CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Ohio Medicaid

List of services, procedures and outpatient medications that require prior authorization for UnitedHealthcare Community Plan of Ohio providers; includes instructions for submitting prior authorization requests and phone numbers. Applies to participating providers for Ohio Medicaid.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Ohio Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2024

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multiplelisted prior-authorization codes and diagnoses in this section

onlineProvider portal available

cancer agentsinjectable oncology agents require prior authorization

20+ICD-10 diagnosis codes shown

30+CPT/HCPCS procedure codes shown

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.

Services, Procedures, and Medications Requiring Prior Authorization

Prior authorization requirements (part 8)

Prior authorization is required for the following service categories and specific items. Where a phone number or special submission workflow is listed, follow that process to request authorization.

Transplants: Prior authorization required. For transplant and CAR T-Cell therapy services including Abecma (idecaptagene vicleucel), Breyanzi (lisocabtagene maraleucel), Kymriah (tisagenlecleucel), Tecartus (brexucabtagene autoleucel) and Yescarta (axicabtagene ciloleucel), please call the UnitedHealthcare Community and State Transplant Case Management team at 888-936-7246 or use the notification number on the back of the member's health plan ID card.

Spinal surgery: Prior authorization required for spinal surgery procedures. Examples of CPT codes that require prior authorization include 22100, 22101, 22102, 22110, 22112, 22114, 22206, 22207.

Stimulators (implantable neurostimulators and bone growth stimulators): Prior authorization required. Bone growth stimulator coding example: E0760. Neurostimulator implantation requires prior authorization.

Ventricular assist devices (VAD): Prior authorization required. For VAD services, 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 codes: 33927, 33976, 33983, 33928, 33979, Q0507, 33929, 33981, Q0508, 33975, 33982, Q0509.

Vein procedures (removal/ablation of saphenous trunks and named branches for venous disease/varicose veins): Prior authorization required. Example CPT/HCPCS codes: 36473, 37718, 37780, 36475, 37722, 36478, 37765, 37700, 37766.

Sleep apnea procedures: Prior authorization required. Example CPT/HCPCS codes: 21685, 41599, 42145.

Site of service (outpatient hospital): Prior authorization is required only when requesting service in an outpatient hospital setting. Prior authorization is not required if performed at a participating Ambulatory Surgery Center (ASC). Examples of procedures that may require SOS prior authorization when performed in an outpatient hospital include certain cataract, colonoscopy and other surgical codes (e.g., 66821, 66988, 45378, 45380, 45384, 45385).

Out-of-network services: Prior authorization required for referrals to non-contracted providers.

Private duty nursing: Prior authorization required. Example CPT/HCPCS codes: T1000, T1001.

Prostate procedures: Prior authorization required. Example CPT/HCPCS codes: 37243, 52441, 52442, 53850, 53852, 55873, 55874.

Radiation therapy: Prior authorization required for radiation therapy services. Examples and modalities requiring prior authorization include Image-Guided Radiation Therapy (IGRT — 77014), Intensity-Modulated Radiation Therapy (IMRT — 77385, 77386), and Proton Beam Therapy. For implantable beta-emitting microspheres for malignant tumors, CPT 79445 requires prior authorization. Submit online via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call 866-889-8054.

Radiology (advanced outpatient imaging): Prior authorization/notification required for certain advanced outpatient imaging procedures (select CT, MRI, MRA, PET scans, nuclear medicine and nuclear cardiology). Care providers ordering advanced outpatient imaging must provide notification prior to scheduling. Submit requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call 866-889-8054.

Home health care: Prior authorization is required only in outpatient settings, including the member's home. Example HCPCS codes: G0151, G0299, G0152, G0300, G0153, G0156.

Genetic and molecular testing (including BRCA): Prior authorization required. Notification/prior authorization required for BRCA testing before DNA sequencing is performed; the ordering provider must notify the laboratory and the lab will notify the plan. Example codes: 81522, 87505, 0007M, 81546, 87506, 0018U, 81595, 87507, 0022U, 81599, 0006M, 0023U.

Durable medical equipment (DME): Prior authorization required regardless of billed amount for many DME items. Certain incontinence supplies are a benefit only when provided through Edgepark Medical Supplies (call 844-564-1008 to request). Examples of HCPCS codes that may require authorization or special routing include E1239, E2310, E2311, K0812, K0830–K0854, K0886, K0890, K0891 (note: prior authorization for K0886/K0890/K0891 is required only for retail purchase or cumulative rental cost > $500).

Enteral services / in-home nutritional therapy: Prior authorization required. Example HCPCS codes: B4034, B4035, B4036, B4100, B4102, B4103, B4104, B4150, B4152, B4153, B4155, B4159, B4160.

Cochlear and other auditory implants: Prior authorization required. Example CPT/HCPCS codes: 69710, 69714, 69930.

Chemotherapy and injectable cancer drugs: Prior authorization required for inpatient chemotherapy services; injectable outpatient chemotherapy drugs administered for a cancer diagnosis require prior authorization (includes J9000–J9999, leucovorin J0640, levoleucovorin J0641/J0642, Lupron Depot J1950, leuprolide J1952, Q-codes, and miscellaneous HCPCS-billed agents). For outpatient injectable chemotherapy prior auth and supportive care drugs, submit via the Provider Portal Prior Authorization and Notification tool or call 888-397-8129.

Cancer supportive care injectables (colony-stimulating factors, erythropoiesis-stimulating agents, bone-modifying agents): Prior authorization required when administered in an outpatient setting for a cancer diagnosis. Examples (selected J/Q codes): J1449 (eflapegrastim), J1442 (filgrastim), Q5110 (filgrastim-aafi), Q5125, J2506 (pegfilgrastim), Q5122, Q5120, Q5111, Q5108, J1447, J2820 (sargramostim), J1448 (trilaciclib). Note: Codes J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122 and Q5125 require prior authorization for non-oncology diagnoses as well (see Cancer supportive care section).

Injectable medications: Many specific injectable medications require prior authorization. Providers should refer to the policy listing for the applicable HCPCS/J-codes and submit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by calling 888-397-8129. Examples of drugs on the prior authorization list include Actemra (J3262), Acthar (J0801), Adakveo (J0791), Aduhelm (J0172), Aldurazyme (J1931), Amondys 45 (J1426), Amvuttra (J0225), Avsola (Q5121), Benlysta (J0490), Berinert (J0597), botulinum toxins (J0585–J0588), Brineura (J0567), Briumvi (J2329), Cerezyme (J1786), Cimzia (J0717), and many others.

Orthotics and prosthetics: Prior authorization required when rental cost exceeds specified thresholds (e.g., rental cost > $500) or per item as listed. Example HCPCS codes: L0710, L0810, L0859, L1000, L1200, L1300, L1310, L1680, L1685, L1720, L1730, L1755, L1832, L1834, L1840, L1844, L1845, L1846.

Cosmetic and reconstructive procedures: Prior authorization required for specified cosmetic and reconstructive procedures. Examples of CPT codes that may require prior auth include 11960, 14020, 13101, 42440.

Bariatric surgery and obesity-related services: Prior authorization required. Examples of procedure codes that may require prior authorization include 43644, 43645, 43659, 43770, 43775, 43842, 43845, 43846, 43847, 43848, 43860.

Abortion/pregnancy termination procedures: Prior authorization required. Examples of CPT codes referenced include 59840–59857 (specific codes vary by procedure).

Relevant CPT/HCPCS/ICD-10 and Drug Codes

How to Submit Requests and Actionable Provider Rules

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 877-842-3210. Prior authorization is not required for emergency or urgent care; out-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services except emergent/urgent care.

Prior Authorization

Cancer supportive care prior authorization

Prior authorization is required for outpatient administration of colony-stimulating factors, erythropoiesis-stimulating agents and bone-modifying agents for a cancer diagnosis; listed J/Q codes (e.g., J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125) are included.

Prior Authorization

Chemotherapy injectable drugs prior authorization

Submit prior authorization requests online using the Prior Authorization and Notification tool for injectable chemotherapy drugs (J9000–J9999), specified J-codes/Q-codes (e.g., J0640, J0641, J0642, J1950, J1952) and miscellaneous HCPCS-coded chemotherapy agents; prior authorization is required for inpatient chemotherapy services and for injectable chemotherapy administered in outpatient settings for a cancer diagnosis.

Key Terms and Scope Notes

inv-67: Prior authorization is a review process requiring providers to request approval before certain services, procedures or medications are provided; not required for emergency or urgent care.

DefinitionPrior authorization is a review process requiring providers to request approval before certain services, procedures or medications are provided.

Emergency carePrior authorization is not required for emergency or urgent care.

Out-of-network ruleOut‑of‑network providers must request prior authorization for non‑emergent services.

inv-68: Prior Authorization and Notification tool

Tool namePrior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com).

Portal accessSign in with One Healthcare ID at UHCprovider.com and select the Prior Authorization and Notification tile on the Provider Portal dashboard.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Ohio Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2024

Next Review DateN/A

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

SourceLink

On This Page

Prior Authorization

Device and monitoring services prior authorization

Prior authorization is required for inpatient video EEG (cerebral seizure monitoring) codes and for cochlear and other auditory implants and continuous glucose monitors as indicated.

Inpatient video EEG examples: 95700, 95711–95713, 95720–95726
Cochlear implant examples: 69710, 69714, 69930
Continuous glucose monitor examples: A4226, A4239, E0787, E2102, E2103

Prior Authorization

Drug screening (G0483) prior authorization

Drug screening prior authorization is required for code G0483.

Prior Authorization

DME cost-threshold prior authorization ($500)

Certain DME K-codes (K0886, K0890, K0891) require prior authorization only when retail purchase or cumulative rental cost exceeds $500.

Prior Authorization

Various services requiring prior authorization

Durable medical equipment (DME), enteral services, genetic/molecular testing, FESS, femoroacetabular impingement (FAI), gender dysphoria treatment and other listed services require prior authorization as indicated in the policy.

Prior Authorization

Example CPT/HCPCS codes requiring prior authorization

Examples of CPT/HCPCS codes subject to prior authorization include B4034, B4100, 31240, 29914 and 55970 among many others listed in the document.

Prior Authorization

Genetic tests, home health, hysterectomy prior authorization/notification

Notification or prior authorization is required for specified genetic tests (including BRCA panels) before DNA sequencing is performed; home health prior authorization is required only in outpatient settings (including the member's home); hysterectomy procedures listed require prior authorization.

BRCA/genetic test examples: 81162, 81163, 81164, 81228, 81229, 81277
Home health notification/prior auth codes: G0151–G0156
Hysterectomy examples: 58150, 58152, 58180, 58260, 58262, 58263

Prior Authorization

Injectable medication prior authorization

Prior authorization is required for a long list of injectable medications billed with J- and Q-codes; submit requests via the Provider Portal Prior Authorization and Notification tool or the phone number specified for injectable medications.

Sample injectable medication codes listed: J3262, J0801, J0567, J2329, J1786 (see full list in policy)
Submit online via UHCprovider.com > Prior Authorization and Notification tile or call 888-397-8129

Prior Authorization

How to obtain prior authorization / notifications

Submit prior authorization requests online via the UnitedHealthcare Provider Portal Prior Authorization and Notification tile or call 888-397-8129; predetermination is recommended for new-to-market medications and Solaris prior notification uses OptumRx at 800-310-6826.

Prior Authorization

Procedures requiring prior authorization

Prior authorization is required for selected procedures including joint replacement (total hip and knee) and non-emergent air ambulance transport; follow the Provider Portal or phone instructions when submitting requests.

Joint replacement example code: 23470
Non-emergent air ambulance examples: A0430, A0431, A0435, A0436

Prior Authorization

Special drug prior authorization note (colony-stimulating factors)

White blood cell colony-stimulating factor codes (e.g., J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125) require prior authorization for both oncology and non-oncology diagnoses; oncology uses the Cancer supportive care section guidance.

Prior Authorization

Orthotics and prosthetics prior authorization ($500 threshold)

Prior authorization is required for orthotics and prosthetics with a retail purchase or cumulative rental cost greater than $500.

Prior Authorization

Radiation therapy / Implantable Beta-Emitting Microspheres prior authorization

To submit an online request for prior authorization for radiation therapy or implantable beta-emitting microspheres (e.g., 79445), sign in to the UnitedHealthcare Provider Portal and access the Prior Authorization and Notification tool.

Prior Authorization

Radiology - advanced outpatient imaging notification / prior authorization

Care providers ordering advanced outpatient imaging procedures must provide notification prior to scheduling and submit prior authorization requests online via the Provider Portal or call 866-889-8054 for assistance.

Advanced imaging types include certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures

Prior Authorization

Private duty nursing prior authorization

Private duty nursing services require prior authorization; example codes include T1000 and T1001.

Private duty nursing codes: T1000, T1001

Prior Authorization

Out-of-network referrals prior authorization

Out-of-network services require prior authorization; obtain prior authorization before referral to non-contracted providers except for emergent or urgent care.

Prior Authorization

Outpatient therapy prior authorization

Outpatient therapy CPT codes listed in the policy require prior authorization; see the code list for specific therapy CPTs (examples include 92507, 97110).

Sample outpatient therapy codes: 92507, 92508, 92526, 97010, 97110

Prior Authorization

Radiation therapy prior authorization

Radiation therapy procedures such as IGRT (77014) and IMRT (77385, 77386) require prior authorization; certain diagnosis codes may trigger prior authorization requirements.

Radiation therapy example codes: 77014, 77385, 77386

Prior Authorization

Rhinoplasty and septoplasty prior authorization

Rhinoplasty and septoplasty procedures for functional nasal treatment require prior authorization; example CPT codes cited include 30400–30462.

Rhinoplasty/septoplasty code range example: 30400–30462

Prior Authorization

Prostate procedures prior authorization

Selected prostate procedures require prior authorization; example CPT codes listed include 37243, 52441, 52442, 53850, 53852, 55873 and 55874.

Sample prostate procedure codes: 37243, 52441, 52442, 53850, 53852, 55873, 55874

Prior Authorization

Respite services prior authorization

Respite services require prior authorization; example HCPCS/CPT codes include H0045, S5150 and S5151.

Respite service codes: H0045, S5150, S5151

Prior Authorization

Site of service — outpatient hospital prior authorization

Prior authorization is required only when requesting services in an outpatient hospital setting; the same services performed at a participating Ambulatory Surgery Center (ASC) do not require prior authorization.

Prior Authorization

Sleep apnea procedures prior authorization

Sleep apnea procedures identified in the policy require prior authorization; example CPT codes listed include 21685, 41599 and 42145.

Prior Authorization

Spinal surgery prior authorization

Spinal surgery procedures listed throughout the policy require prior authorization; sample CPT codes include 22100, 22101, 22102, 22110, 22206, 22207, 22548 and 22612.

Prior Authorization

Stimulators implantation prior authorization

Implantation of stimulators (including bone growth stimulators and neurostimulators) requires prior authorization; HCPCS example E0760 is listed.

Stimulator examples: Bone Growth Stimulator (E0760) and listed neurostimulator CPTs/HCPCS

Prior Authorization

Transplant and CAR T-Cell prior authorization contact

For transplant and CAR T-Cell therapy services (including Abecma, Breyanzi, Kymriah, Tecartus and Yescarta), call the 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 to obtain prior authorization.

Prior Authorization

VAD prior authorization procedure

For Ventricular Assist Devices (VAD) prior authorization: call the notification number on the back of 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.

VAD example codes include 33927, 33976, 33983, 33928, 33979, Q0507, 33929, 33981, Q0508, 33975, 33982, Q0509

Prior Authorization

Vein procedures prior authorization

Removal and ablation of saphenous trunks and named branches for venous disease/varicose veins require prior authorization; example CPTs include 36473, 37718, 37780, 36475, 37722, 36478 and 37765.

Prior Authorization

Stimulators prior authorization

Implantation of stimulators (neurostimulators and bone growth stimulators) requires prior authorization; referenced codes include E0760 and multiple neurostimulator CPTs/HCPCS listed in the policy.

Alternate phonePhone numbers shown in the document: 877-842-3210, 888-397-8129 and 866-889-8054 for specific programs/requests.

inv-69: Cerebral seizure monitoring - inpatient video EEG

ServiceCerebral seizure monitoring — inpatient video EEG (codes listed such as 95712, 95713, 95720–95726).

SettingPrior authorization required for inpatient video EEG services as listed.

SubmissionSubmit prior authorization requests via the Provider Portal Prior Authorization and Notification tool.

inv-70: Incontinence supplies (Edgepark)

Benefit restrictionIncontinence supplies are covered only when provided through Edgepark Medical Supplies.

ContactTo request incontinence supplies call Edgepark Medical Supplies at 844-564-1008.

Coverage noteThis is a Medicaid benefit limitation specified in the DME/incontinence section.

inv-71: DME cost-threshold

ThresholdPrior authorization for specified DME K-codes (e.g., K0886, K0890, K0891) applies only when retail purchase or cumulative rental cost exceeds $500.

Codes referencedExamples include K0886, K0890, K0891 as noted in the DME section.

Provider stepIf expected retail purchase or cumulative rental cost > $500, submit PA via Provider Portal.

inv-72: Testing Prior Authorization/Notification Program

ProgramTesting Prior Authorization/Notification Program — notification/prior authorization required for specified genetic tests (e.g., BRCA) before DNA sequencing is performed.

Ordering provider roleThe ordering provider must notify the laboratory conducting the test; the laboratory will notify the payer as required.

Example codesExample genetic test CPT/HCPCS codes listed include 81522, 87505, 0007M, 81546, 87506, 0018U, etc.

inv-73: Home health prior authorization scope

ScopeHome health prior authorization is required only in outpatient settings, including care provided in the member's home.

Example codesHome health codes noted include G0151, G0299, G0152, G0300, G0153, G0156.

SubmissionSubmit prior authorization/notification via the Provider Portal when required for outpatient home health services.

inv-74: Predetermination is a recommended step for new-to-market medications listed on the Review at Launch Medication List

DefinitionPredetermination is recommended for new‑to‑market medications listed on the Review at Launch Medication List.

When to useUse predetermination for medications newly introduced to market to confirm coverage expectations prior to prescribing/dispensing.

ReferenceSee Review at Launch information on UHCprovider.com as noted in the policy excerpt.

inv-75: Use the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call 888-397-8129; Solaris uses OptumRx prior notifications at 800-310-6826

Primary methodUse the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com) to submit requests.

Phone alternativesGeneral prior authorization phone numbers shown include 877-842-3210 and 888-397-8129; Solaris prior notifications use OptumRx at 800-310-6826.

Portal navigationSign in at UHCprovider.com with One Healthcare ID and select the Prior Authorization and Notification tile on the Provider Portal dashboard.

inv-76: advanced outpatient imaging

DefinitionAdvanced outpatient imaging — care providers ordering advanced outpatient imaging must provide notification prior to scheduling.

SubmissionSubmit prior authorization requests online via the Provider Portal or call 866-889-8054 for radiology prior authorization/notification.

Provider responsibilityProviders are responsible for notifying prior to scheduling the procedure as noted in the radiology section.

inv-77: Site of service prior authorization

RequirementSite‑of‑service prior authorization is required when services are scheduled in an outpatient hospital setting.

ASC exceptionPrior authorization is not required if the same service is performed at a participating Ambulatory Surgery Center (ASC).

ExamplesSample site‑of‑service CPT/HCPCS codes referenced include G0260 and multiple outpatient hospital procedure codes listed in the SOS section.

inv-78: Site of service (SOS)

TermSite of service (SOS) — refers to outpatient hospital setting where prior authorization may be required.

PA rulePrior authorization required only when service is scheduled in an outpatient hospital; not required at participating ASCs.

Example codesSOS examples include G0260 and listed nervous system and ophthalmologic procedure codes in the SOS section.

inv-79: Stimulators / Bone Growth Stimulator

Device categoryStimulators / Bone Growth Stimulator — implantation of device that sends electrical impulses; bone growth stimulators require prior authorization.

Example HCPCSBone growth stimulator HCPCS code listed: E0760.

Provider actionSubmit prior authorization for device implantation via Provider Portal as indicated in the stimulators section.

inv-80: Ventricular assist devices (VAD)

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

Prior authorizationPrior authorization is required for VADs; follow the notification/fax procedure specified in the policy.

Provider stepsCall the notification number on the back of the member's health plan ID card, then fax the nurse‑provided form to Optum VAD Case Management at 855-282-8929.

inv-81: Stimulators / Neurostimulator

DefinitionStimulators / Neurostimulator — devices that send electrical impulses (includes neurostimulators and bone growth stimulators).

PA requirementImplantation of neurostimulators requires prior authorization as noted in the stimulators section.

Example codesNeurostimulator and related CPT/HCPCS codes are listed throughout the stimulators section (e.g., 64553, 64555, 64568, 64570; see full list in document).

inv-82: Vein procedures (saphenous)

Procedure groupVein procedures — removal and ablation of saphenous trunks and named branches for venous disease/varicose veins require prior authorization.

Example CPTsListed CPT codes include 36473, 37718, 37780, 36475, 37722, 36478, 37765, 37700, 37766.

Provider actionSubmit prior authorization via Provider Portal for the listed vein procedure CPTs prior to scheduling.