CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Wisconsin Medicaid

List of services and codes requiring prior authorization for participating UnitedHealthcare Community Plan of Wisconsin providers; instructions for submitting prior authorization requests and applicability to inpatient/outpatient and out-of-network providers.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Wisconsin Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateEffective April 1, 2026

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 877-651-6677.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

UHCprovider.comonline portal

877-651-6677auth phone

$500DME threshold

J9000-J9999chemo codes range

manycode listings

Services Requiring Prior Authorization

Authorization instructions and notes

For prior authorization and notification requests, providers must use the UnitedHealthcare Provider Portal or the phone numbers listed below. This callout highlights key routing, documentation and exceptions for services requiring prior authorization.

Providers must submit prior authorization requests online using the UnitedHealthcare Provider Portal at UHCprovider.com and select the Prior Authorization and Notification tool on the Provider Portal dashboard.

When telephone authorization is permitted, use the phone numbers shown in the policy: general prior auth and chemo line 888-397-8129; advanced outpatient imaging/radiology prior authorization line 866-889-8054.

For transplant and CAR T-Cell therapy services (including Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta) contact the UnitedHealthcare Community and State Transplant team as directed in the transplants section.

For certain specialized services (for example ventricular assist devices), follow the specific routing instructions in the policy: call the notification number on the back of the member's health plan ID card and fax required forms to the team indicated (e.g., Optum VAD Case Management at 855-282-8929).

Providers ordering advanced outpatient imaging procedures are responsible for providing notification prior to scheduling the procedure; see the Radiology Prior Authorization and Notification Program page on UHCprovider.com for CPT code details and submission guidance.

Outpatient injectable chemotherapy

Prior authorization is required for outpatient injectable chemotherapy and related supportive agents for cancer diagnoses. Submit requests online or call the chemotherapy prior authorization line.

Prior authorization required for injectable chemotherapy drugs administered in an outpatient setting (including intravenous, intravesical and intrathecal) for a cancer diagnosis.

Chemotherapy injectable drugs in code range J9000–J9999 and specific J/Q codes listed in the policy require prior authorization.

Colony-stimulating factors and bone-modifying agents administered outpatient for a cancer diagnosis require prior authorization; certain CSF/Q-code drugs also require prior authorization when used for non-oncology diagnoses — see the Injectable medications section.

Submit chemotherapy prior authorization requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) or call 888-397-8129.

Prior authorization requirements (partial) — checklist of services and codes requiring prior auth

The following is a non-exhaustive checklist of services that require prior authorization. Providers should consult the full policy and specific code lists for detailed requirements and any exceptions.

Bariatric surgery (inpatient and outpatient) — prior authorization required; see policy codes such as 43644, 43645, 43659, 43770, 43775, 43842, 43847.

Behavioral health services — prior authorization required for services as specified by the member's plan; contact number on the member's ID card for specific codes and network routing.

Breast reconstruction (non-mastectomy) — prior authorization required for listed CPT/HCPCS codes (examples: 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19367, 19368, 19369).

Durable medical equipment (DME) — prior authorization required for DME codes listed in the policy (examples: A9900, E0194, E0265, E0266, E0277, E0328, E0329, E0445, E0457, E0465, E0466) and limited to codes specified.

Relevant CPT/HCPCS/ICD-10 Codes

Colony-stimulating factors (examples)HCPCSCovered

J1442	Filgrastim (Neupogen) - injectable colony-stimulating factor
J2506	Pegfilgrastim (Neulasta) - injectable colony-stimulating factor
Q5101	Biosimilar (Zarxio) - filgrastim biosimilar

Procedure codes listed for prior authCPTCovered

43644	Bariatric surgery code example
19316	Breast reconstruction procedure code

Injectable chemotherapy HCPCS codes (examples)HCPCS

J9000-J9999	Chemotherapy injectable drugs (range)
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin
J1950	Lupron Depot
J1954	Leuprolide Acetate
J1932	Lanreotide

Selected CPT codes appearing in excerptCPT

11960	CPT — cosmetic procedure (listed in section)
14061	CPT — cosmetic procedure (listed in section)
15820	CPT — cosmetic/reconstructive (listed)

Selected HCPCS/DME codes appearing in excerptHCPCS

E0194	HCPCS DME code listed
E0471	HCPCS DME code listed
K0005	HCPCS fitted equipment code listed

Selected ICD-10 diagnosis codes exempting PAICD-10

C43.0	ICD-10 — melanoma of skin (example listed)
C44.01	ICD-10 — basal cell carcinoma of skin (example listed)

Sample injectable medication codesHCPCSCovered

J2329	Injectable medication (listed)
Q5162	Bildyos

Additional injectable codesHCPCSCovered

J9311	Rituxan Hycela / Rituxan related
J1412	Roctavian

Orthotics/Prosthetics L-codesHCPCS | L-codeCovered

L1000	Orthotics - listed as requiring prior authorization
L1310	Prosthetics - listed as requiring prior authorization
L2106	Prosthetics/orthotics code present in list

Injectable medication J-codes (sample)HCPCSCovered

J2327	Sodium Hyaluronate (example listed)
J9332	Vyvgart (example listed elsewhere in excerpt)

Injectable chemotherapy L-codes (partial list)HCPCSCovered

L5728	Injectable chemotherapy (listed HCPCS L-codes)
L5780	Injectable chemotherapy (listed HCPCS L-codes)
L5795	Injectable chemotherapy (listed HCPCS L-codes)
L5811	Injectable chemotherapy (listed HCPCS L-codes)

Pain injections, personal care, private duty nursingCPT | HCPCSCovered

64490	Injection, therapeutic agent (pain management)
64493	Injection, therapeutic agent (pain management)
T1019	Personal care service
T1001	Private duty nursing
T1002	Private duty nursing
T1003	Private duty nursing

Radiation therapy codesCPTCovered

77387	Image-guided radiation therapy (IGRT)
77520	Proton beam therapy (various modifiers/line items 77522-77525)
77402	Radiation treatment delivery (noted with *)

Selected surgical CPT codes requiring prior authorizationCPTCovered

30400	Rhinoplasty/septoplasty
29806	Arthroscopy procedure (shoulder)
31295	Sinuplasty
22100	Spinal surgery codes (selection)
63001	Spinal surgery

Representative CPT/HCPCS/J-codes listedmixed

E0747	External bone growth stimulator
E0748	External bone growth stimulator
E0760	Implantable neurostimulator component
0313T	Neurosurgical/implanted device CPT add-on (example)
J3389	Gene therapy (carrier code listed for transplant/gene therapy services)
C9399	Unclassified drugs (used in transplant/gene therapy context)
E2402	Wound VAC supply code
33927	VAD-related procedure code

DME cost threshold — more than $500

DME cost thresholdSome DME items require prior authorization when retail purchase or cumulative rental cost is more than $500.

Examples of affected DME codesE0471, E0483, E0486, E0652, E0656, E0669 (see DME list) require review for cost threshold applicability.

ScopeThreshold applies to durable medical equipment entries listed in the chemotherapy/DME sections of the policy.

How to Request Authorization & Provider Responsibilities

Prior Authorization

How to obtain prior authorization

This list contains prior authorization requirements for participating UnitedHealthcare providers. Submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com — sign in with One Healthcare ID) or call 877-651-6677. 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

Bariatric surgery and obesity-related services

Prior authorization is required for inpatient and outpatient bariatric surgery and obesity-related services. Examples of CPT codes include 43644, 43645, 43659, 43770, 43775, 43842, 43847. For behavioral health services and other plan-specific programs, follow the number on the member ID card or the Portal instructions.

Key Terms and Scope Notes

Emergency/urgent care — PA exemption

Emergency/urgent care exemptionPrior authorization is not required for emergency or urgent care.

Submission methods (not required in emergency)Normal PA submission via portal or phone is not required for emergency/urgent services.

Document scopeThis exemption applies to participating UnitedHealthcare Community Plan of Wisconsin providers as stated in General Information.

Out-of-network providers — PA requirement

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

Where statedGeneral Information section directs out-of-network providers to obtain prior authorization despite emergency/urgent exemptions.

Policy Revision Timeline

Effective April 1, 2026policy_effective_dateLatest

Policy listing prior authorization requirements for UnitedHealthcare Community Plan of Wisconsin became effective.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Wisconsin Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateEffective April 1, 2026

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 877-651-6677.

SourceLink

On This Page

Enteral services and in-home nutritional therapy (enteral/gastrostomy tube) — prior authorization required (example codes: B4035, B4036, B4102, B4103, B4104, B9002).

Experimental services and select surgical procedures — prior authorization required (examples of codes listed in policy include 29914, 29915).

Joint replacement (total hip and related procedures) — prior authorization required.

Ambulance transport — prior authorization required; to request prior authorization for transportation call Medical Transportation Management at 866-907-1493 (codes include S9960, S9961).

Radiology — prior authorization required for certain advanced outpatient imaging procedures; providers must notify prior to scheduling and may use the Provider Portal or call 866-889-8054 for radiology prior authorization and resources.

Transplants and CAR T-Cell therapies — prior authorization required; see transplant routing and contact UnitedHealthcare Community and State Transplant as noted in policy.

Spinal surgery, stimulators, pain injections and other musculoskeletal procedures — prior authorization required for the listed CPT/HCPCS codes in the policy (examples: spinal CPTs 63272, 63286, 63300–63305; pain injection codes such as 64490, 64493).

Cumulative rental cost — threshold applies

Cumulative rental cost ruleA cumulative rental cost threshold applies for certain DME and may trigger prior authorization review.

Related DME examplesE0471, E0483, E0486 and other contiguous DME codes noted in the DME section are subject to cumulative rental cost rules.

Provider actionAssess cumulative rental charges for listed DME to determine whether prior authorization is required.

Orthotics/prosthetics retail or cumulative rental cost threshold — $500

Orthotics/prosthetics thresholdPrior authorization is required for orthotics and prosthetics when a retail purchase or cumulative rental cost exceeds $500.

Affected L‑codes examplesL0482, L0629, L0484, L0631, L0486, L0632 and multiple L‑codes in the orthotics/prosthetics list are subject to this rule.

ApplicabilityThreshold applies to many L‑code orthotics/prosthetics entries listed under the injectable chemotherapy/DME section.

Prior Authorization

Cancer supportive care — injectables

Prior authorization is required for colony-stimulating factor drugs and bone-modifying agents administered in an outpatient setting for a cancer diagnosis. Some of these agents also require prior authorization for non-oncology diagnoses — see the Injectable medications section.

J1442 (Filgrastim, Neupogen)
J1447
J1448
J2506 (Pegfilgrastim, Neulasta)
Q5101 (Zarxio)
Q5110 (Filgrastim-aafi, Nivestym)
Q5122 (Pegfilgrastim-apgf, Nyvepria)
Q5120 (Pegfilgrastim-bmez, Ziextenzo)
Q5125 (Filgrastim-ayow, Releuko)
Q5136,Q5157,Q5158,Q5159,Q5148

Prior Authorization

Breast reconstruction (non-mastectomy)

Breast reconstruction (non-mastectomy) requires prior authorization except when billed with specific diagnosis codes that exempt prior authorization. Examples of CPT codes that generally require prior authorization: 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 19396, 11971. Prior Auth NOT required for the specified breast cancer diagnosis codes listed in the member-specific guidance (e.g., C50.xx and related ICD-10 codes) — consult the Portal or plan-specific documentation for the full exempt Dx list.

Prior Authorization

Bone growth stimulator

Prior authorization is required for bone growth stimulators (electronic stimulation or ultrasound devices to heal fractures). Relevant CPT/HCPCS codes include 20975 and 20979.

20975
20979

Prior Authorization

Injectable chemotherapy — prior authorization required

Prior authorization is required for outpatient injectable chemotherapy (including intravenous, intravesical and intrathecal) for a cancer diagnosis. Submit requests online via the UnitedHealthcare Provider Portal at UHCprovider.com or call 888-397-8129.

Prior Authorization

Prior authorization list (partial)

This is a partial list of injectable medications and chemotherapy agents that require prior authorization. It includes J‑series chemotherapy codes, certain Q‑codes, miscellaneous (unclassified) HCPCS codes, and many specialty drug J‑codes. Providers should submit requests via the Portal or by calling 888-397-8129.

Chemotherapy injectable drugs J9000–J9999
Leucovorin J0640; Levoleucovorin J0641, J0642
Lupron Depot J1950; Leuprolide Acetate J1954
Lanreotide J1932
Miscellaneous/unspecified chemotherapy HCPCS (unassigned codes billed under Jxxxx or C9399/J3490/J3590)
Chemotherapy injectable drugs that have a Q‑code

Prior Authorization

Injectable medications requiring prior authorization (sample lines)

Examples of injectable medications (sample lines) that require prior authorization include many specialty and high-cost agents. Submit via the Provider Portal or call 888-397-8129. Sample J/Q codes: J2327, J7331, J7332, J1299, J1930.

J2327
J7331
J7332
J1299
J1930

Prior Authorization

Injectable medications (continued)

Additional injectable medications requiring prior authorization (continued): many newer specialty IV/infusion products and high-cost biologics require prior authorization. Examples from the list include Tremfya IV J1628, Truxima Q5115, Tzield Q5135, Uplizna J1823, Vabysmo J2777, J0218 (Xenpozyme), J1427 (Viltepso), J1322 (Vimizim), J3032 (Vyepti), J3401 (Vyjuvek), J1429 (Vyondys 53), J9332 (Vyvgart), J9334 (Vyvgart Hytrulo), Q5138 (Wezlana IV), and others. Check the Portal for the full, current injectable drug prior authorization list.

Tremfya IV J1628
Truxima Q5115
Tzield Q5135
Uplizna J1823
Vabysmo J2777
Xenpozyme J0218
Viltepso J1427
Vimizim J1322
Vyepti J3032
Vyjuvek J3401
Vyondys 53 J1429
Vyvgart J9332
Vyvgart Hytrulo J9334
Wezlana IV Q5138

Prior Authorization

Ambulance transport prior authorization

Prior authorization is required for ambulance transport when noted. To request prior authorization for transportation services, contact Medical Transportation Management at 866-907-1493.

S9960
S9961
(other ambulance transport codes as applicable)

Prior Authorization

Services and codes requiring prior authorization (partial)

This is a partial list of services and procedure codes that require prior authorization across categories (surgery, implants, radiology, DME, orthotics/prosthetics, pain procedures, transplants, VADs, TMS, stimulators and implants). Providers must verify specific CPT/HCPCS codes and any Dx‑based exemptions via the Provider Portal. Examples include: advanced outpatient imaging (see Radiology Prior Authorization program), joint replacement and major musculoskeletal surgeries, spinal surgery (e.g., 22100–225xx, 63001–63056), proton beam, SRS/SBRT, sleep apnea procedures (e.g., 21685), pain management injections (e.g., 64490, 64493), and many L‑codes for durable medical equipment and orthotics/prosthetics.

Advanced outpatient imaging — submit via UHCprovider.com or call 866-889-8054
Joint replacement and major orthopedic procedures
Spinal surgery (e.g., 22100 series, 63001–63056)
Pain injections (64490, 64493)
DME and L‑codes — some codes require PA or are subject to cost/rental thresholds
Enteral and in-home nutritional therapy (B4035, B4036, B4102–B4104, B9002)

Prior Authorization

Implants, stimulators, TMS prior authorization

Implants, stimulators and Transcranial Magnetic Stimulation (TMS) procedures require prior authorization. Examples include implantation and programming of neurostimulation devices and related HCPCS/CPT codes (e.g., 61863–61886 series, 63650, 63655, 63685, 64553, 64555, 64568, 64570; implantable device HCPCS L‑codes such as L8680, L8685–L8688). TMS CPT codes 90867 and 90868 require prior authorization. Ventricular assist devices (VAD) and select implantable cardiac devices also require prior authorization and specific notification procedures (call number on member ID and fax required forms to Optum VAD Case Management at 855-282-8929). For transplant and CAR T services, contact UnitedHealthcare Community and State Transplant per Portal guidance.

Transcranial Magnetic Stimulation: 90867, 90868
Spinal and cranial stimulators: 61863–61886, 63650, 63655, 63685
Implantable device HCPCS/L‑codes: L8680, L8685–L8688
VADs and selected cardiac implants: call notification number on member ID; fax to Optum VAD Case Management 855-282-8929
Transplant and CAR T-Cell therapies: contact UnitedHealthcare Community and State Transplant

ImplicationOut-of-network status does not exempt providers from PA requirements for scheduled care.

Injectable chemotherapy — definition

DefinitionInjectable chemotherapy refers to chemotherapy drugs administered in an outpatient setting including intravenous, intravesical and intrathecal for a cancer diagnosis.

ContextListed under the Chemotherapy section as services requiring prior authorization when provided outpatient for cancer diagnoses.

Provider instructionPrior authorization required for these outpatient injectable chemotherapy drugs; submission methods are provided elsewhere in the policy.

DME — definition and note

DefinitionDurable medical equipment (DME) denotes listed equipment entries that require prior authorization; some DME entries are subject to cost and cumulative rental thresholds.

Representative codesExamples include A9900, E0194, E0265, E0277, E0328, E0329, E0445 and others shown in the DME listing.

Threshold noteCertain DME items trigger PA only when retail purchase or cumulative rental cost exceeds specified thresholds.

PA exemption by diagnosis code

PA exemption by diagnosisPrior authorization is not required when services are billed with specified diagnosis codes listed in the policy (numerous ICD‑10 codes such as C43.x/C44.x examples are included).

ScopeThis exemption appears in the injectable chemotherapy and related sections where specific Dx codes remove PA requirement.

Provider actionVerify diagnosis codes against the policy list to determine if PA is required before submitting a request.

Prior authorization — overview

TermPrior authorization (PA) is the requirement to obtain approval before providing certain services or medications as listed in this policy.

Submission channelsSubmit PA requests via the UnitedHealthcare Provider Portal (Prior Authorization and Notification tool) or by phone using listed contact numbers.

ApplicabilityPA applies to a broad range of services and codes enumerated across the document, including injectables, DME, surgeries and specialized therapies.

Prior authorization — short PA required label

Short labelPrior authorization required.

Where usedUsed throughout the policy to flag items (e.g., joint replacement, ambulatory transport, stimulators) that require authorization prior to service.

Provider noteFollow the policy's specified submission instructions for items labeled 'Prior authorization required.'

Authorization threshold — $500 for orthotics/prosthetics

Authorization threshold for orthotics/prostheticsA retail purchase or cumulative rental cost exceeding $500 triggers prior authorization for many orthotics and prosthetics (L‑codes) listed.

Examples of L‑codes impactedL0482, L0629, L0484, L0631, L0486, L0632 and additional L‑codes in the orthotics/prosthetics section.

Action for providersConfirm retail purchase price or cumulative rental totals against the $500 threshold to determine need for PA.

Applicable ICD-10 codes (radiation therapy scope)

Applicable ICD‑10 codes (radiation therapy) — hypofractionation scopeBone metastases: C79.51, C79.52 are listed as applicable ICD‑10 codes for hypofractionation scope.

ContextThese ICD‑10 codes are referenced under Proton Beam/Radiation therapy sections to define cancer types in scope.

UsageUse these ICD‑10 codes when determining applicability of hypofractionation and related radiation therapy authorization rules.

Ventricular assist devices (VAD) — note

VAD definitionVentricular assist devices (VAD) are mechanical pumps that take over the function of the damaged heart and restore heart function; prior authorization is required.

Provider instructionsFor VADs, call the notification number on the back of the member's health plan ID card and fax the required form to Optum VAD Case Management at 855-282-8929.

Related codesVAD‑related CPT/HCPCS and procedural codes (e.g., 33927, 33928, 33976, 33979) are listed in the VAD section.

Transplant and CAR T-Cell therapy — routing requirement

Routing requirementTransplant and CAR T‑Cell therapy services (including Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta) must be routed to UnitedHealthcare Community and State Transplant for prior authorization.

Provider actionContact UnitedHealthcare Community and State Transplant using the routing instructions in the Transplants section to initiate authorization.

Coding noteCertain codes and gene therapy codes (e.g., J3389, J3490, J3590, C9399, and select procedure codes) are mentioned with special authorization notes.

Prior authorization required — general note

Prior authorization required (general)Prior authorization is required for many listed services and codes across the document, including outpatient injectable chemotherapy, DME, orthotics/prosthetics over thresholds, specialized procedures, and implants.

How to submitSubmit PA requests via the UnitedHealthcare Provider Portal (Prior Authorization and Notification tool) or by phone using provided contact numbers; specific services may have dedicated contacts.

ExceptionsPA is not required for emergency or urgent care; certain diagnosis codes may exempt services from PA as noted in the policy.