CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid plan)

List of services, CPT/HCPCS/ICD-10 codes and instructions for submitting prior authorization requests for participating UnitedHealthcare Community Plan of Ohio providers; excludes emergency and urgent care and applies to in-network and out-of-network providers per notes.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid plan)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on UHCprovider.com or call 800-600-9007.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2024-09-01policy effective date as written

UHCprovider.comprovider portal for online prior authorization

800-600-9007phone number for prior authorization inquiries

Prior auth requiredstated requirement for many listed items

$1,000

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cost threshold triggering PA for some items

Coverage and Prior Authorization Criteria

Prior authorization and notification criteria (partial)

ALL of the following

Prior authorization is required for the services and procedure codes listed in this policy section.
Requests should be submitted via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by calling 866-889-8054 when indicated.
How to obtain prior authorization
- Submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com > UnitedHealthcare Provider Portal > Prior Authorization and Notification).
- Or call 866-889-8054 for prior authorization assistance as noted in the policy text.
- For transplant and CAR T-Cell therapy services, 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.
- For ventricular assist devices (VAD) and certain gene therapy notifications, follow the instructions to call the notification number on the back of the member's health plan ID card and fax required forms to Optum VAD Case Management Team at 855-282-8929 when specified.
Special prior authorization notes
- Some services require prior authorization regardless of billed amount (e.g., many DME/incontinence HCPCS codes listed in the DME incontinence supplies subsection).
- For certain DME/orthotics/prosthetics items, prior authorization is required when retail purchase or cumulative rental cost exceeds $1,000 as indicated for specific codes.
- Behavioral health, enteral services, bone growth stimulators, BRCA testing, cochlear devices, gender dysphoria treatment, hysterectomy procedures, joint replacement, pain management, private duty nursing, prosthetics, transplants, stimulators, sleep apnea surgeries, and other listed categories require prior authorization as noted.
- For codes C9399, J3490 and J3590, prior authorization is required for specified gene and cell therapies (Amtagvi, Casgevy, Lenmeldy, Lantidra, Skysona) — follow therapy-specific prior authorization instructions.
Notification vs Prior Authorization
- When the policy indicates 'Prior authorization required', a formal prior authorization approval must be obtained before performing the service to avoid denial risk.
- When the policy indicates 'Please call the notification number on the back of the member's health plan ID card', providers must notify UnitedHealthcare per the instructions; additional documentation or authorization steps may be required.
Provider responsibilities
- Include relevant diagnosis codes (e.g., ICD-10 codes listed for gender dysphoria F64.0-F64.9 when applicable) and clinical documentation to support medical necessity when submitting prior authorization requests.
- For transplant, CAR T-Cell, gene therapy, and VAD services, follow the special contact and fax instructions provided in the policy to ensure case management review.

ALL of the following

Failure to obtain required prior authorization may result in claim denial or reduced reimbursement.
Some CPT/HCPCS codes in this section are examples; refer to the full policy code listings and the Provider Portal for the most current list of codes requiring authorization.

CPT, HCPCS and Diagnosis Codes

Sample CPT/HCPCS codes with prior authCPT | HCPCSCovered

20974	Bone growth stimulator — electrical stimulation
20975	Bone growth stimulator — electrical stimulation
20979	Bone growth stimulator — ultrasound
81163	BRCA1/BRCA2 testing
81164	BRCA1/BRCA2 testing

Implant-related codesCPT | HCPCSCovered

27415	Cartilage implant procedure
27416	Cartilage implant procedure
69710	Cochlear implant procedure
69711	Cochlear implant procedure
69714	Cochlear implant procedure
69799	Unlisted otologic procedure (used for some implants)
L8614	Cochlear implant external sound processor HCPCS

Additional ICD-10 / diagnosis codes listedICD-10

170.428	ICD or code fragment as listed in cardiovascular section
M86.051	Osteomyelitis site-specific code (example from list)
S81.801A	Open wound code example

sample codes referenced (section is long; not exhaustive)mixed

E0466	DME incontinence-related HCPCS code referenced multiple times
E0766	DME incontinence-related HCPCS code
E1230	DME incontinence-related HCPCS code
E1239	DME incontinence-related HCPCS code
K0800	DME/K-code mapped from E0466 in list
K0801	DME/K-code mapped from E1230 in list
A4226	Continuous glucose monitor supplies (listed in nearby DME section)
L8614	Cochlear implant device code (listed earlier in section)
69710	Cochlear procedure CPT listed

Sample DME HCPCS codesHCPCS

E1002	HCPCS code listed for DME incontinence supplies
E1007	HCPCS code listed for DME incontinence supplies
E1037	HCPCS code listed for DME incontinence supplies
E1110	HCPCS code listed for DME incontinence supplies

Mixed codes (sample)mixed

G0295	Listed CPT/HCPCS code in table
G0329	Listed CPT/HCPCS code in table
A4575	Listed HCPCS code
E0446	Listed HCPCS code

Diagnosis codes associated with gender dysphoria treatmentICD-10

F64.0	ICD-10 diagnosis code (gender dysphoria)
F64.1	ICD-10 diagnosis code (gender dysphoria)
F64.2	ICD-10 diagnosis code (gender dysphoria)
F64.8	ICD-10 diagnosis code (gender dysphoria)
F64.9	ICD-10 diagnosis code (gender dysphoria)

Selected injectable medication J-codes (partial list)HCPCSCovered

J0791	Adakveo (listed injectable medication)
J0172	Aduhelm
J7171	Adzynma
J0225	Amvuttra
J0585	Botox
J2329	Briumvi

Selected surgical CPT codes (partial)CPTCovered

27130	Total hip replacement (example listed)
27447	Knee arthroplasty related code (example listed)
23470	Shoulder procedure (listed)

DME/orthotics/prosthetics and nursing codes (partial)HCPCSCovered

L1846	Orthotics code listed
T1001	Private duty nursing code listed

Sample CPT codes listedCPT

21685
41512
42145
20930
22100

Additional CPT codes listedCPT

22206
22527
22600
22800
22804

Spinal surgery example codesCPTCovered

22634	Listed as requiring prior authorization in this section
22800	Listed as requiring prior authorization in this section

Additional spinal surgery codesCPTCovered

63001	Spinal surgery code listed
63015	Spinal surgery code listed

Stimulator/neurostimulator device codesHCPCSCovered

E0748	Stimulator device HCPCS code listed
E0749	Stimulator device HCPCS code listed
E0760	Stimulator device HCPCS code listed
L8682	Device code listed
L8683	Device code listed

Neurostimulator procedure codesCPTCovered

64595	Neurostimulator-related CPT code listed
63650	Neurostimulator-related CPT code listed

neurostimulator and related codesmixedCovered

E0748	Neurostimulator related HCPCS
E0749	Neurostimulator related HCPCS
E0760	Neurostimulator related HCPCS
61863	Spinal/neurostimulator CPT
61864	Spinal/neurostimulator CPT
61867	Spinal/neurostimulator CPT
61868	Spinal/neurostimulator CPT

gene therapy / CAR T billing codesmixedCovered

C9399	Unclassified chemotherapy or other specified therapeutic
J3490	Miscellaneous drug, used for Amtagvi/CAR T-related billing per note
J3590	Miscellaneous drug, used for CAR T-related billing per note
0538T	CAR T-Cell therapy tracking code mapping to J3490 or Q2041 variants
J3393	Gene therapy code listed
J3394	Gene therapy code listed

inv-26: Prior authorization threshold for retail purchase or cumulative rental cost

ThresholdPrior authorization required only for retail purchase or cumulative rental cost of more than $1,000 for some DME/incontinence and device codes

ScopeApplies to specified HCPCS codes in the DME/incontinence sections where the note 'Prior authorization required only for a retail purchase or cumulative rental cost of more than $1,000' appears

ActionIf retail purchase or cumulative rental exceeds $1,000, submit prior authorization via the Provider Portal or applicable phone number

How Providers Request Authorization and Operational Contacts

Prior Authorization

How to request prior authorization

Submit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) using your One Healthcare ID or by phone at 800-600-9007. Note: prior authorization is not required for emergency or urgent care.

Prior Authorization

Out-of-network prior authorization requirement

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

Prior Authorization

Behavioral health prior authorization

Behavioral health services require prior authorization; providers should call the number on the member’s health plan ID card when referring for mental health or substance use services.

Key Terms and Vendor Routing

inv-52: Prior authorization required

DefinitionPrior authorization required: many listed services and codes in this document require prior authorization before services are rendered

ExemptionPrior authorization is not required for emergency or urgent care

Submission methodsSubmit requests online via the Prior Authorization and Notification tool on UHCprovider.com (One Healthcare ID) or by phone (800-600-9007 or other numbers listed by service)

inv-53: Emergency/Urgent care

ExemptionEmergency or urgent care is exempt from prior authorization requirements

Provider noteOut-of-network providers must still request prior authorization for non-emergent services

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid plan)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on UHCprovider.com or call 800-600-9007.

SourceLink

On This Page

inv-27: Orthotics prior authorization threshold

Orthotics cost thresholdPrior authorization required for orthotics codes listed when retail purchase or cumulative rental cost is more than $1,000

Example codesL1846, L3020 (orthotics codes listed)

How to submitSubmit prior authorization via the Prior Authorization and Notification tool on UHCprovider.com or by phone per guidance

inv-28: Prosthetics prior authorization threshold

Prosthetics cost thresholdPrior authorization required for listed prosthetic codes when retail purchase or cumulative rental cost is more than $1,000

Example codesL5301, L5856, L5968, L5976, L5981 (sample prosthetic codes listed)

NoteSome prosthetic codes also reference cumulative rental cost language in adjacent entries; confirm specific code guidance on the Provider Portal

inv-29: 38232 oncology PA condition

Code-specific conditionCPT code 38232 requires prior authorization only when billed for an oncology diagnosis

ContextListed under Gene Therapy section where code 38232 is noted with the oncology-only PA condition

ActionFor non-oncology uses, routine PA for 38232 is not indicated in this document; verify clinical coding and diagnosis if uncertain

Prior Authorization

Examples of services requiring prior authorization

Multiple specific procedures are listed as “Prior authorization required,” including bone growth stimulators (20974, 20975, 20979), BRCA genetic testing (81163, 81164), cartilage implants (27415, 27416), and cochlear implants (69710, 69711, 69714, 69799).

Prior Authorization

Prior authorization and supplier routing for incontinence supplies

Incontinence supplies are a benefit only when provided through Edgepark Medical Supplies; to request supplies call Edgepark at 844-564-1008. Many listed HCPCS codes require prior authorization; for some items prior authorization is required only if retail purchase or cumulative rental cost exceeds $1,000.

Prior Authorization

DME incontinence HCPCS codes (sample)

Sample DME incontinence HCPCS codes listed in the policy require prior authorization (examples include E1002, E1007, E1004, E1005, E1006, E1011, E1008, E100g, E1010, E1029, E1017, E1018, E1020).

Prior Authorization

Enteral services prior auth

Enteral in‑home nutritional therapy (enteral or via gastrostomy tube) is marked as prior authorization required; listed HCPCS codes include B4102, B4103 and B4104.

Prior Authorization

Experimental/investigational and linked services prior auth

Various procedures are designated experimental/investigational or require prior authorization; the document lists many CPT codes (e.g., 20985, 22505, 22867, 22869, 25259, 27275) that are flagged as experimental/investigational and/or require prior authorization.

Prior Authorization

Gender dysphoria treatment prior auth

Gender dysphoria treatments and associated surgical CPT codes are flagged as prior authorization required; listed example CPTs include 55970 and 55980 and diagnosis codes F64.x are referenced.

Prior Authorization

How to submit prior authorization requests (general)

For general prior authorization submission, use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 888-397-8129.

Prior Authorization

How to submit prior authorization requests (procedure-specific)

For certain procedure-specific prior authorizations (for example rhinoplasty, nasal procedures, sleep apnea procedures), submit via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 866-889-8054; see UHCprovider.com/OHcommunityplan > Prior Authorization for CPT lists.

Denial Risk

Denial risk / prior auth required (drug specific)

Rivfloza is explicitly noted as requiring prior authorization; failure to obtain prior authorization may result in denial.

Documentation Required

Post-acute inpatient notification and continued care program

Post-acute inpatient services require notification and prior authorization; continued care authorization requests must be submitted through naviHealth (Phone: 855-851-1127) as part of the Continued Care program.

Prior Authorization

How to obtain prior authorization

Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-889-8054 (alternate portal phone noted in policy).

Documentation Required

Portal reference for code details

Refer to UHCprovider.com/OHcommunityplan > Prior Authorization for details and the full CPT/HCPCS code lists that require prior authorization.

Prior Authorization

How to obtain prior authorization

For prior authorization, use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-889-8054 per the policy instruction for multiple sections.

Prior Authorization

Transplant prior authorization contact

For transplant and CAR T‑Cell therapy services, prior authorization is required; contact the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 (or use the notification number on the member’s ID card).

Prior Authorization

Stimulator implantation prior authorization

Implantation of stimulators/neurostimulators is identified as prior authorization required; device and procedure codes listed include E0748, E0749, E0760 and CPTs such as 61863, 61864, 61867, 61868 and 64595.

Prior Authorization

Transplant and CAR T-Cell authorization contact

For transplant and CAR T-Cell therapy services (including named products), call UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or use the notification number on the member’s health plan ID card.

Prior Authorization

VAD notification and fax

For Ventricular Assist Devices (VAD), call the notification number on the member’s health plan ID card, then fax the form provided by the nurse to the Optum VAD Case Management Team at 855-282-8929.

Prior Authorization

Gene/CAR T-Cell therapy PA requirement

Prior authorization is required for specific gene/CAR T‑cell therapies (Amtagvi, Casgevy, Lenmeldy, Lantidra, Skysona) when billed with codes C9399, J3490 or J3590 (policy notes require PA for these mappings).

Prior Authorization

Codes indicating prior authorization required (selection)

The policy lists numerous CPT/HCPCS codes that indicate prior authorization is required for selected services (examples include neurostimulator and vagus nerve stimulation codes, L8682, L8683, 64595, 63650 and multiple vein procedure codes).

RoutingFor urgent clinical issues, follow normal emergency procedures; no prior auth required as per policy note

inv-54: designated supplier / benefit routing

Designated supplierEdgepark Medical Supplies is the vendor to request incontinence supplies from (call 844-564-1008)

Benefit conditionIncontinence supplies are a benefit only when provided through Edgepark Medical Supplies

Authorization noteMany incontinence HCPCS codes require prior authorization; some codes require PA only above cost thresholds

inv-55: prior authorization requirement

ScopePrior authorization required for many listed HCPCS/CPT codes across DME, enteral, and various procedures

Experimental/investigationalCertain procedure codes are labeled experimental/investigational and require prior authorization (examples listed in document)

ExamplesEnteral in-home nutritional therapy (B4102/B4103/B4104) and numerous listed surgical/procedural CPT codes

inv-56: prior authorization

Primary submission toolPrior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com)

Alternate phoneCall 888-397-8129 or service-specific phone numbers listed in the document when indicated

Portal accessSign in using One Healthcare ID to access the Prior Authorization and Notification tool on the Provider Portal dashboard

inv-57: Experimental or investigational

DesignationExperimental or investigational: applied to multiple listed procedure codes in the document

EffectCodes marked experimental/investigational require prior authorization and may be subject to additional review

ExamplesProcedure codes such as 20985, 22505, 22867, 22869 and others are listed under the experimental/investigational section

inv-58: Prior Authorization and Notification tool on UnitedHealthcare Provider Portal

Tool namePrior Authorization and Notification tool on UnitedHealthcare Provider Portal

How to accessGo to UHCprovider.com, sign in with One Healthcare ID, select the Prior Authorization and Notification tool on the Provider Portal dashboard

Use caseUse the tool to submit prior authorization requests for most services listed in this document

inv-59: naviHealth Continued Care program for post-acute inpatient services

ProgramnaviHealth Continued Care program handles authorization requests for continued post-acute inpatient services

PhonenaviHealth phone: 855-851-1127

ScopeUsed for post-acute inpatient facilities participating in the Continued Care program per document guidance

inv-60: Prior Authorization and Notification tool

Primary toolPrior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com)

Phone alternativeCall 866-889-8054 (procedure-specific) or 888-397-8129 for general submissions as noted

ReferenceSee UHCprovider.com/OHcommunityplan > Prior Authorization for lists of CPT codes requiring prior authorization

inv-61: Stimulators

Device categoryStimulators/neurostimulators implantation requires prior authorization

Example HCPCS/CPT codesE0748, E0749, E0760, 61863, 61864, 61867, 61868, 61886, 64595, 63650

ActionSubmit prior authorization via the Provider Portal or follow procedure-specific phone instructions

inv-62: Transplant and CAR T-Cell therapy services

RequirementPrior authorization is required for transplant and CAR T-Cell therapy services

ContactCall UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or use the notification number on the member's ID card

ExamplesListed CAR T products include Abecma, Breyanzi, Kymriah, Tecartus, Yescarta

inv-63: Vagus nerve stimulation

RequirementVagus nerve stimulation (implantation) requires prior authorization

Example codes/devices61888, L8681, 64569, L8689, C1767, C1778 listed for vagus nerve stimulation entries

ContextDocument lists vagus nerve stimulation under Gene Therapy section with explicit PA requirement

inv-64: Ventricular assist devices (VAD)

RequirementVentricular assist devices (VAD) require prior authorization and notification

Notification/faxCall the notification number on the member's health plan ID card, then fax the nurse-provided form to Optum VAD Case Management Team at 855-282-8929

DescriptionVAD: mechanical pump that takes over the function of the damaged ventricle and restores normal blood flow; PA and case management steps required