CurrentUnitedHealthcarePolicy N/A

Prior Authorization Requirements — UnitedHealthcare Community Plan of Louisiana (Provider List)

Governs prior authorization requirements and submission methods for participating UnitedHealthcare Community Plan of Louisiana providers for inpatient and outpatient services; lists services and associated CPT/HCPCS codes requiring prior authorization.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Requirements — UnitedHealthcare Community Plan of Louisiana (Provider List)

Policy CodePolicy N/A

Change TypeNo material change

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 (UHCprovider.com) or call the listed phone numbers.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleservice categories listed requiring prior authorization

dozensCPT/HCPCS codes enumerated

UHCprovider.comonline submission method

2phone numbers provided

PA requiredenteral services

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Services and Codes Requiring Prior Authorization

Prior authorization coverage stance (partial list)

Services and corresponding CPT/HCPCS codes listed below require prior authorization (excerpt — partial document).

Abortion — Prior authorization required for listed abortion procedure codes.

Bariatric surgery — Prior authorization required for listed bariatric procedure codes (e.g., 43644, 43645, 43659, 43770).

Cancer supportive services — Prior authorization required for outpatient administration of colony-stimulating factors and bone-modifying agents (examples: J1442 and other J-/Q-codes).

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Cochlear and other auditory implants — Prior authorization required for listed implant procedure and device codes (e.g., 69714 and specified L-codes).

Continuous glucose monitors — Prior authorization required for specified CGM HCPCS codes (e.g., A4238, A4239, A9274, A9276); coverage may be redirected to pharmacy benefits for some brands.

Durable medical equipment (DME) — Prior authorization required for many listed E-, K- and related DME codes; some items subject to retail purchase or cumulative rental cost thresholds.

Enteral services (in‑home nutritional therapy, enteral or via gastrostomy) — Prior authorization required for listed B‑codes (e.g., B4034–B4036, B4100, B4149, B4150, B4152–B4161, B9002, B9998).

Prior authorization requirements (excerpt)

Items and codes listed below require prior authorization or notification as specified; submission instructions are included where noted.

Enteral services: In‑home nutritional therapy — enteral or via gastrostomy tube requires prior authorization (see B‑code list).

Injectable medications: Extensive list of injectable medications (HCPCS/J‑codes) require prior authorization; examples include many specialty and biologic agents (see J0202, J0174, J1306, J2350, J3399 etc.). Pre‑determination is recommended for new‑to‑market drugs per the Review at Launch policy.

Home health / PDN: Home health services, including extended nursing (PDN), require prior authorization in outpatient settings including the member's home (see G0299, T1000, G0300, S9123, S9124).

Surgical procedures: Certain surgeries (for example femoroacetabular impingement, FESS, joint replacements, orthognathic procedures) require prior authorization (see listed CPT codes such as 29914, 31240–31298, 23470, 27120, 27447).

Prior authorization stance by service

Services and procedures listed below include associated CPT/HCPCS codes and indicate whether prior authorization is required.

Orthotics/Prosthetics and related device codes — listed L‑codes require prior authorization as indicated (see L7009, L7040, L7045, L7170, etc.).

Pediatric day services and personal care services — prior authorization required for listed T‑codes (e.g., T2002, T1025, T1026, T1019).

Radiation and proton beam therapy — prior authorization required for radiation therapy and proton beam CPT codes (examples: 77014, 77372, 77520, 77522).

Advanced outpatient imaging (including PET scans) — care providers ordering these procedures must provide notification prior to scheduling; prior authorization is required for PET scan CPT/HCPCS codes (e.g., 78608, 78813, 78609, 78814 and related radiopharmaceutical codes).

Rhinoplasty/septoplasty, sinuplasty, and sleep apnea procedures — prior authorization required for listed procedure codes (e.g., 30400–30462, 31295–31298, 21685, 41599).

Prior authorization criteria (excerpt)

Prior authorization requirements and contact instructions for selected services in this excerpt.

Radiology / PET scans — PET scan CPT/HCPCS codes listed (e.g., 78608, 78813, 78609, 78814) require prior authorization; providers must obtain prior authorization or provide notification as indicated.

Rhinoplasty, septoplasty, sinuplasty — Prior authorization required for listed CPT codes (e.g., 30400–30462 for rhinoplasty/septoplasty; 31295–31298 for sinuplasty).

Transplant and CAR T‑cell therapies — Prior authorization required; contact UnitedHealthcare Community and State Transplant Case Management Team at 888‑936‑7246 or the notification number on the member's ID card for listed CAR‑T and transplant products.

Ventricular assist devices (VAD) — Prior authorization required; call the notification number on the back of the member's health plan ID card and follow the Optum VAD Case Management Team fax workflow as instructed.

Vein procedures and wound vac — Prior authorization required for listed vein procedure CPT codes (e.g., 36478, 37700, 37718, 37722, 37780) and for wound vac E2402.

Relevant CPT / HCPCS Codes and Groupings

Abortion (CPT)CPT

59830	Termination of pregnancy, vacuum aspiration, first trimester
59850	Termination of pregnancy, dilation and evacuation, second trimester
59851	Termination of pregnancy, dilation and evacuation, incomplete/complicated
59852	Termination of pregnancy, dilation and evacuation, other
59855	Second trimester termination, with complications
59856	Termination of pregnancy, third trimester
59857	Termination of pregnancy, with additional procedures

Cancer Supportive & Colony-Stimulating Factors (HCPCS)HCPCSCovered

J1442	Filgrastim
J1447	Trilaciclib
J1448	Anti-emetics (misc)
J1456	Bone-modifying agent (denosumab/Xgeva)
J0897	Denosumab (Xgeva)
J1449	Colony Stimulating Factors (misc)
J0885	Erythropoiesis-Stimulating Agents (misc)
Q5101	Pegfilgrastim (Neulasta) - Q-code
Q5108	Sargramostim - Q-code
Q5110	Filgrastim-ayow (Releuko) - Q-code

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Cochlear implants & Auditory (CPT/HCPCS)mixedCovered

69714	Removal of cochlear implant
69930	Insertion of intracochlear electrode array
L8691	Cochlear device, internal
L8614	Auditory osseointegrated implant
L8692	External processor for cochlear implant
L8619	Speech processor, cochlear

Durable Medical Equipment (DME) - General HCPCSHCPCSCovered

E0265	Seating and positioning, cane, walker modifications
E0266	Wheelchair accessory
E0328	External ambulatory infusion pump
E0329	Infusion pump, ambulatory, with internal power source
E0445	Oxygen contents, gaseous, rental
E0465	Compressor/pump for nebulizer
E0466	Nebulizer, with compressor
E0470	Noninvasive ventilator
E0766	Spinal orthosis, adjustable
E0784	Spinal device (unclassified)

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Durable Medical Equipment (DME) - Orthotics/Prosthetics (K/S/V) & ThresholdHCPCS

K0005	Standard wheelchair accessory
K0108	Patient lift portion
K0830	Lower limb prosthesis components (K0830-K0886)
K0831	Lower limb prosthesis component
K0848	Prosthetic knee unit
K0849	Prosthetic component
K0850	Prosthetic component
K0851	Prosthetic component
K0852	Prosthetic component
K0853	Prosthetic component

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Orthotics & Prosthetics (L-codes) - Prior Auth ThresholdHCPCS

L8691	Cochlear implant internal device
L8614	Auditory implant
L8692	External cochlear processor
L8619	Speech processor

Enteral Nutrition & Supplies (HCPCS)HCPCSCovered

B4034	Amino acid-based formula, per diem
B4035	Enteral formula, concentrated
B4036	Enteral formula, blenderized
B4100	Enteral feeding supply, pump
B4102	Enteral feeding supply, tube
B4103	Enteral feeding supply, tubing
B4104	Enteral feeding supply, connector
B4149	Enteral feeding supply, supplemental
B4150	Enteral formula, elemental
B4152	Enteral formula, polymeric

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Cosmetic & Reconstructive Procedures (CPT)CPT

11960	Injection procedure for cosmetic purposes
15820	Tissue rearrangement, forehead/eyebrow
15821	Tissue rearrangement, eyelid
15822	Tissue rearrangement, nose
15823	Tissue rearrangement, lip
15830	Excision of redundant skin
15847	Cheek lift
17106	Destruct of benign lesions, scalp/arms/legs (6+ lesions)
17107	Destruct of benign lesions, face/neck/hands (6+ lesions)
17108	Destruct of benign lesions, trunk (6+ lesions)

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Selected Injectable Medications (J-codes)HCPCSCovered

J0172

Injection, abatacept (misc)

How to Submit Requests and Operational Steps

Prior Authorization

Submission methods and general prior authorization rule

For prior authorization, submit requests online using 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 providers must request prior authorization for all non-emergent procedures and services.

Prior Authorization

Chemotherapy prior authorization contact

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

Prior Authorization

How to obtain prior authorization for unclassified codes and new drugs

For unclassified and temporary drug codes C9399, J3490 and J3590, prior authorization is required only for inpatient admissions (post-acute services). Pre-determination is highly recommended for drugs on the Review at Launch list. Submit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-397-8129.

Key Terms and Contact Definitions

Definition of prior authorization (process requiring portal/phone submission)

DefinitionA process requiring providers to submit requests via the UnitedHealthcare Provider Portal (Prior Authorization and Notification tool) or by phone for approval before providing non-emergent services.

Submission methodsOnline via UHCprovider.com Prior Authorization and Notification tool or by calling 877-842-3210.

ExclusionsPrior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for non-emergent services.

Outpatient chemotherapy prior authorization

ScopeAuthorization required for injectable chemotherapy drugs administered in an outpatient setting (intravenous, intravesical, intrathecal) for cancer diagnoses.

How to submit

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Requirements — UnitedHealthcare Community Plan of Louisiana (Provider List)

Policy CodePolicy N/A

Change TypeNo material change

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 (UHCprovider.com) or call the listed phone numbers.

SourceLink

On This Page

Unclassified/temporary codes: Unclassified and temporary drug codes (C9399, J3490, J3590) require prior authorization only for inpatient post‑acute admissions; pre‑determination is highly recommended for drugs on the Review at Launch list.

How to submit: For prior authorization, submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call the listed phone numbers (e.g., 888‑397‑8129 for chemotherapy and many injectable medications).

Skin substitutes and specified wound care — prior authorization required for listed Q‑codes (examples: Q4101, Q4160, Q4106, Q4186).

Prior Authorization

Home health prior authorization

Home health services, including extended nursing (PDN), require prior authorization when provided in outpatient settings, including the member's home. Relevant codes include G0299, T1000, G0300, S9123 and S9124.

Prior Authorization

Enteral services prior authorization

Enteral services (in‑home nutritional therapy, either enteral or via gastrostomy tube) require prior authorization for the listed HCPCS B‑codes.

Examples of codes requiring prior authorization: B4034, B4035, B4036, B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4155, B4158, B4159, B4160, B4161, B9002, B9998

Prior Authorization

Surgical procedures prior authorization

Specific surgical procedures require prior authorization, including femoroacetabular impingement (FAI), functional endoscopic sinus surgery (FESS), and certain joint replacement procedures.

FAI example codes: 29914–29916
FESS example codes: 31240, 31253–31259, 31267, 31276, 31287–31288
Joint replacement examples: 23470, 27120, 27447 (and numerous hip/knee replacement CPT codes listed)

Prior Authorization

Advanced outpatient imaging prior authorization process

Care providers ordering advanced outpatient imaging procedures must provide notification prior to scheduling. For prior authorization, submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

Advanced outpatient imaging includes certain CT, MRI, MRA and other specified advanced imaging (see radiology section).

Prior Authorization

Services requiring prior authorization

Multiple services and procedure groups are noted as 'Prior authorization required' for the listed CPT/HCPCS codes, including radiation therapy, proton beam therapy, pediatric day services, personal care services, PET scans, rhinoplasty/septoplasty, sinuplasty, sleep apnea procedures, skin substitutes, and orthotics/prosthetics.

Prior Authorization

Prior authorization required — examples

Prior authorization is required for the listed examples such as PET scan, rhinoplasty/septoplasty, sinuplasty, and sleep apnea procedure codes; providers must obtain prior authorization as indicated for those CPT/HCPCS codes.

PET scan examples: 78609, 78814, A9526, A9588
Rhinoplasty/septoplasty examples: 30400–30430, 30435, 30450, 30460, 30462
Sinuplasty examples: 31295–31298
Sleep apnea examples: 21685, 41599

Prior Authorization

Transplant/CAR T-cell authorization contact

For transplant and CAR T‑cell therapy services (including specified CAR‑T products), contact 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.

Examples of CAR‑T products listed: Abecma, Breyanzi, Kymriah, Yescarta

Prior Authorization

VAD prior authorization workflow

Ventricular assist devices (VAD) require prior authorization; call the notification number on the back of the member's health plan ID card and then fax the form provided by the nurse to the Optum VAD Case Management Team as instructed.

Follow the phone notification on the member ID card first, then fax the VAD form to Optum VAD Case Management Team per instructions.

Prior Authorization

Vein procedures and wound vac

Vein procedures (including removal/ablation of saphenous trunks and named branches) and wound vacuum therapy require prior authorization. Example CPT codes include 36478, 37700, 37718, 37722, 37780 and wound vac HCPCS code E2402.

Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 888-397-8129.

SettingApplies to outpatient administration; see portal or phone contact for details on specific agents and codes.

Prior authorization required (general definition)

DefinitionPrior authorization required: The insurer requires approval before specified services, procedures, or medications will be covered; some items also require pre-determination or notification of admission date.

Where requiredApplies to multiple service categories and listed CPT/HCPCS codes throughout the document (e.g., enteral services, injectable medications, surgical procedures).

How to obtainSubmit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call the phone numbers provided in the document.

Proton beam therapy definition

DefinitionProton beam therapy: Focused radiation therapy using beams of protons (tiny particles) for which prior authorization is required.

Codes citedExamples include CPT codes 77520, 77522, 77523, 77525 listed in the radiation/proton beam section.

Authorization notePrior authorization is required for proton beam therapy and related radiation therapy codes per the document.

Transplant Case Management Team contact

Team nameUnitedHealthcare Community and State Transplant Case Management Team

When to contactFor transplant and CAR T-cell therapy services (including listed CAR-T products) prior authorization is required; contact the team for authorization guidance.

PhoneCall 888-936-7246 or the notification number on the back of the member's health plan ID card.

Applies toTransplant and CAR T-cell therapies (examples: Abecma, Breyanzi, Kymriah, Yescarta) listed in the document.

Optum VAD Case Management Team contact

Team nameOptum VAD Case Management Team

WorkflowFor ventricular assist device (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 as instructed.

When requiredVentricular assist devices require prior authorization per the document.