CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Missouri Medicaid

Lists services, CPT/HCPCS/ICD codes, and instructions for requesting prior authorization for UnitedHealthcare Community Plan participating providers in Missouri; applies to inpatient and outpatient services and to participating physicians, ancillary providers, hospitals/facilities, and out-of-network providers except for emergency/urgent care.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Missouri Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 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 call 866-815-5334 (PCN: 877-347-9367).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-01-01policy effective date

866-815-5334general PA phone

866-889-8054cardiology PA phone

Largecode lists

Yesgenetic test codes listed

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.

Prior Authorization Coverage Criteria

Prior authorization coverage stance and exceptions

General prior authorization requirements, program-specific rules, and exceptions.

Participating physicians, health care professionals and ancillary care providers are responsible for obtaining prior authorization for services included on this list

Hospitals and facilities are responsible for providing admission notification per the Missouri Provider Manual

Prior authorization is not required for emergency or urgent care

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

Program-specific prior authorization examples

Cardiology: prior authorization required for outpatient and office-based diagnostic catheterizations, echocardiograms, electrophysiology implants and stress echoes prior to performance
Bariatric surgery and certain obesity-related services: prior authorization required (examples: CPT 43644, 43645, 43659, 43770, 43775, 43845, 43846, 43848, 43860)

For cardiology program prior authorization submission and program details, submit via the Prior Authorization and Notification tool or call the Cardiology program phone (866-889-8054)

Authorization requirements for specific services

Authorization requirements for specific services and conditional requirements where noted.

Cochlear implants and other auditory implants require prior authorization

Codes: 69714, 69930, L8614, L8619

Circumcision requires prior authorization only when performed for documented medical necessity

Codes: 54161, 54162, 54163, 54164

ICD-10 diagnosis codes referenced

Selected ICD-10 diagnosis codes referenced in the prior authorization list.

Example diagnosis codes included

S91.301A
S91.302A
S91.309A
M86.051
M86.052
M86.059

Prior authorization-required services (partial)

Services and specific codes in this section that explicitly require prior authorization.

In-home enteral nutritional therapy (enteral or gastrostomy tube) requires prior authorization

Codes: B9002, B9998

Functional endoscopic sinus surgery (FESS) requires prior authorization

Codes: 31237, 31240, 31253, 31254

Genetic and molecular testing requires prior authorization; laboratory testing and documentation may be required to complete the request

Representative codes: 81162, 81163, 81164, 81228, 81229, 81277, 81400–81437, 81460, 81465, 81518–81522, 81546

Services listed as Experimental and Investigational require prior authorization where noted

Representative codes: 33477, 36514, 64722, 65765, 65767, 66180, A6000, E0231

Prior authorization criteria (code-based)

Code-based prior authorization and notification criteria.

Notification/prior authorization is required for certain genetic tests (including BRCA) before DNA sequencing is performed; the ordering provider must notify the laboratory

Representative codes: 0006M, 0007M, 0060U, 0022U, 0023U, 0111U, 81546

Specified hysterectomy CPT codes require prior authorization

Representative codes: 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58290, 58291, 58292, 58542–58544

Non-emergent air ambulance transport requires prior authorization

Codes: A0430, A0431, A0435, A0436

Orthotics and prosthetics L-codes listed require prior authorization; notes apply for purchase vs rental and for items with retail cost > $500

Representative L-codes include L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486

Prior authorization required — examples

Examples of procedures and services requiring prior authorization.

Certain pain management injections require prior authorization

Examples: 64490, 64493

Proton beam therapy requires prior authorization

Codes: 77520, 77522, 77523, 77525

Selected outpatient surgical procedures (e.g., septoplasty, shoulder surgery, sinuplasty) indicate prior authorization is required

Representative codes appear in the surgical sections (see policy)

SOS: outpatient hospital prior authorization conditional

Site‑of‑service (SOS) rule for outpatient hospital settings.

Prior authorization is required only when the service is requested to be performed in an outpatient hospital setting

If the procedure is performed at a participating (non‑hospital) site of service, prior authorization is not required

Prior authorization required procedures (partial list)

Representative procedures and codes that require prior authorization (partial list).

Sleep apnea surgical procedures such as maxillomandibular advancement and oral‑pharyngeal tissue reduction require prior authorization

Codes: 21685, 41599, 42145

Attended and unattended sleep studies require prior authorization

Attended: 95805, 95807, 95808, 95810. Unattended: 95800, 95801, 95806

Spinal surgery procedures require prior authorization

Representative spinal codes include 22100, 22101, 22102, 22110, 22206–22214, 22532, 22600, 22850

Implantation of stimulators and related neurostimulation device procedures require prior authorization

Representative codes: 61864, 61868, 61885, 61886, 63650, 63655

Prior authorization criteria — services listed in this part

Prior authorization requirements and contact instructions for specific high‑acuity service groups.

Stimulator/implantation procedures require prior authorization

Representative codes: 61864, 61868, 61885, 61886, 63650, 63655

Transplant and CAR T‑cell therapy services require prior authorization and coordination with UnitedHealthcare Community and State Transplant Case Management

Call Transplant Case Management at 888-936-7246 or use the notification number on the member's ID card

Ventricular assist device (VAD) services require prior authorization and Optum VAD Case Management coordination

Call the notification number on the member's ID card and fax the nurse‑provided form to Optum VAD Case Management at 855-282-8929

Negative pressure wound therapy (wound vac) requires prior authorization

Code: E2402

CPT / HCPCS / ICD-10 Codes

Selected ICD-10 codes (arterial/vascular & related)ICD-10

I70.*	Atherosclerosis (all subcodes)
I72.*	Other aneurysm (arterial)
I74.*	Arterial embolism and thrombosis
I75.*	Embolism and thrombosis of other specified arteries
I77.*	Other disorders of arteries and arterioles

Selected ICD-10 codes (device/implant & trauma)ICD-10

T82.*	Complications of cardiac and vascular prosthetic devices, implants and grafts
S81.*	Open wound of lower leg
S91.*	Open wound of ankle and foot

Selected ICD-10 codes (infection/osteomyelitis & skin/wound related)ICD-10

M86.*	Osteomyelitis (all subcodes)
S81.801A	Open wound of right lower leg, initial encounter
S81.802A	Open wound of left lower leg, initial encounter
S81.809A	Open wound of unspecified lower leg, initial encounter
S91.301A	Open wound of right ankle and foot, initial encounter
S91.302A	Open wound of left ankle and foot, initial encounter
S91.309A	Open wound of unspecified ankle and foot, initial encounter

Provider Responsibilities and How to Request Prior Authorization

Prior Authorization

How to request prior authorization and provider responsibilities

This list contains prior authorization requirements for participating UnitedHealthcare Community Plan in Missouri care providers for inpatient and outpatient services. To request prior authorization, please submit your request online or by phone: - Online: Use the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal. Go to UHCprovider.com and click Sign In in the top-right corner. Then, select the Prior Authorization and Notification tile on your provider portal dashboard. - Phone: Call 866-815-5334 - To request prior authorization for the Pediatric Care Network (PCN), call 877-347-9367 Physicians, health care professionals and ancillary care providers are responsible for obtaining prior authorization for services included on this list. Hospitals and facilities are responsible for providing admission notification. For admission notification requirements, please see the Missouri Provider Manual at UHCprovider.com/MOcommunityplan > Provider Administrative Manual and Guides > Missouri. Prior authorization is not required for emergency or urgent care. Out-of-network physicians, facilities and other health care providers must request prior authorization for all procedures and services, excluding emergent or urgent care.

Providers must obtain prior authorization for items and services listed in this document before scheduling or performing the service unless the situation is emergent or urgent.
Submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call the numbers above.
Hospitals/facilities are responsible for admission notification per the Missouri Provider Manual.

Definitions and Key Terms

Prior authorization

DefinitionPrior authorization: A review and approval process required before specified services are rendered to be eligible for coverage

When requiredRequired for services and codes explicitly listed in this document, except for emergency or urgent care

Provider actionSubmit requests online via the Provider Portal tool or by phone to the numbers listed in this policy

Prior authorization

Requirement statementPrior authorization required — the service or code must have prior authorization approved before rendering to be eligible for coverage

ExceptionsPrior authorization is not required for emergency or urgent care; out-of-network providers must request PA except for emergent/urgent care

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Missouri Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 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 call 866-815-5334 (PCN: 877-347-9367).

SourceLink

On This Page

Extensive M86.x series codes and other cardiovascular/related ICD-10 codes are listed in the policy; see the document for full code list and any diagnosis‑specific PA exceptions

Prior Authorization

Cardiology outpatient/office-based procedures requiring prior authorization

Prior authorization is required for participating physicians for outpatient and office-based cardiology procedures before they are performed. This includes diagnostic catheterizations, echocardiograms, electrophysiology implants, stress echocardiography, and select interventional cardiology CPT/HCPCS codes.

For prior authorization, submit requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-889-8054.
See the Cardiology Prior Authorization and Notification Program page at UHCprovider.com/MOcommunityplan > Prior Authorization and Notification Resources for full CPT lists.

Prior Authorization

Cardiology prior authorization submission instructions

Submit cardiology prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com). If you cannot submit online, call 866-889-8054. For detailed cardology CPT/HCPCS code lists and program guidance, visit UHCprovider.com/MOcommunityplan > Prior Authorization and Notification Resources > Cardiology Prior Authorization and Notification Program.

Sample cardiology codes that require prior authorization: 37220, 37221, 37224–37231, 93580 (not exhaustive).
Provide clinical documentation supporting medical necessity when submitting requests.

Prior Authorization

Examples of items requiring prior authorization

Examples of items and services that require prior authorization are listed throughout this document. Providers should review the full list and verify requirements before scheduling services.

Circumcision in selected cases (medical necessity required) — see circ codes below.
Cochlear and other auditory implants (prior authorization required).
Enteral services (in-home nutritional therapy through gastrostomy) — HCPCS B9002, B9998.
Experimental and investigational procedures (prior authorization required) — various CPTs listed.
Functional endoscopic sinus surgery (FESS) — CPTs 31237, 31240, 31253, 31254.
Genetic and molecular testing — many CPTs (see genetic testing callouts) and laboratory documentation required.
Home health care, hysterectomy, joint replacement, spinal surgery, stimulators/implantable devices, proton beam therapy, advanced radiology, and more as noted in the policy.

Prior Authorization

Circumcision codes requiring PA in selected cases

Circumcision procedures require prior authorization in selected medically necessary cases. Authorization must document the medical necessity for the circumcision.

CPTs: 54161, 54162, 54163, 54164 — prior authorization required only for cases with documented medical necessity.

Prior Authorization

Cochlear implant codes

Cochlear implants and related auditory implantable devices require prior authorization. Submit clinical documentation supporting candidacy and medical necessity.

CPT/HCPCS: 69714, 69930, L8614, L8619 — prior authorization required.

Prior Authorization

Enteral services (in-home nutritional therapy)

Enteral (in‑home nutritional) therapy delivered enterally or via gastrostomy requires prior authorization. Provide supporting clinical documentation when requesting authorization.

HCPCS: B9002, B9998 — prior authorization required.

Prior Authorization

Functional endoscopic sinus surgery (FESS)

Functional endoscopic sinus surgery (FESS) requires prior authorization. Request must include clinical notes, imaging, and prior conservative management where applicable.

CPTs: 31237, 31240, 31253, 31254 — prior authorization required.

Prior Authorization

Genetic and molecular testing

Genetic and molecular testing requires prior authorization or notification depending on the test. Many molecular and genomic CPT codes require submission of laboratory test documentation to complete the authorization process.

Common CPTs requiring prior authorization/notification include: 81162–81164, 81228–81229, 81277, 81400–81420 series, 81431–81432, 81405–81417, 0006M, 0007M, 0022U, 0023U, 0026U, 0018U, 0060U, 0111U, and others listed in the genetic testing section.
Notification/prior authorization is specifically required for BRCA testing prior to DNA sequencing. The ordering provider must notify the laboratory and follow the program process; laboratory testing may be required to complete the prior authorization/notification.

Prior Authorization

Home health care and hysterectomy prior authorization

Home health care and hysterectomy procedures require prior authorization or notification as noted. Provide clinical documentation and follow the portal or phone submission processes.

Home health care CPT/HCPCS: G0299, G0300, G0493, G0494 — prior authorization required to include member's home.
Hysterectomy CPTs: 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58290, 58291, 58292, 58542–58573 series — prior authorization required.

Prior Authorization

Non-emergent air ambulance transport

Non-emergent air ambulance transport requires prior authorization. Use the standard portal/phone process and include transport justification.

HCPCS: A0430, A0431, A0435 — prior authorization required.

Prior Authorization

Orthotics and prosthetics prior authorization

Orthotics and prosthetics require prior authorization for specified codes and when purchase or cumulative rental exceeds plan thresholds. Include cost information and clinical justification.

Examples of HCPCS: L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631–L0640, L0700, L0710, L0810–L0830, L0859 — prior authorization required for listed items or when cost > $500.

Prior Authorization

Surgical procedures prior authorization

Musculoskeletal and many surgical procedures require prior authorization. Providers must submit clinical documentation, prior conservative treatment when applicable, and use the portal or phone numbers provided.

Shoulder surgery CPTs include arthroscopic shoulder procedures (e.g., 29805–29827) — prior authorization required.
Joint replacement (hip/knee) and other orthopedic procedures listed in the policy require prior authorization.
Spinal surgery codes (e.g., 22100–22595 series) require prior authorization.

Prior Authorization

Proton beam therapy prior authorization

Proton beam therapy (focused proton radiation) requires prior authorization. Submit treatment plan, diagnosis, and supporting clinical documentation.

CPTs: 77520, 77522, 77523, 77525 — prior authorization required.

Prior Authorization

Site-of-service authorization rule

Care providers ordering advanced outpatient imaging or other services in an outpatient hospital setting must verify site-of-service authorization requirements. Prior authorization may be required when services are requested in an outpatient hospital location (SOS = outpatient hospital). If the identical service is provided at a participating ambulatory surgery center or physician office, prior authorization may not be required.

Site-of-service prior authorization applies when requesting services in an outpatient hospital setting.
Examples where SOS prior authorization applies: certain auditory procedures, cardiovascular procedures (e.g., 36590, 36832), select male genital system procedures (e.g., 54840), and other services listed in the SOS outpatient hospital sections.
Prior authorization not required if the service is performed at a participating non‑hospital site when guidance indicates such.

Prior Authorization

Site of service (outpatient hospital) / Radiology prior authorization

Certain advanced outpatient imaging and radiology procedures require prior authorization or notification. Providers ordering these exams are responsible for notification prior to scheduling.

Advanced imaging examples include select CT, MRI, MRA, PET scans, nuclear medicine and nuclear cardiology procedures — follow portal submission or call 866-889-8054 for authorization.
Care providers must provide clinical indications and prior conservative management when applicable.

Prior Authorization

Stimulators / Implantable devices

Implantable stimulators and other implantable electrical devices require prior authorization. Submit device details, indication, prior conservative therapy, and supporting clinical documentation.

Stimulator/implantation CPTs that commonly require prior authorization include neurostimulator/spinal cord stimulator implantation codes (e.g., 61864, 61868, 61885, 61886, 63650, 63655) and related device codes.
Bone growth stimulator and other electrical impulse devices also require prior authorization.
Provide device model, manufacturer, and clinical rationale when requesting authorization.

Prior Authorization

How to submit prior authorization requests

For prior authorization, submit requests online by using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com). Click Sign In in the top-right corner, then select the Prior Authorization and Notification tile. If you cannot submit online, call 866-815-5334 (general) or 866-889-8054 for specific program lines per the guidance in this section. For transplant and CAR T-cell therapy services, call the Community and State Transplant Case Management team at 888-936-7246. For VAD notifications, follow the instructions on the member's ID card and fax to Optum VAD Case Management Team at 855-282-8929.

Include all pertinent clinical records, imaging, labs, and procedure notes required to demonstrate medical necessity.
Genetic testing: ordering provider must notify the laboratory for BRCA testing and follow the laboratory/authorization process; lab testing documentation may be required to complete authorization.
When prior authorization is required only for a specific site of service (outpatient hospital SOS), indicate the requested site on the submission and provide justification if hospital outpatient is requested instead of an alternative site.

ReferenceSee Missouri Provider Manual for hospital admission notification requirements

Circumcision (medical necessity condition)

ConditionCircumcision requires prior authorization only when performed for documented medical necessity

Relevant CPT codes54161, 54162, 54163, 54164

NotesPolicy text: 'only for cases with documented medical necessity' — routine or non‑medical circumcisions are not indicated as requiring PA

DME

DefinitionDurable Medical Equipment (DME): Equipment and supplies listed by HCPCS/K-codes in the policy; PA required for codes listed with retail or cost notes

Examples (sample codes)A9900, E0194, E0265, E0270, E0328, E0329, E0445, E0457, E0465

PA triggerPA required only for the DME codes listed with 'retail' or 'cost of more than $500' in the policy text

Experimental and Investigational

DefinitionExperimental and Investigational: Services/procedures flagged as investigational in the document require prior authorization

Examples (sample codes)33477, 36514, 64722, 65765, 65767, 66180, A6000, E0231

RequirementPrior authorization required for procedures listed under 'Experimental and Investigational' where noted

BRCA/genetic testing notification

BRCA/genetic testing notificationNotification/prior authorization required for BRCA testing before DNA sequencing is performed; ordering provider must notify the laboratory and the lab will notify the plan

Relevant codes (examples)0111U, 0060U, 0006M, 0007M, 0022U, 0023U, 81546

DocumentationGenetic and molecular testing requires prior authorization and may require lab testing/documentation to complete the request

Orthotics and prosthetics prior authorization

RequirementOrthotics and prosthetics L-codes listed require prior authorization (applies only to the listed orthotics/prosthetics codes)

Cost and purchase notesPolicy notes purchase vs cumulative rental and flags items with cost of more than $500 for PA consideration

Sample L-codesL0484, L0486, L0624, L0629 (listed as examples in policy)

Proton beam therapy

DefinitionProton beam therapy: Focused radiation therapy using beams of protons (listed as requiring prior authorization)

Relevant CPT codes77520, 77522, 77523, 77525

RequirementPrior authorization required for proton beam therapy per the policy text

Submission via UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by phone

Submission channelsSubmit via UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com) or by phone

Phone numbersGeneral PA phone: 866-815-5334; advanced imaging phone: 866-889-8054; PCN prior auth: 877-347-9367

Portal instructionsSign in at UHCprovider.com and select the Prior Authorization and Notification tile on the provider portal dashboard

Site of service (SOS) - outpatient hospital

DefinitionSite of service (SOS) — outpatient hospital: Certain services require prior authorization only when performed in an outpatient hospital setting

Example codes47000, 54840 noted in SOS entries in the policy

ConditionPA not required if service performed at a participating non-hospital site unless otherwise specified

Prior authorization required

General rulePrior authorization required for a range of procedures and services explicitly listed (e.g., sleep apnea surgeries, sleep studies, spinal surgery, stimulators/implantation)

Representative proceduresMaxillomandibular advancement (21685), attended sleep studies (95805, 95807, 95808, 95810), spinal surgery codes (e.g., 22100, 22532, 22600), stimulator implantation codes (61864, 61868, 61885, 61886, 63650, 63655)

Provider actionObtain prior authorization before scheduling/performing these procedures to ensure eligibility for coverage

VAD definition and case management

DefinitionVentricular assist device (VAD): A mechanical pump that takes over the function of the heart; PA required and Optum VAD Case Management coordination needed

Provider actionCall the notification number on the member's ID card and fax the form provided by the nurse to Optum VAD Case Management at 855-282-8929

Coverage notePrior authorization required for VAD services per the policy text

Transplant / CAR T-cell therapy

RequirementTransplant and CAR T-cell therapy services require prior authorization

Contact for authorizationFor transplant and CAR T-cell therapy (including Kymriah and Yescarta) call UnitedHealthcare Community and State Transplant Case Management at 888-936-7246 or the notification number on the member's ID card

ScopeApplies to inpatient transplant procedures (inpatient transplant procedures may be carved out to state as noted)

Stimulators / Implantation

RequirementImplantation of stimulators and related neurostimulation devices require prior authorization

Representative CPT codes61864, 61868, 61885, 61886, 63650, 63655 (plus bone growth stimulator references)

NotePrior authorization required before implantation to verify coverage eligibility