9165, J9171–J9179, J9181, J9190, J9196, J9198, J9201–J9207, J9212–J9229, J9246–J9274, J9280–J9309, J9311–J9359, J9360–J9400, J9600, J9999 and many others. For unclassified/temporary codes (C9399, J3490, J3590) prior authorization is only required for specific products (e.g., Nulibry®, Rivfloza®). For code J0897: prior authorization is required for non-oncology diagnoses.

Terminology and Program Definitions

Prior authorization

DefinitionPrior authorization: a payer process requiring providers to obtain approval before certain services are performed or billed

Submission methodsRequests may be submitted online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone (888-980-8728)

Emergency carePrior authorization is not required for emergency or urgent care

auditory implants

DefinitionAuditory implants: medical devices within the inner ear with an external portion to help persons with profound sensorineural hearing loss (examples: cochlear implants)

Example codesCochlear and auditory implant CPT/HCPCS codes listed include 69710, 69714, 69930 and HCPCS L8614/L8619

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Hawaii

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateEffective Jan. 1,2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone at 888-980-8728.

SourceLink

On This Page

Home- and community-based services and home health: prior authorization required only in outpatient/home settings (codes such as G0151, G0152, G0153, G0155, G0156, G0160 and others listed).

Hospice: prior authorization required only in inpatient settings; other hospice settings may not require prior authorization (document lists hospice-related codes).

Injectable medications: document enumerates many J- and Q-codes; the segment notes prior authorization is required for many injectable medications (extensive drug list provided).

Sinuplasty codes (31295–31298): prior authorization required. Sleep apnea procedural entries include age-specific rules and prior authorization notes (partial list in document).

Implantable stimulators and bone growth stimulators: multiple CPT/HCPCS codes are listed with prior authorization required (see document for enumerated codes such as 0098T, E0747–E0760, L8680–L8688 and various CPT device/implant codes).

DME rental prior auth threshold

DME rental thresholdPrior authorization required when rental cost is more than $500 (retail purchase or cumulative rental cost trigger)

Applies toApplies to DME codes listed with retail purchase or cumulative rental cost amounts

Related noteMost listed DME/HCPCS codes do not require prior authorization except when above this cost threshold

Genetic testing prior authorization/notification program

Program requirementGenetic and molecular testing (including BRCA) require prior authorization/notification under the Authorization/Notification Program

Ordering provider actionThe ordering care provider must notify UnitedHealthcare as part of the prior authorization/notification process

Lab actionLaboratories will be required to notify UnitedHealthcare per the program when applicable CPT/HCPCS codes are submitted

Orthotics/prosthetics prior auth cost threshold

Cost threshold>$500 retail purchase or cumulative rental cost triggers prior authorization for orthotics and prosthetics

ApplicabilityPrior authorization required only for orthotics/prosthetic codes listed with retail purchase or cumulative rental cost over $500

ExceptionsMultiple L-codes are listed as not requiring prior authorization unless the cost threshold is met

Examples of outpatient chemotherapy/antineoplastic codes: A9590, A9607, A9699
Selected J-codes that often require authorization when outpatient: J0640, J0897, J1442, J9075, J9118–J9179, J9181, J9190, J9201–J9274, J9280–J9400
Unclassified/temporary codes (C9399, J3490, J3590): authorization required only for specific drugs (e.g., Nulibry®, Rivfloza)

Prior Authorization

EEG / seizure monitoring

EEG and cerebral/seizure monitoring have specific prior-authorization guidance. Outpatient EEG and ambulatory EEG generally do not require prior authorization. Inpatient video EEG and longer-term inpatient seizure monitoring do require prior authorization. Relevant CPT codes include 95700, 95711–95713, 95714–95718, 95720, 95722, 95724, 95726 and related inpatient EEG/video monitoring codes.

Outpatient/ambulatory EEG: prior authorization not required in many outpatient settings
Inpatient video EEG / prolonged inpatient seizure monitoring: prior authorization required
Representative codes: 95700, 95711–95713, 95714–95718, 95720, 95722, 95724, 95726

Note

Chemotherapy and related injectables (no prior authorization list)

Many chemotherapy-related injectable drugs are listed in the policy materials as not requiring prior authorization when billed with specified codes or under specified conditions. The policy contains an extensive list of J-, Q-, and miscellaneous HCPCS codes that are handled per the drug list; check the Provider Portal or drug-specific guidance for the most current list. Note exceptions: some codes (e.g., J0897) may require authorization when used for non-oncology diagnoses and unclassified codes may be product-specific.

Extensive list of J- and Q-codes (e.g., J0174, J1306, J2778, J1551, J0178, J0177, etc.) included in the policy as managed without prior authorization under certain conditions
Check Portal for Review at Launch and up-to-date lists
Exceptions: J0897 requires authorization for non-oncology use; unclassified codes (C9399/J3490/J3590) may require authorization for specific products

Prior Authorization

Cosmetic and reconstructive procedures

Cosmetic and reconstructive procedures have defined prior-authorization requirements. Reconstructive procedures that treat or restore physiologic function are generally medically indicated but still may require prior authorization. Cosmetic procedures that change or improve appearance without significant improvement in physiological function require prior authorization. Representative CPT codes (not exhaustive) include 11960, 14020–14021, 14041, 14060–14061, 14301, 15820–15830, 15847, 15877–15879, 17106–17108, 17999, 21137–21139, 21172, 21175–21184, 21230, 21235, 21256, 21275, 21280, 21282, 21295, 21740–21743, 28344, 30620, 67900–67922, 67924, 67950, 67961, 67966, Q2026 and related codes.

Prior authorization required for cosmetic procedures that primarily affect appearance
Reconstructive procedures that restore physiologic function may still need prior authorization
Representative codes (examples): 11960, 14020–14021, 15820–15830, 21137–21139, 21230, 21235, 67900–67922

Prior Authorization

DME / HCPCS codes and special prior-authorization notes

Durable medical equipment (DME) and HCPCS codes include special prior-authorization rules. Prior authorization is required only for DME codes listed with a retail purchase or cumulative rental cost greater than $500. Prosthetics are not billed as DME and follow prosthetic-specific rules. Examples of DME/HCPCS codes requiring review include A9279, A9280, E0194, E0265–E0277, E0300, E0328–E0329, E0445, E0457, E0460, E0465 and select L-codes noted below. Incontinence supplies are a benefit when provided per plan rules; to request incontinence supplies call Medline at 877-816-5587.

Prior authorization required for DME with retail purchase or cumulative rental cost > $500
Examples of DME codes requiring review: A9279, A9280, E0194, E0265–E0277, E0300, E0328–E0329, E0445
Prosthetics follow separate authorization rules (not DME)
Incontinence supplies: request via Medline 877-816-5587

Prior Authorization

Enteral services prior authorization

Enteral and in-home nutritional therapy (enteral services) require prior authorization. Common HCPCS codes for enteral formula, supplies and feeding-related items include B4034–B4036, B4100, B4102–B4104, B4149, B4150, B4152–B4155, B4158–B4161 and related gastrostomy tube supply codes. Submit prior authorization requests using the Provider Portal or by phone.

Enteral formula and supply codes: B4034–B4036, B4100, B4102–B4104, B4149
Enteral therapy and feeding supplies: B4150, B4152–B4155, B4158–B4161
Prior authorization required for enteral services and in-home nutritional therapy

Prior Authorization

Injectable medications prior authorization

Injectable medications (non-chemotherapy biologics and specialty injectables) require prior authorization. The policy lists many specific products and corresponding HCPCS/J-codes that are managed via prior authorization (examples include Actemra J3262, Acthar J0801, Adakveo J0791, Aduhelm J0172, Amvuttra J0225, Avsola Q5121, Benlysta J0490, Beovu J0179, Cinryze J0598, Cosentyx IV J3247, Crysvita J0584, Cutaquig J1551, IvIG codes J1555/J1561/J1572, Lucentis J2778, Ocrevus J2350, and many others). Check the Provider Portal for the complete and current injectable medication prior-authorization list and for guidance on unclassified codes.

Prior authorization required for many specialty injectable medications and biologics
Example products/codes: Actemra J3262; Acthar J0801; Adakveo J0791; Aduhelm J0172; Avsola Q5121; Cinryze J0598; Cutaquig J1551; Lucentis J2778; Ocrevus J2350; IVIG J1555/J1561/J1572
Unclassified/temporary codes: verify product-specific requirements on the Portal

Prior Authorization

Orthotics / prosthetics L-code exceptions (partial)

Orthotics and prosthetics include numerous L-codes. Prior authorization is required for orthotics and prosthetic codes with a retail purchase or cumulative rental cost over $500. The policy lists many L-code exceptions where prior authorization is not required (partial list includes L0112, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631–L0638, L0710, L0810–L0830, L0859, L1005, L1200, L1300, L1310, L1499, L1680, L1685, L1700, L5610, L5613, L5614, L5616, L5639, L5640, L5642–L5653, L5661, L5673, L5682–L5683, L8042–L8047, L8499, L8610, L8612, L8631, L8659, L8614, L8619, L8690–L8692). Consult the policy for the full L-code lists and conditions.

Prior authorization required if retail purchase or cumulative rental cost > $500
Partial list of L-code exceptions (no prior authorization): L0112, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631–L0638, L0710, L0810–L0830, L0859, L1005, L1200, L1300, L1310, L1499, L1680, L1685, L1700, L5610–L5616, L5639–L5683, L8042–L8047, L8499, L8610–L8631, L8659
Refer to full policy L-code listings for completeness

Prior Authorization

Private duty nursing and potentially unproven services

Private duty nursing requires prior authorization (examples include T1002, T1003). Potentially unproven services require prior authorization and include specified CPT/HCPCS codes (example: 33289, C2624). Always check the policy for the full list of codes and any plan-specific limits.

Private duty nursing codes: T1002, T1003 (prior authorization required)
Potentially unproven services example codes: 33289, C2624 (prior authorization required)
Verify program limits and criteria on the Provider Portal

Prior Authorization

Proton beam, prostate procedures, transplants / CAR T-cell

Proton beam therapy, selected prostate procedures, and transplant/CAR T-cell therapies require prior authorization. Proton beam therapy CPT/HCPCS examples: 77520, 77522, 77523, 77525. Prostate procedure codes requiring authorization include 37243, 52441, 52442, 53850, 53852, 55873, 55874. For organ transplants and CAR T-cell therapies (for example Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Tecelra, Yescarta), call the UnitedHealthcare Community and State Transplant Case Management team at 888-936-7246 or use the notification number on the member's ID card; note that SHOTT (State of Hawaii Organ and Tissue Transplant) program carve-outs may apply.

Proton beam therapy codes: 77520, 77522, 77523, 77525
Prostate procedures: 37243, 52441, 52442, 53850, 53852, 55873, 55874
Transplant / CAR T-cell services: contact Transplant Case Management at 888-936-7246; SHOTT program carve-outs may apply

Prior Authorization

Vein procedures prior authorization

Vein procedures (removal and ablation of main trunks and named branches of the saphenous veins) require prior authorization. Representative CPT codes include 36473, 36475, 36478, 37700, 37718, 37722, 37765, 37766 and related venous intervention codes.

Prior authorization required for saphenous vein removal/ablation and related procedures
Representative codes: 36473, 36475, 36478, 37700, 37718, 37722, 37765, 37766

Prior Authorization

Vision services prior authorization and age-based exceptions

Vision services have age-based prior-authorization rules. Prior authorization is required for many vision-related HCPCS/V-codes for members under specified ages. Some vision services are not subject to prior authorization for members 40 years of age or older; however, prior authorization is required for members ages 21 and older for other specified codes. Representative codes listed in the policy include S0500, S0580 and numerous V-codes (V2201–V2783 series). Confirm member age and specific code requirements when submitting requests.

Vision prior-authorization rules vary by member age and code
Some V-codes not required for members ≥ 40 years; other vision codes require prior authorization for members ≥ 21 years
Representative codes: S0500, S0580 and V2201–V2783 (verify specific code/age rules on the Portal)

Prior Authorization

Wound VAC prior authorization

Wound VAC (negative pressure wound therapy) requires prior authorization. Common HCPCS codes include E2402. Submit clinical documentation and details of prior wound therapy when requesting authorization.

Wound VAC HCPCS example: E2402
Prior authorization required — include relevant clinical documentation and prior wound-care history

Authorization stancePrior authorization required for cochlear and other auditory implants as noted in the document

Continuous

DefinitionContinuous (home medical supplies): ongoing supplies/equipment provided on a continuous basis (examples: HCPCS A4226, A4239, A9276, A9277)

Authorization noteContinuous supplies are listed with 'Prior authorization required' in the document

Coding examplesA4226, A4239, A9276, A9277 listed as continuous supply codes

DME prior authorization threshold

RuleDME codes with a retail purchase or cumulative rental cost over $500 require prior authorization

ScopeApplies to DME/HCPCS items specifically flagged with purchase or rental cost information in the listing

Common examplesEquipment codes referenced include A9279, A9280, E0194, E0265, E0266, E0270, E0277

Incontinence supplies provision

ProvisionIncontinence supplies are a benefit only when provided through the vendor-managed program

Vendor contactTo request incontinence supplies, call Medline at 877-816-5587

Authorization noteIncontinence supply entries indicate benefit provision and vendor coordination rather than standard PA submission

Home- and Community-Based Services

DefinitionHome- and Community-Based Services: outpatient/home-based services (environmental modifications, home-delivered meals, home health nursing, personal care, PERS, etc.)

Prior authorizationPrior authorization required only in outpatient settings, including the patient’s home; request via Provider Portal or phone

Example codesRepresentative codes include G0151, G0152, G0153, G0155 and home health codes G0156, G0160, G0493

Genetic and molecular testing prior authorization/notification

Program definitionGenetic and molecular testing prior authorization/notification: testing (including BRCA) requires prior authorization or notification under the Authorization/Notification Program

Required actionsOrdering provider must notify UnitedHealthcare; laboratories will also be required to notify per program procedures

Example codesListed CPT/HCPCS codes include 81162, 81229, 81401, 81277, 81405, 81410 and multiple proprietary 'U' and 'M' codes noted for notification

Unclassified and temporary codes

Unclassified/temporary codes ruleUnclassified and temporary codes C9399, J3490 and J3590 require prior authorization only for specified products (example: Nulibry and Rivfloza)

ActionCheck specific product-level guidance to determine whether PA applies when these codes are used

Related policy noteReview at Launch for new-to-market medications is recommended; pre-determination advised for drugs on that list

J0897 special rule

Special ruleFor HCPCS code J0897, prior authorization is required when billed for a non-oncology diagnosis

ContextJ0897 may be treated differently when used for oncology indications — see code-specific guidance

Provider actionConfirm diagnosis coding when submitting PA for J0897 to determine PA requirement

SHOTT program

SHOTT carve-outOrgan transplants are a carve-out benefit under the State of Hawaii Organ and Tissue Transplant (SHOTT) program and are not covered by the Hawaii Medicaid QUEST Integration plan

Payer roleUnitedHealthcare Community Plan of Hawaii manages the referral process to SHOTT for organ transplants

ImplicationTransplant clinical and authorization routing follows SHOTT program rules; contact UnitedHealthcare for referral coordination

Proton beam therapy

DefinitionProton beam therapy: focused radiation therapy using beams of protons

Authorization stanceProton beam therapy requires prior authorization (example CPT codes: 77520, 77522, 77523)

Clinical noteThis therapy is listed with specific PA requirements given its specialized nature

UnitedHealthcare Community and State Transplant Case Management

Program contactUnitedHealthcare Community and State Transplant Case Management: call 888-936-7246 for transplant and CAR T-cell therapy prior authorization/notification

ScopeHandles prior authorization/notification for transplant and CAR T-cell therapies (listed products included) and referral coordination

Alternate contactProviders may also use the notification number on the back of the member’s health plan ID card

Prior authorization — miscellaneous notes

Misc PA notesPrior authorization is indicated for vein procedures, specified vision services (age-based rules), and wound VAC therapy (E2402)

Vision servicesPrior authorization required for many V- and S-codes; some vision services are not required for members 40+ while others require PA for members 21+

Wound VACWound VAC therapy (E2402) requires prior authorization