Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee
This document lists prior authorization requirements and submission instructions for participating health care professionals providing inpatient and outpatient services to UnitedHealthcare Community Plan of Tennessee members.
Policy Summary
PayerUnitedHealthcare
PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Tennessee
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionSubmit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 866-604-3267.
No material clinical or coverage changes in this revision.
UHCprovider.comOnline submission method
866-604-3267Phone (general)
800-690-1606Behavioral health contact
$500DME prior auth threshold
No prior auth requiredEmergency care
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Coverage and Prior Authorization Criteria
Behavioral health prior auth criteria — Behavioral health and substance use services prior authorization requirements
Behavioral health and substance use services require prior authorization for most voluntary inpatient and many residential and ambulatory services. Emergency and involuntary admissions have special handling — see details below.
ALL of the following
Prior authorization is required for voluntary psychiatric hospitalizations and other behavioral-related requests.
Prior authorization is not required for involuntary psychiatric hospitalizations; however, documentation supporting inpatient psychiatric hospitalization for involuntary admissions must be submitted the next business day.
Per the contractor risk agreement (CRA), UnitedHealthcare Community Plan applies medical necessity criteria after the first 24 hours of an involuntary admission.
For all behavioral-related prior authorization requests, call UnitedHealthcare Community Plan Member Services at 800-690-1606.
Applied behavior analysis (ABA) — submit via fax or Provider Express
ALL of the following
In case of an emergency, call your local mobile crisis line; refer to the Key Contact Information section of the Tennessee Medicaid Administrative Guide for region-specific crisis lines.
ALL of the following
Contact information: For behavioral-related prior authorization requests and HCBS assistance, call UnitedHealthcare Community Plan at 800-690-1606.
Cancer supportive care prior auth criteria — Cancer supportive care medication prior authorization
Cancer supportive care medications (including colony-stimulating factors, pegfilgrastim, anti-emetics, bone-modifying agents, and selected chemotherapy-related injectables) require prior authorization when administered in outpatient settings for a cancer diagnosis. Specific HCPCS/J-codes listed below require prior authorization.
ALL of the following
Prior authorization is required for colony-stimulating factor drugs and other cancer supportive care medications administered in an outpatient setting for a cancer diagnosis.
Codes that commonly require prior authorization include, but are not limited to: J1442, J1447, J2506, J1627, J1456, J0897, J1449, J0885, J2506 and Q-codes listed (Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125, Q5120 etc.).
Pegfilgrastim/filgrastim biosimilars and originator products (examples: J2506, Q5101, Q5110, Q5122, Q5108, J1447, Q5125) require prior authorization; some codes also require authorization when used for non-oncology diagnoses — see injectable medications section.
Anti-emetic injectable agents (examples: J1454, J0185, J1627, J1456) and bone-modifying agents (example: J0897 for denosumab/Xgeva) require prior authorization.
Cardiology procedures and selected diagnostic/interventional services (outpatient and office-based) require prior authorization for participating physicians. Submit requests via the UnitedHealthcare Provider Portal or call the provided number.
ALL of the following
Prior authorization is required for participating physicians for outpatient and office-based diagnostic catheterizations, echocardiograms, electrophysiology device implants, and stress echocardiograms prior to performance.
Examples of CPT codes referenced in the cardiology prior authorization list include multiple device and catheterization codes (e.g., 33206, 33207, 33208, 33212, 33213, 33214, 33221, 33224, 33225, 33227, 33228, 33229, 33230, 33231, 33240, 33249, 33262-33264, 33270, 93319, 93350, 93351, 93452-93461).
For prior authorization, submit requests online using the UnitedHealthcare Provider Portal at UHCprovider.com or call 866-889-8054. For more details and a full CPT code list, visit Cardiology Prior Authorization and Notification resources on the portal.
ALL of the following
Prior authorization coverage criteria (partial) — Coverage and prior authorization stance for listed services
This partial coverage and prior authorization summary highlights select service categories: cardiovascular monitoring, chemotherapy/injectable chemotherapy drugs, and durable medical equipment (DME) incontinence supplies. Additional details and full lists of codes are maintained on the Provider Portal.
ALL of the following
Cerebral seizure monitoring: Prior authorization is required for inpatient video EEG/cerebral seizure monitoring (examples: CPT 95700, 95711-95713, 95715-95718). Outpatient hospital or ambulatory surgical center video EEG monitoring does not require prior authorization.
Chemotherapy: Prior authorization is required for injectable chemotherapy drugs administered in outpatient settings for a cancer diagnosis. This includes J9000-J9999 range, Leucovorin (J0640) and Levoleucovorin (J0641, J0642), Lupron Depot (J1950), Q-code chemotherapy injectables, and miscellaneous HCPCS-billed chemotherapy agents.
Durable medical equipment (DME) — incontinence supplies are a benefit only when provided through Edgepark Medical Supplies. To request incontinence supplies, call Edgepark at 844-564-1008. Incontinence supplies billed with certain diagnoses may not require prior authorization per policy notes.
ALL of the following
Coverage stance by code/service — Coverage/prior authorization stance by code or service category as presented in these chunks
Coverage stance and prior authorization requirements by code/service category. The policy contains many explicit HCPCS/CPT/ICD references; below are consolidated operational rules and examples.
ALL of the following
DME prior authorization: Prior authorization is required only for DME codes listed with a retail purchase or a cumulative rental cost of more than $500.
Enteral and in-home nutritional services (examples: B4034, B4035, B4036, B4100-B4153 range) require prior authorization for in-home/enteral therapy; certain billings with skin cancer diagnoses may be exempt from prior authorization as noted in the source document.
Experimental and investigational services: Prior authorization is required for services identified as experimental/investigational (examples include various procedure and HCPCS codes listed in the experimental section).
Functional procedures such as FESS (Functional Endoscopic Sinus Surgery, CPT 31240, 31253-31255) require prior authorization.
HCBS / Home health prior authorization criteria (summary) — HCBS / CHOICES / ECF CHOICES prior authorization criteria (summary)
Home- and Community-Based Services (HCBS) including CHOICES and ECF CHOICES require prior authorization. Authorization is individualized and based on a comprehensive needs assessment conducted by the plan care coordinator.
ALL of the following
Prior authorization is required for HCBS services. Authorization for each service (description, amount, frequency, duration) is determined by the individual's needs and is based on a full assessment of the individual's physical, mental, and social needs as well as the availability and willingness of natural supports.
The assessment process is facilitated by the Health Plan CHOICES Care Coordinator or ECF CHOICES Support Coordinator.
For HCBS assistance or to request prior authorization for CHOICES or ECF CHOICES services, call UnitedHealthcare Community Plan at 800-690-1606.
Genetic and molecular testing (including BRCA) requires prior authorization or laboratory notification to UnitedHealthcare. A broad range of U-codes and other molecular test CPTs are included.
ALL of the following
Genetic and molecular testing to include breast cancer (BRCA) requires prior authorization. Laboratories will notify UnitedHealthcare as noted in the policy.
Representative CPT/U-code examples include 81162, 81163, 81164 and multiple proprietary U-codes (e.g., 0269U, 0270U–0300U, S3870) — see the policy/code list for the full set of applicable codes.
For prior authorization submission and specific laboratory notification workflows, follow the instructions in the genetic testing section of the Provider Portal or contact the plan as directed.
ALL of the following
Home health prior authorization — Home health care prior authorization statement
Home health care prior authorization summary and how to request HCBS assistance.
ALL of the following
Prior authorization is required for home health care in outpatient/home settings; see the home health care code examples (G0159, G0160, G0493-G0496, etc.) provided in the policy.
To request HCBS or home health prior authorization and assessment assistance, call UnitedHealthcare Community Plan at 800-690-1606 and request CHOICES or ECF CHOICES support as applicable.
ALL of the following
Operational note: Authorization is based on a full needs assessment facilitated by the plan care coordinator; documentation of medical necessity and care plans will be required for authorization determinations.
Operational prior authorization and notification criteria — Operational coverage/authorization instructions
Operational prior authorization and notification instructions: use the Provider Portal for most prior authorization submissions; phone numbers are provided for specific service categories and programs.
ALL of the following
For prior authorization submissions, use the UnitedHealthcare Provider Portal (UHCprovider.com) Prior Authorization and Notification tool; phone options are provided for specific programs or questions (e.g., 800-690-1606 for Community Plan Member Services; 866-889-8054 for some cardiology prior auths; 888-397-8129 for certain drug prior auths as noted).
Review at Launch for New to Market Medications: predetermination is highly recommended for drugs on the Review at Launch list; follow the policy for newly approved medications.
Inpatient hospital services and post-acute facility admissions require prior authorization/notification for specified facility types — verify requirements on the portal.
ALL of the following
Prior authorization requirement nodes — Procedures and services requiring prior authorization in this excerpt
This node lists categories of procedures and services that require prior authorization as identified across the source excerpts, including joint replacement, musculoskeletal surgeries, ambulance transports, and orthognathic surgery.
ALL of the following
Musculoskeletal and joint replacement procedures (including total hip and knee replacements and many shoulder surgeries) require prior authorization.
Ambulance transport: non-emergent ground and air ambulance transports require prior authorization; example HCPCS codes include A0430, A0431, A0435, A0436, S9960 and others as listed in the policy.
Orthotics/Prosthetics Prior Authorization Criteria — Prior authorization requirement for orthotics and prosthetics purchases/rentals above threshold
Orthotics and prosthetics (O&P) prior authorization is required only for items with a retail purchase or cumulative rental cost exceeding $500. The policy contains many specific L-codes that are subject to this rule.
ALL of the following
Prior authorization is required only for orthotic and prosthetic items with a retail purchase or a cumulative rental cost of more than $500.
Representative HCPCS L-codes referenced include L0112, L0170, L0456, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631, L0632, L0634, L0636, L0637 and others listed in the policy. These codes may require prior authorization when the $500 threshold is exceeded.
For prior authorization submission for O&P, follow the Provider Portal process and include cost documentation when applicable to demonstrate whether the $500 threshold is met or exceeded.
ALL of the following
Orthotics and prosthetics prior authorization criteria — HCPCS/L-codes and dollar threshold references
Detailed orthotics and prosthetics code guidance and reiteration of the $500 prior authorization threshold.
ALL of the following
Prior authorization required only for orthotic and prosthetic items that exceed a retail purchase price or cumulative rental cost of $500. Codes frequently referenced across the policy include L0112, L0464, L0486, L0170, L0480, L0624, L0456, L0482, L0629, L0484, L0631, L0632, L0634, L0636, L0637, and others.
Operational note: When submitting a prior authorization request for O&P items near the threshold, include detailed cost documentation and rental history to support the authorization determination.
Provider actions
Confirm whether the item is being billed as a purchase or rental and provide invoices or rental cumulative totals in the prior authorization request.
Coverage statements — not present in this excerpt — coding/billing details only
Coverage statements: the document excerpt primarily contains coding and operational rules rather than standalone coverage determinations. The following summarizes coverage-related coding guidance present in the source.
ALL of the following
Many service categories in the policy include code-level guidance tied to prior authorization requirements rather than isolated coverage statements; providers should reference the specific code lists and the Provider Portal for definitive coverage determinations.
Where coverage exceptions exist (for example, incontinence supplies provided through Edgepark or DME items billed with specific diagnoses), those operational notes are included in the relevant sections above.
ALL of the following
Administrative note: This excerpt did not include comprehensive 'covered vs not covered' statements for many services; code-level and procedural prior authorization guidance should be used to determine preauthorization needs and subsequent coverage adjudication.
ALL of the following
Administrative notes (no coverage criteria) — Administrative/coding fragment referencing codes and cost threshold
Administrative and coding notes: repetitive references in the source emphasize the $500 threshold for O&P prior authorization and list multiple L-codes subject to that rule. This block consolidates those administrative reminders.
ALL of the following
Administrative note: Prior authorization is required for orthotic and prosthetic items when a retail purchase or cumulative rental cost exceeds $500. Multiple repeated entries in the source reinforce this threshold across numerous codes.
Administrative note: For DME and O&P requests, include cost documentation and use the Provider Portal for submission. Edgepark Medical Supplies is the vendor for incontinence supplies — call 844-564-1008 to request supplies.
Administrative note: For program-specific authorization (e.g., HCBS/CHOICES), call UnitedHealthcare Community Plan at 800-690-1606 for assistance and to initiate the assessment/authorization process.
ALL of the following
Code Listings and Coding Notes
Covered HCPCS / J-codes - Cancer Supportive Care and Colony-Stimulating FactorsHCPCSCovered
J1442
Filgrastim (Neupogen)
J1447
Tbo-filgrastim (Granix)
J2506
Pegfilgrastim (Neulasta)
Q5101
Filgrastim-sndz (Zarxio)
Q5108
Pegfilgrastim-jmdb (Fulphila)
Q5110
Filgrastim-aafi (Nivestym)
Q5111
(Q5111) biosimilar
Q5120
(Q5120) biosimilar
Q5122
Pegfilgrastim-apgf (Nyvepria)
Q5125
Filgrastim-ayow (Releuko)
1–10 of 16
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Submission Instructions and Provider Responsibilities
Prior Authorization
Submit prior auth via Provider Portal or phone
Submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-604-3267. Prior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all procedures and services.
Prior Authorization
Behavioral health inpatient/residential prior authorization
Prior authorization is required for voluntary psychiatric hospitalizations and specified behavioral health inpatient/residential services (including inpatient detoxification, inpatient psychiatric, psychiatric residential treatment, and substance abuse residential detoxification and treatment). For behavioral-related prior authorization call UnitedHealthcare Community Plan Member Services at 800-690-1606.
Prior Authorization
Cancer supportive care drugs require prior authorization
Definitions and Terms
Prior authorization — definition
DefinitionPrior authorization: approval required by the payer before payment for certain listed services or codes
Submission methodsRequests can be submitted using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone as specified
ExceptionsPrior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all procedures and services
Documentation timingFor involuntary psychiatric hospitalizations, documentation supporting inpatient psychiatric hospitalization must be submitted the next business day
Medical necessity timing
Policy Summary
PayerUnitedHealthcare
PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Tennessee
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionSubmit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 866-604-3267.
For prior authorization submission, use the UnitedHealthcare Provider Portal Prior Authorization and Notification tool at UHCprovider.com or call the number provided for injectable medications/prior auth inquiries.
Operational notes
Some codes flagged in the policy (unclassified or miscellaneous codes such as C9090, C9094, C9149, J3490, J3590) have specific prior authorization rules (e.g., prior authorization only required for certain drugs like Rivfloza).
See the Review at Launch for New to Market Medications policy for newly FDA-approved drugs; predetermination is recommended for drugs on that list.
Operational note: inpatient cardiac services may have separate admission/authorization processes — verify via the portal or provider relations.
Operational note: For chemotherapy and complex oncology injectables, follow the portal prior authorization workflow; some J/Q codes may also require authorization for non-oncology diagnoses — consult the injectable medications section.
Procedures in the gynecologic and related groups (examples: CPTs 56800, 56805, 57110, 57335, 58661, 58720, 58940) have prior authorization requirements as listed.
Genetic and molecular testing (including BRCA-related codes such as 81162-81164 and multiple U-codes 0269U–0300U and others) require prior authorization or laboratory notification to UnitedHealthcare per the policy.
Home health care: Prior authorization is required only in outpatient settings including the patient's home; example service codes referenced include G0159, G0160, G0493-G0496, S9122-S9131, S9474, S9127, S9129, and related codes as listed in the source.
Operational note: laboratories may be instructed to notify UnitedHealthcare directly for certain molecular tests; providers should confirm authorization requirements before ordering.
Operational note: For injectable medications, follow the specific prior authorization instructions in the injectable medications list; unclassified/miscellaneous codes may have special prior authorization rules.
Operational note: Confirm site-specific inpatient vs outpatient authorization rules and submit via the Provider Portal or the applicable prior authorization phone number.
Administrative note: The $500 threshold applies to either a single retail purchase or the cumulative rental cost; ensure billing reflects purchase vs rental and include supporting invoices or rental agreements when requesting authorization.
Use the Provider Portal for submission and attach supporting documentation for cost and medical necessity.
ALL of the following
Administrative note: If coding or pricing changes occur (e.g., new L-codes or updates), providers should consult the Provider Portal or provider relations for the most current list of codes subject to the $500 rule.
$500
Applies to retail purchase or cumulative rental cost
Providers seeking formal coverage determinations should submit predetermination requests via the Provider Portal or contact provider services for clarification.
Administrative instruction: When submitting prior authorization requests for multiple codes or high-cost equipment, consolidate documentation, clearly indicate purchase vs rental, and include expected cumulative rental duration and cost calculations.
ALL of the following
Administrative reminder: Use the Provider Portal (UHCprovider.com) for most prior authorization submissions; phone numbers listed in relevant sections can be used for assistance or when the portal workflow indicates phone submission is required.
Prior authorization is required for many cancer supportive care drugs including colony-stimulating factors, pegfilgrastim/filgrastim biosimilars, anti-emetics and bone-modifying agents when administered in an outpatient setting for a cancer diagnosis. Submit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-397-8129 as noted.
Prior Authorization
Cardiology procedures require prior authorization
Participating physicians must obtain prior authorization for outpatient and office-based cardiology procedures including diagnostic catheterizations, echocardiograms, electrophysiology implants, and stress echoes. Submit via the Provider Portal or call the cardiology prior authorization number 866-889-8054.
Injectable chemotherapy drugs administered in an outpatient setting require prior authorization, including chemotherapy J‑codes (J9000–J9999) and specified agents such as Leucovorin (J0640), Levoleucovorin (J0641, J0642) and Lupron Depot (J1950). Submit requests via the UnitedHealthcare Provider Portal (UHCprovider.com).
Includes chemotherapy drugs with Q codes and miscellaneous HCPCS billed items
Cerebral seizure monitoring requires prior authorization when performed in the inpatient setting (CPT codes include 95700, 95711, 95712, 95713, 95715, 95716, 95718). Prior authorization is not required for outpatient hospital or ambulatory surgical center settings.
Prior Authorization
Cochlear implants require prior authorization
Cochlear implants and related auditory procedures require prior authorization (examples: CPT 69710, 69714, 69930; HCPCS L8614).
Billing Rule
Incontinence supplies — Edgepark vendor and DME prior auth threshold
Incontinence supplies are a covered benefit only when provided through Edgepark Medical Supplies; to request incontinence supplies call Edgepark at 844-564-1008. Prior authorization is required for DME items when the retail purchase or cumulative rental cost is more than $500; some incontinence DME codes will not require prior authorization when billed with skin cancer diagnoses.
Some incontinence HCPCS codes exempt if billed with skin cancer diagnosis
Prior Authorization
Cosmetic procedures require prior authorization
Cosmetic procedures listed require prior authorization; reconstructive procedures that treat a medical condition or improve/restore physiologic function are listed and handled per the document’s indications.
Billing Rule
Codes exempt from prior authorization with skin cancer diagnosis
Numerous CPT/HCPCS/E-codes enumerated in the document will NOT require prior authorization when billed with skin cancer diagnoses; those specific code exemptions are listed in the policy.
For enteral and in‑home nutritional services, some codes will not require prior authorization when billed with skin cancer diagnoses (examples: B4034, B4035, B4036, B4100); other enteral/in-home nutritional items are labeled 'Prior authorization required.'
Services identified as experimental or investigational (and/or linked services) are marked 'Prior authorization required' in the document and list multiple CPT/HCPCS codes (examples include 33477, 36514, 64722 and placeholders B9002/B9998).
Specific clinical services are annotated as requiring prior authorization, including femoroacetabular impingement (FAI) procedures, functional endoscopic sinus surgery (FESS), gender dysphoria treatment, various surgical codes, and genetic/molecular testing (including BRCA-related CPTs).
Prior Authorization
HCBS prior authorization — call 800‑690‑1606
For Home- and Community‑Based Services (HCBS) including CHOICES and ECF CHOICES, prior authorization is required; call UnitedHealthcare Community Plan at 800-690-1606 for assistance. Prior authorization for each service (description, amount, frequency and duration) is determined by the individual's full assessment.
Genetic and molecular testing (including BRCA) requires prior authorization/notification; the performing laboratory will notify UnitedHealthcare for specified codes listed in the document.
Examples of listed codes include 81162, 81228, 81406 and multiple U‑codes (0269U–0300U)
Prior Authorization
Home health prior authorization required in outpatient/home settings
Home health care requires prior authorization in outpatient settings, including the patient's home (examples: G0159, G0160, G0493–G0496, S9122–S9124).
A large list of injectable medications included in the document are subject to prior authorization; examples appear in the injectable medications section (e.g., J3262 Actemra, J0801 Acthar, J0172 Aduhelm, J3380 Entyvio).
See injectable medications section for full HCPCS/J‑code list and submission instructions
Prior Authorization
How to obtain prior authorization — Portal or service‑specific phone numbers
Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call the numbers shown for specific services (e.g., 866-604-3267 general; 888-397-8129 for cancer supportive care; 866-889-8054 for cardiology). Predetermination is highly recommended for drugs on the Review at Launch Medication List.
General phone: 866-604-3267
Cancer supportive care phone: 888-397-8129
Cardiology prior auth phone: 866-889-8054
Predetermination recommended for Review at Launch drugs
Prior Authorization
Inpatient and post‑acute services require prior authorization/notification
Prior authorization is required for inpatient hospital services including acute medical/surgical levels, maternity, rehabilitation, skilled nursing facility and other post‑acute inpatient services; notification of admission date is required for specified facilities.
Musculoskeletal procedures called out in the document (including joint replacement and shoulder surgery) are labeled 'Prior authorization required.'
Prior Authorization
Non‑emergent air ambulance transport requires prior authorization
Non‑emergent air ambulance transport requires prior authorization; example HCPCS codes include A0430, S9960, A0431, A0435 and A0436.
Prior Authorization
Orthognathic/maxillofacial surgery requires prior authorization
Orthognathic and maxillofacial surgery for treatment of jaw functional impairment requires prior authorization; CPT examples listed include 21121, 21123, 21125, 21127, 21141, 21142, 21143 and 21145.
Prior authorization is required only for orthotics and prosthetics when the retail purchase or cumulative rental cost exceeds $500 (examples of HCPCS/L‑codes listed such as L0112, L0464, L0486, L0624, L0631).
Threshold: retail purchase or cumulative rental cost > $500
Documentation Required
Orthotics/prosthetics — threshold and listed L‑codes
Restating: prior authorization for orthotics and prosthetics applies only when retail purchase or cumulative rental cost is more than $500; multiple HCPCS L‑codes are listed in the policy for reference.
Zolgensma — HCPCS/L‑code and prior authorization references
For Zolgensma and related HCPCS/CPT coding, the document references HCPCS L‑codes (L0632, L0634 and others) and notes L0634 as a prior authorization reference; see the listed HCPCS codes in the policy for details.
Referenced HCPCS L‑codes include L0632, L0634, L0636, L0637
Documentation Required
HCPCS/L‑codes referenced for coding and prior authorization
Multiple HCPCS L‑codes are listed across the document in relation to coding and prior authorization (examples include L0624, L0629, L0631, L0632, L0634, L0636, L0637 and L0486); follow the policy coding entries and submission instructions for authorizations.
Prior Authorization
Zolgensma coding/prior auth notes and cost threshold
The policy repeats coding and prior authorization references for Zolgensma across several L‑codes (L0486, L0624, L0634, L0629, L0631, L0632); additional information notes a purchase or cumulative rental cost threshold of more than $500 where applicable.
Coding references and prior authorization instructions (L‑codes)
The document includes multiple coding and prior authorization references—see the listed CPT/HCPCS/L‑codes (e.g., L0624, L0634, L0629, L0631, L0632, L0486) and follow the policy instructions for obtaining prior authorization for these items.
The policy notes the purchase or a cumulative rental cost of more than $500 as the threshold triggering additional prior authorization/coding rules for applicable items (orthotics, prosthetics, certain HCPCS L‑codes).
Threshold: purchase or cumulative rental cost > $500
Documentation Required
Zolgensma HCPCS codes and prior authorization guidance
Additional repeated entries reference Zolgensma HCPCS codes and indicate prior authorization procedures tied to those HCPCS/L‑codes; follow the HCPCS listings in the policy and submission instructions for authorization requests.
See L0624, L0634, L0629, L0631, L0632, L0636, L0637, L0486 for specific coding guidance
Note
Note
UnitedHealthcare Community Plan applies medical necessity criteria after the first 24 hours of an involuntary admission per the contractor risk agreement (CRA)
Contact for behavioral prior authFor behavioral-related prior authorization requests call UnitedHealthcare Community Plan Member Services at 800-690-1606
Edgepark Medical Supplies — incontinence supplies vendor
VendorEdgepark Medical Supplies (incontinence supplies are a benefit only when provided through Edgepark)
ContactTo request incontinence supplies call Edgepark Medical Supplies at 844-564-1008
Prior authorization noteCertain DME incontinence codes will not require prior authorization when billed with skin cancer diagnoses; otherwise DME prior authorization applies when purchase/rental threshold exceeded
Cerebral seizure monitoring prior auth rule
Setting distinctionInpatient cerebral seizure monitoring requires prior authorization, while outpatient hospital or ambulatory surgical center monitoring does not require prior authorization
Example CPT codes95700, 95711, 95712, 95713, 95715, 95716, 95718 (listed for cerebral seizure monitoring)
Provider actionObtain prior authorization for inpatient monitoring; no prior authorization needed for outpatient settings per document
Not requiring prior authorization with skin cancer diagnosis — explanation
Exemption meaningCodes listed 'will NOT require prior authorization when billed with skin cancer diagnoses' are exempt from prior authorization if billed with designated skin cancer diagnosis codes
ExamplesE0329, E0445, E0457, E0465, E0466, E0470, E0471, E0483, E0486, etc. (enumerated in document)
ImplicationWhen billed with qualifying skin cancer diagnoses, these codes do not need prior authorization as noted
Prior authorization required — meaning
Meaning'Prior authorization required' indicates the payer requires prior approval before payment for the listed service or code
ExamplesExperimental/investigational services listed with B9002/B9998 placeholders and numerous CPT/HCPCS codes are annotated as prior authorization required
ActionProviders must obtain prior authorization before performing/billing these services to avoid denial risk
Prior authorization (HCBS context)
HCBS contextPrior authorization is required for HCBS (CHOICES/ECF CHOICES) and is determined per service based on a full assessment of individual needs
ContactFor HCBS assistance call UnitedHealthcare Community Plan at 800-690-1606
Injectable medicationsMany injectable medications listed in the document also require prior authorization
Laboratory notification — genetic/molecular tests
Laboratory notificationFor specified genetic/molecular tests (including BRCA-related CPTs), the performing laboratory will notify UnitedHealthcare
Prior authorization/notificationGenetic and molecular testing requires prior authorization/notification as indicated in the document
Example codes0273U, 0278U, 0293U and other U-codes listed for genetic/molecular testing
Review at Launch for New to Market Medications — policy reference
Policy referenceReview at Launch for New to Market Medications — check policy for up-to-date inclusion on the Review at Launch Medication List
RecommendationPredetermination is highly recommended for drugs on the Review at Launch list
Submission methodsSubmit prior authorization requests via the Prior Authorization and Notification tool on UHCprovider.com or call the specified phone number
Prior authorization — summary
RestatementPrior authorization is approval required before payment for certain services; providers must follow submission instructions in this document
Submission optionsOnline via UHCprovider.com Prior Authorization and Notification tool or by calling the phone numbers listed in the document
Emergency exceptionPrior authorization is not required for emergency or urgent care
Prior authorization threshold for orthotics/prosthetics
Threshold definitionPrior authorization is required only for orthotic and prosthetic retail purchases or cumulative rentals exceeding $500
ActionWhen cost threshold exceeded, follow prior authorization process in the document
Additional information — rental cost > $500
Additional infoRental cost of more than $500 is repeatedly noted as triggering additional prior authorization/coding considerations
ContextThis note appears especially in sections referencing Zolgensma HCPCS/L-codes
Provider actionProvide rental/purchase cost details and obtain prior authorization when rental cost exceeds $500
HCPCS/CPT coding for Zolgensma
Coding referencesHCPCS/L-codes for Zolgensma and related products are listed with prior authorization/coding guidance (examples: L0624, L0634, L0629, L0631, L0486)
ActionFollow the CPT/HCPCS coding and prior authorization instructions in the document when billing Zolgensma or related L-codes
Cost thresholdSeveral Zolgensma entries reference purchase or cumulative rental cost thresholds (> $500) that affect authorization/coding
Purchase or cumulative rental cost — definition
DefinitionPurchase or cumulative rental cost — the combined purchase price or accumulated rental charges used to determine whether threshold-based prior authorization rules apply (threshold noted as more than $500)
ImplicationWhen the purchase or cumulative rental cost exceeds $500, additional information and prior authorization are required
Document usageThis threshold language is repeated across multiple HCPCS/L-code entries in the document
Additional information required when purchase/cumulative rental cost > $500
Additional info requiredWhen purchase or cumulative rental cost exceeds $500, additional information is required and prior authorization applies
ExamplesEntries referencing L0486 and other L-codes include this requirement in the Zolgensma-related sections
Provider actionSubmit required cost details and obtain prior authorization per instructions when threshold exceeded
Purchase or cumulative rental cost > $500 — repeated threshold
Threshold statementPurchase or a cumulative rental cost of more than $500 (repeated across multiple lines)
Applies toOrthotics/prosthetics and specified HCPCS/L-code items including Zolgensma-related codes