UnitedHealthcare Arizona LTC Prior Auth Policy Update

Coverage Criteria and Scope

inv-01: Allergy testing — medical necessity — Covered when ALL of the following are met

Covered when ALL of the following are met:

Allergy testing — medical necessity: Member has sustained an anaphylactic reaction to an unknown allergen OR exhibited a severe allergic reaction where further exposure to the unknown allergen may reasonably be expected to result in a life‑threatening situation

Examples: severe facial swelling, breathing difficulties, epiglottal swelling, extensive urticaria

inv-02: Authorization summary — Coverage and authorization stance as listed in this section

Coverage and authorization stance as listed in this section:

Inpatient observation: Prior authorization is not required for inpatient observation; notification is required if the member is admitted for an inpatient stay and observation must be ordered in writing by a physician or other individual authorized by hospital staff bylaws

See inpatient observation details

Prior authorization required for listed procedures: Prior authorization is required for the listed codes for joint replacement/total hip and knee replacement procedures, knee replacement, nonemergent air ambulance, and orthognathic surgery

See code lists in the Orthognathic, Joint replacement and Nonemergent air ambulance sections

Allergy immunotherapy for members age 21 is covered under EPSDT when medically necessary; however, for members age 21 and older the policy states that allergy immunotherapy is not a covered benefit. The document also affirms that experimental and investigational services are not covered benefits and that only medically necessary, cost‑effective, federal- and state‑reimbursable services are eligible for authorization.

This section of the source is corrupted and contains repeated CPT/HCPCS placeholders; there are no explicit exclusions or clear coverage statements provided in the fragmented text.

The fragments indicate that routine circumcision requires documentation of medical necessity (prior authorization is required for members younger than 21 per the excerpt) and also reiterate that services furnished solely for a cosmetic purpose are excluded from AHCCCS coverage.

The policy notes an explicit coding exception: CPT code 67966 will not require prior authorization when billed with skin cancer, as stated repeatedly in the fragment.

The document clarifies prior authorization expectations for several unclassified and temporary codes (e.g., C9094, C9149, C9157, C9166, C9167, C9168, C9172, C9399, J3490, J3590): prior authorization is only required for specific products named in the fragment (examples listed include Beqvez, Nulibry, Revcovi, Rivfloza, Vabysmo); providers should refer to the referenced Review at Launch guidance for product‑specific requirements.

Certain codes and situations in the excerpt are designated as requiring prior authorization only when clinical or documentation conditions apply; the fragment explicitly states that inpatient observation does not require prior authorization but notification is required if a member is admitted, and observation orders must be written by an authorized physician or other authorized individual per hospital bylaws.

This section is a corrupted listing of repeated 'Treatment of' entries and code placeholders and contains no usable coverage items or explicit criteria to apply.

The fragment repeatedly lists 'Treatment of' entries without providing explicit statements of coverage or exclusion; no clear coverage criteria are present in the repeated text.

This fragment does not present explicit exclusions; it is composed of repeated placeholder entries and does not assert any additional not‑covered services.

The content here is a duplicative code list and contains no explicit coverage criteria or exclusions; it should not be used alone to determine coverage without consulting the full policy.

As restated elsewhere in the document, allergy immunotherapy for members age 21 and older is not a covered benefit. Allergy testing remains covered only when the member has sustained an anaphylactic or comparably severe allergic reaction to an unknown allergen such that further exposure could be life‑threatening.

A thorough review of the provided fragments found no explicit 'not medically necessary' statements

The excerpts reiterate that services or items provided solely for cosmetic purposes are excluded per AHCCCS guidance; where a procedure is performed only to change appearance without improving or restoring physiological function, it is not a covered service under the program.

No content available in this placeholder block.

This placeholder chunk contains repeated 'Treatment of' slots and blank code entries; no actionable coverage criteria are present in the fragment.

CPT, HCPCS, and Billing Codes

Augmentative and alternative communication codesCPTCovered

92607	Augmentative and alternative communication
92608	Augmentative and alternative communication
92609	Augmentative and alternative communication
A9901	Augmentative and alternative communication (HCPCS)

Bariatric surgery codesCPTCovered

43644	Bariatric surgery
43645	Bariatric surgery
43775	Bariatric surgery
43842	Bariatric surgery
43659	Bariatric surgery
43845	Bariatric surgery
43770	Bariatric surgery

Bone growth stimulator / electronic stimulation codesCPTCovered

20975	Bone growth stimulator / electronic stimulation
20979	Bone growth stimulator / electronic stimulation

Breast cancer genetic testing codesCPTCovered

81162	Breast cancer genetic testing
81163	Breast cancer genetic testing
81164	Breast cancer genetic testing
81165	Breast cancer genetic testing
81166	Breast cancer genetic testing
81212	Breast cancer genetic testing
81215	Breast cancer genetic testing
81432	Breast cancer genetic testing
81433	Breast cancer genetic testing

Breast reconstruction (nonmastectomy) codesCPTCovered

19316	Breast reconstruction (nonmastectomy)
19330	Breast reconstruction (nonmastectomy)
19396	Breast reconstruction (nonmastectomy)
37221	Breast reconstruction (nonmastectomy) / vascular code listed
19370	Breast reconstruction (nonmastectomy)
19350	Breast reconstruction (nonmastectomy)
19367	Breast reconstruction (nonmastectomy)

Cardiovascular codes (examples)CPTCovered

19380	Cardiovascular procedure
37220	Cardiovascular procedure
37231	Cardiovascular procedure
37229	Cardiovascular procedure
37230	Cardiovascular procedure

Referenced codes (corrupted section)CPT | HCPCS

170.333	Referenced in document (no description provided)
170.334	Referenced in document (no description provided)
170.335	Referenced in document (no description provided)
170.338	Predominant repeated code reference (no description provided)

Referenced CPT/HCPCS codes (fragmented)CPT | HCPCS

170.322	Referenced CPT/HCPCS code cluster (fragment)
170.329	Referenced CPT/HCPCS code cluster (fragment)
170.331	Referenced CPT/HCPCS code cluster (fragment)
170.332	Referenced CPT/HCPCS code cluster (fragment)
170.333	Referenced CPT/HCPCS code cluster (fragment)
170.334	Referenced CPT/HCPCS code cluster (fragment)
170.335	Referenced CPT/HCPCS code cluster (fragment)
170.338	Referenced CPT/HCPCS code cluster (fragment)

Codes referenced in fragment (partial)mixed

170.268
170.269
170.321
170.322
170.329
170.331
170.332
170.333
170.334
170.339

1–10 of 63
1/7

Listed numeric codes (partial)mixed

170.432
170.433
170.434
170.439
170.441
170.442
170.443
170.444
170.445
170.448

1–10 of 18
1/2

Listed numeric codes (continued)mixed

170.523
170.528
170.529
170.531
170.532
170.533
170.534
170.535
170.538
170.539

1–10 of 21
1/3

Diagnosis and external cause codes (partial)ICD-10

174.3
174.4
174.5
174.8
174.9
175.021
175.022
175.023
175.029
175.89

1–10 of 15
1/2

Mapped ICD/CPT/HCPCS examples and pediatric-focused codesmixed

M86.461
M86.472
M86.50
M86.561
M86.451
M86.462
M86.479
M86.551
M86.452
M86.469

1–10 of 34
1/4

Reconstructive procedure CPT codes listed as covered when restoring functionCPTCovered

21172
21175
21179
21180
21181
21182
21183
21184
21230
21235

1–10 of 26
1/3

Reconstructive / surgical CPT codes (partial)CPT

21230	CPT code listed (reconstructive procedures)
21235	CPT code listed (reconstructive procedures)
21256	CPT code listed (reconstructive procedures)
21275	CPT code listed (reconstructive procedures)
21280	CPT code listed (reconstructive procedures)
21282	CPT code listed (reconstructive procedures)
21295	CPT code listed (reconstructive procedures)
21740	CPT code listed
21742	CPT code listed
21743	CPT code listed

1–10 of 12
1/2

Ophthalmic/ eyelid CPT codes (partial)CPT

67900	CPT code listed
67901	CPT code listed
67902	CPT code listed
67903	CPT code listed
67904	CPT code listed
67906	CPT code listed
67908	CPT code listed
67909	CPT code listed
67911	CPT code listed
67912	CPT code listed

1–10 of 21
1/3

DME HCPCS codes (partial)HCPCS

E0193	DME code listed
E0270	DME code listed
E0194	DME code listed
E0277	DME code listed
E0265	DME code listed
E0266	DME code listed
E0300	DME code listed
E0302	DME code listed
E0304	DME code listed
E0329	DME code listed

1–10 of 12
1/2

K-codes (power mobility / specialized DME) (partial)HCPCS

K0008	DME/power mobility code listed
K0013	DME/power mobility code listed
K0108	DME/power mobility code listed
K0800	DME/power mobility code listed
K0801	DME/power mobility code listed
K0802	DME/power mobility code listed

Enteral/parenteral nutrition HCPCS codesHCPCS

B4034	Enteral services/parenteral/oral code
B4035	Enteral services/parenteral/oral code
B4036	Enteral services/parenteral/oral code
B4100	Enteral supplies code
B4158	In-home TPN / lipids code
B4159	In-home TPN / lipids code
B4160	In-home TPN / lipids code
B4161	In-home TPN / lipids code

Experimental and investigational (codes listed)mixed

33477	Experimental and investigational codes listed
A4638	Experimental and investigational codes listed
G0293	Experimental and investigational codes listed
S9991	Experimental and investigational codes listed
36514	Experimental and investigational codes listed
A9274	Experimental and investigational codes listed
G2000	Experimental and investigational codes listed
64722	Experimental and investigational codes listed
E1831	Experimental and investigational codes listed
S9988	Experimental and investigational codes listed

1–10 of 13
1/2

Functional endoscopic sinus surgery CPT codesCPT

31240	Functional endoscopic sinus surgery CPT code
31253	FESS CPT code
31254	FESS CPT code
31255	FESS CPT code
31256	FESS CPT code
31257	FESS CPT code
31259	FESS CPT code
31267	FESS CPT code
31276	FESS CPT code
31287	FESS CPT code

1–10 of 11
1/2

Genetic testing / lab CPT codesCPT

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

1–10 of 18
1/2

Functional endoscopic sinus CPT codesCPTCovered

31240	Functional endoscopic sinus procedure (listed)
31253	Functional endoscopic sinus procedure (listed)
31254	Functional endoscopic sinus procedure (listed)
31255	Functional endoscopic sinus procedure (listed)
31256	Functional endoscopic sinus procedure (listed)
31257	Functional endoscopic sinus procedure (listed)
31259	Functional endoscopic sinus procedure (listed)
31267	Functional endoscopic sinus procedure (listed)
31276	Functional endoscopic sinus procedure (listed)
31287	Functional endoscopic sinus procedure (listed)

1–10 of 11
1/2

Genetic / biomarker / lab CPT codesCPT

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 41
1/5

Home health care codesCPT | HCPCSCovered

G0299	Home health care code requiring fax to Case Management
G0300	Home health care code requiring fax to Case Management
S9123	Home health care code requiring fax to Case Management
S9124	Home health care code requiring fax to Case Management

Injectable / specialty medication codes (J/Q/C/unclassified)HCPCS | CPT | mixedCovered

multiple J/Q/C unclassified codes

Extensive list of injectable/specialty medication J-, Q-, C- and unclassified codes requiring prior authorization (see fragment).

Hysterectomy CPT codesCPTCovered

58150	Hysterectomy CPT code
58152	Hysterectomy CPT code
58180	Hysterectomy CPT code
58200	Hysterectomy CPT code
58210	Hysterectomy CPT code
58240	Hysterectomy CPT code
58260	Hysterectomy CPT code
58262	Hysterectomy CPT code
58263	Hysterectomy CPT code
58267	Hysterectomy CPT code

1–10 of 28
1/3

Incontinence supplies related codesCPT | HCPCSCovered

58570

Incontinence supplies related CPT/HCPCS (listed in fragment)

Inpatient observationmixed

No codes listed

Joint replacement / total hip and knee replacementCPTCovered

24360	listed under Joint replacement Joint; total hip and knee replacement
24361	listed under Joint replacement Joint; total hip and knee replacement
24362	listed under Joint replacement Joint; total hip and knee replacement
24363	listed under Joint replacement Joint; total hip and knee replacement
24370	listed under Joint; total hip and knee replacement procedures
27120	joint; total hip and knee replacement procedures
27125	joint; total hip and knee replacement procedures

Knee replacement and Nonemergent air ambulancemixedCovered

27134	knee replacement
27446	knee replacement
A0430	nonemergent air ambulance
A0431	nonemergent air ambulance
A0436	nonemergent air ambulance

Orthognathic surgeryCPTCovered

21121	Orthognathic surgery
21123	Orthognathic surgery
21125	Orthognathic surgery
21127	Orthognathic surgery
21141	Orthognathic surgery treatment of
21142	Orthognathic surgery treatment of
21143	Orthognathic surgery treatment of
21145	Orthognathic surgery treatment of

Codes requiring prior authorization (repeated)CPTCovered

21121
21123
21125
21127
21141
21142
21143
21145

The codes listed (partial)CPT

21141	21141 (listed in document as 'Treatment of')
21142	21142 (listed in document as 'Treatment of')
21143	21143 (listed in document as 'Treatment of')
21145	21145 (listed in document as 'Treatment of')

Listed CPT Codes (partial)CPT

21141	21141 (listed in document)
21142	21142 (listed in document)
21143	21143 (listed in document)
21145	21145 (listed in document)

Codes listed (partial/duplicated)CPT

21141	surgery Treatment of
21142	surgery Treatment of
21143	surgery Treatment of
21145	surgery Treatment of

Listed CPT codes (partial)CPT

21141	surgery Treatment of (as listed)
21142	surgery Treatment of (as listed)
21143	surgery Treatment of (as listed)
21145	surgery Treatment of (as listed)

The codes listedCPT

21141	21141 (as listed in document)
21142	21142 (as listed in document)
21145	21145 (as listed in document)

Listed CPT Codes (partial/corrupted)CPT

21141	21141 (as listed in fragment)
21142	21142 (as listed in fragment)
21145	21145 (as listed in fragment)

Prior Authorization Process and Provider Steps

Prior Authorization
Coding / obtainment references
Prior authorization and coding: Many entries in this provider-facing list reference CPT/HCPCS codes and indicate prior authorization requirements — but the source contains repeated, fragmented code lists and several code groupings without explicit authorization direction. Providers must treat each listed code as potentially authorization-triggering and follow the submission instructions below. Services must be covered benefits per AHCCCS and medical necessity must be documented. Experimental/investigational services are not covered.
If a code is listed with explicit language such as "Prior authorization is required" treat it as requiring prior authorization.
Where codes are listed but the fragment omits an explicit PA statement, confirm PA requirements via the UnitedHealthcare Provider Portal or by calling 877-842-3210 before scheduling or furnishing the service.
Repeated code groupings (examples: CPT/HCPCS ranges 170.321–170.563, 21141–21145, numerous K- and E-codes, many J-/Q-/C- injectable codes) are present in the source — verify each specific code in the portal rather than relying on this fragmentary extract.

Prior Authorization
Referenced codes relevant to prior authorization

Background and Scope Notes

Background: UnitedHealthcare Community Plan of Arizona differentiates allergy immunotherapy and testing by age: members younger than 21 may receive allergy immunotherapy and testing under EPSDT when medically necessary; for members age 21 and older, allergy immunotherapy (including subcutaneous injections and sublingual immunotherapy) is not a covered benefit. In addition, the policy reiterates that experimental and investigational services are not covered and that cosmetic‑only services are excluded.

Definitions and Terms

Severe allergic reaction

DefinitionSevere allergic reaction — examples of life‑threatening allergic reactions include severe facial swelling, breathing difficulties, epiglottal swelling and extensive urticaria

Context for PAThese signs/symptoms define situations when allergy testing prior authorization may be required

ImplicationFurther exposure to the unknown allergen may reasonably be assumed to result in a life‑threatening situation

Certificate of Medical Necessity

Form requiredCertificate of Medical Necessity (or equivalent medical necessity documentation) must accompany prior authorization requests for in‑home nutritional, total parenteral nutrition/lipids and commercial oral nutritional supplements

AMPM guidance

Policy Revision History

Effective March 1, 2025policy_effective_dateLatest

Policy effective date established for the UnitedHealthcare Community Plan of Arizona Long Term Care prior authorization requirements.

publication_notice

Provider portal and phone contact instructions for prior authorization requests documented (UHCprovider.com and 877-842-3210).

OpenPayer

Prior authorization requirements for Arizona Long Term Care