Prior authorization requirements for Kansas Medicaid
Lists services, codes, and submission methods that require prior authorization for UnitedHealthcare Community Plan of Kansas participating providers; applies to inpatient and outpatient services for Kansas Medicaid members.
Policy Summary
PayerUnitedHealthcare
PolicyPrior authorization requirements for Kansas Medicaid
Policy CodePolicy N/A
Change TypeNo material change
Effective DateJun 1, 2024
Next Review DateN/A
Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 866-604-3267 (PCN: 833-802-6427).
No material clinical or coverage changes in this revision.
online, phone, faxsubmission methods for prior authorization
1primary online tool for prior authorization
PA requiredcommon requirement text repeated for many services
$500DME prior authorization threshold
skin cancerexplicit exception
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Coverage Criteria and Requirements
Cancer supportive care PA criteria
Covered when ALL of the following are met:
Member has a diagnosis of cancer (outpatient setting).
Prior authorization required for colony-stimulating factor drugs and bone-modifying agents administered in an outpatient setting for a cancer diagnosis.
Requested medication is a colony-stimulating factor or bone-modifying agent listed in policy (examples below).
See listed HCPCS/J-codes in next node; these codes also require prior authorization when billed for non-oncology diagnoses.
Prior authorization request submitted via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or other channels as specified by payer.
See submission instructions in policy.
Examples of agents that require prior authorization
Prior authorization required for outpatient-administered injectable chemotherapy; submission and exceptions:
Requested drug is an outpatient injectable chemotherapy agent (includes intravenous, intravesical, intrathecal and other injectable routes).
Prior authorization required for injectable chemotherapy drugs administered in an outpatient setting.
Applies to drugs billed with J-codes in the J9000-J9999 series, specific J-codes listed in policy (e.g., J0640, J0641, J0642, J1950), drugs with Q-codes, and agents billed under miscellaneous HCPCS when no assigned code exists.
Prior authorization requests must be submitted using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (sign in with One Healthcare ID).
See policy for portal navigation and other submission channels.
Exception: Items billed with skin cancer diagnoses will NOT require prior authorization as noted in the policy.
Prior authorization criteria (partial, by service)
Prior authorization requirements and notes for selected service categories and codes:
Experimental and investigational procedures/services — prior authorization required when noted.
Policy lists specific example codes and links experimental/investigational status to PA requirement.
Functional endoscopic sinus surgery (FESS) — CPT codes include 31240, 31253-31259, 31276-31288 (and related codes); prior authorization required.
Genetic and molecular testing (including BRCA) performed in outpatient settings — prior authorization required and the ordering provider must notify the laboratory before sequencing.
Durable medical equipment (listed HCPCS codes) — prior authorization required when retail purchase or cumulative rental cost exceeds $500; prosthetics are not included under this DME rule.
Prior authorization requirements for listed injectables and select services
The following injectable medications and select services require prior authorization when billed under the medical benefit:
Examples of injectable medications requiring prior authorization
Adynovate — J7207
Akynzeo — J1454
Bortezomib (Velcade) — J9041
Cyramza — J9308
Darzalex — J9145
Service-specific authorization & coverage notes
Coverage notes and authorization stance for selected services:
Personal care services (mapped from L-codes such as L8045, L8609) — prior authorization required.
Positron emission tomography (PET) scans — not a covered benefit unless medically necessary and prior authorization is obtained; representative CPT codes include 78459, 78609, 78814, 78491, 78811, 78815, 78492, 78812, 78608, 78813.
Prostate procedures — prior authorization required for listed CPT codes (examples include 37243, 53852, 52441, 55873, 52442, 55874, 53850).
Coverage stance: covered with prior authorization/notification
Services that require prior authorization and/or case management notification:
Personal care services — prior authorization required; see L-code mappings and T1019 mapping in policy.
PET scans — prior authorization required when medically necessary; not covered otherwise. Representative CPT/HCPCS include 78459, 78491, 78492, 78609, 78811, 78812, 78813, 78814, 78815.
Transplant and CAR-T cell therapies (examples: Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta) — contact UnitedHealthcare Community & State Transplant Case Management at 888-936-7246 or the notification number on the member's ID prior to services (notification and prior authorization required).
Ventricular assist devices (VAD) — prior authorization required; call the notification number on the back of the member's health plan ID and fax the Optum VAD Case Management form to 855-282-8929. Representative CPT/HCPCS include 33927-33929, 33975 and related device codes.
Codes and Mappings (CPT, HCPCS, ICD-10, L-Codes)
Bariatric surgery codesCPTCovered
43644
Bariatric surgery CPT code listed requiring prior authorization
43645
Bariatric surgery CPT code listed requiring prior authorization
43659
Bariatric surgery CPT code listed requiring prior authorization
43770
Bariatric surgery CPT code listed requiring prior authorization
43775
Bariatric/obesity-related service CPT code listed
43842
Bariatric/obesity-related service CPT code listed
43845
Bariatric/obesity-related service CPT code listed
Bone growth stimulator codesCPTCovered
20975
Bone growth stimulator CPT/HCPCS code
20979
Bone growth stimulator CPT/HCPCS code
BRCA/genetic testing codesCPTCovered
81162
BRCA testing CPT code
81163
BRCA testing CPT code
81164
BRCA testing CPT code
81165
BRCA testing CPT code
81166
BRCA testing CPT code
81212
BRCA/genetic testing CPT code
81432
BRCA/genetic testing CPT code
81433
BRCA/genetic testing CPT code
Breast reconstruction codesmixedCovered
11971
Breast reconstruction (non-mastectomy) code
19316
Breast reconstruction code
19318
Breast reconstruction code
19325
Breast reconstruction code
19328
Breast reconstruction code
19330
Breast reconstruction code
19340
Breast reconstruction code
19342
Breast reconstruction code
19350
Breast reconstruction code
19357
Breast reconstruction code
1–10 of 20
1/2
Oncology injectables (CSFs and bone-modifying agents)HCPCSCovered
Q5101
Zarxio (biosimilar) HCPCS code - requires PA
J1442
Filgrastim (Neupogen) J-code - requires PA
Q5110
Filgrastim-aafi (Nivestym) HCPCS code - requires PA
Q5122
Pegfilgrastim-apgf (Nyvepria) HCPCS code - requires PA
J2506
Pegfilgrastim (Neulasta) J-code - requires PA
Q5120
Pegfilgrastim-bmez (Ziextenzo) HCPCS code - requires PA
Q5108
Pegfilgrastim-jmdb (Fulphila) HCPCS code - requires PA
Extensive spinal and related surgery CPT ranges listed
CAR-T and unclassified drug codesCPT | HCPCS | mixedCovered
0537T-0540T, J9999, Q2041-Q2056
CAR-T and associated drug/procedure codes; unclassified codes (J3490/J3590/C9399) require PA for specific agents
Cancer diagnosis requirement — CSFs and bone-modifying agents
RequirementPrior authorization is required for colony-stimulating factor (CSF) drugs and certain bone-modifying agents when administered in an outpatient setting for a cancer diagnosis.
ScopeApplies to CSFs and bone-modifying agents billed under the medical benefit for outpatient cancer treatment.
What Providers Must Do / How to Obtain Prior Authorization
Note
How to submit prior authorization requests
This list contains prior authorization requirements for participating UnitedHealthcare Community Plan of Kansas health care professionals providing inpatient and outpatient services. For prior authorization, submit requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com — Sign In with One Healthcare ID). You may also call 866-604-3267. Note: Prior authorization is not required for emergency or urgent care. Out-of-network providers must request prior authorization for all procedures and services except emergent or urgent care.
Prior Authorization
Services requiring prior authorization (examples)
The following is an illustrative (non‑exhaustive) list of services that require prior authorization when provided to UnitedHealthcare Community Plan members in an outpatient or inpatient setting. Providers should verify authorization requirements for each member and service before scheduling.
Applied behavior analysis (ABA) therapy (submit via fax or Provider Express)
DefinitionPrior authorization: A process requiring approval from UnitedHealthcare before certain procedures, services or items are provided to determine coverage eligibility.
Submission channelsRequests can be submitted online via the Prior Authorization and Notification tool, by phone, or where noted in the policy.
ExemptionPrior authorization is not required for emergency or urgent care.
Emergency or urgent care — definition
DefinitionEmergency or urgent care: Services for which prior authorization is not required under this policy (emergent or urgent situations are excluded from PA requirements).
ImplicationOut-of-network providers still must request PA for non-emergent services; emergent/urgent care remains exempt.
Policy Summary
PayerUnitedHealthcare
PolicyPrior authorization requirements for Kansas Medicaid
Policy CodePolicy N/A
Change TypeNo material change
Effective DateJun 1, 2024
Next Review DateN/A
Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 866-604-3267 (PCN: 833-802-6427).
Rental cost threshold textPolicy references a 'rental cost of more than $500' for certain L-code entries (cumulative rental cost triggering PA).
Affected entriesMultiple L-code mappings for CPT examples include notes that cumulative rental cost or rental cost of more than $500 requires prior authorization.
ActionSubmit PA when cumulative rental costs for the listed orthotic/prosthetic L-codes exceed $500.
Genetic and molecular testing including BRCA (e.g., 81162–81166, 81212, 81432–81433, 81228, 81277 and others)
Rhinoplasty for nasal functional treatment (30400–30462 variants)
Sinuplasty (31295–31298)
Sleep apnea procedures and surgeries (e.g., maxillomandibular advancement codes)
Spinal surgery (wide range of CPTs — authorization required, especially for members age 21 and older)
Stimulators and implantable neurostimulation devices (see implantable device and stimulator CPT/HCPCS lists)
Ventricular assist devices (VAD) and wound vac devices (authorization required)
Proton therapy (e.g., 77520–77525)
Positron emission tomography (PET) scans — see above
Other services that are experimental/investigational, FAI, FESS, and many device/implantable procedures
Prior Authorization
Cancer supportive care prior authorization requirement
Colony-stimulating factor (CSF) drugs and bone-modifying agents administered in an outpatient setting for a cancer diagnosis require prior authorization.
CSF and related injectable codes that require prior authorization include: J1442, J1447, J1448, J2506, J2820, J0897, Q5101, Q5108, Q5110, Q5120, Q5122, Q5125 (these codes may also require prior authorization for non-oncology diagnoses)
Bone‑modifying agent example requiring authorization: Denosumab (Xgeva® J0897*)
Antiemetic/supportive agents and other oncology‑related J‑codes may also be subject to predetermination or authorization requirements
Note
How to obtain prior authorization
Submit prior authorization requests for cancer supportive care drugs and other injectable medications using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com — Sign In with One Healthcare ID, then select the Prior Authorization and Notification tile). You may also call 888-397-8129 for assistance.
Prior authorization is required for outpatient injectable chemotherapy drugs (including intravenous, intravesical and intrathecal administrations) when billed in the outpatient setting.
Included drugs: chemotherapy injectable drugs billed in the J9000–J9999 range and agents with J‑codes (e.g., Leucovorin J0640; Levoleucovorin J0641/J0642; Lupron Depot J1950)
Also included: chemotherapy agents billed with Q‑codes, agents billed under miscellaneous/unassigned HCPCS (e.g., J9999, J3490, J3590, C9399 when applicable — certain unclassified codes require authorization for specified drugs)
For drugs newly approved by the FDA or listed on UnitedHealthcare's Review at Launch for New to Market Medications policy, predetermination is highly recommended (see Community Plan Medical Benefit Drug Policy)
Submit requests via the Prior Authorization and Notification tile on the Provider Portal or call 888-397-8129
Note
Exception — skin cancer diagnoses
Exception: Certain injectable chemotherapy items will NOT require prior authorization when billed with skin cancer diagnoses. Verify diagnosis coding when submitting claims; if the chemotherapy is billed with an appropriate skin cancer DX, prior authorization for those injectable items may be waived.
When applicable, document the skin cancer diagnosis on the claim so the exemption can be applied
Prior Authorization
Surgery and implantable devices prior authorization
Surgery and implantable devices frequently require prior authorization. Prior authorization is required for many procedure groups and specific CPT/HCPCS codes including, but not limited to: spinal surgery, implantable stimulators and neurostimulation devices, VAD implantation, and a broad set of listed surgical CPTs. Authorization requirements may vary by member age (for example, many spinal surgery and stimulator procedures explicitly require authorization for members age 21 and older).
Spinal surgery examples: CPTs in the 22100–22856, 22510–22633, 22800–22861, 22899 and extensive related code ranges — prior authorization required
Implantable neurostimulator/stimulator procedures and related HCPCS (e.g., E0747–E0760, L8680–L8688 and associated CPTs such as 61863–61868, 63650, 63655, 63685) require prior authorization
Bone growth stimulator implantation and related device codes require prior authorization
Ventricular assist devices (VADs): authorization and case management required — call the notification number on the member's ID card and fax required forms to Optum VAD Case Management at 855-282-8929
Transplants and CAR‑T therapies require authorization/notification through the UnitedHealthcare Community & State Transplant Case Management team at 888-936-7246
Reference noteSee submission instructions for standard PA channels when care is not emergent or urgent.
UHC Provider Portal — Prior Authorization and Notification tool
Tool namePrior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com)
Access stepsGo to UHCprovider.com, click Sign In and sign in with One Healthcare ID, then select the Prior Authorization and Notification tile on your dashboard.
AlternativePhone numbers for PA submission are provided in the policy for specific programs (see policy for exact numbers).
Prior Authorization and Notification tool — online submission mechanism
What it isAn online submission mechanism on UHCprovider.com used to request prior authorization for services listed in the policy.
How to find itAfter signing in with One Healthcare ID, select the Prior Authorization and Notification tile on your Provider Portal dashboard to submit requests.
When to usePrimary route for submitting PA requests for injectable chemotherapy, cancer supportive care agents, DME and other listed services.
Injectable chemotherapy drugs — definition
DefinitionInjectable chemotherapy drugs: Outpatient-administered injectable agents (including intravenous, intravesical, intrathecal where referenced) billed with J-codes, Q-codes, or miscellaneous HCPCS when no assigned code exists.
ExamplesJ9000-J9999 range and specific J- and Q-codes listed in the policy (see code tables).
Prior Authorization and Notification tool — One Healthcare ID access
Access requirementThe Prior Authorization and Notification tool is accessed via UHCprovider.com using a One Healthcare ID to submit prior authorization requests.
Portal stepsSign in at UHCprovider.com with One Healthcare ID, then select the Prior Authorization and Notification tile on the dashboard.
Use casesRequired for submitting PA for injectable chemotherapy, cancer supportive care agents, DME, and other services listed in the policy.
Durable Medical Equipment (DME) prior authorization — definition
DefinitionDME prior authorization: Prior authorization is required for listed DME codes when retail purchase or cumulative rental cost exceeds $500.
ExclusionProsthetics are not considered DME for this rule and are addressed separately.
Cost threshold$500 retail purchase or cumulative rental cost triggers PA requirement for the listed DME codes.
Genetic and molecular testing (BRCA) — PA applies to outpatient testing
ScopeBRCA and other genetic/molecular testing: Prior authorization is required when testing is performed in an outpatient setting.
Process requirementOrdering provider must notify the laboratory conducting the test; the laboratory will notify UnitedHealthcare before DNA sequencing is performed.
LimitationPrior authorization requirement applies only to outpatient settings per policy language.
Predetermination — advance review recommended
DefinitionPredetermination: An advance review recommended for drugs on the list to determine coverage and prior authorization requirements.
RecommendationPredetermination is highly recommended for listed drugs; check the Review at Launch policy for newly approved drugs.
Where to checkSee the Review at Launch for New to Market Medications - Community Plan Medical Benefit Drug Policy for updates.
Orthotics and prosthetics retail/rental cost threshold
ThresholdOrthotics and prosthetics require prior authorization when retail purchase or cumulative rental cost exceeds $500.
Rental languagePolicy text specifically references 'rental cost of more than $500' for some L-code entries as the trigger for PA.
Representative codesExamples include mappings such as 27486→L0112, 27487→L0170 and numerous L-code entries with rental/cost notes.
Orthotics and prosthetics — definition
DefinitionOrthotics and prosthetics: Medical devices and related supplies listed under L-codes and HCPCS; specific mappings and PA requirements are provided in the policy.
ExamplesL5535, L5540, L5560, L5570, L5580, L5585, L5590 shown as part of orthotics/prosthetics listings.
NoteSome orthotics/prosthetics entries include additional information and cost-based PA triggers.
Prior authorization — PET scans
RequirementPET scans are not a covered benefit unless medically necessary and prior authorization is obtained.
ActionObtain prior authorization for PET scans to establish medical necessity and coverage per policy.
VAD — ventricular assist device (definition and PA note)
DefinitionVentricular assist device (VAD): A mechanical pump that takes over the function of the damaged ventricle and restores normal blood flow.
PA requirementPrior authorization is required for VAD device and supplies; follow case management notification instructions in the policy.
Contact actionCall the notification number on the back of the member's health plan ID and fax required form to Optum VAD Case Management at 855-282-8929.
CAR-T cell therapy — definition and case management notification
DefinitionCAR-T cell therapy: Includes specified CAR-T products (e.g., Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta) and related codes; these services require case management notification and prior authorization.
ActionContact UnitedHealthcare Community & State Transplant Case Management at 888-936-7246 or the notification number on the member's ID prior to services.
Coding noteCAR-T related codes include 0537T-0540T and mappings to J9999/Q2041-Q2056 as applicable per policy.