CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Wisconsin Medicaid

Lists procedures, services, and drugs that require prior authorization for UnitedHealthcare Community Plan of Wisconsin providers and explains how to submit requests; applies to participating in-network and out-of-network health care professionals providing inpatient and outpatient services in Wisconsin.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Wisconsin Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone at 877-651-6677.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2026-04-01policy effective date noted

UHCprovider.comonline submission option

Exemptemergency/urgent care exemption

Bariatric, Behavioral, Cancersample service categories requiring prior auth

$500

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

orthotics/prosthetics cost threshold

Services and Items Requiring Prior Authorization

Prior authorization criteria overview

Services and drugs listed require prior authorization as noted; submission methods and exceptions provided.

Provider must obtain prior authorization for listed procedures, services, and injectable agents except in emergency or urgent care situations.

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

How to submit prior authorization requests: online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com; One Healthcare ID) or by phone at 877-651-6677.

Outpatient injectable chemotherapy

Prior authorization criteria (partial):

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

Includes

Chemotherapy injectable drugs billed within J9000–J9999 range require prior authorization.
Chemotherapy items billed under Q-codes, miscellaneous HCPCS, or unassigned/miscellaneous HCPCS codes require prior authorization.
Specific supportive agents (e.g., Leucovorin J0640; Levoleucovorin J0641/J0642; Lupron Depot J1950; Leuprolide acetate J1954; selected J-/Q-codes listed in the document) require prior authorization.

Requests for these outpatient injectable chemotherapy drugs should be submitted online via the UnitedHealthcare Provider Portal or by calling 888-397-8129 as noted in the chemotherapy sections.

Submission instruction

Exemptions

Prior authorization not required when the service is billed with certain ICD-10 diagnosis codes listed in the document (examples include many C43.* and C44.* codes).

Supportive devices and procedures

Other items/devices with PA noted (partial list):

Other devices/procedures requiring prior authorization (examples)

Cochlear and other auditory implants (device and associated CPT/HCPCS codes listed) — prior authorization required.
Continuous glucose monitors — prior authorization required when billed with specified Type 2 or gestational diabetes diagnosis codes.
Cosmetic and reconstructive procedures — many cosmetic CPT codes listed are marked prior authorization required; reconstructive CPT codes are enumerated separately.

For specific codes and clinical details, refer to the enumerated CPT/HCPCS entries in the document; follow the listed submission instructions for PA.

Prior Authorization Coverage Criteria (partial excerpt)

Items, drugs, procedures, and equipment listed require prior authorization unless specifically exempted when billed with certain diagnosis codes or when below cost thresholds.

Listed injectable chemotherapy drugs and associated CPT/HCPCS codes require prior authorization as indicated in the document.

PA exemptions by diagnosis

Prior authorization is not required when billed with the specific ICD-10 diagnosis codes enumerated in the document (examples include C43.* and C44.* series).

Durable medical equipment (DME) entries listed require prior authorization; cumulative rental cost thresholds are applicable (see orthotics/prosthetics threshold).

Prosthetics are not considered DME for the purposes of this prior authorization policy (see DME/orthotics guidance in the document).

Prosthetics exclusion

Prior authorization required items (excerpt)

Items listed below require prior authorization as indicated in the document excerpt.

Enteral services and in-home nutritional therapy (examples: B4035, B4036, B4102, B4103, B4104, B9002) require prior authorization.

Selected injectable medications and biologics (examples: J0791 Adakveo, J7171 Adzynma, J1931 Aldurazyme and other listed J-codes) require prior authorization; submit requests online via the UnitedHealthcare Provider Portal or call 888-397-8129 per the document.

Prior authorization coverage criteria (partial — this document segment)

Prior authorization is required for the listed injectable medications, orthotics/prosthetics above cost thresholds, certain surgeries, and transport services.

Injectable medications and biologics listed in the document (numerous J- and Q-codes and unclassified codes) require prior authorization.

Orthotics and prosthetics require prior authorization only when the retail purchase price or cumulative rental cost exceeds $500; many L‑codes are listed for reference.

Ambulance/transport services require prior authorization; contact Medical Transportation Management as specified in the document.

Joint replacement (total hip and joint) procedures require prior authorization; specific CPT codes are provided in the document.

Prior authorization requirement list (partial)

Services and procedures explicitly labeled 'Prior authorization required' in this excerpt include:

ANY of the following

Pain injections and management procedures (examples: CPT 64490, 64493) — prior authorization required.
Personal care and private duty nursing services (examples: T1019, T1001, T1002) — prior authorization required.
Advanced outpatient imaging/radiology procedures (certain CT, MRI, MRA and other advanced imaging) — prior authorization required; submit via the Provider Portal or call the radiology PA number as noted.
Sinuplasty and selected ENT procedures (examples: 31295–31298) — prior authorization required.

Coverage rules in this segment

Authorization/coverage stance for listed services in this segment:

Spinal surgery and implantation of stimulator devices (specific CPT/HCPCS codes listed) require prior authorization.

Transcranial magnetic stimulation (CPT 90867, 90868) requires prior authorization.

Transplant and CAR T‑cell therapy services (including specified products) require prior authorization; for these services contact UnitedHealthcare Community and State Transplant as directed in the document. Certain unclassified drug/biologic codes (e.g., J3490, J3590, C9399) and listed procedure codes may require authorization.

Ventricular assist devices (VAD) require prior authorization; providers must call the notification number on the member's ID card and fax the provided Optum VAD form to 855-282-8929.

Wound VAC devices (e.g., HCPCS E2402) are identified as prior authorization required.

Relevant CPT / HCPCS / ICD-10 Codes

Bariatric surgery example CPT/HCPCS codesCPTCovered

43644	Bariatric surgery procedure code listed as requiring prior authorization
43775	Bariatric surgery procedure code listed as requiring prior authorization

Colony-stimulating factor and related injectable codesHCPCSCovered

J1442	Filgrastim (Neupogen) - prior authorization required when used in outpatient oncology
J2506	Pegfilgrastim (Neulasta) - prior authorization required when used in outpatient oncology
Q5101	Biosimilar Zarxio - prior authorization required

Breast reconstruction and related diagnosis codesmixedCovered

19316	Breast reconstruction (non-mastectomy) example CPT code
19318	Breast reconstruction (non-mastectomy) example CPT code
C50.011	Example diagnosis code listed as not requiring prior auth for certain reconstruction scenarios

Injectable chemotherapy HCPCS/J codes and select supportive drug codesHCPCSCovered

J9000-J9999	Chemotherapy injectable drugs
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin
J1950	Lupron Depot
J1954	Leuprolide Acetate

Selected device and procedure codes referencedmixed

L8614	Cochlear implant device code (example listed)
A9276	Continuous glucose monitor example
11960	Cosmetic CPT example
15822	Reconstructive CPT example

DME/HCPCS codes requiring prior authorization (partial list)HCPCSCovered

A9900	Durable medical equipment — listed code requiring prior authorization
E0194	DME code listed
E0265	DME code listed
E0266	DME code listed
E0277	DME code listed
E0328	DME code listed
E0329	DME code listed
E0445	DME code listed
E0457	DME code listed
E0465	DME code listed

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CPT procedure codes (cosmetic/reconstructive) referencedCPTCovered

11960	Cosmetic procedure CPT code listed
14061	Cosmetic/reconstructive CPT code listed
15820	Cosmetic/reconstructive CPT code listed
17106	Cosmetic CPT code listed
21137	Procedure CPT code listed

Selected injectable medication HCPCS/CPT codes listedHCPCS

J9311	Rituxan Hycela
J1412	Roctavian
J2998	Ryplazim

Genetic and molecular testing codesCPTCovered

81415	Genetic/molecular testing (example BRCA-related codes)
81443	Genetic/molecular testing

Selected injectable and orthotic/prosthetic codesHCPCSCovered

J1628	Tremfya IV
J3316	Triptodur
Q5115	Truxima
L0112	Orthotic/prosthetic HCPCS example
L0464	Orthotic/prosthetic HCPCS example

Selected L-codes (injectable chemotherapy / orthotics & prosthetics)HCPCSCovered

L5728	HCPCS L-code listed under injectable chemotherapy requiring prior authorization
L5780	HCPCS L-code listed under injectable chemotherapy requiring prior authorization
L5790	HCPCS L-code listed under injectable chemotherapy requiring prior authorization
L5811	HCPCS L-code listed
L5961	HCPCS L-code listed

Selected CPT/HCPCS across radiation, pain, ENT, orthopedicsCPTCovered

77387	IGRT
77520	Proton beam coding (multiple related codes listed)
64490	Pain injection procedure
29805	Arthroscopic shoulder procedure
31295	Sinuplasty

Unclassified drug/biologic codes referenced for transplant/gene therapyHCPCSCovered

J3490	Unclassified drugs (used for gene therapy/transplant contexts in this segment)
J3590	Unclassified biologics (used for gene therapy/transplant contexts in this segment)
C9399	Unclassified drugs or biologicals (listed for transplant/gene therapy)

Bone growth stimulator HCPCSHCPCSCovered

E0747	Bone growth stimulator
E0748	Bone growth stimulator
E0760	External bone growth stimulator

HCPCS miscellaneous / Q-code and unassigned codes — chemotherapy

Policy statementPrior authorization required for chemotherapy items billed under Q-codes, miscellaneous HCPCS, or unassigned (miscellaneous) HCPCS codes (e.g., chemotherapy injectable drugs that have a Q code or have not yet received an assigned code and will be billed under a miscellaneous HCPCS code).

Example code rangeChemotherapy injectable drugs billed under J9000-J9999 are listed separately and also require prior authorization when appropriate.

Supporting examplesLeucovorin (J0640), Levoleucovorin (J0641/J0642), Lupron Depot (J1950) and other specified J‑codes are called out in the injectable chemotherapy section.

How to Request Prior Authorization and Provider Responsibilities

Prior Authorization

Bariatric surgery prior authorization

Bariatric surgery (inpatient and outpatient) and obesity-related services require prior authorization. Example CPT/HCPCS codes include 43644, 43645, 43659, 43770, 43775, 43842 and 43847. Submit prior authorization requests online via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by phone.

Prior authorization required for inpatient and outpatient bariatric surgery and obesity-related services
Example procedure codes: 43644, 43645, 43659, 43770, 43775, 43842, 43847

Prior Authorization

Other service categories requiring prior authorization

Many other service categories require prior authorization. Behavioral health services often require prior authorization through the designated behavioral health network — call the number on the member’s ID card for specific codes and routing. Birth-to-age-3 and in-school therapies, breast reconstruction (non‑mastectomy), certain sinus and sleep apnea procedures, spinal surgery, joint replacement (total hip/total joint), pain injections/management, private duty nursing, personal care services, prostate procedures and vein procedures are examples that are marked as prior authorization required in the provider list. For orthotics and prosthetics, prior authorization is required only when the retail purchase or cumulative rental cost exceeds the plan threshold.

Terms and Policy Definitions

Definition of Prior authorization

DefinitionPrior authorization is the process by which providers must obtain approval from the health plan before performing certain procedures or services.

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

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

Cancer supportive care injectable agents

Covered agentsColony-stimulating factor drugs and bone-modifying agents administered in the outpatient setting for a cancer diagnosis require prior authorization.

Specific HCPCS/J codesExamples listed include J1442, J1447, J1448, J2506 and multiple Q-codes such as Q5101, Q5110, Q5122 and others.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Wisconsin Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone at 877-651-6677.

SourceLink

On This Page

DME cost threshold

ThresholdPrior authorization required when the cumulative rental cost of durable medical equipment (DME) exceeds $500.

Examples of DME codes referencedE0471, E0483, E0486 and other DME HCPCS codes are listed in the DME section as requiring prior authorization when thresholds apply.

Prosthetics noteProsthetics are specifically noted as not considered DME for the purposes of this rule (see separate prosthetics guidance).

Orthotics/prosthetics retail/rental cost threshold

Orthotics/prosthetics cost thresholdPrior authorization required for orthotic and prosthetic items with a retail purchase or cumulative rental cost of more than $500.

Example L-codesExamples include L0482, L0629, L0484 and L0631 among many L-codes listed for orthotics and prosthetics.

Purchase vs rentalApplies to either retail purchase or cumulative rental cost exceeding $500 (whichever is applicable).

Applicable ICD-10 for hypofractionation (example)

Applicable ICD-10 (example)Bone metastases: C79.51, C79.52.

ContextThese ICD-10 codes are listed as applicable cancer diagnosis codes in the Hypofractionation / Proton Beam scope section.

Use caseUsed as example diagnosis codes for services such as hypofractionation and proton beam therapy where diagnosis-specific coding is relevant to authorization scope.

Behavioral health — call the number on the member’s health plan ID card for specific prior authorization requirements
Birth-to-age-3 program and in-school therapies — prior authorization required
Breast reconstruction (non-mastectomy) — prior authorization required; example codes include 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19367, 19368, 19369
Joint replacement (total hip/total joint) — prior authorization required; example codes listed
Orthotics and prosthetics — prior authorization required only when retail purchase or cumulative rental cost exceeds plan threshold

Prior Authorization

Drugs requiring prior authorization

A wide range of injectable chemotherapy and other injectable medications require prior authorization when administered outpatient. This includes chemotherapy J‑codes (J9000–J9999), select supportive agents and many specialty biologic/IV therapies. For oncology supportive care, colony-stimulating factors and bone‑modifying agents administered outpatient for a cancer diagnosis require prior authorization.

Chemotherapy injectable drugs administered outpatient (IV, intravesical, intrathecal) — prior authorization required
Chemotherapy J‑codes (J9000–J9999) and many Q‑ and miscellaneous HCPCS-coded injectables require prior authorization
Cancer supportive care agents (e.g., filgrastim, pegfilgrastim biosimilars, eflapegrastim) require prior authorization for oncology and some codes require authorization for non‑oncology diagnoses as listed

Prior Authorization

Other devices/procedures with PA requirements (partial list)

Certain devices and procedures require prior authorization. Examples include cochlear and other auditory implants (e.g., 69710, 69714, 69930; device codes L8614, L8619, L8690, L8691, L8692), continuous glucose monitors (A9276, A9277, A9278; subject to Type 2/gestational diabetes Dx requirements), stimulators and implanted devices (various CPT/HCPCS listed), bone growth stimulators and many prosthetic/orthotic device codes. Review the provider prior authorization list for full code sets.

Cochlear and auditory implants — prior authorization required (device and procedure codes noted)
Continuous glucose monitors — prior authorization required with qualifying Type 2 or gestational diabetes diagnosis; example codes A9276/A9277/A9278
Implanted stimulators, bone growth stimulators and related device procedures — prior authorization required
Prosthetic and orthotic device codes (L-series) — prior authorization required when thresholds apply

Prior Authorization

DME prior authorization and cost threshold

Durable medical equipment (DME) items listed require prior authorization when the cumulative rental cost or purchase price exceeds the plan threshold. Many DME HCPCS codes are included in the list (for example E0470, E0471, E0483, E0486, E0652, E0656, E0669, E0745, E0784, E0984, E0986, E1002–E1005, E1007–E1008, L‑series orthotic/prosthetic codes). Prior authorization is required when cumulative rental cost or retail purchase exceeds $500 (or other plan-specified threshold).

DME prior authorization required when cumulative rental cost or retail purchase > $500
Examples of affected HCPCS: E0470, E0471, E0483, E0486, E0652, E0656, E0669, E0745, E0784, E0984–E1005

Prior Authorization

How to obtain prior authorization (injectable medications)

For injectable medications (including many specialty biologics and chemotherapy/supportive agents) please submit prior authorization requests online using the UnitedHealthcare Provider Portal (UHCprovider.com) or call 888-397-8129.

Submit injectable medication prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal
Phone option for injectable medications: 888-397-8129

Prior Authorization

Ambulance transport prior authorization

Ambulance transport requires prior authorization. To request prior authorization for transportation services, contact Medical Transportation Management at 866-907-1493.

Ambulance transport prior authorization — call Medical Transportation Management: 866-907-1493
Example transport codes: S9960, S9961

Prior Authorization

How to obtain prior authorization (radiology/advanced imaging)

For radiology and advanced outpatient imaging (certain CT, MRI, MRA and other advanced imaging procedures) submit prior authorization requests online using the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call 866-889-8054. Providers are responsible for providing notification prior to scheduling advanced outpatient imaging; see UHCprovider.com/WIcommunityplan Prior Authorization and Notification Resources for CPT lists and program details.

Submit radiology/advanced imaging prior authorization via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool
Phone option for radiology prior authorization: 866-889-8054
See UHCprovider.com/WIcommunityplan > Prior Authorization and Notification Resources for CPT code lists and program details

Prior Authorization

Radiation therapy prior authorization

Radiation therapy modalities (including IMRT/IGRT, proton beam, SRS/SBRT and related techniques) require prior authorization. Proton beam therapy and other advanced radiation services have diagnosis‑specific indications listed in the provider resources; providers must obtain authorization before scheduling.

Radiation therapy prior authorization required for modalities such as IGRT, proton beam therapy, SRS/SBRT and related CPT/HCPCS codes
Proton beam therapy requires prior authorization with specified diagnosis codes and supporting documentation

Prior Authorization

Transplant and CAR T-Cell therapy prior authorization process

Transplant and CAR T‑cell therapy services require prior authorization. For transplant and CAR T‑Cell therapies (including Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta and other listed cellular/gene therapies), providers must call UnitedHealthcare Community and State Transplant to request prior authorization and follow the transplant program’s referral process. For ventricular assist devices (VADs), 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.

Transplant and CAR T‑Cell therapy prior authorization — call UnitedHealthcare Community and State Transplant for authorization and referral instructions
CAR T products explicitly noted: Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta
VAD notification and prior authorization — call the number on the member ID card and fax forms to Optum VAD Case Management at 855-282-8929

Prior Authorization

Wound VAC prior authorization

Wound VAC therapy requires prior authorization. Example HCPCS code: E2402. Submit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by phone as directed in the provider resources.

Wound VAC prior authorization required — example HCPCS: E2402
Submit authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by the phone numbers provided in this section

Non-oncology useSome listed codes (Q-codes) also require prior authorization when used for non-oncology diagnoses; refer to the injectable medications section for details.

Injectable chemotherapy

ScopeInjectable chemotherapy drugs administered in an outpatient setting (intravenous, intravesical, intrathecal) for a cancer diagnosis require prior authorization.

Code examplesChemotherapy injectable drugs billed under J9000–J9999, leucovorin (J0640), levoleucovorin (J0641/J0642) and other specified J‑codes require prior authorization.

Miscellaneous/Q-code casesChemotherapy drugs with Q-codes or those not yet assigned an HCPCS code (billed under miscellaneous HCPCS) are also subject to prior authorization.

Prosthetics vs DME

Policy distinctionProsthetics are not considered durable medical equipment (DME) for the purposes of this prior authorization policy.

ImplicationOrthotics and prosthetics have separate prior authorization rules and thresholds (see orthotics/prosthetics threshold).

Reference codesDME HCPCS examples are listed separately (e.g., E0471, E0483) and associated with the DME cost threshold rule.

PA exemption by diagnosis

Exemption by diagnosisPrior authorization is not required when items are billed with certain ICD-10 diagnosis codes (examples include C43.* and C44.* series for skin/melanoma codes listed in the document).

How appliedWhen the applicable item or procedure is billed with an exempting diagnosis code listed in the policy, the prior authorization requirement does not apply.

ExamplesThe document lists specific C43.x codes as examples where prior authorization is waived when billed with those diagnoses.

Prior authorization required

General rulePrior authorization required — many services, drugs, devices and procedures in this document are explicitly labeled 'Prior authorization required.'

ExamplesEntries include enteral services (B4035, B4036), pain injections (64490, 64493), private duty nursing (T1001/T1002) and many injectable medications/biologics.

SubmissionRequests should be submitted online via the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone as indicated in the document.

Orthotics/prosthetics prior authorization threshold

Orthotics/prosthetics thresholdPrior authorization required for orthotic and prosthetic items with a retail purchase or cumulative rental cost of more than $500.

Representative HCPCS/L-codesL0482, L0629, L0484, L0631 and many other L-codes are provided as examples in the orthotics/prosthetics entries.

Purchase vs rentalApplies to either a single retail purchase or the accumulated rental cost exceeding $500.

Proton Beam

Modality referencedProton beam therapy is referenced as a radiation therapy modality that requires prior authorization.

Related codesAssociated CPT/HCPCS codes listed include 77520 and related 77522/77523/77525 entries and radiation delivery codes (77402, 77407, 77412).

ContextProton beam appears in the Radiation Therapy section alongside IGRT and SRS/SBRT modalities that require authorization.

IGRT

TermIGRT = image-guided radiation therapy; associated codes and IGRT modality are referenced in the Radiation Therapy section.

Associated codesRadiation delivery and related codes such as 77371–77373 and 77402/77407/77412 are provided in the Radiation Therapy entries.

AuthorizationIGRT is listed among radiation therapy modalities that require prior authorization.

Ventricular assist devices (VAD)

DefinitionVentricular assist devices (VAD) — a mechanical pump that takes over the function of the damaged ventricle of the heart and restores normal blood flow.

Authorization procedurePrior authorization required; providers should call the notification number on the member's ID card and fax the Optum VAD form to 855-282-8929.

Example CPT/HCPCSExamples include codes 33927, 33928, 33976, 33979 and related VAD procedure codes listed in the document.

Transplants / CAR T-Cell therapy

ScopeTransplant and CAR T-cell therapy services require prior authorization and direct contact with UnitedHealthcare Community and State Transplant for authorization/referral.

Named productsSpecified CAR T products listed include Abecma, Breyanzi, Carvykti, Kymriah, Tecartus and Yescarta.

Codes notedUnclassified drug/biologic codes such as J3389, J3490, J3590 and C9399 are referenced in the transplant/gene therapy authorization guidance.