CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Arizona Developmental Disabilities

List of services and specific CPT/HCPCS codes that require prior authorization for UnitedHealthcare Community Plan of Arizona Developmental Disabilities; includes general PA process, eligibility notes, exclusions, and contact/portal instructions. This is Part 1 of 12 and contains multiple service categories and code lists.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Arizona Developmental Disabilities

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review Date

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID or call the listed phone numbers per category.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes reported in this update.

20+Service categories with PA requirements listed in this part

100+CPT/HCPCS codes referenced in this part

fragmentDocument completeness

3Prior auth pathways listed

Policy summary and scope

This matrix lists prior authorization requirements for UnitedHealthcare Community Plan of Arizona Developmental Disabilities and is effective January 1, 2026. It states that services eligible for prior authorization must be covered benefits as defined by AHCCCS and that providers should submit requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com) or by phone; additional specialty contacts and submission instructions are provided for many service categories. For detailed code lists, coverage rules (including AHCCCS AMPM references), and specialty submission contacts (for example LabCorp, Optum Infusion, Preferred Homecare, Transplant Case Management, Radiology PA resources), providers must refer to the UHC provider portal pages and the specific specialty sections in this document.

Key metadata

Effective dateEffective January 1, 2026

Scope summaryList of services and specific CPT/HCPCS codes that require prior authorization for UnitedHealthcare Community Plan of Arizona Developmental Disabilities; includes general PA process, eligibility notes, exclusions, and contact/portal instructions.

Applies-toMembers 21 and older where noted; members younger than 21 follow EPSDT rules

PayerUnitedHealthcare Community Plan of Arizona

Contact pathwaysProvider Portal: Prior Authorization & Notification tool at UHCprovider.com (One Healthcare ID); Phone general: 800-445-1638; specialty numbers noted in document (e.g., 888-397-8129, 866-889-8054)

General prior authorization eligibility & coverage rules

General Prior Authorization Eligibility

Covered when ALL of the following are met:

ALL of the following

Service is a benefit covered under AHCCCS (Arizona Health Care Cost Containment System).
AHCCCS-defined covered benefits only are eligible for prior authorization.
Rendering health care professional, facility, or vendor is actively registered with AHCCCS.
Only one health care professional may be listed as the requester on a single prior authorization request form.
Out-of-network / Non‑network requests

How to request authorization, documentation & vendor contacts

Prior Authorization

How to request prior authorization

Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) with a One Healthcare ID, or call the prior authorization phone numbers listed for specialty categories (examples: 888-397-8129, 866-889-8054).

Online: Prior Authorization and Notification tool on UHCprovider.com (sign in with One Healthcare ID)
By phone: use specialty numbers such as 888-397-8129 or 866-889-8054

Billing Rule

Include J‑codes and NDCs on service requests

Service requests for physician‑administered drugs must include both the J‑code and the drug NDC on the submission. Fax and phone contacts for pharmacy PA submission: Fax 866-940-7328; Pharmacy PA phone 800-310-6826.

Actionable billing rules and denial risk highlights

Prior Authorization

Circumcision prior authorization requirement

Routine circumcision is not covered. Prior authorization is required only when medical necessity is documented.

CPT codes: 54150, 54160, 54161, 54162

Billing Rule

Chemotherapy drug billing and PA

Prior authorization is required for outpatient injectable chemotherapy and supportive oncology drugs. Includes the J9000–J9999 chemotherapy range and specified J‑codes.

PA required for J9000–J9999 range and listed J‑codes such as J0640, J0641, J0642, J1950
Include J‑code and NDC on the submission

Services & categories explicitly requiring prior authorization

Code lists (grouped by category and coverage status)

Augmentative and alternative communication codes (PA required)mixedCovered

92607
E2500
E2508
92608
E2502
E2510
92609
E2504
A9901
E2506

1–10 of 11

1/2

Bariatric surgery (PA required)CPTCovered

43644
43775
43645
43842
43659
43845
43770
43846

Bone growth stimulator (PA required)mixedCovered

20975
20979
E0760

Breast cancer genetic testing (PA required)CPTCovered

81162
81166
81217
81163
81212
81432
81164
81215
81165
81216

Breast reconstruction (non-mastectomy) (PA required)mixedCovered

11971
19328
19350
19367
19371
19330
19357
19368
19380
19340

1–10 of 17

1/2

Cosmetic and reconstructive procedures (not covered / AHCCCS exclusions)CPT|HCPCSNot Covered

67916
67922
67924
67950
67961
67966
C2624
13101
11440
11450

1–10 of 16

1/2

DME - E-series codes requiring prior authorizationHCPCSCovered

E0194
E0250
E0251
E0260
E0261
E0280
E0290
E0291
E0292
E0293

1–10 of 38

1/4

DME - K-series requiring prior authorizationHCPCS

K0001
K0108
K0109
K0123
K0800

Injectable medications J/Q-codes (prior auth required)HCPCS

J9202
J1299
J1429
J2840
J3399
J0224
J1303
J1786
J3060
J0717

1–10 of 20

1/2

Outpatient therapy CPT codesCPT

92507
97110
97112
97116
97150
97530

Joint replacement CPT codes requiring prior authorizationCPT

27130
27134
27137
27447
27138

Transplant procedures and CAR T-Cell therapymixedCovered

C9399
J3490
J3590

VAD and Wound VACmixedCovered

Q0507
Q0508
Q0509
E2402

Additional surgical, genetic, radiology, DME, and miscellaneous codes consolidatedmixed

33477
36514
64722
66180
58150
58152
58180
58200
58210
58260

1–10 of 84

1/9

Key terms

Definitions (brief)

Common provider questions

Note

Portal / General PA

UHCprovider.com Prior Authorization & Notification tool — sign in with One Healthcare ID. Phone (general): 800-445-1638. For many PA categories call 888-397-8129 or 866-889-8054 for advanced imaging.

Note

DME / Homecare

Preferred Homecare — to request DME, enteral nutrition or incontinence supplies: 800-636-2123.

Note

Lab / Hearing

LabCorp — genetic testing and hearing inquiries: 800-533-0567 (labs); 800-788-9743 (hearing).

Document changes

2026-01-01EffectiveLatest

Policy effective date as provided in brief; partial/fragment document (Part 1 of 12) — see provider portal for full policy.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Arizona Developmental Disabilities

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review Date

SourceLink

On This Page

Services provided by non-network or out‑of‑state practitioners require prior authorization and submission of documentation supporting the medical necessity and reason for out‑of‑network care.

Requests must include documentation demonstrating attempts to obtain in‑network care when applicable.

Service is not investigational or experimental. Experimental and investigational services are not covered benefits and are excluded from authorization.

Service is medically necessary, cost-effective, and reimbursable under federal and state requirements (AHCCCS).

Allergy testing and immunotherapy (age-based rules)

Any of the following apply:

ANY of the following

For members younger than 21 (EPSDT coverage)
- Allergy testing is medically necessary to diagnose a condition that, if untreated, would adversely affect the member’s health or development.
- Allergy immunotherapy and allergy testing are covered under Early and Periodic Screening, Diagnostic and Treatment (EPSDT) when medically necessary.
- Prior authorization is required for allergy testing procedures and for provider‑administered therapies per AHCCCS rules.
For members 21 and older
- Prior authorization is required for allergy testing and for allergy immunotherapy requests (including desensitization procedures).
- Subcutaneous allergy injections (allergy shots), sublingual immunotherapy (SLIT), or other routes of administration may be limited or not a covered benefit; verify specific route coverage and submit appropriate justification with the request.
- Allergy testing may be covered when the member has had a prior anaphylactic reaction to an unknown allergen or a severe allergic reaction where further exposure is reasonably likely to be life‑threatening (examples: severe facial swelling, respiratory compromise, epiglottal swelling, extensive urticaria).

General prior authorization requirement

The following lists common categories and examples of services that generally require prior authorization or notification. This list is illustrative — refer to state AMPM chapters and the UnitedHealthcare provider portal for full code-level lists and submission instructions.

ANY of the following

Durable Medical Equipment (DME), prosthetics, orthotics, and specified supplies — prior authorization required for DME and items listed by AHCCCS; includes orthotics and prosthetics for members 21 and older.
Submit supporting clinical documentation, prior attempts at conservative management, and itemized vendor quotes when applicable.
General prior authorization / notification instructions for members 21 and older — many outpatient procedures, imaging, and specialty services require prior authorization; follow online Prior Authorization and Notification tool or call the listed numbers.
Providers should use the UnitedHealthcare Prior Authorization and Notification tool on the Provider Portal or call the provider line. Failure to obtain required authorization may result in claim denial.
Inpatient admissions and post‑acute services — prior authorization is required for elective inpatient admissions and many post‑acute services; obtain prior authorization before admission when possible.
For behavioral health inpatient admissions and other specialty inpatient services follow the specialty prior authorization process and phone numbers referenced elsewhere in this policy.
Joint replacement (total hip and total knee) for members 21 and older — prior authorization required.
Include documentation of failed conservative therapy, pain and functional limitations, and imaging reports.
Laboratory services — select genetic and specialty testing require prior authorization. Direct routine lab requests to LabCorp at 800-533-0567 as indicated.
Genetic testing codes (for example breast cancer panels) require prior authorization per code list.
Nonemergent air ambulance transport — prior authorization required except in documented emergent situations per AHCCCS rules.
Orthotics and prosthetics (members 21 and older) — prior authorization required.
Include measurements, fitting reports, prior devices, and justification for new device versus repair.
Outpatient therapy (members 21 and older) — prior authorization required for specified therapy services and episodes as listed in the state code lists.
Include treatment plans, goals, and progress notes when requesting authorization for ongoing therapy.
Pain injections and interventional pain management procedures — prior authorization required for many injections, implantable devices, and radiofrequency procedures.
Provide conservative therapy documentation, prior imaging, and procedure-specific rationale.
Pharmacy drugs (provider-administered drugs and specialty medications) — prior authorization required for select injectable, infused, and specialty pharmacy drugs (including colony‑stimulating factors, bone‑modifying agents, provider‑administered biologics, and selected biotech/hemophilia factor products).
Providers must follow specialty pharmacy prior authorization pathways; some drugs require medical benefit prior authorization.
Potentially unproven or experimental services — not covered; prior authorization will be denied for investigational services.
Provide published evidence when requesting exceptions; AHCCCS investigational definitions apply.
Pregnancy termination — prior authorization and state requirements apply per AHCCCS and UnitedHealthcare policy; follow submission rules and clinical documentation requirements.
Submission and contact requirements — use the UnitedHealthcare Provider Portal Prior Authorization and Notification tool for online submissions, or call the provider PA phone numbers found in this policy. Include supporting clinical documentation, imaging, labs, and vendor quotes as applicable.
Only one requesting provider per PA form; include AHCCCS provider identifiers and rendering provider information.
Prior Authorization Required — general listing by service and member age: many services (inpatient, outpatient procedures, DME, durable medical equipment, prosthetics/orthotics, home health services, hospice, certain surgeries such as hysterectomy, functional procedures, genetic testing, hearing aids, certain eye care services, home health, hospice, nonemergent transports, and many outpatient specialty services) require prior authorization.
Refer to the Health Prior Authorization Code List by State on the provider portal for full CPT/HCPCS lists and age‑specific rules.

Include J‑code and NDC on service request
Fax: 866-940-7328
Pharmacy PA phone: 800-310-6826

Documentation Required

Out‑of‑network and non‑network services require PA and documentation

Services delivered by non‑network or out‑of‑state professionals require prior authorization plus supporting documentation. Only one health care professional may request services on a PA request form; providers and vendors must be actively registered with AHCCCS.

Non‑network or out‑of‑state services require PA and documentation supporting the out‑of‑network request
Only one requester allowed per prior authorization request form
Rendering provider/facility/vendor must be registered with AHCCCS

Prior Authorization

Transportation and transplant contacts

Medical Transportation Management schedules nonemergent transport; call to request prior authorization and arrange nonemergent taxi or stretcher van services. Transplant/CAR‑T services require early contact with the UnitedHealthcare Community and State Transplant Case Management team for case management and clinical documentation.

Medical Transportation Management: 888-700-6822 — for nonemergent taxi/stretcher van scheduling
Transplant Case Management: call UnitedHealthcare Community and State Transplant Case Management Team at 800-418-4994 — pre‑notification and clinical documentation required

Documentation Required

Documentation required for enteral/oral nutritional therapy

Requests for enteral, parenteral and oral in‑home nutritional therapy must include clinical documentation and, when applicable, the Certificate of Medical Necessity (CMN). Preferred Homecare is the contact to request services and supplies.

Clinical documentation and the oral supplement Certificate of Medical Necessity must accompany the request
To request services/supplies call Preferred Homecare: 800-636-2123

Prior Authorization

Optum Infusion / injectable medications

Optum Infusion manages prior authorization and requests for infusion and many injectable medications. Call Optum Infusion for in‑home infusion or injectable medication requests.

Optum Infusion phone: 800-985-3059
Many injectable J/Q codes require prior authorization (see provider portal lists)

Billing Rule

Outpatient therapy visit limits

Outpatient occupational and physical therapy have benefit year limits. Prior authorization is required for the listed outpatient therapy codes.

Outpatient PT/OT: limited to 15 visits per benefit year (Oct 1–Sept 30) to restore/maintain function and a separate 15‑visit limit to acquire a new skill and maintain it
Outpatient speech therapy is not a covered benefit

Prior Authorization

DME codes require prior authorization regardless of dollar amount

Many durable medical equipment (DME) HCPCS codes require prior authorization regardless of dollar amount. Preferred Homecare is the designated contact for requesting DME items and incontinence supplies.

Preferred Homecare (DME/incontinence supplies): 800-636-2123
Requests must include Certificate of Medical Necessity (CMN) and supporting clinical documentation where applicable

Documentation Required

Inpatient admission notification requirement

Notification is required for inpatient admissions. Providers must use the notification/prior authorization portals or phone contacts and notify acute care hospitals per instructions.

Notification of admissions required for acute care hospitals
Use the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call the listed notification numbers on the member ID

Note

Infusion / Injectables

Optum Infusion for in-home infusion and many injectable meds: 800-985-3059.

Note

Transplant Case Management

UnitedHealthcare Community & State Transplant Case Management: 800-418-4994 (or use notification number on member ID card).

Note

Nonemergent Transportation

Medical Transportation Management (schedule taxi/stretcher van): 888-700-6822.