CurrentUnitedHealthcarePolicy N/A

Prior Authorization Requirements — UnitedHealthcare Community Plan of Louisiana

Lists services, CPT/HCPCS codes, and submission instructions for prior authorization for participating UnitedHealthcare Community Plan of Louisiana providers; affects in-network providers and notes out-of-network requirements and emergency exceptions.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Requirements — UnitedHealthcare Community Plan of Louisiana

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 877-842-3210.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>100distinct services / code entries listed for prior authorization

~200+codes requiring prior authorization (approx)

1primary phone number for prior authorization

888-936-7246transplant/CAR T notification contact

855-282-8929VAD prior authorization contact (fax)

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$500DME retail/rental threshold

Coverage and Prior Authorization Requirements

Coverage criteria and routing notes

Prior authorization is required for the listed services and codes; emergency and urgent care are exceptions.

Prior authorization is required for the services and codes listed in this document unless the service is emergency or urgent care.

Out-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services, excluding emergent or urgent care.

Submit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 877-842-3210.

For outpatient injectable chemotherapy drugs, submit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-397-8129.

Colony-stimulating factors and certain oncology supportive agents (listed J/Q codes) require prior authorization; some listed codes also require authorization for non-oncology diagnoses.

Prior authorization required — enumerated services

Services and codes in this excerpt that explicitly require prior authorization include:

Examples of DME and enteral services

Enteral services (in-home nutritional therapy, including gastrostomy tube products and supplies) — prior authorization required (examples: B4034, B4100, B4102, B4150, B4158, etc.).
Durable medical equipment (DME) codes listed — may require prior authorization; some items may be exempt from the $500 retail/cumulative rental threshold.

Surgical and procedure examples

Functional endoscopic sinus surgery (FESS) — prior authorization required (examples: 31240, 31253–31259, 31267, 31276, 31287, 31288).
Femoroacetabular impingement syndrome (FAI) procedures — prior authorization required (examples: 29914–29916).

Prior authorization requirements (selected services)

Services listed below are identified as requiring prior authorization where noted.

Musculoskeletal and related procedures

Joint replacement (total hip and knee and related procedures) — prior authorization required (multiple CPT codes listed).
Orthognathic surgery / maxillofacial procedures — prior authorization required (multiple CPT codes listed).

Pediatric and personal care services

Pediatric day services — prior authorization required (examples: T2002, T1025, T1026).
Personal care services — prior authorization required (example: T1019).

Air ambulance and related transport

VAD coverage

Ventricular assist devices (VAD):

VAD devices and supplies are not covered.

For VAD prior authorization/notification, call the notification number on the back of the member's health plan ID card and fax the form provided by the nurse to the Optum VAD Case Management Team at 855-282-8929.

Example CPT/HCPCS device-related procedure codes are listed (examples include 33975, 33976, 33979, 33981, 33982, 33983) and require the notification process above.

Transplant/CAR T authorization

Transplant and CAR T-cell therapy:

Prior authorization/notification is required for transplant and CAR T-cell therapy services (including specified CAR T products).

Call the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or the notification number on the back of the member's health plan ID card for prior authorization/notification.

Some gene therapies and specified products (e.g., Amtagvi, Lantidra, Ryoncil, Skysona and certain HCPCS/J‑codes) require prior authorization through Optum Transplant per the document notes.

Imaging authorization

Advanced outpatient imaging and PET scans:

Prior authorization is required for advanced outpatient imaging including certain CT, MRI, MRA, nuclear medicine and nuclear cardiology procedures and PET scans.

Submit prior authorization requests for radiology/advanced imaging online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-889-8054.

PET scan CPT/HCPCS examples listed include 78608, 78609, 78811–78816 and associated A‑codes; confirm specific CPT/HCPCS codes in the radiology section when submitting a request.

CPT / HCPCS Code Listings and Coding Rules

Colony-stimulating factors / supportive oncology injectablesHCPCSCovered

J1442	Filgrastim (Neupogen) - prior authorization required
Q5110	Filgrastim-ayow (Releuko) - prior authorization required
Q5125	Filgrastim-sndz (Zarxio) - prior authorization required
Q5101	Pegfilgrastim (Neulasta) - prior authorization required
J2506	Pegfilgrastim-apgf (Nyvepria) - prior authorization required
J1447	Tbo-filgrastim (Granix) - prior authorization required
J1449	Colony stimulating factors - prior authorization required

Continuous glucose monitorsHCPCS

A4238	Continuous glucose monitor - prior authorization required
A4239	Continuous glucose monitor - prior authorization required
A9274	Continuous glucose monitor - prior authorization required
A9276	Continuous glucose monitor - prior authorization required

Cosmetic, reconstructive, and breast reconstruction codesCPTCovered

11960	Cosmetic/reconstructive service - prior authorization required
15820	Cosmetic/reconstructive service - prior authorization required
19340	Breast reconstruction (non-mastectomy) - prior authorization required
19342	Breast reconstruction - prior authorization required

Cochlear implants / auditory implantsmixedCovered

69714	Cochlear implant procedure code listed
69930	Cochlear implant - prior authorization required
L8691	Cochlear implant device HCPCS

Selected surgical codes requiring prior authorizationCPTCovered

59830	Abortion procedure code - prior authorization required
59850	Abortion procedure code - prior authorization required
43644	Bariatric surgery code - prior authorization required

DME K-codes (examples)HCPCS

K0868	Durable medical equipment (DME) prior auth code listed
K0869	Durable medical equipment (DME) prior auth code listed
K0870	Durable medical equipment (DME) prior auth code listed

Enteral services (examples)HCPCSCovered

B4034	Enteral nutrition product code (prior authorization required)
B4100	Enteral service code (prior authorization required)
B4150	Enteral product/service code (prior authorization required)

Injectable medications (selected examples)mixedCovered

J0172	Aduhelm (injectable) — prior authorization noted
J0801	Acthar (injectable) — prior authorization noted
J0597	Botulinum toxins (example codes J0585/J0586/J0587 listed)

Joint replacement CPT examplesCPTCovered

27130	Total hip replacement (example code listed)
27447	Total knee replacement (example code listed)

Air ambulanceHCPCSCovered

A0430	Non-emergent air ambulance transport
A0435	Non-emergent air ambulance transport

Joint replacement codes (selection)CPT

27130	Total hip arthroplasty
27132	Revision hip arthroplasty (example code listed)

Orthotics/Prosthetics HCPCS L-codes (selection)HCPCS

L0170	Orthotic/prosthetic supply (example L-code)
L5780	Orthotic/prosthetic supply (example L-code toward end of list)

Radiation/proton therapy codes (selection)CPT

77520	Proton beam therapy
77014	Radiation therapy imaging

Selected CPT/HCPCS codes listed in this sectionmixedCovered

30400	Rhinoplasty
30410	Rhinoplasty
31295	Sinuplasty
21685	Sleep apnea procedure/surgery
Q4101	Skin substitute
Q4160	Skin substitute

Spinal surgery code examplesCPTCovered

63001	Spinal surgery CPT examples
63005	Spinal surgery CPT examples
63250	Spinal surgery CPT examples

$500 retail/cumulative rental threshold — PA required when retail purchase or cumulative rental >= $500

Threshold rulePrior authorization is required only for the DME codes listed when the retail purchase or cumulative rental cost meets or exceeds $500.

Applies toDurable medical equipment codes explicitly listed in the DME sections (examples: E2630, E8000, K0005, K0108, K0830).

Submission noteIf a DME item meets the $500 retail/cumulative rental threshold, submit prior authorization via the Provider Portal or the phone numbers listed in the policy.

How to Submit Prior Authorization Requests and Provider Routing

Prior Authorization

Prior authorization submission instructions

For prior authorization, submit requests using the UnitedHealthcare Prior Authorization and Notification tool on the Provider Portal or by phone. To access the portal, go to UHCprovider.com and click Sign In (One Healthcare ID). On the Provider Portal dashboard select the Prior Authorization and Notification tile. If you need a One Healthcare ID, visit UHCprovider.com/access. Phone submission options: general prior authorization call 877-842-3210; chemotherapy and injectable medication inquiries call 888-397-8129; radiology/advanced imaging call 866-889-8054. 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.

Online: UHCprovider.com > Sign In (One Healthcare ID) > Prior Authorization and Notification tile
Phone: General PA — 877-842-3210
Chemotherapy / many injectable drugs — 888-397-8129
Radiology / advanced outpatient imaging — 866-889-8054

Prior Authorization

Behavioral health prior authorization routing

Definitions and Benefit Routing Notes

Definition of Prior Authorization — process and emergency/urgent care exceptions

DefinitionPrior authorization is the process of obtaining approval from UnitedHealthcare before providing certain services.

Emergency/urgent carePrior authorization is NOT required for emergency or urgent care services.

Out-of-network providersOut-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services, excluding emergent or urgent care.

Pharmacy benefit redirection — some CGMs and DME may be covered under pharmacy (Prime Therapeutics/PDL)

Pharmacy redirection noteCertain continuous glucose monitors and some DME items may be covered under pharmacy benefits and should be redirected to Prime Therapeutics/PDL when indicated.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Requirements — UnitedHealthcare Community Plan of Louisiana

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 877-842-3210.

SourceLink

On This Page

Selected surgical procedures such as abortion and bariatric surgery list prior authorization (examples: 59830, 59850, 43644, 43645, 43659, 43770).

Medications and injectables

Injectable medications — prior authorization required (numerous J‑codes listed including J0801 Acthar, J3262 Actemra, and many specialty injectable J/Q codes).

Other services

Home health services (including extended nursing/PDN) — prior authorization required only in outpatient settings, including the member's home (examples: G0299, T1000, G0300, S9123, S9124).
Non-emergent air ambulance transport — prior authorization required (A0430, A0435).

Orthotics/Prosthetics and threshold note

Orthotics and prosthetics — prior authorization required only for retail purchase or cumulative rental cost exceeding the $500 threshold (examples: L0170, L0464, L0482, L8042, L8499, etc.).

Radiation and proton therapy

Proton beam therapy and radiation therapy — prior authorization required (proton examples: 77520, 77522, 77523, 77525; radiation examples: 77014, 77331, 77370–77373, 77385–77387, 77399, 77401, 77402, 77407, 77412).

Non-emergent air ambulance transport — prior authorization required (A0430, A0435).

Proton and radiation therapy

Proton beam therapy — prior authorization required (77520, 77522, 77523, 77525).
Radiation therapy — prior authorization required (multiple CPT codes listed, see radiation therapy section).

Orthotics/prosthetics

Orthotics and prosthetics — prior authorization required only if retail purchase or cumulative rental cost exceeds $500 (extensive HCPCS L‑codes listed).

Sinonasal procedures

Sinuplasty and rhinoplasty-related procedures — prior authorization required (examples: 31295–31297 for sinuplasty; 30400, 30410, 30420, 30430, 30435, 30450, 30460 for rhinoplasty/septal procedures).

$500 retail purchase / cumulative rental threshold — note that some DME may qualify but are not subject to the threshold

Exception noteSome DME codes may qualify but are not subject to the $500 retail purchase or cumulative rental cost threshold — these codes are identified in the DME lists.

Examples referencedMultiple K-codes (e.g., K0868, K0869, K0870, etc.) are listed with the annotation that they may qualify but are not subject to the $500 threshold.

Action for providersCheck the specific DME code entry in this guide to determine whether the $500 threshold applies before submitting PA requests.

Orthotics/Prosthetics prior authorization threshold — retail purchase or cumulative rental cost > $500 requires PA

Orthotics/Prosthetics PA triggerPrior authorization is required for orthotic and prosthetic items when the retail purchase or cumulative rental cost is more than $500.

ScopeApplies to HCPCS L-codes listed in the orthotics/prosthetics section (examples include L0484, L0486, L0631, L0700, L0710, etc.).

Provider actionSubmit PA via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or the phone numbers in the policy when cost exceeds $500.

Many UnitedHealthcare Community Plan benefits route behavioral health services through a designated behavioral health network. For referrals for mental health and substance use services, call the number on the member's health plan ID card. For ABA therapy prior authorization requests, submit via fax or Provider Express per the member's plan routing instructions.

Behavioral health network — call number on member ID card
ABA therapy — submit via fax or Provider Express

Prior Authorization

Home health prior authorization

Home health and extended nursing services (including personal care/PDN) require prior authorization when delivered in outpatient settings including the member's home. Use the Provider Portal Prior Authorization and Notification tool or call the number on the member's ID card for plan-specific routing.

PA required for home health and extended nursing services when provided in the home
Representative HCPCS/Codes: G0299, T1000, G0300, S9123, S9124

Prior Authorization

Joint replacement (hip/knee) prior authorization

Total joint (hip and knee) replacement procedures require prior authorization. Submit requests via the Provider Portal Prior Authorization and Notification tool or call the general prior authorization number. Include relevant operative codes and clinical documentation to support medical necessity.

Examples of associated CPT codes (not exhaustive): 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27412, 27446, 27447, 27486, 27487

Prior Authorization

Radiology / Advanced Imaging prior authorization

Certain outpatient advanced imaging and radiology procedures require prior authorization, including specified CT, MRI, MRA, nuclear medicine, nuclear cardiology and PET scans. Submit radiology PA requests using the Provider Portal Prior Authorization and Notification tool or call 866-889-8054. For PET scans, PA is required for codes such as 78608, 78609, 78811–78816 and associated HCPCS A9515, A9526, A9552, A9580, A9587.

Submit via Provider Portal Prior Authorization and Notification tile or call 866-889-8054
PET scan codes (examples): 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816; HCPCS: A9515, A9526, A9552, A9580, A9587

Prior Authorization

Miscellaneous services prior authorization

Miscellaneous services such as pediatric day services, personal care services, proton beam therapy, radiation therapy, skin substitutes and select DME/orthotics/prosthetics have specific prior authorization requirements. Use the Provider Portal Prior Authorization and Notification tool or the phone number on the member's ID card for plan-specific routing. Verify applicable CPT/HCPCS codes and thresholds (for example, orthotics/prosthetics generally require PA when retail purchase or cumulative rental cost exceeds $500).

Pediatric day services — PA required. Example codes: T2002, T1025, T1026
Personal care services — PA required. Example code: T1019
Proton beam therapy — PA required. Example codes: 77520, 77522, 77523, 77525
Radiation therapy — PA required. Example codes: 77014, 77331, 77370–77373, 77385–77387, 77399, 77401–77412
Orthotics & prosthetics — PA required when retail purchase or cumulative rental > $500; examples: L0170, L0464, L0482, L0484, L0631

The continuous glucose monitor entries (A4238, A4239, A9274, A9276) include a note to check the PDL to determine pharmacy coverage and redirection.

Effect on medical PAItems reimbursable as pharmacy may deny if billed as medical DME; verify benefit routing before submitting medical PA.

Prior authorization required — submission process via Provider Portal or phone

How to submitSubmit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call the applicable phone numbers listed in the policy (examples: 877-842-3210; 888-397-8129).

Alternate phone contactsChemotherapy/outpatient injectable PA requests can be submitted via phone at 888-397-8129 as noted in the injectable medications section.

Portal accessAccess the Provider Portal via UHCprovider.com with a One Healthcare ID; instructions are provided in the general information section.

Enteral services — definition of in-home nutritional therapy (enteral/gastrostomy)

DefinitionEnteral services = in‑home nutritional therapy, either enteral or through a gastrostomy tube.

PA requirementEnteral services (B4034, B4035, B4036, B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4155, B4158, B4159, etc.) — Prior authorization required.

Scope for providersIncludes enteral nutrition products and supplies used for in‑home nutritional therapy; submit PA via the Provider Portal or phone as directed.

Proton beam therapy — definition/description

DefinitionProton beam therapy = focused radiation therapy using beams of protons (tiny particles with a positive charge).

PA requirementProton beam therapy CPT codes (e.g., 77522, 77523, 77525) — Prior authorization required.

ContextProton beam therapy entries include the focused radiation therapy description alongside the PA instruction.

Ventricular assist device (VAD) — definition of VAD

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

Notification/PA processFor VADs, call the notification number on the member's health plan ID card and fax the form provided by the nurse to the Optum VAD Case Management Team at 855-282-8929.

Coverage noteVAD device and supplies are not covered.

Proton beam therapy — duplicate/descriptive entry (focused radiation therapy)

Definition (duplicate)Proton beam therapy = focused radiation therapy using beams of protons.

Associated CPTsCPT codes listed for proton therapy include 77522, 77523, 77525; entries pair the definition with prior authorization instructions.

Clinical noteDescribed as focused radiation using positively charged proton particles; used where indicated in radiation therapy section.