UnitedHealthcare Prior Auth Requirements — AZ LTC | OpenPayer
CurrentUnitedHealthcarePolicy N/A
Prior authorization requirements for Arizona Long Term Care — UnitedHealthcare Community Plan
List of prior authorization requirements and related instructions for health care professionals participating with the UnitedHealthcare Community Plan of Arizona Long Term Care; governs inpatient and outpatient services and includes state-specific coverage notes for allergy immunotherapy and testing.
Policy Summary
PayerUnitedHealthcare
PolicyPrior authorization requirements for Arizona Long Term Care — UnitedHealthcare Community Plan
Policy CodePolicy N/A
Change TypeNo material change
Effective DateApril 1, 2025
Next Review DateN/A
Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone at 877-842-3210.
No material clinical or coverage changes in this revision.
1Effective date listed
UHCprovider.comProvider portal listed
877-842-3210Prior auth phone
I70.338Most referenced ICD-10
members <21
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Age-based rule
Coverage and Medical Necessity Criteria
COVERAGE CRITERIA
Covered when ALL of the following apply:
Services must be covered benefits per AHCCCS and UnitedHealthcare Community Plan policy and meet medical necessity and cost-effectiveness requirements.
Rendering provider, facility or vendor must be actively registered with AHCCCS; only one health care professional may submit a prior authorization request for a given service.
Out-of-state services are only approved when emergent or the service is unavailable in Arizona.
Experimental or investigational services are not covered; prior authorization is required for services considered experimental/investigational.
Allergy immunotherapy and testing routing
Members younger than 21: allergy immunotherapy and testing are covered under EPSDT when medically necessary.
Members 21 and older: allergy immunotherapy (including subcutaneous injections, sublingual immunotherapy or other routes) is not a covered benefit; allergy testing is covered only when the member has sustained an anaphylactic reaction to an unknown allergen or a severe allergic reaction where further exposure could be life-threatening. Prior authorization is required when criteria are met.
Reconstructive procedures
Reconstructive procedures that restore or improve physiological function are covered when documentation supports medical necessity; prior authorization is required for listed reconstructive codes.
Procedures furnished solely for cosmetic purposes are excluded per AHCCCS and are not covered.
Durable Medical Equipment (DME) and Prosthetics
Prior authorization is required for DME codes when retail purchase or cumulative rental cost exceeds $500. Specific HCPCS/E-codes listed in policy require authorization.
Prosthetics are not classified as DME; separate prior authorization and documentation requirements apply for prosthetic L-codes. Arizona Long Term Care will review Medicare denials of DME — clinical documentation and a copy of the denial must accompany a request to establish medical necessity.
Enteral / Nutritional therapy
In-home enteral nutrition, total parenteral nutrition (TPN), lipids and commercial oral nutritional supplements require clinical documentation and the Certificate of Medical Necessity as applicable; certificates are available via the AMPM (AZ state) links referenced in policy.
Members younger than 21: EPSDT rules apply; members 21 and older: follow AMPM Chapter 300 guidance for covered services and certificate requirements.
children":[]}]}
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children":[]},{"operator":"all","text":"No step therapy requirements are explicitly stated in this fragment; refer to the pharmacy program for step therapy or quantity limit rules where applicable.","children":[]}]}
Outpatient therapy (PT/OT/SLP)
For members younger than 21: occupational, physical and speech therapy are covered when medically necessary with no annual limits; prior authorization required after the initial evaluation and before the initial therapy visit when indicated per policy.
Therapy CPT/HCPCS codes listed in policy include 97012, 97014, 97022, 97026, 97028, 97033, 97034, 97039, 97110, 97112-97116, 97124, 97140, 97113, 97530, 97535, G0283 and others — prior authorization rules apply as noted.
Orthotics and Prosthetics prior authorization
Prior authorization is required for many orthotic and prosthetic L-codes listed (examples include L0480-L0486 series, L0624, L0631-L0640, L0700-L0830, L1000, L2000-L2136, L2350, L2526, L2627-L2678, L3230, L3265, L3649, L3671, L3674, L5613-L5649). Authorization requests must include documentation showing the device is required, operating effectively, and repair/replacement rationale when applicable.
Adjustments of purchased orthotics are covered when cost-effective; replacements require documentation at authorization request time indicating component condition and need.
children":[]}]}
Special routing and contact notes
For transplant and CAR T-Cell services contact the UnitedHealthcare Community and State Transplant Case Management Team at the phone number listed in the policy prior to scheduling.
For genetic testing prior authorization and lab routing, follow the lab vendor instructions (e.g., LabCorp) and call the numbers listed to determine PA requirements and how to submit specimens/requests.
Operational notes
Only one authorized requester per prior authorization form; review/predetermination at launch and provider must ensure correct code mapping is used — cardiovascular and other specialty code groups in the policy require PA when listed (ICD I70.x examples and other cardiovascular diagnosis/coding entries are present in the policy).
No explicit step therapy requirements are provided in this fragment; where step therapy applies it will be referenced in the specific drug or service policy. Providers should include pregnancy termination, transplant, and transportation-related documentation when requesting authorization for those services as directed in their respective policy subsections.
If prior authorization is required but not obtained, services may be denied; providers are responsible for obtaining PA, submitting complete documentation, and ensuring their enrollment/active status with AHCCCS to avoid denial risk.
Prior Authorization
Provider Action Callouts
Prior Authorization Required: Prior authorization is required for the majority of services and specific codes listed throughout this policy (including, but not limited to, bariatric surgery, joint replacement, many inpatient admissions, transplant and CAR T-cell therapies, proton beam therapy, selected pain management procedures, orthotics/prosthetics, DME over $500 purchase/rental threshold, genetic and biomarker testing, specialty pharmacy and selected J-codes). Out-of-network and out-of-state non-emergent services require PA and supporting documentation. Laboratory services and emergency services do not require prior authorization per policy.
Provider action: Code reference — several code groups are referenced in the policy without explicit PA mapping; providers must use the code lists in this policy when preparing requests.
Provider action: Prior authorization mapping — ensure submitted CPT/HCPCS/ICD-10 codes match the policy's listed code groups; contact UnitedHealthcare if mapping is unclear.
Provider action: Cardiovascular codes — policy fragment lists multiple I70.x diagnosis codes that map to cardiovascular procedures which may require prior authorization; verify code-specific PA requirements before scheduling.
Provider action: Reconstructive procedure prior authorization — prior authorization required for listed reconstructive and nonmastectomy breast reconstruction codes (examples in policy include 19316, 19330, 19350, 19367, 19370, 19396 and related codes).
Provider action: Genetic testing prior authorization — numerous CPT codes listed (examples: 81265, 81302, 81321, 81323, 81325, 81401-81408, 81415-81416, 81435, 81460, 81479, 81313, 81327, 81490 and many cytogenetic/molecular codes) — call LabCorp or follow lab routing for PA.
Code Lists and Coding Rules
Augmentative and alternativeCPT/HCPCSCovered
92607
Augmentative and alternative communication code listed (document lists prior authorization required)
92608
Augmentative and alternative communication code listed
92609
Augmentative and alternative communication code listed
A9901
Augmentative and alternative HCPCS listed repeatedly
Bariatric surgeryCPTCovered
43644
Bariatric surgery CPT code listed
43645
Bariatric surgery CPT code listed
43775
Bariatric surgery CPT code listed
43842
Bariatric surgery CPT code listed
Bone growth stimulator / electronic stimulationCPTCovered
20975
Bone growth stimulator / electronic stimulation code listed
20979
Bone growth stimulator / ultrasound to heal code listed
Surgical, proton beam, spinal, facility, transplant and related CPT/HCPCS codesCPTCovered
77520
Proton beam therapy code
77522
Proton beam therapy code
77523
Proton beam therapy code
77525
Proton beam therapy code
30400
Rhinoplasty/septoplasty related code
30410
Rhinoplasty code
29805
Shoulder arthroscopy
31295
Sinuplasty
21685
Facility service example
22100
Spinal surgery code
1–10 of 18
1/2
Durable Medical Equipment HCPCSHCPCSCovered
E0747
Bone growth stimulator
E0760
Neurostimulator related HCPCS
Cardiac/thoracic CPT codesCPTCovered
32850
Thoracic surgery code
32851
Thoracic surgery code
32852
Thoracic surgery code
32853
Thoracic surgery code
32854
Thoracic surgery code
32855
Thoracic surgery code
32856
Thoracic surgery code
33930
Cardiac surgery code
33933
Cardiac surgery code
33935
Cardiac surgery code
1–10 of 13
1/2
Additional pharmacy codesHCPCSCovered
J0224
Immune globulin or vaccine J-code
J0717
Injection J-code
J1290
Injection J-code (also listed earlier)
90378
Vaccine/immune globulin code
Codes requiring prior authorization or referenced in this partmixedCovered
32850
32851
32852
32853
32854
32855
32856
33930
33933
33935
1–10 of 84
1/9
Cellular therapies / CAR-TneutralCovered
CAR-T cell therapy
Various CAR-T products (e.g., tisagenlecleucel, lovotibeglogene autotemcel, brexucabtagene autoleucel, axicabtagene ciloleucel) indicated — providers should call transplant case management for auth
TransportationneutralCovered
Transportation (nonemergent taxi, stretcher van)
Call Medical Transportation Management at 888-700-6822 to schedule; prior authorization required
Age threshold for allergy immunotherapy
What Providers Must Do
Prior Authorization
Prior authorization required for listed CPT/HCPCS codes
Prior authorization must be obtained for the specific procedure and HCPCS/CPT codes listed in the policy (examples include augmentative/alternative codes 92607, 92608, 92609 and A9901; bariatric surgery codes 43644, 43645, 43775, 43842; bone growth stimulator codes 20975, 20979; and selected genetic testing codes).
Examples of codes requiring PA are provided in the document code lists (see augmentative/alternative, bariatric surgery, bone growth stimulator, genetic testing sections).
Submit PA via the Provider Portal or phone per submission guidance.
Note
Code references present without explicit PA statements
Some fragments reference diagnosis codes (for example I70.338) or code strings without an explicit prior authorization statement; these are code references only and do not themselves state a PA requirement.
Example: multiple repeated mentions of I70.338 appear without a PA directive in those fragments.
Background and Context
Allergy immunotherapy and allergy testing coverage varies by age in the Arizona (AHCCCS) context. For members younger than 21, allergy immunotherapy and allergy testing are covered under EPSDT when medically necessary. For members 21 and older, allergy immunotherapy — including desensitization by subcutaneous injections (allergy shots), sublingual immunotherapy, or other routes — is not a covered benefit. Allergy testing remains covered for members who have sustained an anaphylactic reaction to an unknown allergen or who have had a severe allergic reaction where further exposure could be life‑threatening; such requests should be supported by clinical documentation and, when applicable, prior authorization.
Definitions and Key Terms
Allergy immunotherapy
DefinitionAllergy immunotherapy: desensitization treatments administered by subcutaneous injections (allergy shots), sublingual immunotherapy, or another route of administration.
Coverage noteCovered for members younger than 21 under EPSDT when medically necessary; not covered for members 21 and older (see policy age thresholds).
TestingAllergy testing is covered when member has sustained anaphylaxis to an unknown allergen or severe allergic reaction where further exposure may be life‑threatening; PA required when criteria met.
I70.338
ICD‑10 codeI70.338
Related codesI70.333, I70.334, I70.335 and others are listed alongside I70.338 in mapping tables.
Policy Summary
PayerUnitedHealthcare
PolicyPrior authorization requirements for Arizona Long Term Care — UnitedHealthcare Community Plan
Policy CodePolicy N/A
Change TypeNo material change
Effective DateApril 1, 2025
Next Review DateN/A
Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone at 877-842-3210.
Provider action: Pharmacy prior authorization — contact UnitedHealthcare Pharmacy Prior Authorization Service (phone/fax) for both standard and specialty pharmacy PA; forms and fax numbers are provided in the policy.
Provider action: Outpatient therapy prior authorization — for pediatric members, PA is required after initial evaluation and before the first therapy visit when indicated; include therapy codes and evaluation notes.
Provider action: Prior authorization required for listed codes — use the explicit code lists in each subsection; absence of a code in a subsection does not imply automatic coverage without PA when otherwise indicated.
Provider action: No explicit authorization or denial criteria — this fragment does not list exhaustive denial criteria; rely on AHCCCS and UnitedHealthcare medical necessity rules and include full documentation to mitigate denial risk.
Provider action: No explicit denial triggers stated in fragment — but requests missing documentation, provider enrollment, or PA when required are common denial triggers.
Provider action: Prior authorization required (cardiovascular codes) — verify I70.x and related code groups in the policy for PA requirements prior to scheduling vascular procedures.
Provider action: Out-of-state services restriction — obtain documentation demonstrating emergent need or unavailability in Arizona for out-of-state requests.
Provider action: Out-of-network prior authorization — prior authorization is required for all out-of-network services; include justification and supporting documentation.
Provider action: No documentation requirements provided in fragment — where documentation is referenced (e.g., transplants, DME Medicare denials, enteral nutrition), include clinical records, denial letters, and Certificates of Medical Necessity as applicable.
Provider action: Fragment lists numerous diagnosis codes — reconcile diagnosis lists (for example multiple I70.x codes) with procedure codes when submitting PA requests.
Provider action: Medicare DME denial documentation — include copy of Medicare denial and supporting clinical documentation when requesting AHCCCS/UnitedHealthcare review of DME denied by Medicare.
Provider action: Pregnancy termination documentation — follow the policy's cross-reference to Section E Pregnancy Termination for required documentation when applicable.
Provider action: Transplant documentation — include clinical records and transplant-specific documentation; contact the transplant case management team prior to authorization submission.
Provider action: Review at Launch / predetermination note — providers should perform predetermination and verify PA requirements at time of scheduling; UnitedHealthcare provides phone/fax contacts in the policy.
Provider action: Specialty drug prior authorization — specialty medications listed require PA; use specialty PA cover sheet and drug-specific service request forms as referenced.
Age threshold
Members younger than 21: allergy immunotherapy and allergy testing are covered under EPSDT when medically necessary; Members 21 and older: allergy immunotherapy (including subcutaneous injections/allergy shots and sublingual immunotherapy) is not a covered benefit.
Coverage condition for <21Coverage under EPSDT only when medically necessary; prior authorization required for allergy testing when clinical severity meets criteria (e.g., life‑threatening reactions such as severe facial swelling, breathing difficulties, epiglottal swelling, extensive urticaria).
Coverage condition for >=21Allergy immunotherapy is explicitly not a covered benefit for members 21 and older.
Member age threshold
Member age thresholdYounger than 21: certain services (e.g., cerebral seizure monitoring, hearing services, outpatient therapy) have different prior authorization rules and coverage — PA often required after initial evaluation for therapy; age‑based rules referenced throughout the policy.
Documentation noteFor members younger than 21, refer to AHCCCS AMPM Chapter 400 (EPSDT) for additional requirements (e.g., nutrition/oral supplements).
Outpatient exceptionsPrior authorization is not required for some outpatient hospital or ambulatory surgical center services despite age‑based PA rules (see specific code listings).
DME prior authorization cost threshold
DME PA cost thresholdPrior authorization is required for DME when the retail purchase or cumulative rental cost exceeds $500.
Medicare denial documentationArizona Long Term Care will review Medicare denials of DME; clinical documentation and a copy of the denial must accompany PA requests.
Cumulative rental referenceCumulative rental cost thresholds referenced in orthotics/prosthetics and inpatient sections (see L‑codes).
Incontinence supplies monthly limit
Monthly limits (members <21)Prior authorization required for incontinence briefs/diapers/pull‑ups when requests exceed 240 per month.
Monthly limits (members >=21)Prior authorization required for incontinence briefs/diapers/pull‑ups when requests exceed 180 per month.
Related codesSpecific CPT/HCPCS codes for incontinence supplies are listed in the policy (see incontinence supplies code group).
Cumulative rental cost threshold
Cumulative rental cost thresholdPrior authorization required when cumulative rental cost is greater than $500.
ContextThreshold cited in inpatient/orthotics/prosthetics and DME sections where cumulative rental cost influences PA requirement.
PA evidenceWhen Medicare denies DME rental, include Medicare denial and clinical documentation with the PA request for review by Arizona Long Term Care.
Age threshold for outpatient therapy
Age threshold for outpatient therapyMembers younger than 21: occupational, physical and speech therapy are covered when medically necessary with no annual benefit limits; prior authorization is required after the initial evaluation and before the initial therapy visit.
Review for medical necessityRequests for therapy will be reviewed for medical necessity despite no annual limits for members <21.
Affected codesOutpatient therapy CPT/HCPCS codes listed (e.g., 97012, 97110, 97140) require authorization as specified in the policy.
38232 oncology PA requirement
38232 oncology PA requirementCode 38232 will only require prior authorization when billed with an oncology diagnosis.
ScopeThis cancer‑specific PA note is repeated in the transplant/procedure code section as an exception to general PA rules for 38232.
Temporary/unclassified codesPolicy also lists temporary and unclassified codes (C9301, C9399, J3490, J3590) with PA guidance in the same section.
Note
Caution: prior authorization mapping may be missing in fragments
Certain document fragments present code lists or 'Please note' headings but do not include the mapping from diagnosis codes to the authorization process; providers should not assume mapping is present in every fragment.
When mapping is missing, reference the policy sections with 'how to obtain prior authorization' or contact UnitedHealthcare for guidance.
Prior Authorization
Cardiovascular codes: follow 'how to obtain prior authorization' instructions
Cardiovascular-related diagnosis and code strings are presented with 'how to obtain prior authorization' markers — providers must follow the policy's 'how to obtain prior authorization' instructions when submitting requests for these cardiovascular codes.
Cardiovascular code examples include numerous I70.* codes; follow the policy mapping and submission instructions for these entries.
Prior Authorization
PA expectations and affected services — review code-specific notes
The policy includes prior authorization expectations and affected code lists for multiple services (e.g., cerebral seizure monitoring, cochlear implants, continuous glucose monitors); review the listed codes and 'Additional information' notes when preparing PA requests.
Some services note age‑specific PA rules (members <21) or diagnosis‑specific PA (e.g., continuous glucose monitors require PA with a type 2 diabetes diagnosis).
The policy identifies facility‑type exceptions (e.g., PA not required for certain outpatient hospital/ASC settings).
Prior Authorization
Reconstructive procedures: PA required; 67966 exception with skin cancer
Reconstructive procedure codes listed require prior authorization; note that CPT 67966 specifically will NOT require prior authorization when billed with skin cancer.
Multiple reconstructive CPT/HCPCS codes are listed with PA instructions.
67966: no prior authorization required when billed with skin cancer.
Prior Authorization
DME and enteral services: PA required (cost threshold and documentation)
Prior authorization is required for many durable medical equipment (DME), enteral, and related HCPCS codes listed in the DME and enteral services sections; DME PAs are required when retail purchase or cumulative rental cost exceeds $500.
DME PA trigger: retail purchase or cumulative rental cost > $500.
Enteral/nutrition: in‑home nutritional therapy and oral supplements require clinical documentation and a Certificate of Medical Necessity.
Prior Authorization
Procedural PA: functional endoscopic sinus and FAI codes
Functional endoscopic sinus (FES) and femoroacetabular impingement (FAI) procedural codes listed in the policy require prior authorization; follow the policy's 'how to obtain prior authorization' entries when submitting requests.
FES example codes: 31240, 31253–31259, 31267, 31276, 31287–31288.
FAI example codes: 29914–29916.
Prior Authorization
Genetic/biomarker testing: PA required; contact LabCorp for routing
Genetic, biomarker and molecular testing codes listed require prior authorization; the policy directs providers to contact LabCorp (and provides a phone number) to determine PA requirements and processes.
Example codes: 81265, 81302, 81401–81408, 81415–81416, 86353, 88245–88275, biomarker codes such as 81313, 81435.
Call LabCorp (800‑788‑9743) or follow the policy instructions to determine PA routing.
Prior Authorization
Injectable medications: PA required; include drug identifiers
Prior authorization is required for the injectable medications and many J/HCPCS codes listed; providers should consult the Review at Launch list for newly approved drugs and include required drug identifiers when submitting PA requests.
PA examples include many J‑codes (see injectable medication lists in the policy).
For newly approved drugs on the Review at Launch list, predetermination is highly recommended.
Prior Authorization
Drug PA and predetermination recommendation for new drugs
Certain drugs (examples listed in the policy) require prior authorization; the policy advises providers to check the Review at Launch for New to Market Medications and consider predetermination for drugs on that list.
Examples called out include J9334, J1558, J0218, J1748.
Predetermination is highly recommended for Review at Launch medications.
Prior Authorization
Air ambulance: PA required for nonemergent transport codes
Nonemergent air ambulance transport codes (examples A0430–A0436) require prior authorization per the policy.
Prior authorization is required for listed nonemergent air ambulance transport codes.
Prior Authorization
Prior authorization required for multiple procedure and surgical codes
The policy lists numerous surgical, spinal, proton beam, transplant and other procedure codes that require prior authorization; follow the policy's PA routing and contact transplant case management where specified.
Examples include proton beam codes (77520–77525), spinal surgery and multiple CPTs listed across sections.
For transplant/CAR‑T related codes, contact UnitedHealthcare Community & State Transplant Case Management at 800‑418‑4994.
Billing Rule
Pharmacy/physician‑administered drugs: J‑code and NDC required on PA
Pharmacy and physician‑administered drug requests (J‑codes) require prior authorization; PA submissions must include the J‑code and NDC for the medication requested and utilize the Pharmacy Prior Authorization Service contact information when applicable.
Include J‑codes and NDCs on PA requests for physician‑administered drugs.
Pharmacy PA phone: 800‑310‑6826; fax: 866‑940‑7328 (specialty fax: 866‑940‑7328).
Prior Authorization
Outpatient therapy: PA required after initial evaluation for members <21
Outpatient occupational, physical and speech therapy for members younger than 21 is covered when medically necessary without annual limits, but prior authorization is required after the initial evaluation and before the initial therapy visit for the listed codes.
PA required after the initial evaluation and before the initial therapy visit for members <21.
Example outpatient therapy codes: 97012, 97113, 97530, G0283, etc.
Prior Authorization
Transplant: PA required; contact transplant case management
Prior authorization is required for the listed transplant‑related CPT/HCPCS codes; providers must contact UnitedHealthcare Community and State Transplant Case Management for cellular therapies and transplant authorizations.
Contact Transplant Case Management at 800‑418‑4994 as directed in the policy.
Example transplant‑related codes include 38208–38215 and others listed.
Prior Authorization
Cancer‑specific PA: 38232 only requires PA for oncology diagnoses
Code 38232 requires prior authorization only when billed with an oncology diagnosis; do not submit PA for 38232 unless the oncology diagnosis condition is met.
38232: PA required only for an oncology diagnosis per the policy note.
Note
Step Therapy
No step therapy statements in this extract
No step therapy requirements are stated in the extracted policy fragments; providers should not assume step therapy pathways are defined here.
The extract explicitly indicates there are no step therapy requirements present in this section.
Step Therapy
No step therapy requirements present in these fragments
This fragment likewise contains no step therapy requirements; the policy extract does not define step therapy processes for the listed drugs or services.
Confirm step therapy expectations via the Review at Launch policy or other drug‑specific policies if needed.
Note
Note
Step Therapy
Step therapy: no step therapy statements present
No step therapy statements are present in the cited policy chunks — the document advises checking Review at Launch for New to Market Medications but does not list step therapy requirements here.
Step therapy guidance is not provided in these chunks.
Note
Review at Launch: check policy for New to Market medications
Providers should check the Review at Launch for New to Market Medications policy for the most up‑to‑date handling of newly approved drugs and the Review at Launch Medication List referenced in this policy.
Review at Launch policy location: UHCprovider.com/policies > Community Plan Policies > Medical & Drug Policies and Coverage Determination Guidelines for Community Plan.
Prior Authorization
Predetermination recommended for Review at Launch drugs
Predetermination is highly recommended for drugs included on the Review at Launch Medication List; providers should obtain predetermination for newly approved medications where indicated.
Predetermination is recommended for drugs on the Review at Launch list.
Prior Authorization
Specialty drug PA: use specific service request forms
Certain specialty and biotech drugs listed require prior authorization and the use of specific service request forms; follow the policy instructions and use the attached service request forms for those medications.
Specialty PA forms available at UHCprovider.com/AZcommunityplan > Pharmacy Program > Pharmacy Prior Authorization Forms > Specialty Medication Prior Authorization Cover Sheet.
Use the medication‑specific service request form when the policy indicates one is required.
Documentation Required
Submission: use Provider Portal or listed phone/fax contacts for PA
Submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone at 877‑842‑3210; phone and fax contacts for specific PA types (pharmacy, transplant, transportation, VAD, Case Management) are provided in the policy.
Online: UHCprovider.com Prior Authorization and Notification tool.
Phone for general PA submissions: 877‑842‑3210.
Pharmacy PA phone: 800‑310‑6826; fax: 866‑940‑7328.
Transplant Case Management: 800‑418‑4994; Medical Transportation Management: 888‑700‑6822; VAD fax: 855‑282‑8929.
Note
Documentation Required
Coding implication: match diagnosis codes to PA requirements
The document lists numerous diagnosis codes alongside placeholders for CPT/HCPCS mapping, implying that submitted PA requests must align diagnosis coding with the requested CPT/HCPCS codes per the policy mapping.
When 'how to obtain prior authorization' markers are present, reference those mappings and include the appropriate diagnosis codes on the PA request.
Documentation Required
Documentation: reference 'how to obtain prior authorization' markers
When 'how to obtain prior authorization' markers appear with code lists, providers must reference those markers and include the listed diagnosis codes on the authorization request to support routing and determination.
The policy shows many ICD‑10 strings with 'how to obtain prior authorization' indicators — include the referenced diagnosis codes when applicable.
The document maps diagnosis codes to CPT/HCPCS and includes 'Additional information' about prior authorization requirements and facility‑type exceptions; providers should follow these mappings and notes when completing PA requests.
Example: the policy notes PA is not required for certain outpatient hospital or ASC settings; check 'Additional information' per code group.
Documentation Required
Nutrition therapy documentation: clinical notes and Certificate of Medical Necessity required
In‑home nutritional therapy, enteral support and oral supplements require clinical documentation and the Certificate of Medical Necessity to accompany the prior authorization request to establish medical necessity.
Certificate of Medical Necessity for Commercial Oral Nutritional Supplements must be provided as applicable.
For members <21, refer to AMPM Chapter 400 Section 430‑10 for EPSDT guidance.
Documentation Required
Medicare DME denials: include denial and clinical documentation with PA
When Medicare has denied DME, Arizona Long Term Care will review the Medicare denial; prior authorization requests must include clinical documentation and a copy of the Medicare denial to establish medical necessity.
Include the Medicare denial documentation with the PA request for DME when applicable.
Billing Rule
Home health PA: fax Case Management for G0299/G0300/S9123/S9124
For home health care codes G0299, G0300, S9123 and S9124, providers must fax Case Management at 877‑395‑5993 to complete the prior authorization request.
Home health / infusion PA: fax Case Management at 877‑395‑5993 for the listed codes.
Documentation Required
Orthotics/prosthetics: provide documentation that component is not functioning
Authorization requests for orthotics and prosthetics must include documentation demonstrating the component is not operating effectively and other supporting documentation as noted in the policy.
Documentation should demonstrate repair/replacement necessity and that repair cost is less than purchasing a new unit when applicable.
Documentation Required
Pregnancy termination: PA requires clinical documentation and Certificate of Medical Necessity
Pregnancy termination procedures require prior authorization and must include clinical documentation plus the Certificate of Medical Necessity for Pregnancy Termination with the PA request.
Certificate of Medical Necessity for Pregnancy Termination is available at azahcccs.gov per AMPM reference.
Documentation Required
Transplant/CAR‑T: include clinical documentation and call transplant case management
Transplant and CAR‑T cell therapy PA requests must include clinical documentation supporting medical necessity and providers must call UnitedHealthcare Community & State Transplant Case Management as directed in the policy.
Call Transplant Case Management at 800‑418‑4994 as instructed for transplant and CAR‑T authorization processing.
Documentation Required
Pharmacy drug documentation: include J‑code and NDC on PA requests
Pharmacy and physician‑administered drug service requests must include the medication’s J‑code and NDC on the prior authorization submission.
Pharmacy PA contacts: phone 800‑310‑6826; fax 866‑940‑7328. Specialty PA fax: 866‑940‑7328.
Documentation Required
VAD PA routing: call ID card notification number and fax to Optum VAD Case Management
For ventricular assist devices (VAD), providers must call the notification number on the member’s health plan ID card and then fax the form provided by the nurse to the Optum VAD Case Management Team at 855‑282‑8929.
Call notification number on member ID card first, then fax the completed form to Optum VAD Case Management at 855‑282‑8929.
Billing Rule
Transportation: schedule nonemergent transport via Medical Transportation Management
Schedule nonemergent medical transportation (taxi or stretcher van) by calling Medical Transportation Management at 888‑700‑6822; prior authorization is required for nonemergent transportation.
Transportation scheduling contact: Medical Transportation Management 888‑700‑6822.
Denial Risk
Denial triggers: noncovered, experimental, not medically necessary, or inactive AHCCCS provider
Prior authorization requests may be denied if services are not covered benefits, are experimental/investigational, not medically necessary/cost‑effective, or if the requesting provider is not actively registered with AHCCCS.
Ensure services are AHCCCS‑covered, medically necessary, and the requesting provider is actively registered to reduce denial risk.
Note
Note
Prior Authorization
Cardiovascular codes: PA indicated with 'how to obtain prior authorization' markers
Cardiovascular CPT/HCPCS/diagnosis code entries are accompanied by 'how to obtain prior authorization' markers — follow those markers and mapping when preparing PA submissions for cardiovascular services.
Numerous I70.* codes are presented with PA mapping indicators in the cardiovascular section.
Prior Authorization
Age‑based PA: prior authorization required for certain services for members <21
The policy includes several services for which PA is specifically required when the member is younger than 21 (for example, cerebral seizure monitoring, cochlear implants, certain therapy requests); providers should apply age‑based rules from the policy when submitting PA.
Example: for members <21, PA is required for the codes listed under cerebral seizure monitoring and cochlear/auditory implants (policy provides specific CPT/HCPCS examples).
Note
Site‑of‑service exception: no PA for certain outpatient hospital/ASC services
Some outpatient hospital or ambulatory surgical center services listed note that prior authorization is not required; review the 'Additional information' and site‑of‑service notes in the policy before submitting PA.
The policy states PA is not required for certain outpatient hospital or ASC settings for the codes indicated.
Billing Rule
DME PA and Medicare denial review: cost threshold and required documentation
DME prior authorization is required when a retail purchase or cumulative rental cost is more than $500; Arizona Long Term Care will review Medicare denials and requires clinical documentation plus a copy of the denial with the PA request.
DME PA trigger: retail purchase or cumulative rental cost > $500.
Include Medicare denial documentation when applicable.
Prior Authorization
Enteral and experimental services: PA required; provide required documentation
Prior authorization is required for enteral/parenteral/oral nutrition services listed; experimental and investigational services are also subject to PA and noncoverage rules as indicated.
Enteral codes (B4034–B4161 series) require clinical documentation and, where applicable, Certificate of Medical Necessity.
Prior Authorization
Injectable medications: PA required — include J‑code/NDC
Injectable medications listed in the policy require prior authorization; follow the listed J‑codes and the PA routing and include required identifiers on submissions.
Many J‑codes are listed across sections; include J‑code and NDC and use pharmacy PA contact information when submitting.
Prior Authorization
Home health: PA required and fax instruction for specific codes
For home health care codes, prior authorization is required for the listed codes; for codes G0299, G0300, S9123 and S9124, providers must fax Case Management at 877‑395‑5993 to complete the request.
Home health PA fax: 877‑395‑5993 for G0299/G0300/S9123/S9124.
Hearing evaluations and hearing aids have age‑differentiated PA rules: for members younger than 21, prior authorization is not required for certain hearing aids/services; for members 21 and older, certain hearing items require prior authorization — follow the code‑specific notes in the policy.
Example codes: 92590–92595 and multiple V‑codes and L‑codes for devices; review policy sections for age distinctions.
Prior Authorization
Inpatient admissions: PA required for listed admission types; notification required on admission
Inpatient admissions (behavioral/substance abuse, elective surgical admissions, hospice, long‑term acute care/rehabilitation, skilled nursing facility stays) require prior authorization; notification is required if a member is admitted for an inpatient stay.
Prior authorization is not required for emergency services, but notification is required for inpatient admissions per policy.
Denial Risk
Out‑of‑state and out‑of‑network: PA restrictions and requirements
Out‑of‑state services are approved only when emergent or the service is unavailable in Arizona; out‑of‑network services require prior authorization for all out‑of‑network requests.
Obtain documentation supporting out‑of‑network/out‑of‑state requests as required by the policy.
Prior Authorization
Out‑of‑network services: PA required
Prior authorization is required for all out‑of‑network services per the policy; submit documentation supporting the out‑of‑network request when applicable.
Ensure out‑of‑network requests include supporting documentation as specified.
Denial Risk
Wound VAC: denial triggers and continuation criteria
Negative pressure wound therapy (wound VAC) supplies and pumps will be denied if continued coverage criteria are not met — examples of denial triggers include cancer tissue in the wound, necrotic tissue with eschar if debridement isn't attempted, supplies no longer used by the member, untreated fistula to an organ/body cavity near the wound, or untreated osteomyelitis near the wound.
Wound VAC denial examples: cancer tissue in the wound; necrotic tissue with eschar without attempted debridement; supplies/equipment not used by the member; untreated fistula or osteomyelitis in vicinity.
Certificate of Medical Necessity for Commercial Oral Nutritional Supplements
Form nameCertificate of Medical Necessity for Commercial Oral Nutritional Supplements.
Use caseRequired to establish medical necessity for in‑home nutritional therapy and oral supplements; referenced for members younger than 21 (EPSDT) and for members 21 and older per AMPM chapters.
Where to findCertificate is available at azahcccs.gov > Resources > Guides‑Manuals‑Policies > AHCCCS Medical Policy Manual (AMPM) in the chapters referenced (Chapter 400 for EPSDT; Chapter 300 for adults).
Proton beam therapy
DefinitionProton beam therapy: focused radiation therapy using beams of protons.
PA requirementCPT/HCPCS codes for proton beam therapy listed in the policy require prior authorization.
Example codesProton beam therapy mapping includes codes 77520, 77522, 77523, 77525 referenced alongside surgical codes in the policy.
Transplant/CAR T-Cell therapy
DefinitionTransplant/CAR T‑Cell therapy: transplant services and CAR T‑Cell therapies (specific products named such as Kymriah™, Yescarta™, Abecma® etc.).
Authorization routingRequests must include clinical documentation to support medical necessity and providers must call UnitedHealthcare Community & State Transplant Case Management at 800‑418‑4994 (or use notification number on member ID card).
PA requirementPrior authorization is required for listed transplant and CAR T‑Cell therapy codes; case management coordination is mandatory.