CurrentUnitedHealthcarePolicy N/A

Prior Authorization Requirements for Rhode Island Medicaid

Lists prior authorization requirements and submission methods for participating UnitedHealthcare Community Plan of Rhode Island providers for inpatient and outpatient services, including specific service categories and codes that require prior authorization.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Requirements for Rhode Island Medicaid

Policy CodePolicy N/A

Change TypeAdministrative update — no material coverage changes

Effective DateEffective July. 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone at 855-766-0344.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Online portalprimary submission method

855-766-0344phone number for prior authorization

> $500DME threshold

J9000-J9999Injectable chemotherapy range

ExemptESRD exemption

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Prior Authorization Coverage Criteria

Prior authorization coverage criteria (summary)

Services and drugs that require prior authorization for Rhode Island Medicaid participating providers include but are not limited to:

ANY of the following

Outpatient-administered colony-stimulating factor drugs and related agents require prior authorization (see specific J-/Q-codes).
Examples: J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122
Injectable erythropoiesis-stimulating agents and specified bone-modifying agents require prior authorization.
Examples: J0885 (Procrit); J0897 (Denosumab/Xgeva)
Selected cardiology diagnostic and interventional procedures require prior authorization prior to performance.
Includes outpatient/office diagnostic catheterizations, echocardiograms, electrophysiology implants, stress echoes, lower extremity angiogram
Many surgical, radiology, genetic/molecular tests, DME, enteral and other procedure codes listed in the document require prior authorization or notification.
See specific sections and code lists in the policy document

EEG authorization criteria

EEG / cerebral seizure monitoring coverage notes

Prior authorization required for inpatient cerebral seizure monitoring (inpatient video EEG).

Document lists inpatient EEG CPTs (e.g., 95700–95726) and states prior authorization is required for inpatient services.

Prior authorization is NOT required for outpatient hospital or ambulatory surgical center EEG (inpatient-specific rule does not apply to outpatient/ASC).

Policy explicitly states prior authorization is not required for outpatient hospital or ambulatory surgical center EEG.

Injectable chemotherapy authorization criteria

Injectable chemotherapy prior authorization criteria

Prior authorization required for injectable chemotherapy drugs administered in an outpatient setting for a cancer diagnosis.

Includes intravenous, intravesical and intrathecal administration; examples: chemotherapy injectable drugs J9000–J9999, leucovorin J0640, levoleucovorin J0641/J0642, Lupron Depot J1950, leuprolide acetate J1954, lanreotide J1932, Q‑coded chemotherapy and miscellaneous HCPCS-billed drugs.

Requests should be submitted online via the UnitedHealthcare Provider Portal per policy instructions.

Policy directs submission through UHCprovider.com.

Device authorization criteria

Device coverage notes

Prior authorization required for cochlear and other auditory implants.

Document lists cochlear implant CPTs (69710, 69714, 69930) and HCPCS (L8690–L8692, L8614) with prior authorization required.

Prior authorization required for continuous glucose monitoring (CGM) devices when used with a Type 2 Diabetes diagnosis.

Policy lists CGM HCPCS examples (A4226, A9278, A4239, A9276, A9277, E2102, E2103) and states prior authorization is required with Type 2 Diabetes Dx (E11.*).

Prior authorization criteria (excerpt)

Cosmetic and reconstructive procedures — prior authorization requirements and exceptions

Certain cosmetic and reconstructive procedures require prior authorization (specific CPT codes are enumerated in the document).

Document lists numerous CPTs for cosmetic and reconstructive services and marks them 'Prior authorization required'.

Some reconstructive/cosmetic procedures are exempt from prior authorization when billed with specified diagnosis codes (e.g., listed C43.*, C44.*, C4A.*, D04.* ranges).

Policy indicates prior authorization not required when billed with the Dx codes listed in the document.

Durable medical equipment (DME) requires prior authorization only when the equipment cost exceeds $500 and for specified HCPCS codes.

DME HCPCS lists and the >$500 threshold are noted in the policy.

Authorization requirement summary

Prior authorization required for the listed procedure and testing codes.

ANY of the following

Selected surgical procedures (e.g., femoroacetabular impingement procedures, FESS, gender dysphoria treatments) require prior authorization.
Policy provides CPT examples (29914–29916, 31240–31288, 14000 series, etc.) and marks them as prior authorization required.
Genetic and molecular testing (including BRCA and related outpatient testing) requires prior authorization/notification when performed in an outpatient setting.
Document lists numerous CPT/HCPCS codes for genetic/molecular tests and states prior authorization required.
Enteral services and in-home nutritional therapy codes require prior authorization.
Examples include B4034, B4035, B4036, B4100 and related codes listed in the policy.

Prior Authorization and Coverage Notes

Prior authorization requirements and obtainment instructions for services listed

Prior authorization required for home health care services when provided in outpatient settings (codes include G0299, G0300, G0493–G0496, S9122–S9124, S9474).

Policy states PA required only in outpatient settings for home health and provides specific codes.

Hospice services require prior authorization (codes T2042–T2045).

Document explicitly lists hospice HCPCS codes and marks PA required.

For injectable medications listed in the document, submit prior authorization requests online via the UnitedHealthcare Provider Portal or by phone (888-397-8129).

Submission instructions are provided in the injectable medications section.

Administrative coverage criteria

Administrative coverage stance and submission requirements

Prior authorization is required for select unclassified/temporary HCPCS codes (e.g., J3490, J3590, C9399) when used for specified new-to-market medications listed in the policy.

Document names specific agents and advises PA required for those codes.

Prior notification (with service detail) is required for post-acute inpatient services; prior authorization and notification of admission date required for specified facility types (acute care hospitals, inpatient rehab, CAHs, LTACHs, SNFs).

Policy outlines notification and PA requirements for post-acute settings.

Prior authorization is not required for services associated with an ESRD diagnosis (exemption).

Policy explicitly states PA not required for ESRD diagnosis.

Providers should submit prior authorization requests online using the UnitedHealthcare Provider Portal or call the designated phone number per policy instructions.

Submission guidance and portal/phone contact referenced in the administrative section.

Prior authorization criteria (document segment)

Prior authorization/notification requirements for specified services and site-of-service rules.

Care providers ordering advanced outpatient imaging procedures (CT/MRI/MRA/PET and certain nuclear medicine) must provide notification prior to scheduling; submit via the UnitedHealthcare Provider Portal or by phone (866-889-8054).

Document requires notification prior to scheduling and provides portal/phone contact.

Standard radiation therapy (2D/3D IMRT) requires prior authorization only when obtained with specified diagnosis code ranges (examples listed: C34.00–C34.92, C50.011–C50.929, C61, C79.51–C79.52, C84.7A, D05.00–D05.92) and CPTs (77401, 77402, 77407, 77412).

Policy describes diagnosis-range trigger for radiation therapy PA.

Site-of-service rule: prior authorization is required when requesting a service in an outpatient hospital setting; prior authorization is not required if the procedure is performed at a participating ambulatory surgery center (ASC).

Policy clarifies SOS outpatient hospital vs ASC PA requirement.

Selected prostate and other procedure CPTs listed in the document require prior authorization as indicated (examples provided in the code lists).

Prior authorization for sleep-related procedures

Prior authorization requirements appearing in this section

Prior authorization required for sleep apnea procedures and surgeries as indicated in the policy list.

Policy marks sleep apnea procedures and surgeries as 'Prior authorization required'.

Prior authorization required for sleep studies (polysomnography) as listed (examples: 95805, 95807, 95808, 95810).

Document explicitly lists sleep study CPTs and states PA required.

Partial prior authorization criteria and notes

Prior authorization requirements and special routing notes (partial).

Prior authorization required for transplant and CAR T‑Cell therapy services; certain unclassified J‑codes and C9399 for specified agents require Optum Transplant prior authorization routing.

Document lists CAR T agents (Abecma, Breyanzi, Carvykti, Kymriah, Tecartus) and instructs Optum Transplant PA for certain codes/agents; also notes some unclassified codes require Optum Transplant PA.

Vein procedures require prior authorization (examples include CPTs 36473, 36475, 36478 and 37700 series).

Policy provides example vein procedure CPTs and marks them as PA required.

Code-specific condition: CPT code 38232 requires prior authorization only when billed for an oncology diagnosis.

Policy explicitly calls out the oncology-only PA condition for code 38232.

Extensive lists of other CPT/HCPCS codes related to device implantation, surgical and transplant procedures are provided in the document with PA requirements; see the full code lists for specifics.

Codes and Code-Based Rules

Covered HCPCS/DME codes requiring prior authorizationHCPCSCovered

A9279	Durable medical equipment — required prior authorization
A9280	Durable medical equipment — required prior authorization
A9900	Miscellaneous DME supply code — prior authorization required
E0194	Crutch replacement/repair — prior authorization required
E0265	Powered pressure-reducing support surface, specialized — prior authorization required
E0266	Powered pressure-reducing support surface, replacement — prior authorization required
E0270	Patient lift, stand-assist — prior authorization required
E0277	Sit-to-stand patient lift — prior authorization required
E0300	Wheelchair accessory — prior authorization required
E0328	Manual wheelchair, hemi-height — prior authorization required

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How to Obtain Prior Authorization / Provider Responsibilities

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 the numbers listed below. Prior authorization is required for many outpatient and inpatient services; emergency and urgent care are exceptions. Out-of-network providers must request prior authorization for all procedures and services.

Online: Sign in at UHCprovider.com with a One Healthcare ID and select Prior Authorization and Notification on your dashboard.
Call: 855-766-0344 for general prior authorization; see specific categories below for alternative contact numbers (e.g., 888-397-8129 for injectable medications).

Prior Authorization

Surgical Procedure Prior Authorization

Prior authorization is required for many surgical procedures when billed with the listed diagnosis codes. Examples include femoroacetabular impingement (CPT 29914, 29915, 29916); functional endoscopic sinus surgery (FESS) (CPT 31240, 31253–31259, 31267, 31276, 31287–31288); many gender dysphoria–related procedures (multiple CPT codes listed); joint replacement and total hip/knee procedures (multiple CPT codes listed); shoulder surgery (CPT 29805–29819); septoplasty/rhinoplasty (CPT 30400–30462, 30465); and numerous other surgical categories. Providers must obtain prior authorization before scheduling these elective procedures.

Key Terms and Definitions

Definition — Prior authorization

DefinitionPrior authorization is the process by which providers request approval from UnitedHealthcare before performing certain services; not required for emergency or urgent care.

Submission methodsRequests may be submitted online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone (855-766-0344).

Out-of-network ruleOut-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services.

Inpatient EEG — Requirement

ServiceInpatient video EEG / cerebral seizure monitoring requires prior authorization when performed inpatient.

Outpatient exceptionPrior authorization is not required for outpatient hospital or ambulatory surgical center EEG (document note).

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Requirements for Rhode Island Medicaid

Policy CodePolicy N/A

Change TypeAdministrative update — no material coverage changes

Effective DateEffective July. 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone at 855-766-0344.

SourceLink

On This Page

Document includes examples of CPTs requiring PA (e.g., 37243, 52441/52442, 53850, septoplasty/rhinoplasty series).

This block is a partial excerpt; full document contains comprehensive code lists and submission instructions.

Surgical prior authorization applies to outpatient and many inpatient elective surgeries — check the specific CPT code and associated diagnosis codes before scheduling.
Some procedures may be exempt from prior authorization when billed with specific diagnosis codes — verify the exception lists in the portal or policy.
Submit surgical prior authorization requests online at UHCprovider.com or call the appropriate prior authorization phone number.
Failure to obtain required prior authorization may result in claim denial or delayed payment.

Prior Authorization

Genetic and Molecular Testing Prior Authorization / Notification

Genetic and molecular testing (including BRCA testing and other DNA sequencing tests) performed in an outpatient setting requires prior authorization or notification. For BRCA and many other registered CPT/HCPCS and proprietary (U-code) molecular tests, the ordering provider must complete the prior authorization/notification process and indicate the performing laboratory and specific test.

Notification/prior authorization is required before DNA sequencing for BRCA testing; the ordering provider must notify the laboratory and the laboratory will notify UnitedHealthcare.
A broad set of CPT, HCPCS and Proprietary codes (e.g., 81162–81164, 81228–81229, 81400–81417, 81431–81445, 81460, 81479, 81518–81523, multiple 0000U–0299U codes, and many others) are subject to prior authorization/notification — check the portal for the full code list.
Health care professionals requesting laboratory testing must complete the prior authorization/notification process and include the laboratory and test details in the request.
Submit requests online at UHCprovider.com using the Prior Authorization and Notification tool or follow portal instructions for laboratory-notification workflows.

Prior Authorization

Private Duty Nursing Prior Authorization

Private duty nursing services require prior authorization. Prior authorization is required to determine medical necessity and appropriate scope/level of services prior to care initiation.

Submit private duty nursing prior authorization requests online at UHCprovider.com or contact the prior authorization phone line shown in the portal.
Include documentation supporting the need for private duty nursing (orders, plan of care, hours requested, prior home health services) to expedite review.
Prior authorization determination is required before claims for private duty nursing will be approved.

Prior Authorization

Prior Authorization for Sleep Procedures and Studies

Sleep apnea procedures, sleep surgeries and diagnostic sleep studies all require prior authorization before scheduling. This includes surgical interventions for sleep apnea and facility-based polysomnography (sleep studies) CPT codes.

Sleep apnea procedures and surgeries (e.g., relevant CPT codes in the sleep apnea surgical category) require prior authorization.
Sleep studies (polysomnography) — examples include CPT 95805, 95807, 95808, 95810 — require prior authorization before scheduling.
Submit sleep-related prior authorization requests online at UHCprovider.com or via the phone number in the portal; include relevant diagnostic documentation and prior conservative therapy where applicable.

Example CPT rangeDocument shows cerebral seizure monitoring/EEG CPT codes 95700–95726 across related entries.

Injectable chemotherapy — Prior authorization

RequirementInjectable chemotherapy drugs administered in an outpatient setting for a cancer diagnosis require prior authorization.

Code examplesChemotherapy injectable drugs (J9000–J9999) and specified J-codes such as J0640, J0641, J0642, J1950, J1954, J1932 are listed.

Submission instructionPlease submit requests online using the UnitedHealthcare Provider Portal as noted in the chemotherapy section.

Continuous glucose monitor (CGM) — Definition

DefinitionContinuous glucose monitor (CGM) devices require prior authorization when used with a Type 2 Diabetes diagnosis (document-specified requirement).

Example device codesCGM HCPCS examples in the document include A4226, A9278, A4239, A9276, A9277, E2102, E2103.

ConditionPrior authorization entries are shown alongside Type 2 diabetes ICD-10 mappings (e.g., E11.*) in the CGM section.

Prosthetics — Definition

DefinitionProsthetics are explicitly noted in the document as not being classified as durable medical equipment (DME).

Related codesProsthetics and orthotics HCPCS examples are listed with their own 'How to Obtain Prior Authorization' entries separate from DME codes.

ReferenceSee listed E03xx–E06xx HCPCS entries and 'Prosthetics are not DME' note in the Additional Information section.

Prior authorization/notification for genetic testing

RequirementPrior authorization or prior notification is required for genetic and molecular testing performed in an outpatient setting (includes BRCA testing).

Ordering responsibilityOrdering care provider must notify the laboratory performing the test; the laboratory will notify UnitedHealthcare as noted for BRCA/DNA sequencing tests.

Example CPTsDocument lists many genetic/molecular CPTs (e.g., 81162, 81163, 81400+ and various U-codes) that require prior authorization/notification.

Enteral services prior authorization

RequirementEnteral services and in-home nutritional therapy codes require prior authorization.

Example codesEnteral HCPCS examples include B4034, B4035 and related B4xxx codes listed in the document.

How to obtain'How to Obtain Prior Authorization' entries are provided with these codes in the Additional Information section.

Prior authorization — Outpatient home health and hospice

RequirementPrior authorization is required in outpatient home health settings and for hospice services as noted in the document.

Submission methodsRequests should be submitted online via the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone as listed in the document guidance.

Example codesHome health codes referenced include G0299, G0300, G0493–G0496; hospice codes include T2042–T2045.

ESRD exemption and unclassified code prior authorization notes

ExemptionPrior authorization is not required for services with an ESRD (end-stage renal disease) diagnosis.

Unclassified/temporary code ruleFor select unclassified/temporary codes (J3490, J3590, C9399) prior authorization is required for specific new-to-market medications listed (document provides examples).

OptumRx notificationPlease obtain prior notification for Cimzia and Synagis through OptumRx prior notifications services at 800-310-6826 as noted.

Unclassified/temporary code prior authorization

RequirementPrior authorization is required for select unclassified/temporary HCPCS codes (e.g., J3490, J3590, C9399) when used for specified newly marketed drugs.

ExamplesDocument lists specific agents (e.g., Casgevy, Lantidra, Nulibry, Revcovi, Rivfloza, Xenpozyme) that require prior authorization when billed under these codes.

Submission instructionSubmit requests online via the UnitedHealthcare Provider Portal or call the phone number provided in the document for prior authorization submissions.

Proton Beam — Definition

DefinitionProton Beam is defined as focused radiation therapy that uses beams of protons (tiny particles with a positive charge).

Associated CPTsDocument lists associated CPTs/technique codes for proton beam therapy (e.g., 77520 series, 77331, 77371, G0339/G0340 entries).

ContextProton Beam appears in the Radiation Therapy section with related procedural coding guidance.

Site of service (SOS) — Outpatient hospital rule

RuleSite of service (SOS) outpatient hospital: prior authorization is required only when requesting a service in an outpatient hospital setting.

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

ApplicationDocument applies this SOS rule across multiple procedure listings where outpatient hospital versus ASC location affects prior authorization requirement.

SOS outpatient hospital — Clarification

FocusPrior authorization only required when services are requested in an outpatient hospital setting (SOS outpatient hospital).

ExceptionNot required at participating Ambulatory Surgery Centers (ASCs) per the document note.

ReferenceSee document 'Site of service (SOS) - outpatient hospital' section for more context and code groupings.

Optum Transplant — Prior authorization

RequirementOptum Transplant prior authorization is required for certain transplant-related unclassified J‑codes and agents as noted in the Transplants section.

ExamplesUnclassified codes J3490, J3590 and C9399 for agents such as Amtagvi, Ryoncil, Skysona will require Prior Authorization through Optum Transplant per the document.

ContextOptum Transplant routing notes appear alongside transplant/CAR T-Cell therapy entries in the Transplants section.

CAR T-Cell therapy — Prior authorization

RequirementCAR T-Cell therapy services require prior authorization; listed CAR T agents include Abecma, Breyanzi, Carvykti, Kymriah, Tecartus.

Routing noteSome CAR T-Cell agents or unclassified code uses may require Optum Transplant prior authorization per Transplants section notes.

ExamplesDocument names specific CAR T agents (Abecma/ Breyanzi/ Carvykti/ Kymriah/ Tecartus) in the Transplants section.