Prior authorization requirements for Rhode Island Medicaid

This statewide prior authorization (PA) matrix describes UnitedHealthcare Community Plan of Rhode Island PA requirements for participating providers for inpatient and outpatient services. It specifies services and CPT/HCPCS/J/Q code groups that require PA and lists diagnosis-code exceptions (for example, many C43/C44 and C50/D05/Z codes) and special rules (e.g., speech therapy age threshold).

Requests may be submitted online via the UnitedHealthcare Provider Portal at UHCprovider.com using a One Healthcare ID (select the Prior Authorization and Notification tool) or by phone at 855-766-0344; several sections also list alternate phone numbers for submission and guidance (examples: 888-397-8129, 866-889-8054).

OptumRx is the PA vendor for many pharmacy- and injectable-related items; the matrix directs submission or contact to OptumRx for oncology injectables, cosmetic/reconstructive codes and other specified items and provides the OptumRx Help Desk at 800-711-4555 and an OptumRx prior-notification number for Synagis/Cimzia at 800-310-6826 where noted.

The policy is effective 2026-03-01 and the scope covers inpatient admissions, outpatient procedures, DME/orthotics & prosthetics (with retail purchase or cumulative rental cost thresholds noted), enteral/home health/hospice, genetic testing notification requirements, radiation therapy, transplants/CAR-T, many injectable medications, and numerous surgical and therapy CPT/HCPCS code groups requiring PA.

General prior authorization rules & submission actions

General prior authorization rules

Prior authorization required (when ALL of the following apply):

For services explicitly requiring prior authorization, see the service list (e.g., bariatric surgery, bone growth stimulators, breast reconstruction codes listed, cochlear implants, CGMs, select cardiology outpatient procedures, advanced outpatient imaging, radiation fractionation management including 77402, orthotics/prosthetics above cost thresholds, selected drugs requiring OptumRx review such as Synagis and Cimzia).

General prior authorization requirements and exceptions: Providers must submit clinical documentation supporting medical necessity; use applicable diagnosis codes to exempt certain services from prior authorization where noted (e.g., specified diagnosis codes for post-mastectomy breast reconstruction).

Services explicitly requiring prior authorization include (representative, not exhaustive): bariatric surgery codes (43644, 43645, 43659, 43770, 43775, 43842, 43845, 43846, 43847, 43848, 43860), bone growth stimulator (20975, 20979), adult day services (S5102), breast reconstruction and related codes (19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19367-19371, 19380, 19396, L8600, 11971), cochlear implants, continuous glucose monitors (CGMs), cardiology outpatient procedures (see specialty PA list), orthotics/prosthetics exceeding cost threshold, advanced outpatient imaging, radiation therapy fractionation adjustments (including code 77402), and select drugs/devices routed to OptumRx.

General Prior Authorization Requirements: submit indication, relevant clinical history, prior treatments, and proposed service details; include expected admission date for inpatient notifications; use unclassified or temporary codes only when appropriate and provide supporting documentation explaining use; occupational and physical therapy may require PA depending on service limits—obtain prior authorization before starting services when required.

Prior Authorization

Submit prior authorization requests

Use the UnitedHealthcare Provider Portal first — the Prior Authorization and Notification tool at UHCprovider.com (sign in with your One Healthcare ID). If you do not have a One Healthcare ID, register at UHCprovider.com/access. Phone options are available when portal submission is not possible.

Submit prior authorization and notification requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) using your One Healthcare ID and password; select the Prior Authorization and Notification tab.
If unable to use the portal, call UnitedHealthcare Prior Authorization: 855-766-0344.
Use specialty/section-specific phone lines where provided: 888-397-8129 and 866-889-8054 for designated services as noted in specialty guidance.
Bill with an exempting diagnosis code exactly as listed in the policy to avoid prior authorization when an exemption is specified (e.g., the listed post-mastectomy diagnosis codes for breast reconstruction).
For cardiology outpatient procedures follow the specialty PA list and submit clinical indications and procedure details with the PA request.
For cochlear implants and continuous glucose monitors (CGMs): submit device-specific clinical documentation and prior authorization per the device section; include hearing evaluations and failed conservative management for cochlear implants; include diabetes management history and supply needs for CGMs.
When using unclassified or temporary codes, include explanatory documentation justifying the code choice and clinical rationale to avoid delays or denials.

Documentation Required

Notification & inpatient admission requirements

Notification and documentation are required for inpatient admissions and certain facility placements. Provide complete service details and requested admission date when notifying. Post-acute facilities must obtain prior authorization including the admission date before placement.

Inpatient admission notification: notify UnitedHealthcare with service details at or before admission when possible; include admitting diagnosis, expected length of stay, and relevant clinical documentation.
Post-acute facility placements (skilled nursing, inpatient rehab, long-term acute care): prior authorization and the admission date are required before placement; include documentation supporting the need for post-acute level of care.
Advanced outpatient imaging (e.g., MR/CT/PET) requires prior authorization/notification where listed; include clinical indication and prior conservative measures.
Include required documentation to support medical necessity for procedures, device implants, radiation fractionation requests, and any unclassified/temporary code usage.

Prior Authorization

OptumRx submission and products

Some drug and device prior authorizations are managed by OptumRx. Follow OptumRx submission processes and contact OptumRx for prior-notification requirements on specific products.

OptumRx Help Desk: 800-711-4555 for general pharmacy prior-authorization assistance.
Prior notification for Synagis and Cimzia: OptumRx prior-notification line 800-310-6826.
Certain specialty drugs/devices may require OptumRx review — submit required clinical documentation per pharmacy prior-authorization instructions.
If a medication or device routes to OptumRx, follow OptumRx determination before scheduling procedures or dispensing product to avoid claim denials.

Service-specific prior authorization requirements (examples)

Service-specific prior authorization requirements (examples listed in this part)

Entries below indicate services that require prior authorization and associated codes where provided.

Adult day services

Adult day services - PA: Prior authorization required
CPT/HCPCS: S5102

Bariatric surgery: Prior authorization required

CPT examples: 43644, 43645, 43659, 43770, 43775, 43847, 43842, 43848, 43845, 43860, 43846

Behavioral health services

Behavioral health - routine outpatient: Prior authorization is not required for routine outpatient services through a designated behavioral health network
For specific behavioral health codes requiring prior authorization, call the number on the member's health plan ID card

Bone growth stimulator: Prior authorization required

HCPCS: 20975, 20979

Breast reconstruction (non-mastectomy and reconstruction codes): Prior authorization required for listed reconstruction CPT/HCPCS codes; prior authorization NOT required when billed following mastectomy with listed diagnosis codes

CPT examples: 19316,19318,19325,19328,19330,19340,19342,19350,19357,19361,19364,19367,19368,19369,19370,19371,19380,19396; HCPCS L8600; 11971. See listed diagnosis codes (C50.*, D05.*, Z42.1, Z85.3, Z90.xx) that exempt PA when following mastectomy

Cancer supportive services - colony-stimulating factors and bone-modifying agents: Prior authorization required for outpatient administration for a cancer diagnosis; selected colony-stimulating factor and bone-modifying J/Q codes also require PA for non-oncology diagnoses

Examples: J1449, J1442, Q5110, Q5125, Q5101, J2506, Q5122, Q5111, J2820, J1447, J1448; erythropoiesis agent J0885; denosumab J0897; antiemetic J-codes J0185, J1453, J1454, J1627, J1456, J1434, J2468

Cardiology / cardiovascular procedures: Prior authorization required for participating physicians for outpatient and office-based diagnostic catheterizations, echocardiograms, electrophysiology implants, stress echoes, and lower extremity angiogram; certain diagnosis codes listed in the document exempt PA

Example CPT: 93580; many ICD-10 codes (e.g., E08.52, E09.52, E10.52, E11.52, E13.52, I70.221, etc.) are listed as no prior authorization required

Cerebral seizure monitoring / inpatient EEG: Prior authorization required for inpatient cerebral seizure monitoring services and inpatient video EEG codes; outpatient hospital or ambulatory surgical center video EEGs do not require PA

CPT seizure monitoring: 95700,95711-95716,95718; inpatient video EEG: 95720,95722,95724,95726

Chemotherapy injectables: Prior authorization required for injectable chemotherapy drugs administered in an outpatient setting for a cancer diagnosis; includes J9000-J9999 range and listed specific J-codes/Q-codes

Examples: J9000-J9999, J0640, J0641, J0642, J1950, J1954, J1932, J1299, J1323, J1326, J2277, J3055, J3263; submit to Provider Portal or OptumRx as noted

Cochlear and other auditory implants: Prior authorization required

CPT/HCPCS examples: 69710, 69714, 69930, L8614, L8619, L8690, L8691, L8692

Continuous glucose monitor (CGM): Prior authorization required with Type 2 diabetes diagnosis and specified diagnosis codes

HCPCS examples: A4226, A9278*, A4239, E0787, A9276*, E2103, A9277*; document lists Type 2 and gestational diabetes ICD-10 codes (e.g., E11.xx series) that must accompany PA

Billing Rule

Breast reconstruction exception

Breast reconstruction procedures following mastectomy are exempt from prior authorization when billed with the listed diagnosis codes. Bill the procedure with an exempting diagnosis from the document's diagnosis code group to avoid PA — see the Code Lists/Diagnosis Codes section for the full list (C50.*, D05.*, Z42.1, Z85.3, Z90.*).

See diagnosis code group in Code Lists (examples: C50.xx series, D05.xx, Z42.1, Z85.3, Z90.10–Z90.13).
If billed with an exempting Dx, PA is not required for breast reconstruction following mastectomy.

Prior Authorization

Cancer supportive services and injectables

Colony-stimulating factors, bone-modifying agents, antinemetics and chemotherapy injectables administered in the outpatient setting require prior authorization. Notable J/Q codes called out include J1449, J1442, J2506, Q5110, Q5125, Q5101, Q5122, Q5111 and J0885 (erythropoiesis‑stimulating agent) and J0897 (denosumab). Some colony-stimulating factor codes (e.g., J1442, J1447, J1448, J2506, Q5101, Q5110, Q5111, Q5120, Q5122) require PA for both oncology and non‑oncology diagnoses; oncology requests follow the cancer supportive care section.

Examples called out in cancer supportive services: J1449, J1442, Q5110, Q5125, Q5101, J2506, Q5122, Q5111.
Erythropoiesis‑stimulating agent: J0885; bone‑modifying agent: J0897.
White blood cell colony‑stimulating factor codes noted require PA for oncology and non‑oncology Dx (see list in policy).

Documentation Required

Behavioral health referrals

Routine outpatient behavioral health through a designated behavioral health network does not require prior authorization. For specific behavioral health codes that do require PA, providers should call the phone number printed on the member's health plan ID card when referring for mental health or substance use services.

Billing rules, site-of-service and conditional exceptions

Prior authorization requirements and exceptions

Prior authorization is required except when billed with listed Dx codes below (exemptions).

OptumRx matrix - submission and contact

Exempt when billed with ANY of the following Dx codes
- C43 and related codes: C43.0, C43.10, C43.111, C43.112, C43.121, C43.122, C43.20, C43.21, C43.22, C43.30, C43.31, C43.39, C43.4, C43.51, C43.52, C43.59, C43.60, C43.61, C43.62, C43.70, C43.71, C43.72, C43.8, C43.9
- C44 series and others: C44.01, C44.02, C44.09, C44.101, C44.1021, C44.1022, C44.1091, C44.1092, C44.111, C44.1121, C44.1122, C44.1191, C44.1192, C44.121, C44.1221, C44.1222, C44.1291, C44.1292, C44.131, C44.1321, C44.1322, C44.1391, C44.1392, ... (and many additional C44 codes listed in the document)

OptumRx exempt codes detail note: Prior authorization not required when billed with the listed Dx codes (primarily C43/C44 series and numerous subcodes) as enumerated in the OptumRx matrix in the document

See document chunks 52-64 for the complete enumerated list

Billing Rule

Site-of-Service (SOS) outpatient hospital rules

Site‑of‑Service (SOS) guidance: prior authorization is required only when requesting a service in an outpatient hospital setting for codes annotated as 'SOS outpatient hospital' in the matrix. Review the code‑level matrix for SOS annotations to determine when PA applies.

SOS PA applies only for requests specifying the outpatient hospital setting for codes annotated as SOS.
Refer to the code‑level matrix in the document for which codes are marked SOS.

Billing Rule

Unclassified/temporary codes handling

Unclassified/temporary HCPCS/J codes C9399, J3490 and J3590 require prior authorization when used for specific products. The document lists products that trigger PA for these unclassified codes (examples include Casgevy, Kebilidi, Lantidra, Revcovi, Rivfloza, Starjemza, Xenpozyme). Special handling and PA are required as noted.

Unclassified/temporary codes: C9399, J3490, J3590.
PA required for specific products billed under these unclassified codes — examples: Casgevy, Kebilidi, Lantidra, Revcovi, Rivfloza, Starjemza, Xenpozyme.

Prior Authorization

Orthotics/Prosthetics DME threshold

Prior authorization is required for orthotics and prosthetics L‑codes when the retail purchase or cumulative rental cost exceeds $500. The policy lists many L‑codes (orthotics/prosthetics) and specifically notes E0445 as an example where rental cost > $500 triggers PA.

PA required for L‑codes listed when retail purchase or cumulative rental cost > $500.
Example DME/rental threshold: E0445 (rental cost of more than $500).

Code lists requiring prior authorization

Oculoplastic and eyelid CPT codes requiring prior authorizationCPT

67900	Repair of eyelid
67901	Correction of congenital ptosis
67902	Correction of ptosis, other
67903	Levator resection
67904	Frontal suspension
67906	Excision of tarsal cyst
67908	Lid reconstruction
67909	Canthoplasty
67911	Other eyelid procedure
67912	Repair of lid margin

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Diagnosis codes exempting PA for breast reconstruction following mastectomy (ICD-10)ICD-10Covered

E11.3599	Type 2 diabetes mellitus with unspecified complications
E11.36	Type 2 diabetes mellitus with diabetic cataract
E11.37X1	Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene, right leg
E11.37X2	Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene, left leg
E11.37X3	Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene, bilateral legs
E11.37X9	Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene, unspecified
E11.39	Type 2 diabetes mellitus with other circulatory complications
E11.40	Type 2 diabetes mellitus with diabetic neuropathy, unspecified
E11.41	Type 2 diabetes mellitus with diabetic mononeuropathy
E11.42	Type 2 diabetes mellitus with diabetic polyneuropathy

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DME/Orthotics & Prosthetics HCPCS/L-codes requiring prior authorizationHCPCS

E0710	External counterpulsation device, non-invasive
E0745	Oxygen concentrator, single flow
E0762	Power wheelchair, group 2
E0764	Power wheelchair, group 3
E0766	Power wheelchair with environmental controls
E0784	Powered pressure-relieving cushion
E0984	Home ventilator, single limb
E0986	Respiratory assist device
E1002	External hydrotherapy device
E1003	Suction equipment

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Orthotics and prosthetics L-codes requiring prior authorizationHCPCS

L0859	Limb prosthesis, adjustable
L1000	Custom foot orthosis
L1005	Serial fitting orthosis
L1200	Ankle foot orthosis, plastic
L1300	Ankle foot orthosis, double upright
L1310	Ankle foot orthosis, double upright, bilateral
L1499	Unlisted ankle-foot orthosis
L1680	Knee-ankle-foot orthosis, initial
L1685	Knee-ankle-foot orthosis, replacement
L1700	Knee orthosis, static

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Comprehensive L-code continuation (prosthetics/orthotics) — see policy for full descriptionsHCPCS

L5535	Shoulder unit
L5540	Cable system
L5560	Electronic elbow
L5570	Elbow control
L5580	Terminal device, flexor
L5585	Terminal device, extensor
L5590	Special harness
L5595	Harness accessory
L5600	Socket modification
L5610	Socket reinforcement

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Continued prosthetic L-codes — complete list included in policyHCPCS

L5644	Prosthetic part, endoskeletal
L5646	Prosthetic part, exoskeletal
L5647	Prosthetic part, sleeve
L5648	Prosthetic part, interface
L5649	Prosthetic part, cushion
L5651	Prosthetic foot component
L5653	Prosthetic foot end
L5661	Prosthetic foot, dynamic
L5673	Prosthetic component
L5682	Prosthetic component

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Remaining prosthetic/orthotic L-codes — see full policyHCPCS

L5718	Prosthetic harness
L5722	Prosthetic component
L5724	Prosthetic component
L5726	Prosthetic component
L5728	Prosthetic component
L5780	Prosthetic component
L5790	Prosthetic accessory
L5795	Prosthetic accessory
L5811	Lower limb prosthesis
L5812	Lower limb prosthesis, modular

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Joint replacement and major orthopedic CPT codes requiring prior authorizationCPT

27130	Total hip arthroplasty
27447	Total knee arthroplasty
27536	Revision hip prosthesis
27538	Revision knee prosthesis
28344	Revision ankle arthrodesis

Surgical supplies and miscellaneous HCPCS/V-codes requiring prior authorizationHCPCS

S2060	Intraoperative neuromonitoring
S2061	Intraoperative interpreter
S2152	Other surgical supply
V2786	Breast pump, electric
V5269	Non-covered supply
V5270	Prosthetic supply
V5271	Prosthetic supply, replacement
V5272	Prosthetic supply, accessory
V5274	Prosthetic supply accessory
V5281	Surgical dressing

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Injectable medications (J/Q codes) requiring prior authorizationHCPCS

J2782	Injection, palonosetron
J1290	Injection, Furosemide
J2840	Injection, Ropivacaine
J0175	Injection, Epoprostenol
J2350	Injection, Injection, unspecified prostacyclin
J2351	Injection, Iloprost
J2354	Injection, Treprostinil
J2267	Injection, Nesiritide
J0222	Injection, Streptokinase
J0129	Injection, Injectible antibiotic

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Selected HCPCS Q and miscellaneous supply codes requiring prior authorizationHCPCS

Q5136	Tissue expander with port
Q5147	Breast implant, silicone
Q9997	Unlisted biologic

Orthotics/prosthetics miscellaneous L-codes and modifiersHCPCS

T1999	Unlisted DME supply
E2298	Breast prosthesis, custom

Orthotics — shoe and foot device codesHCPCS

V2786	Breast pump, electric (also listed earlier)
V5269	Non-covered supply

Miscellaneous J/Q HCPCS codes (additional) requiring prior authorizationHCPCS

J3392	Injection, Other
J3393	Injection, Other
J3394	Injection, Other
J3389	Injection, Other
Q2056	Breast implant expander
Q2041	Breast implant silicone
Q2042	Breast implant saline
Q2053	Breast reconstruction kit
Q2054	Breast reconstruction kit
Q2055	Breast reconstruction kit

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OpenPayer

Prior authorization requirements for Rhode Island Medicaid

Policy overview and scope

General prior authorization rules & submission actions

Service-specific prior authorization requirements (examples)

Billing rules, site-of-service and conditional exceptions

Code lists requiring prior authorization

Key definitions

Common questions / quick answers

Document changes and history