CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for developmentally disabled Arizona members

Lists services, CPT/HCPCS codes and situations that require prior authorization for participating providers serving Developmentally Disabled Arizona members; includes submission methods, eligibility notes, and code-level PA requirements for many service categories (partial document). Effective June 1, 2024.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for developmentally disabled Arizona members

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2024

Next Review Date

Key ActionSubmit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone to the numbers listed (general: 800-445-1638; chemo/DME alternate: 888-397-8129; cardiology: 866-889-8054).

POLICY UPDATE CHANGES

No material clinical/coverage changes — this brief lists prior authorization requirements and code-level PA rules but does not introduce a material change.

100+CPT/HCPCS codes listed

MultipleService categories requiring PA

15Outpatient PT/OT visit limit

1Code with oncology-only PA exception

Codes effective date

Policy overview and scope

Background: This policy lists prior authorization (PA) requirements for UnitedHealthcare Community Plan of Arizona Developmentally Disabled Program providers serving Arizona members and references AHCCCS coverage rules and EPSDT for members under 21. Purpose: describe PA requirements for UHC Community Plan AZ Developmentally Disabled Program providers, the services and CPT/HCPCS/J-code groups that require PA, and submission channels for PA requests. Effective date: 2024-06-01.

Applicability: PA eligibility requires that the service is a covered benefit per the Arizona Health Care Cost Containment System (AHCCCS); EPSDT applies for members younger than 21 for services such as allergy immunotherapy/testing where medically necessary. Non-network and out-of-state services require PA and supporting documentation; all rendering providers, facilities and vendors must be actively registered with AHCCCS.

How to submit: Providers must submit PA requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call the listed phone numbers. High-level submission and contact numbers referenced: general portal sign-in and phone 800-445-1638; chemotherapy and many drug/DME PA requests: 888-397-8129; cardiology PA: 866-889-8054. For pharmacy PA contact UnitedHealthcare Pharmacy Prior Authorization Service via phone 800-310-6826 or fax 866-940-7328. DME/enteral/home infusion vendor contacts: Preferred Homecare 800-636-2123 and Optum Infusion 800-985-3059.

Compact policy facts

Orthotics/Prosthetics PA thresholdRetail purchase or cumulative rental cost > $500

Outpatient PT/OT visit limits15 visits per benefit year (Oct 1 - Sept 30) — restoration; 15 visits per benefit year — acquisition of new skill

Effective dateJune 1, 2024

StatusCURRENT

Scope summaryLists services, CPT/HCPCS codes and situations that require prior authorization for participating providers serving Developmentally Disabled Arizona members; includes submission methods, eligibility notes, and code-level PA requirements (partial document).

Preferred Homecare (enteral/parenteral/DME/incontinence)Call 800-636-2123 to request services/supplies; incontinence supplies benefit only when provided through Preferred Homecare

Optum Infusion (in-home infusion/injectables)Call 800-985-3059 to request infusion services, supplies and injectable medications not covered by Optum

LabCorp (genetic testing PA)Direct lab requests / determine PA requirements: call LabCorp at 800-788-9743 (source shows 800-533-0567 in one place and 800-788-9743 for PA routing; PA routing directions reference LabCorp)

Nationwide Vision (member eye care)For member eye care services call 480-961-1702

MTM (non-emergent transportation scheduling)To schedule non-emergent taxi or stretcher van call Medical Transportation Management (MTM) at 888-700-6822

General prior authorization rules & eligibility

General Prior Authorization Eligibility

Covered when ALL of the following are met:

ALL of the following

Patient is a UnitedHealthcare Community Plan of Arizona Developmentally Disabled Program member
Requested service is a benefit covered under AHCCCS and is medically necessary and cost‑effective
Only one health care professional may submit the prior authorization request on behalf of the member
Rendering health care professional, facility or vendor is actively registered with AHCCCS

Required provider actions, submission channels, and documentation

Prior Authorization

How to submit prior authorization requests

Submit PA requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone. General contact numbers provided: 800-445-1638; alternate/chemo/DME line 888-397-8129; cardiology line 866-889-8054. For pharmacy prior authorization fax for specialty pharmacy is 866-940-7328.

Prior Authorization and Notification tool (UHCprovider.com)
Phone: 800-445-1638
Alternate / chemotherapy / DME: 888-397-8129
Cardiology: 866-889-8054
Pharmacy specialty fax: 866-940-7328

Documentation Required

Codes requiring prior authorization (grouped)

AACCPTCovered

92607	Evaluation of speech, language, voice, communication, and/or auditory processing, with a device
92608	Treatment of speech, language, voice, communication, and/or auditory processing disorder; with device
92609	Evaluation of speech acquisition, with a device

AAC - HCPCS devicesHCPCSCovered

A9901	Speech generating device, non-covered by Medicare (use per policy)
E2500	Speech generating device, dedicated
E2502	Speech generating device, dedicated, portable
E2504	Speech generating device, dedicated, with dynamic display
E2506	Speech generating device; integrated with other equipment
E2508	Communication device component or accessory
E2510	Communication device; software
E2511	Communication device; mounting system
E2512	Communication device; alternative access component
E2599	Communication device, miscellaneous

1–10 of 11

1/2

Bariatric surgeryCPTCovered

43644	Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and roux-en-y gastroenterostomy (roux limb)
43645	Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and other limb
43659	Unlisted laparoscopy procedure, stomach
43770	Laparoscopy, gastric restrictive procedure, with bypass
43775	Laparoscopy, gastric restrictive procedure, conversion of previous restrictive procedure to another
43842	Laparoscopy, gastric restrictive procedure; adjustable band
43845	Laparoscopy, gastric restrictive procedure; with partial gastrectomy
43846	Laparoscopy, gastric restrictive procedure; with gastroplasty
43847	Laparoscopy, gastric restrictive procedure; with other
43848	Laparoscopy, gastric restrictive procedure; with revision

1–10 of 11

1/2

Behavioral health (external link)mixed

(providerexpress.com)

Full list of Behavioral Health prior authorization requirements available at providerexpress.com

Bone growth stimulatorsmixedCovered

20975	Insertion of implantable bone stimulation system, cervical; with or without fusion
20979	Removal of implantable bone stimulation system
E0760	Bone growth stimulator, electrical, implanted
E0747	Bone growth stimulator, electrical, noninvasive, electronic or magnetic, cervicothoracic, other
E0748	Bone growth stimulator, electrical, noninvasive, electronic or magnetic, appendicular skeleton, other
E0749	Bone growth stimulator, electrical, noninvasive, electronic or magnetic, unspecified

Cancer supportive care (J-codes)HCPCSCovered

J1449	Injection, filgrastim, biosimilar, 1 mcg
J1456	Injection, pegfilgrastim, 6 mg
J0897	Injection, denosumab, 1 mg
J3241	Injection, tbo-filgrastim, 1 mcg

Chemotherapy injectablesHCPCSCovered

J2356	Injection, bevacizumab-awwb, biosimilar, 10 mg
C9094	Injection, trastuzumab-deam, biosimilar, 10 mg
C9149	Injection, rituximab-abbs, biosimilar, 10 mg
C9157	Injection, pertuzumab, biosimilar (if applicable), 10 mg
C9162	Injection, palivizumab biosimilar (example lineage), 10 mg
C9166	Injection, other monoclonal antibody or biosimilar code example, 10 mg
C9167	Injection, monoclonal antibody biosimilar, 10 mg
C9168	Injection, monoclonal antibody biosimilar, 10 mg

BRCA/genetic testingCPTCovered

81162	BRCA1/BRCA2, common variants screening
81163	BRCA1 sequencing
81164	BRCA2 sequencing
81165	BRCA1/BRCA2 full sequence analysis
81166	BRCA duplication/deletion analysis
81212	BRCA family variant testing
81215	BRCA test, other
81216	BRCA test, other panel
81217	BRCA sequencing, comprehensive
81432	Cancer genetic testing panel

1–10 of 11

1/2

CircumcisionCPT

(varies)

Circumcision codes may have mixed status depending on age/medical necessity; verify policy

Cochlear/implant codesCPTCovered

(see policy)

Cochlear implant evaluation, implantation, and programming codes require prior auth per policy

Continuous glucose monitor (CGM)HCPCSCovered

(see policy)

CGM supply and device HCPCS codes require prior authorization per diabetes management criteria

Cosmetic/ReconstructiveCPTNot Covered

(varies)

Cosmetic procedures not medically necessary are not covered

DMEHCPCSCovered

E1399	Durable medical equipment, miscellaneous
E0601	CPAP device
E0748	Bone growth stimulator, noninvasive
A9270	Non-covered item or service

CardiovascularCPTCovered

93580

Invasive cardiovascular procedure code example requiring prior authorization as listed

Cerebral seizure monitoringCPTCovered

95700	Continuous overnight EEG monitoring, inpatient — covered
95711	Ambulatory EEG recording; one channel, in inpatient — covered
95712	Ambulatory EEG recording; two channels — covered
95713	Ambulatory EEG recording; three channels — covered
95714	Ambulatory EEG recording, outpatient, not routinely covered/neutral
95715	Ambulatory EEG recording, outpatient, neutral
95716	Ambulatory EEG recording, outpatient, neutral
95717	Ambulatory EEG recording, outpatient, neutral
95718	Ambulatory EEG recording, outpatient, neutral

Hearing / hearing aid V-codesmixedCovered

V5261	Hearing aid fitting
V5262	Hearing aid verification

Home health / hospiceCPTCovered

(see policy)

Home health and hospice admissions and services require prior authorization per plan rules

HysterectomyCPTCovered

(see policy)

Hysterectomy CPT codes require prior authorization per clinical criteria

Injectable medications (J-code list)HCPCSCovered

J1449	Filgrastim, colony-stimulating factor
J1456	Pegfilgrastim
J3241	Tbo-filgrastim, 1 mcg
J2356	Bevacizumab-awwb, biosimilar, 10 mg

Sodium hyaluronateHCPCSCovered

J7321

Hyaluronic acid injection

Orthotics / Prosthetics L-codesHCPCSCovered

Lxxxx

Orthotic and prosthetic L-codes require prior authorization per policy

Outpatient therapy (PT/OT)CPTCovered

97001	Physical therapy evaluation
97110	Therapeutic exercise
97112	Neuromuscular reeducation

Pain injectionsCPTCovered

(see policy)

Pain management injection codes require prior authorization per interventional pain criteria

Private duty nursing (T-codes)HCPCSCovered

T1000

Nursing services, private duty, per 15 minutes

Proton beam therapyCPTExperimental

77520	Proton beam therapy, cranial
77522	Proton beam therapy, body

Procedure / sample list (Part 4)mixed

(see policy)

Additional procedures and sample codes listed in Part 4 of the policy

Implantable stimulatorsHCPCSCovered

L8680	Implantable neurostimulator, pulse generator
L8685	Implantable neurostimulator, lead

Transplant / CAR T CPTsCPTCovered

(see policy)

Transplant and CAR-T therapy CPTs require prior authorization per transplant policy

SOS-flagged codesmixed

(see policy)

Codes flagged by SOS program require special review

Temporary / unclassified codes and drug referencesmixed

C9094	Trastuzumab biosimilar code (temporary) — included for reference and prior auth
C9149	Rituximab biosimilar code (temporary) — included for reference and prior auth
C9157	Pertuzumab biosimilar code (temporary) — included for reference and prior auth
C9162	Example monoclonal antibody biosimilar temporary code — included for reference
C9166	Temporary code for monoclonal antibody biosimilar — included for reference
C9167	Temporary code for monoclonal antibody biosimilar — included for reference
C9168	Temporary code for monoclonal antibody biosimilar — included for reference

Wound VACHCPCSCovered

E2402	Negative pressure wound therapy pump, stationary
E2403	Negative pressure wound therapy pump, portable

Intravitreal VEGF codesHCPCSCovered

J2778	Aflibercept injection, 1 mg
J0178	Bevacizumab, intravitreal (hospital outpatient billing guidance)

Category-specific PA rules (by service)

Behavioral health

Behavioral health PA requirements and external reference:

Inpatient PA: Prior authorization required for inpatient behavioral health admissions

inpatient behavioral health

Outpatient PA and reviews: Prior authorization required for specified outpatient behavioral health services; second-level review required by the division for out-of-state service requests

outpatient and out-of-state review

External list reference: Full list of Behavioral Health prior authorization requirements available at providerexpress.com

see providerexpress.com

Key definitions and abbreviations

Definitions / brief terms

EPSDTEarly and Periodic Screening, Diagnostic and Treatment — coverage for members younger than 21 where applicable

AHCCCSArizona Health Care Cost Containment System — state Medicaid agency whose coverage definitions govern eligibility for PA

Preferred Homecare (vendor)Vendor referenced for in-home supplies and enteral/parenteral nutrition; call 800-636-2123 to request services/supplies; incontinence supplies must be provided via Preferred Homecare

Optum Infusion (vendor)Vendor referenced for infusion services and injectable medications; call 800-985-3059 to request services/supplies/medications

LabCorp (vendor)Vendor referenced for genetic testing prior authorization; to determine PA requirements call LabCorp at 800-788-9743

Nationwide Vision (vendor)

Common questions and operational answers

Policy revision history

2024-06-01Effective DateLatest

Policy effective date (Part 2 of 5)

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for developmentally disabled Arizona members

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2024

Next Review Date

On This Page

Services provided inside multi‑specialty interdisciplinary clinics (MSIC) to children’s rehabilitative services (CRS)-designated members do not require prior authorization (if applicable)

For out‑of‑network or out‑of‑state providers, prior authorization must include documentation supporting the out‑of‑network request

Experimental or investigational services are not covered

Allergy immunotherapy / testing

Age‑based coverage for allergy services and criteria for allergy testing:

ALL of the following

Members younger than 21
- Allergy immunotherapy and allergy testing are covered under EPSDT when medically necessary
Members 21 and older
- Allergy immunotherapy, including desensitization treatments administered by subcutaneous injections, sublingual immunotherapy (SLIT) or other routes, is not a covered benefit
Allergy testing criteria (any age when life‑threatening concern)
- Allergy testing (including common allergens) is covered when the member has sustained an anaphylactic reaction to an unknown allergen
- Allergy testing is covered when the member has exhibited such a severe allergic reaction that further exposure to the unknown allergen may result in a life‑threatening situation (examples: severe facial swelling, breathing difficulties, epiglottal swelling, extensive urticaria)
- Prior authorization is required when allergy testing meets the criteria above

General prior authorization requirement

Prior authorization is required for the services listed below. Include supporting clinical documentation and, for medication requests, provide J‑codes and NDCs.

ALL of the following

A prior authorization (PA) is required for the outpatient and inpatient services listed in this policy unless the service is explicitly exempt (for example, certain MSIC/CRS services for eligible children)
For inpatient admissions, some services require notification rather than full PA — follow the specific service rules; behavioral health inpatient admissions require prior authorization
Service requests for medications and certain infused or administered drugs must include J‑codes and NDCs on the PA submission
Only one health care professional may request PA per request form
Out‑of‑state or out‑of‑network service requests require second‑level review when specified by the Division; include documentation to support out‑of‑network necessity

Services provided by non‑network and out‑of‑state providers require prior authorization and documentation supporting the out‑of‑network request. Inpatient admissions may require notification in some circumstances while other inpatient or outpatient services require full prior authorization — follow the specific service line guidance. Repeated reminder: all service requests for medications (including colony‑stimulating factors, bone‑modifying agents, antineoplastic supportive drugs, and other infused/administration drugs) must include J‑codes and NDCs on the prior authorization submission; failure to provide required codes or supporting clinical documentation may result in delay or denial.

Medication service requests must include J-codes and NDCs

Service requests for medications must include the J‑code and the NDC for the medication requested. Omitting J‑codes or NDCs may prevent prior authorization processing. For specialty pharmacy or pharmacy PA, use the pharmacy contacts (phone/fax) and fax specialty PA forms to the specialty pharmacy fax number.

Service requests must include J‑code and NDC
Omission may prevent PA processing
Specialty pharmacy fax: 866-940-7328; pharmacy PA phone: 800-310-6826

Documentation Required

Documentation requirements for non-network or out-of-state services

Requests for services provided by non‑network or out‑of‑state providers require prior authorization and supporting documentation. Out‑of‑state services will only be approved when the service is emergent or unavailable in Arizona; otherwise claims may be denied.

Non‑network/out‑of‑state services require PA and supporting documentation
Out‑of‑state services: benefit only approved when emergent or unavailable in AZ — risk of denial otherwise

Documentation Required

Clinical documentation for cochlear implants

Clinical documentation must accompany prior authorization requests for cochlear and other auditory implants to establish medical necessity. Codes that require documentation and PA include: 69710, 69714, 69930, L8619, L8690, L8614, L8692.

Clinical documentation must accompany PA requests
Relevant codes: 69710, 69714, 69930, L8619, L8690, L8614, L8692

Prior Authorization

DME requests / Preferred Homecare authorization for enteral/parenteral nutrition

To request DME items or enteral/parenteral nutrition services from Preferred Homecare call 800-636-2123 or submit via the Provider Portal as applicable. Certain DME items require prior authorization regardless of dollar amount and other listed DME codes require PA when retail purchase or cumulative rental thresholds apply.

Preferred Homecare contact: 800-636-2123
Some DME require PA regardless of dollar amount
PA required for listed DME codes or when retail/cumulative rental cost > $500

Prior Authorization

Chemotherapy and oncology supportive drugs

Prior authorization is required for outpatient injectable chemotherapy and many oncology supportive drugs. Codes and ranges requiring PA include J9000–J9999, J0640, J0641, J0642, J1950 and additional listed J‑codes. Submit PA requests via the Provider Portal or by calling 888-397-8129.

Chemotherapy J‑codes: J9000–J9999
Leucovorin/Levoleucovorin: J0640, J0641, J0642
Lupron Depot: J1950
Submit via Provider Portal or call 888-397-8129

Denial Risk

Routine circumcision denial risk

Routine circumcision is not a covered benefit and claims may be denied. Prior authorization is required only when medical necessity is documented. Relevant CPT codes include 54150–54162.

Circumcision codes: 54150, 54160, 54161, 54162
Routine circumcision not covered; PA required only with documented medical necessity — denial risk if not documented

Prior Authorization

Pharmacy prior authorization contact and specialty PA fax

For pharmacy prior authorization contact UnitedHealthcare Pharmacy Prior Authorization Service by phone at 800-310-6826. Specialty pharmacy prior authorization fax number is 866-940-7328 (use specialty fax for specialty PA submissions).

Pharmacy PA phone: 800-310-6826
Specialty pharmacy PA fax: 866-940-7328

Documentation Required

Transportation scheduling and prior authorization

Prior authorization is required for non‑emergent transportation (taxi, stretcher van). To schedule, contact Medical Transportation Management (MTM) at 888-700-6822 and include required PA documentation as specified.

MTM scheduling: 888-700-6822
Prior authorization required for non‑emergent transportation

Prior Authorization

VAD notification and fax requirement

For Ventricular Assist Devices (VAD) call the notification number on the back of the member's ID card and fax the form provided by the nurse to Optum VAD Case Management at 855-282-8929 as part of the notification/PA process.

Call notification number on member ID card
Fax nurse‑provided VAD form to Optum VAD Case Management: 855-282-8929

Bone growth stimulators / electronic stimulation

Bone growth stimulator / electronic stimulation PA requirement and codes:

PA required: Prior authorization required for bone growth stimulator and related electronic stimulation codes

codes listed in code_groups

Codes: CPT/HCPCS codes requiring PA include 20975, 20979 and E0760 (and HCPCS E0747/E0748/E0749 for bone growth stimulators)

code references

Cancer supportive care / injectable oncology supportive drugs

PA required for outpatient-administered supportive cancer drugs; BRCA lab routing:

Supportive oncology drugs PA: Prior authorization required for colony-stimulating factors, bone-modifying agents, and certain antiemetic and erythropoiesis-stimulating agents administered outpatient for a cancer diagnosis

J0897, J1456, J1449, J0885, J2820 referenced

Specific J-codes: Specific HCPCS J-codes referenced as requiring PA include J0897 (denosumab/Xgeva), J1456 (antiemetic), J1449 (colony-stimulating factor) and J0885 (ESA); sargramostim J2820 also referenced

code list from source

BRCA/genetic testing: Lab genetic testing (BRCA) requires prior authorization and lab requests should be directed to LabCorp for review

BRCA CPT codes listed and LabCorp routing

Chemotherapy (injectable drugs)

Chemotherapy injectable drugs PA and submission instructions:

Scope: Prior authorization required for outpatient injectable chemotherapy drugs billed J9000-J9999 and specified agents (Leucovorin J0640, Levoleucovorin J0641/J0642, Lupron Depot J1950), Q-code drugs and miscellaneous HCPCS chemo agents

J9000-J9999 and listed J-codes

Submission: Submit PA requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-397-8129

portal or 888-397-8129

Cochlear and other auditory implants

Cochlear and other auditory implants — age differences, PA and clinical documentation:

Age-based PA: Members younger than 21: prior authorization required for listed cochlear implant codes; Members 21 and older: prior authorization required for supplies, equipment maintenance and repair (hardware not covered)

age-based differences

Clinical documentation must accompany PA requests to establish medical necessity for cochlear and auditory implant services

documentation requirement

Codes: Representative codes listed include 69710, 69714, 69930 and HCPCS L8619, L8690, L8614, L8692

codes referenced in document

Continuous glucose monitors (CGM)

PA requirement for Continuous Glucose Monitors (CGM):

CGM PA condition: Prior authorization is required for continuous glucose monitors when the member has a Type 2 diabetes diagnosis

codes include A4226, A9277, A4238, A9278, A4239, A9276

Cosmetic vs Reconstructive procedures

Cosmetic vs reconstructive PA rules and exceptions:

Cosmetic exclusion: Services/items furnished solely for cosmetic purposes are excluded from AHCCCS coverage and are not covered

cosmetic exclusion

Reconstructive exception: Reconstructive procedures that treat a medical condition or restore physiologic function may be covered and require prior authorization with supporting documentation

reconstructive coverage exceptions

SOS/skincare exception: Certain codes (marked with *) will NOT require prior authorization when billed with skin cancer diagnoses per document note

* SOS/skin cancer note

Durable Medical Equipment (DME)

DME prior authorization conditions and vendor contact:

PA conditions: Prior authorization is required only for the DME codes listed that have a retail purchase or cumulative rental cost threshold; certain items require PA regardless of dollar amount (e.g., cost > $500 and items marked with *)Retail purchase or cumulative rental cost > $500; items marked '*' require PA regardless of amount

threshold and PA-exception rules

Vendor contact: To request DME items when Preferred Homecare is the vendor or when PA is required, contact Preferred Homecare at 800-636-2123

Preferred Homecare contact

Items requiring PA regardless of dollar amount: Examples include specialty beds, wound vacs and bone stimulators (see code lists in document) which may require PA regardless of dollar amount

examples noted

Cardiology / Cardiovascular procedures

Cardiology / cardiovascular PA expectations and code reference:

Outpatient PA requirement: Prior authorization is required for participating physicians for outpatient and office-based diagnostic catheterizations, electrophysiology implants and stress echos prior to performance

cardiology outpatient PA

Submission channels: For cardiology prior authorization submit via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 866-889-8054; details and CPT lists at UHCprovider.com/AZcommunityplan > Prior Authorization

portal or 866-889-8054

Specific code: Cardiovascular code 93580 is listed as requiring prior authorization

93580 listed

Pregnancy termination

Pregnancy termination PA and documentation requirements:

PA required: Prior authorization is required for pregnancy termination and must include clinical documentation and a certificate of medical necessity

certificate and clinical documentation required

Includes medication: Prior authorization includes mifepristone (Mifeprex/RU-486)

medication included in PA

Associated CPT/HCPCS mappings listed include 33289 = 59840, 59852; 33289 = 59841, 59855; C2624 = 59850; 59851 (as indicated)

associated code mappings provided

Private duty nursing

Private duty nursing PA requirement and codes:

PA required: Prior authorization is required for private duty nursing services

private duty nursing PA

Codes listed include T1002 and T1003 (private duty nursing) and are subject to prior authorization

T1002/T1003 referenced

Provider actions: Providers should follow DME/provider actions and submission channels as appropriate for nursing and related DME requests

refer to DME/Provider Portal instructions

Radiology - advanced outpatient imaging

Radiology — advanced outpatient imaging notification/PA:

Notification requirement: Health care professionals ordering advanced outpatient imaging (certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology) are responsible for providing notification prior to scheduling the procedure

notification prior to scheduling

Submission channel: Submit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal

portal submission

Site of service (SOS) - outpatient hospital

Site of service (SOS) — outpatient hospital PA rules and example codes:

SOS rule: Prior authorization is required only when requesting the listed service in an outpatient hospital setting; not required if performed at a participating ambulatory surgery center (ASC) unless otherwise noted

SOS outpatient hospital rule

Codes requiring PA in outpatient hospital setting: Examples of codes requiring PA only when performed in outpatient hospital include 31295, 31296, 31297, 31298, 69205 and cataract surgery codes 66821, 66982, 66984

codes listed as SOS examples

Procedure-specific groups (Proton beam therapy, Rhinoplasty/septoplasty, Shoulder surgery, Sinuplasty, Colonoscopy and related GI procedures, etc.)

Procedure-specific prior authorization rules and code lists (each node reflects a procedure group requiring PA):

Proton beam therapy: Prior authorization required for proton beam therapy CPT/HCPCS codes 77520, 77522, 77523, 77525

proton beam therapy codes

Rhinoplasty and septoplasty: Prior authorization required for rhinoplasty/septoplasty codes (examples 30400, 30435, 30465, 30410, 30450, 30420, 30460, 30430, 30462)

nasal functional impairment codes

Shoulder surgery: Prior authorization required for shoulder surgery codes including 29805, 29806, 29807, 29819

shoulder CPT examples

Sinuplasty: Prior authorization required for sinuplasty CPT codes 29820, 29822, 29823, 29824

sinuplasty codes

Colonoscopy and related GI procedures: Prior authorization required for colonoscopy and related GI CPT codes such as 45378, 45380, 45384, 45385

GI procedure examples

Other procedure groups: Additional procedure-specific PA required for many GI, ENT, ophthalmologic, respiratory, urologic and other CPT codes listed across the document (see code lists)

extensive lists in source

Vendor referenced for member eye care services; call 480-961-1702

SOS (Site of Service)Indicates PA required when performed in an outpatient hospital setting; may not be required at participating ASCs

Code 38232 noteCode 38232 requires prior authorization only when diagnosis is oncology

J Codes and NDC CodesService requests for medications must include the 'J' code and the NDC code for the medication requested (required for physician-administered drugs and pharmacy PA)