Prior authorization coverage stance — lists numerous service categories and specific procedures/drugs that require prior authorization
This section lists services, procedures, devices, medications and related codes that require prior authorization for UnitedHealthcare Community Plan in Louisiana. Providers should submit prior authorization requests via the UnitedHealthcare Provider Portal (Prior Authorization and Notification tile), by phone, or by fax. Prior authorization is not required for emergency or urgent care. Out-of-network providers must request prior authorization for all procedures and services except emergent/urgent care. Non-emergency inpatient admissions and observation stays >48 hours require prior authorization.
Abortion procedures (prior authorization required) — examples of CPT codes: 59830, 59850, 59851, 59852, 59855, 59856, 59857.
Bariatric surgery and related obesity services (prior authorization required) — examples of CPT codes: 43644, 43645, 43659, 43770, 43775, 43842, 43845.
Cancer supportive services and certain oncology injectable medications (prior authorization required). Examples of HCPCS/J-codes requiring prior authorization: J1442*, J1447*, J2506*, Q5101*, Q5108*, Q5110*, Q5111*, Q5125*, Q5122, J2820, J1448, J1456, J0897, J0885. (Note: some listed codes require PA for non-oncology diagnoses; see Injectable medications.)
Continuous glucose monitors (CGMs) — HCPCS A4239, A9274, A9276. Effective 12/1/23 some CGMs are pharmacy benefit only; providers should verify benefit and prior authorization route (Magellan Medicaid Administration for pharmacy benefit period noted).
Cosmetic and reconstructive procedures (prior authorization required) — examples of CPT codes: 21183, 21184, 21230.
Durable medical equipment (DME) — prior authorization required only for codes listed and for items with retail purchase or cumulative rental cost thresholds (rental cost > $500 or retail purchase). Example HCPCS/Codes: A9900, E0265, E0445, E0465, E0466.
Enteral services — in-home nutritional therapy via enteral or gastrostomy tube (prior authorization required). Example HCPCS: B4034, B4035, B4036, B4100, B4102, B4103, B4104, B4149, B4150.
Home health services, including extended nursing (PDN) — prior authorization required. Example codes: G0299, T1000, G0300, S9123, S9124.
Injectable medications (prior authorization required). For unclassified/temporary codes C9399, J3490, J3590, PA is required only for specific products (Nulibry™, Rivfloza, Revcovi®). Certain J-codes (e.g., J0897) may have diagnosis-specific PA requirements. For specialty injectable agents (Actemra® J3262; Acthar®* J0801; Adakveo® J0791 and many others) follow the PA process via the Provider Portal or phone.
Inpatient admissions — post-acute services (prior authorization and notification of admission date required) for acute care hospitals, inpatient rehabilitation, critical access hospitals, long-term acute care hospitals, and skilled nursing facilities.
Joint replacement (total hip and knee and related procedures) — prior authorization required. Examples of codes listed include: 23470, 23472, 23473, 23474, 24360, 24361, 24362, 24363, 24370, 24371, 27120, 27125.
Maxillofacial / orthognathic surgery for jaw functional impairment — prior authorization required. Example CPT codes: 21249, 21255.
Orthotics and prosthetics — prior authorization required only for items with retail purchase or cumulative rental cost > $500. Example HCPCS codes: L0170, L0464, L0482, L0484, L0486, L0631, L0700, L0710, L7190, L7191, L7405, L7510, L8040, L8042, L8499.
Pediatric day services (prior authorization required) — example codes: T2002, T1025, T1026.
Personal care services (prior authorization required) — example code: T1019.
Proton beam therapy and Radiation Therapy (prior authorization required). Proton beam CPT examples: 77520, 77522, 77523. Radiation therapy examples: 77014, 77331, 77370, 77371, 77372, 77373, 77385, 77386, 77387, 77399, 77401, 77402, 77407, 77412, 77470, 79445, G0339, G0340.
Advanced outpatient radiology (prior authorization/notification required for ordering providers) — includes certain CT, MRI, MRA, nuclear medicine and nuclear cardiology procedures. For the specific CPT codes and submission process, providers should visit UHCprovider.com/LAcommunityplan or use the Provider Portal. For assistance call the radiology prior auth line.
PET scans (prior authorization required) — examples of CPT/HCPCS: 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, A9515, A9526, A9552.
Treatment of nasal functional impairment and septal deviation (examples listed) — CPT codes include 30435, 30450, 30460, 30462. Sinuplasty (prior authorization required) — CPT codes: 31295, 31296, 31297, 31298.
Sleep apnea procedures and surgeries (prior authorization required) — examples of CPT codes include 21685, 41599, 42145.
Transplants and CAR T-cell therapy (prior authorization required) — for transplant and CAR T-cell services (examples: Abecma®, Breyanzi®, Kymriah™, Yescarta™) contact the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 for prior authorization and coordination.
Gene therapy and certain high-cost biologics (prior authorization required) — select gene therapies and related unclassified/temporary codes (C9399*, J3490*, J3590*) require PA and in some cases PA via Optum Transplant or other specified routes; specific products requiring Optum Transplant PA include Amtagvi, Casgevy, Lantidra, Skysona™. Code 38232 requires PA only for oncology diagnoses.
Ventricular assist devices (VAD) and related supplies (prior authorization required). Providers should call the notification number on the member's ID card and fax required forms to the Optum VAD Case Management Team at 855-282-8929 for device, supply and management authorization.