UnitedHealthcare Arizona Developmental Disabilities Prior Auth

Coverage Criteria and Medical Necessity

Allergy immunotherapy coverage rules

Covered/Not covered rules for allergy immunotherapy

Allergy immunotherapy coverage for members <21: For members younger than 21: Allergy immunotherapy and allergy testing is covered under Early and Periodic Screening, Diagnostic and Treatment (EPSDT) when medically necessary.age <21

Allergy immunotherapy coverage for members >=21: For members 21 and older: Allergy immunotherapy, including desensitization treatments administered by subcutaneous injections (allergy shots), sublingual immunotherapy (SLIT) or another route of administration, is not a covered benefit.age >=21

Severe allergic reaction examples: Sustained an anaphylactic reaction to an unknown allergen or exhibited such a severe allergic reaction where further exposure may be life-threatening (examples: severe facial swelling, breathing difficulties, epiglottal swelling, extensive urticaria).clinical severity

These examples are provided as context for when immunotherapy/testing may be medically necessary for EPSDT-eligible members.

Cancer supportive care prior authorization

Colony-stimulating factors and bone-modifying agents: Prior authorization is required for outpatient administration of injectable colony-stimulating factor drugs and certain bone-modifying agents for a cancer diagnosis (examples and HCPCS/J codes are listed in the document, e.g., J1442, J2506, J1447, J0897).outpatient administration for cancer diagnosis

Includes specified HCPCS J/Q codes and miscellaneous HCPCS when unassigned.

General prior authorization requirements

General prior authorization workflow

Submission methods: Submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone to the numbers listed in the policy.

Portal access via UHCprovider.com; phone 800-445-1638.

Provider and service eligibility: Services must be covered benefits per AHCCCS; rendering professionals, facilities and vendors must be actively registered with AHCCCS; only one health care professional may request services on a prior authorization form.AHCCCS registration and coverage determination

Authorization and medical necessity

Covered when documentation establishes medical necessity and prior authorization is obtained as required

General PA and medical necessity: Provider obtains prior authorization for listed CPT/HCPCS/DME codes and supplies; clinical documentation (and Certificate of Medical Necessity for oral supplements when applicable) must accompany requests; DME and in-home supplies obtained via Preferred Homecare as indicated.see DME dollar threshold

See contact numbers for Preferred Homecare and UnitedHealthcare resources

General prior authorization and medical necessity criteria

Prior authorization requirements and routes

Enteral/Parenteral nutrition (all ages): Requests for in-home enteral or parenteral nutrition (including gastrostomy tube feeding, TPN, lipids, and oral supplements) must be submitted to Preferred Homecare at 800-636-2123 with clinical documentation and Certificate of Medical Necessity as applicable.

Chunks: 37, 38

Members <21 (EPSDT): Providers should follow AHCCCS AMPM Chapter 400 EPSDT guidance and use the Certificate of Medical Necessity for Commercial Oral Nutritional Supplements as referenced.

Chunk: 38

Members >=21: For adults, refer to AMPM Chapter 300 policies; prior authorization is required for many adult services including genetic testing not covered by LabCorp and in-home infusion/injectable medications not covered by Optum Infusion.

Chunks: 39, 42, 46, 47

Coverage criteria for orthotics and prosthetics

Covered when ALL of the following are met

Ordering: Orthotic must be ordered by a physician or primary care provider for members 21 and older.

Repair vs Replacement: Reasonable repairs or adjustments of purchased orthotics are covered when they make the orthotic serviceable and when repair cost is less than purchasing another unit; replacement requires documentation that the component is not operating effectively at time of authorization.

Medical necessity/cost: Orthotic is considered medically necessary when it is the preferred treatment option, is less expensive than surgical procedures for the same diagnosed condition, or is consistent with Medicare guidelines.

Outpatient OT/PT therapy coverage

Outpatient therapy coverage and prior authorization rules

Outpatient therapy for members younger than 21: Occupational and physical therapy are covered in an inpatient or outpatient setting; outpatient OT/PT are limited to 15 visits per benefit year for restoring/maintaining function and 15 visits per benefit year to acquire/maintain a new skill; prior authorization is required for the listed codes.15 visits

Outpatient speech therapy is not a covered benefit for the referenced population.

Site of service / network rules

Site of service and out-of-state/out-of-network rules

Out-of-network and out-of-state services: Prior authorization is required for all out-of-network services; out-of-state services are approved only when emergent or not available in Arizona; prior authorization is required for advanced outpatient imaging and certain outpatient hospital site-of-service requests.

Providers ordering advanced outpatient imaging must notify prior to scheduling and submit prior authorization via the UnitedHealthcare Provider Portal.

Pharmacy / physician-administered drug coverage

Pharmacy and physician-administered drugs

Drug prior authorization and documentation: Service requests for physician-administered and pharmacy drugs must include J-codes and NDC codes; a maintained list of medications requires prior authorization; specialty biotech drugs require faxed or online specialty pharmacy prior authorization forms as specified.

Phone and fax contacts provided for pharmacy prior authorization and specialty pharmacy (e.g., phone 800-310-6826; fax 866-940-7328).

Pregnancy termination prior auth

Pregnancy termination

Pregnancy termination prior authorization: Prior authorization is required and must include clinical documentation and the Certificate of Medical Necessity; prior authorization includes Mifepristone (Mifeprex/RU-486).

Refer to AMPM Chapter 400 Section 410E for further policy details.

Prior authorization requirement

Covered when prior authorization obtained for listed procedures

Prior Authorization Required: Prior authorization is required for the specific CPT/HCPCS codes listed in this section (examples include spinal surgery codes, specialty/enclosed bed HCPCS, sleep apnea procedures, and other listed surgical and advanced services); follow the submission routes and site-of-service notes where specified.

Applies to qualified Medicare beneficiaries where noted; includes site-of-service notes.

Prior authorization required

Covered when prior authorization is obtained for qualified Medicare beneficiaries for the listed codes

PA requirement for sterilization codes: Prior authorization must be obtained for the listed sterilization CPT/HCPCS codes or their mapped equivalents for qualified Medicare beneficiaries (document maps codes such as 55700→52601 and 57288→52630 among others).

Consent and mapping details referenced in AMPM guidance.

General prior authorization criteria

Covered when prior authorization is obtained for the listed codes and supporting documentation is provided

Prior authorization and documentation: Prior authorization is required for the listed sterilization, stimulator/implant, transplant, CAR T‑cell, vascular/VAD, wound VAC, infusion, and transportation codes; clinical documentation or consent (where noted) must accompany the request and special call/notification steps (e.g., transplant/CAR T-cell case management, VAD notification) must be followed as directed.

Some codes have special routes or phone contacts (e.g., Transplant Case Management Team 800-418-4994; Transportation scheduling via Medical Transportation Management 888-700-6822).

Experimental and investigational services are not covered benefits. Per AHCCCS eligibility rules cited in this policy, services must be covered benefits to be eligible for prior authorization; procedures classified as experimental or investigational require prior authorization when requested and may be denied if not authorized.

Routine circumcision is not a covered benefit. Prior authorization is required only when a circumcision is requested with documented medical necessity; otherwise routine circumcision is excluded from coverage.

Procedures furnished solely to improve appearance without significant functional impairment are excluded as cosmetic and are not covered. Many cosmetic or reconstructive CPT/HCPCS codes listed in this policy require prior authorization if submitted; services determined to be cosmetic will be denied as not a covered benefit.

Incontinence supplies are a covered benefit only when provided through Preferred Homecare. Requests for in-home enteral/parenteral nutrition, related supplies, or DME should be routed to Preferred Homecare (contact details provided in the policy) with supporting clinical documentation and any required certificates of medical necessity.

Orthotics and prosthetics listed in the policy require prior authorization when the item is associated with a retail purchase or when the cumulative rental cost exceeds $500. Providers should follow the prior authorization instructions included beside many HCPCS/L codes in the document.

Replacement of orthotic components is not covered unless documentation establishes the existing component is not operating effectively at the time of the authorization request. Reasonable repairs or adjustments of purchased orthotics are covered when the repair cost is less than purchasing another unit; replacement is supported only when repair is not feasible or the component fails to function.

Outpatient speech therapy is not a covered benefit under the policies excerpted here. Occupational and physical therapy are covered but outpatient OT/PT visits are limited to 15 visits per benefit year for restoring/maintaining function and an additional 15 visits per benefit year to acquire/maintain a new skill; prior authorization is required where specified.

For transplant/CAR T‑cell related authorization, note that code 38232 requires prior authorization only when billed with an oncology diagnosis. Some CAR T‑cell and temporary/unclassified codes have special prior authorization routing and notification instructions; follow the policy’s CAR T‑cell guidance and contact numbers when submitting requests.

Allergy immunotherapy is covered for members younger than 21 under EPSDT when medically necessary, but is not a covered benefit for members 21 and older. The policy explicitly excludes allergy immunotherapy (including subcutaneous allergy shots and sublingual immunotherapy) from coverage for adults age 21 and over.

Reiterating the cosmetic exclusion: procedures performed solely to improve physical appearance without significant functional impairment are considered cosmetic and are excluded from coverage; many such CPT/HCPCS codes also require prior authorization when submitted.

Services classified as experimental or investigational require prior authorization and are subject to denial if not authorized; providers should confirm coverage eligibility against AHCCCS guidance before submitting requests to avoid denial for noncovered experimental services.

CPT / HCPCS / DME / Related Codes

Communication/related codes listedCPT|HCPCS

92607
92608
92609
A9901
E2500
E2502
E2504
E2506
E2508
E2510

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Bariatric surgery CPT codesCPTCovered

43644
43645
43659
43770
43775
43842
43845
43846
43847
43848

1–10 of 11

1/2

Selected musculoskeletal/implant codesCPT | HCPCSCovered

20975
20979
E0760

Cancer supportive care / colony-stimulating and bone-modifying agentsHCPCSCovered

J1442	Filgrastim (Neupogen)
Q5110	Filgrastim-aafi (Nivestym)
Q5125	Filgrastim-ayow (Releuko)
Q5101	Filgrastim-sndz (Zarxio)
J2506	Pegfilgrastim (Neulasta)
Q5122	Pegfilgrastim-apgf (Nyvepria)
Q5120	Pegfilgrastim-bmez (Ziextenzo)
Q5111	Pegfilgrastim-cbqv (UDENYCA)
J1447	Tbo-filgrastim (Granix)
J1448	Trilaciclib (Cosela)

1–10 of 13

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Continuous glucose monitor related HCPCS codesHCPCSCovered

A4226
A9277
E2103
A4238
A9278
A4239
E0787
A9276
E2102

Genetic testing and breast reconstruction related codesCPT | HCPCS

81162
81163
81164
81165
81166
81212
81215
81216
81217
81432

1–10 of 30

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Circumcision and cochlear/aural implant related codesCPT | HCPCS

54150
54160
54161
54162
69710
69714
69930
L8614

Cosmetic and reconstructive procedure codesCPT

11960
14061
14020
14021
15830
14041
15847
17106
17107
17108

1–10 of 14

1/2

Prior authorization CPT/HCPCS/DME/K/S codesmixedCovered

11960
14020
14021
14041
15823
15830
15847
17106
17107
17108

1–10 of 194

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Experimental or investigational example codesmixed

33477	Listed under experimental/investigational examples
A4638	Listed under experimental/investigational examples
G0293	Listed under experimental/investigational examples
S9991	Listed under experimental/investigational examples
36514	Listed under experimental/investigational examples
A9274	Listed under experimental/investigational examples
G2000	Listed under experimental/investigational examples
S9992	Listed under experimental/investigational examples
64722	Listed under experimental/investigational examples
E1831	Listed under experimental/investigational examples

1–10 of 16

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Hearing evaluation and hearing aid codesCPT | HCPCSCovered

92590	Hearing aids related code
92591	Hearing aids related code
92592	Hearing aids related code
92593	Hearing aids related code
92595	Hearing evaluation code
V5010	Hearing evaluation/supplies code
V5011	Hearing evaluation/supplies code
V5014	Hearing evaluations and hearing aids prior auth

Injectable/biologic HCPCS J-codesHCPCSCovered

J3262	Actemra (example injectable) listed requiring prior authorization
J0791	Adakveo listed requiring prior authorization
J0172	Aduhelm listed requiring prior authorization
J7171	Amondys 45 listed requiring prior authorization
J0256	Aralast NP/Prolastin-C/Zemaira listed
J0597	Berinert listed
J2329	Briumvi listed
Q5128	Cinqair listed
J2786	Cinqair J-code
J3247	Cosentyx IV listed

1–10 of 20

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Genetic testing CPT/HCPCS codesCPT | HCPCS

81265	Genetic testing code listed
81302	Genetic testing code listed
81321	Genetic testing code listed
81323	Genetic testing code listed
81325	Genetic testing code listed
81401	Genetic testing code listed
81403	Genetic testing code listed
81404	Genetic testing code listed
81405	Genetic testing code listed
81406	Genetic testing code listed

1–10 of 37

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Nonemergent air ambulanceHCPCSCovered

A0430	Nonemergent air ambulance transport
A0431	Nonemergent air ambulance transport
A0435	Nonemergent air ambulance transport
A0436	Nonemergent air ambulance transport

Joint replacement — total hip and knee procedure CPT codesCPTCovered

24360
24370
27130
27138
27486
24361
24371
24362
27120
27134

1–10 of 21

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Orthognathic / maxillofacial procedure CPT codesCPTCovered

21121	Orthognathic surgery
21123	Orthognathic surgery
21125	Orthognathic surgery
21127	Orthognathic surgery
21141
21142
21143
21145
21146
21147

1–10 of 39

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Orthotics and prosthetics codes requiring prior authorizationHCPCSCovered

L0112	Orthotics/prosthetics
L0170	Orthotics/prosthetics
L0456	Orthotics/prosthetics
L0462	Orthotics/prosthetics
L0464	Orthotics/prosthetics
L0480	Orthotics/prosthetics
L0482	Orthotics/prosthetics
L0484	Orthotics/prosthetics
L0486	Orthotics/prosthetics
L0624	Orthotics/prosthetics

1–10 of 12

1/2

Miscellaneous drug/C-codes and unclassified codesmixed

C9094
C9149
C9157
C9166
C9172
C9399
J3490
J3590
J1823	Uplizna

Surgical CPT/HCPCS codes referencedmixed

21199	Treatment of maxillofacial/jaw functional impairment
21206	Treatment of maxillofacial/jaw functional impairment
21208	Treatment of maxillofacial/jaw functional impairment
21209	Treatment of maxillofacial/jaw functional impairment
21210	Treatment of maxillofacial/jaw functional impairment
21215	Treatment of maxillofacial/jaw functional impairment
21240	Treatment of maxillofacial/jaw functional impairment
21242	Treatment of maxillofacial/jaw functional impairment
21244	Treatment of maxillofacial/jaw functional impairment
21245	Treatment of maxillofacial/jaw functional impairment

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Orthotics/Prosthetics HCPCS L-codes requiring prior authorizationHCPCSCovered

L0112	Orthotics and prosthetics
L0170	Orthotics and prosthetics
L0456	Orthotics and prosthetics
L0462	Orthotics and prosthetics
L0464	Orthotics and prosthetics
L0480	Orthotics and prosthetics
L0482	Orthotics and prosthetics
L0484	Orthotics and prosthetics
L0486	Orthotics and prosthetics
L0624	Orthotics and prosthetics

1–10 of 299

1/30

Listed CPT/HCPCS/L-codes requiring prior authorization or noted in sectionmixed

L6940
L6945
L6950
L6955
L6960
L6965
L6970
L6975
L7007
L7008

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Mixed specialty CPT codes (partial list)CPT

57522	CPT code listed in gynecologic procedures group
58353	CPT code listed in gynecologic procedures group
58558	CPT code listed in gynecologic procedures group
58563	CPT code listed in gynecologic procedures group
58565	CPT code listed in gynecologic procedures group
38500	Hemic and lymphatic systems
38510	Hemic and lymphatic systems
38525	Hemic and lymphatic systems
10121	Integumentary system
11440	Integumentary system

1–10 of 11

1/2

Gastrointestinal/Urologic and other CPT codesCPT

49505	Hernia repair
49650	Hernia repair
49651	Hernia repair
47000	Liver biopsy / site-specific outpatient entry
52276	Urinary system / urologic procedures
52287	Urinary system / urologic procedures
52320	Urinary system / urologic procedures
52344	Urinary system
50590	Renal procedure
52000	Urologic procedure

Musculoskeletal / arthroscopy CPT codesCPT

20552	Musculoskeletal system
20553	Musculoskeletal system
21012	Musculoskeletal system
21336	Musculoskeletal system
21554	Musculoskeletal system
21930	Musculoskeletal system
22902	Musculoskeletal system
22903	Musculoskeletal system
23071	Musculoskeletal system
29835	Arthroscopy / musculoskeletal

1–10 of 12

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Nervous system / Ophthalmologic CPT codesCPT

64561	Nervous system procedure
64640	Nervous system procedure
65426	Ophthalmologic
65730	Ophthalmologic
67028	Ophthalmologic
67228	Ophthalmologic

Respiratory / ENT / GI endoscopy CPT codesCPT

30802	Respiratory system
30930	Respiratory system
31525	Respiratory system
31535	Respiratory system
42820	Tonsillectomy and adenoidectomy group
42821	Tonsillectomy and adenoidectomy group
43235	Upper gastrointestinal endoscopy
43239	Upper gastrointestinal endoscopy
43249	Upper gastrointestinal endoscopy

HCPCS E-codes (specialty/enclosed beds)HCPCS

E0260	Specialty/enclosed bed HCPCS
E0291	Specialty/enclosed bed HCPCS
E0295	Specialty/enclosed bed HCPCS
E0315	Specialty/enclosed bed HCPCS
E0328	Specialty/enclosed bed HCPCS
E0329	Specialty/enclosed bed HCPCS
E0462	Specialty/enclosed bed HCPCS

Spinal and neurosurgery CPT codesCPT

22100	Spinal surgery CPT
22101	Spinal surgery CPT
22102	Spinal surgery CPT
22110	Spinal surgery CPT
22804	Spinal instrumentation CPT
22808	Spinal instrumentation CPT
22810	Spinal instrumentation CPT
22830	Spinal instrumentation CPT
22855	Spinal instrumentation CPT
63005	Laminectomy / spinal decompression CPT

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Sterilization and related CPT codesCPT

52601	Sterilization CPT
52630	Sterilization CPT
52647	Sterilization CPT
52648	Sterilization CPT
22514*	Listed with SOS applies (asterisk present)

CPT/HCPCS code mappingsmixed

63191	mapped from 55700
63200	mapped from 57288
63250	mapped from unspecified CPT
63251	mapped repeatedly
63270	mapped from 55700
63300	mapped from 55700/other
63271	mapped from 57288
63301	mapped from 57288
63272	mapped from unspecified
63302	mapped from unspecified

1–10 of 16

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Sterilization CPT/HCPCS codesCPTCovered

52601	Sterilization
52630	Sterilization
52647	Sterilization
52648	Sterilization
52649	Sterilization
55821	Sterilization
55700	mapped in sterilization section
57288	mapped in sterilization section

Sterilization CPT/HCPCS mappingsmixed

55700	listed / mapped to 52601 in document
57288	listed / mapped to 52630 in document
52601	mapped equivalent for 55700
52630	mapped equivalent for 57288
52647	appears as mapped equivalent
52648	appears as mapped equivalent
52649	appears in mapping list
55801	appears in mapping list
63011	sterilization-related mapping
63017	sterilization-related mapping

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Sterilization codesCPTCovered

63190	Sterilization
55700	Sterilization (listed equivalence)
57288	Sterilization (listed equivalence)
52601	Listed as equivalent/either
52630	Listed as equivalent/either
52647	Listed as equivalent/either
63011	Sterilization (repeated)
63017	Sterilization

Stimulators/Implants codesmixedCovered

55831	Sterilization related
58600	Sterilization related
58605	Sterilization related
58611	Sterilization related
E0747	Bone growth stimulator
E0748	Bone growth stimulator
E0749	Bone growth stimulator
43648	Neurostimulator related
43882	Neurostimulator related
61863	Neurostimulator related

1–10 of 29

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Transplant, CAR T-cell, temporary/unclassified codesmixedCovered

32850	Transplant related
32851	Transplant related
32852	Transplant related
32853	Transplant related
32854	Transplant related
32855	Transplant related
32856	Transplant related
33930	Cardiac transplant related
33933	Cardiac transplant related
33935	Cardiac transplant related

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Vascular, VAD, Wound VAC codesmixedCovered

36473	Phlebotomy/infusion related
36475	Phlebotomy/infusion related
36478	Phlebotomy/infusion related
37700	Vascular procedure
37718	Removal and ablation main trunks
37722	Removal and ablation main trunks
37765	Removal and ablation main trunks
37766	Removal and ablation main trunks
37780	Trunks and named branches
33927	Ventricular assist device

1–10 of 22

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What Providers Must Do

Prior Authorization

Submit prior authorization requests via portal or phone

Prior authorization is required for many services and codes listed throughout this section. Submit prior authorization (PA) requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com — sign in with One Healthcare ID) or by phone at 888-397-8129 (for general PA) or 800-445-1638 (alternative contact). For transplant/CAR T-cell services call the Transplant Case Management Team at 800-418-4994. Use the portal resources for specialty pharmacy and physician-administered drug forms.

PA submissions: UHCprovider.com Prior Authorization and Notification tool or call 888-397-8129. Some services still reference 800-445-1638.
Transplant/CAR T-cell notification: UnitedHealthcare Community and State Transplant Case Management Team 800-418-4994.

Prior Authorization

Injectable and specialty drug prior authorization

Injectable and physician‑administered medications often require prior authorization. Many J- and Q-codes are listed in this document; service requests must include the J-code and NDC, and specialty drug PA requests may require specific service request forms available on the provider portal. For in‑home infusion or injectable medications not covered by Optum Infusion, prior authorization is required and Preferred Homecare support numbers are provided where applicable.

Background and Scope

Allergy immunotherapy for EPSDT-eligible members (<21) is covered when medically necessary under AHCCCS guidance and EPSDT policy references. For members age 21, providers should follow AHCCCS AMPM Chapter 400 EPSDT procedures and include clinical documentation supporting medical necessity; for members age 21 and under routine EPSDT coverage applies, while for members age 21 and older allergy immunotherapy is not covered.

Key Definitions and Notes

Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

EPSDT definitionEarly and Periodic Screening, Diagnostic and Treatment (EPSDT) — coverage pathway for members younger than 21; see AHCCCS AMPM Chapter 400, Section 430 for details and Certificate of Medical Necessity forms.

Certificate of Medical NecessityCertificate for Commercial Oral Nutritional Supplements located via AMPM Chapter 400, Section 430-2 at azahcccs.gov.

ApplicabilityEPSDT guidance applies to clinical coverage decisions for members under 21 (refer to AHCCCS policy links provided).

Cosmetic procedures

Cosmetic procedure exclusionProcedures furnished solely for cosmetic purposes (to improve appearance without significant functional impairment) are excluded from coverage.

PA note for cosmetic codes

OpenPayer

Prior authorization requirements for Arizona Developmental Disabilities

Coverage Criteria and Medical Necessity

CPT / HCPCS / DME / Related Codes

What Providers Must Do

Background and Scope

Key Definitions and Notes