UnitedHealthcare AZ Long Term Care Prior Auth

Coverage Criteria and Prior Authorization Conditions

General coverage and eligibility

Covered when ALL of the following are met:

General coverage eligibility: Services must be covered benefits per AHCCCS and be medically necessary, cost‑effective, and federally/state reimbursable. All rendering providers, facilities and vendors must be actively registered with AHCCCS. Only one requesting provider may appear on a prior authorization request form.

From general eligibility notes (AHCCCS).

Out-of-network/out-of-state services: Services provided by out‑of‑network or out‑of‑state health care professionals require prior authorization and supporting documentation for the out‑of‑network request.

Prior authorization and documentation required for OON/OOS providers.

Experimental and investigational services are not covered benefits and are not eligible for authorization.

Non‑coverage exclusion.

Medical necessity requirement: Only medically necessary services that meet AHCCCS definitions (medically necessary, cost‑effective, federally/state reimbursable) will be authorized.

Standard medical necessity requirement.

Allergy immunotherapy coverage

Covered when ALL of the following are met:

Age-based coverage: Member is younger than 21 and the requested allergy immunotherapy or allergy testing is medically necessary and meets EPSDT criteria.age <21

EPSDT coverage for members <21 per policy.

Life‑threatening reaction criteria (testing): Allergy testing requires prior authorization when there is a reaction where further exposure to the unknown allergen could reasonably be expected to result in a life‑threatening situation (examples: severe facial swelling, breathing difficulties, epiglottal swelling, extensive urticaria).

From allergy immunotherapy continuation notes.

Adults not covered: For members 21 and older, allergy immunotherapy (including SCIT, SLIT, or other routes) is not a covered benefit.age >=21

Coverage stances in excerpt

Cochlear and other auditory implants: Prior authorization is required for cochlear and other auditory implant procedures and listed HCPCS/CPT codes; clinical documentation establishing medical necessity must be provided. For members younger than 21 prior authorization is required; for members 21 and older prior authorization is required for supplies, maintenance and repair but hardware is not a covered benefit.

Clinical documentation requirement and age‑specific notes.

Continuous glucose monitors (CGMs): Prior authorization is required for continuous glucose monitor supplies and equipment (HCPCS A42xx/A92xx/E21xx/E07xx codes shown) when used with a Type 2 diabetes diagnosis.

PA required with Type 2 diabetes diagnosis.

Cosmetic and reconstructive procedures: Prior authorization is required for the listed cosmetic and reconstructive CPT/HCPCS codes; services solely for cosmetic purposes are excluded from AHCCCS coverage.

Reconstructive vs cosmetic distinctions noted; PA required for listed codes.

Authorization for listed services

Covered when ALL of the following apply

Service/code included in PA list: The request is for a CPT/HCPCS code or service category that is listed in the policy as requiring prior authorization (examples include DME with retail purchase or cumulative rental cost > $500; enteral services; in‑home nutritional therapy/TPN; genetic testing not covered by LabCorp; home‑ and community‑based services; selected surgical procedures including FAI and FESS codes).

See code tables for enumerated codes and categories.

Required documentation provided: Clinical documentation supporting medical necessity is provided with the prior authorization request; for certain DME requests a copy of a Medicare denial and supporting clinical documentation must accompany the submission when applicable.

Medicare denial review and documentation requirement for DME noted.

Incontinence supplies — members younger than 21

Covered when PA is obtained for quantities above age-based thresholds

Incontinence supplies (<21): Prior authorization is required when requests for incontinence briefs and diapers (including pull‑ups) exceed 240 units per month for members younger than 21.>240 per month

Monthly quantity threshold for members <21.

Incontinence supplies — members 21 and older

Covered when PA is obtained for quantities above age-based thresholds

Incontinence supplies (>=21): Prior authorization is required when requests for incontinence briefs and diapers (including pull‑ups) exceed 180 units per month for members 21 and older.>180 per month

Monthly quantity threshold for members >=21.

Injectable medications requiring PA

Prior authorization is required for the following injectable medications when billed with the listed HCPCS/J-codes

Injectable medications requiring PA: Prior authorization is required for the injectable medications listed in the policy and must be obtained when billed with the associated HCPCS/J‑codes (see policy lists for full code-to-drug mapping, e.g., J3262, J0791, J0172, J7171, J1426, J0225, J0739, J0256, Q5121, J0585, J0567, J2329, J2786, J3247, J0584, J1551, J0589, J1413, J2508, J1302, J3380, J7204, J3111, J1305, J0177, J0517, J1951, Q0138, J9210, J0223, J0257, J1411, J0638, J3245, Q5103, J1439, J1459, J1559, J1572, J1566, J2782, J2507, J0217, J1306, J3397, J1437, J0219, J1458, J2796, J2182, J2350, J0129, J2267, J0222, J1576 etc.).

See injectable medication code groups in coding section for the enumerated list.

Inpatient admission PA criteria

Prior authorization required for inpatient admissions when any of the following apply:

Inpatient admission categories requiring PA: Behavioral/substance abuse; Elective surgical admissions; Hospice; Long‑term acute care/rehabilitation (LTAC); Skilled nursing facility admissions.

Emergency services do not require prior authorization; observation does not require PA but notification is required.

Inpatient admission — prior authorization required

Covered when prior authorization is obtained for the listed admission types

Inpatient admissions — PA required: Prior authorization must be obtained for inpatient admissions including behavioral/substance abuse, elective surgical with admission, hospice, long‑term acute care/rehabilitation and skilled nursing facility stays. Emergency services are exempt from prior authorization. Observation status does not require prior authorization but notification is required if a member is admitted for an inpatient stay.

Notification and ordering requirements for observation noted.

Orthotics and prosthetics — prior authorization and medical necessity

Covered when prior authorization requirements and documentation conditions for orthotics/prosthetics are met

Orthotics and prosthetics — PA and documentation: Orthotics and prosthetic items (HCPCS L‑codes listed in the policy) require prior authorization. Requests must include documentation of medical necessity, that the item is ordered by a physician, justification that repair is reasonable or that repair cost is less than replacement when applicable, and evidence the component is not operating effectively when replacement is requested. Some codes have member‑age specific rules (e.g., members younger than 21). For items with retail purchase or cumulative rental cost thresholds, PA applies when cost exceeds $500 as noted elsewhere.

Repair vs replacement, serviceability, and AHCCCS orthotics coverage references.

Out-of-state services

Out-of-state services: Out‑of‑state services are approved only when the service is emergent or unavailable in Arizona; prior authorization and supporting documentation are required for out‑of‑state requests.

Benefit only approved when emergent or unavailable in AZ.

Experimental and investigational services are expressly excluded from coverage. Additionally, allergy immunotherapy is not a covered benefit for members 21 and older. For members younger than 21, allergy immunotherapy and allergy testing may be covered under EPSDT when medically necessary. All services must be medically necessary, cost‑effective, federally- and state‑reimbursable, and AHCCCS rules apply (providers/facilities must be actively registered with AHCCCS).

This section does not present structured coverage criteria or exclusion logic; it primarily lists diagnosis and procedure code references and indicates prior authorization pointers tied to those codes. Providers should consult the specific code entries and the document's 'how to obtain prior authorization' annotations when submitting requests.

Prior authorization is not required for circumcision when performed in an outpatient hospital setting or an ambulatory surgical center.

Cosmetic procedures that solely change or improve physical appearance without significantly improving or restoring physiological function are excluded from AHCCCS coverage. Reconstructive procedures that treat a medical condition may be covered when medically necessary; however, services provided solely for cosmetic purposes are not covered and prior authorization alone does not make cosmetic care eligible for payment.

Diabetic supplies are supplied through the member's local pharmacy. Certain diabetes devices (for example, talking glucometers) may have prior authorization pathways through the medical prior authorization process; follow the listed code‑level instructions and pharmacy/vendor guidance.

Emergency department services and emergency admissions are exempt from prior authorization requirements. When a member is admitted for an emergency, prior authorization is not required for the emergency admission.

Emergency services do not require prior authorization. Providers should follow standard emergency care procedures and submit notifications as required when the member is admitted.

Out‑of‑state services are covered only when the service is emergent or the required service is unavailable in Arizona; out‑of‑network or out‑of‑state requests require supporting documentation and prior authorization per AHCCCS rules.

Negative pressure wound therapy (wound vac) supplies and equipment are subject to denial when continued‑coverage criteria are not met. Examples of denial triggers include presence of cancer tissue in the wound, necrotic tissue with eschar if debridement has not been attempted, supplies no longer being used by the member, untreated fistula near the wound, or untreated osteomyelitis in the wound vicinity.

Services that are not medically necessary, not cost‑effective, or not reimbursable under federal or state rules are not covered. Claims for services that fail to meet medical necessity or AHCCCS eligibility requirements may be denied.

Codes and Coding Notes

Listed CPT/HCPCS codes (mixed group)mixed

92607	Augmentative and alternative communication – CPT code listed in document
92608	Augmentative and alternative communication – CPT code listed in document
92609	Augmentative and alternative communication – CPT code listed in document
A9901	Augmentative and alternative HCPCS code listed in document
20975	Procedure code listed (context: outpatient services)
20979	Procedure code listed (context: outpatient services)
81162	Genetic testing code (listed under BRCA/breast reconstruction context)
81163	Genetic testing code (BRCA)
81164	Genetic testing code
81165	Genetic testing code

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Listed ICD-10 CodesICD-10

E08.52	ICD-10 diagnosis code listed
E13.52	ICD-10 diagnosis code listed
E09.52	ICD-10 diagnosis code listed
I70.221	ICD-10 diagnosis code listed
I70.228	ICD-10 diagnosis code listed
I70.229	ICD-10 diagnosis code listed
I70.231	ICD-10 diagnosis code listed
I70.232	ICD-10 diagnosis code listed
I70.233	ICD-10 diagnosis code listed
I70.234	ICD-10 diagnosis code listed

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Cardiovascular I70.* codes (as listed)ICD-10

I70.25	I70.25 (as listed)
I70.261	I70.261
I70.262	I70.262
I70.263	I70.263
I70.268	I70.268
I70.269	I70.269
I70.321	I70.321
I70.322	I70.322
I70.323	I70.323
I70.329	I70.329

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Procedure and supply CPT/HCPCS codes referencedmixed

95700	Cerebral seizure monitoring - Inpatient video (mapped diagnoses listed)
95711	Cerebral seizure monitoring - Inpatient video (mapped diagnoses listed)
95712	Cerebral seizure monitoring - Inpatient video (mapped diagnoses listed)
95713	Cerebral seizure monitoring - Inpatient video (mapped diagnoses listed)
54150	Circumcision
54160	Circumcision
54161	Circumcision
54162	Circumcision
69710	Cochlear and other auditory implants
69714	Cochlear and other auditory implants

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Mapped ICD-10 diagnosis codesICD-10

I70.423	Diagnosis code appearing in list
I70.428	Diagnosis code appearing in list
I70.429	Diagnosis code appearing in list
I75.021	Diagnosis code appearing in list
T82.818A	Diagnosis code appearing in list
S81.801A	Diagnosis code appearing in list
M86.40	Diagnosis codes (many M86.x osteomyelitis codes) mapped to procedures
M86.379	Diagnosis code appearing in list
M86.369	Diagnosis code appearing in list
M86.39	Diagnosis code appearing in list

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Cosmetic/Reconstructive CPT & HCPCS codesmixedCovered

11960	CPT code listed in document associated with specified diagnoses
11971	CPT code listed in document associated with specified diagnoses
14020*	CPT code with asterisk noted in document
14021*	CPT code with asterisk noted in document
14041	CPT code listed
14061*	CPT code with asterisk
15823	CPT code listed
15830	CPT code listed
A9278	HCPCS code listed
A9277	HCPCS code listed

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Durable Medical Equipment (DME) HCPCS codesHCPCSCovered

E0193	Durable medical equipment HCPCS code
E0194	Durable medical equipment HCPCS code
E0265	Durable medical equipment HCPCS code
E0266	Durable medical equipment HCPCS code
E0270	Durable medical equipment HCPCS code
E0277	Durable medical equipment HCPCS code
E0300	Durable medical equipment HCPCS code
E0302	Durable medical equipment HCPCS code
E0304	Durable medical equipment HCPCS code
E0329	Durable medical equipment HCPCS code

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Prior authorization required codesmixedCovered

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

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Procedures with PA notesCPT

58550	CPT/HCPCS reference as listed for how to obtain prior authorization
58552	CPT/HCPCS reference as listed for how to obtain prior authorization
58553	CPT/HCPCS reference as listed for how to obtain prior authorization
58554	CPT/HCPCS reference as listed
58570	CPT/HCPCS reference as listed
58571	CPT/HCPCS reference as listed
58572	CPT/HCPCS reference as listed
58573	CPT/HCPCS reference as listed
58951	CPT/HCPCS reference as listed
58953	CPT/HCPCS reference as listed

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Injectable medication HCPCS/J-codes requiring PAHCPCSCovered

J3262	Actemra
J0791	Adakveo
J0172	Aduhelm
J7171	Adzynma
J1426	Amondys 45
J0225	Amvuttra
J0739	Apretude
J0256	Aralast NP, Prolastin-C, Zemaira
Q5121	Avsola
J0585	Botulinum toxin (various)

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Covered/PA-required injectable codes (partial list)HCPCSCovered

J3358	Stelara
Q9991	Sublocade
Q9992	Sublocade
J2781	Syfovre
90378	Synagis
J3241	Tepezza
J2356	Tezspire
J3316	Triptodur
J9381	Tzield
C9094	Unclassified code

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Additional injectable and intravitreal codes (partial)HCPCSCovered

J1823	Uplizna
J0178	Intravitreal VEGF
J0179	Intravitreal VEGF
J2777	Intravitreal VEGF
J2778	Intravitreal VEGF
J2779	Intravitreal VEGF
Q5124	Intravitreal product
Q5128	Intravitreal product
J9376	Veopoz
J1322	Vimizim

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Injectables referenced across earlier chunksHCPCSCovered

J0222	Injectable medication (Onpattro referenced in section)
J1576	Panzyga
J0606	Pombiliti (listed as PA pathway code)
J1203	Pombiliti (listed as PA pathway code)

Joint replacement / joint proceduresCPTCovered

24360	Listed under joint replacement group
24361	Listed under joint replacement group
24362	Listed under joint replacement group
24363	Listed under joint replacement group
24370	Joint, total hip and knee replacement group
24371	Joint, total hip and knee replacement group
27120	Total hip replacement
27125	Total hip replacement
27130	Knee replacement
27132	Knee replacement

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Non-emergent air ambulanceHCPCSCovered

A0430	Non-emergent air ambulance transport
A0431	Non-emergent air ambulance transport
A0435	Non-emergent air ambulance transport
A0436	Non-emergent air ambulance transport

Orthotics and prosthetics HCPCS L-codes (extensive list)HCPCSCovered

No codes listed

Craniofacial / orthognathic CPT codesCPTCovered

21240	Craniofacial/maxillofacial related CPT codes listed in table
21242	Craniofacial/maxillofacial related CPT code
21244	Craniofacial/maxillofacial related CPT code
21245	Craniofacial/maxillofacial related CPT code
21246	Craniofacial/maxillofacial related CPT code
21247	Craniofacial/maxillofacial related CPT code
21248	Craniofacial/maxillofacial related CPT code
21249	Craniofacial/maxillofacial related CPT code
21255	Craniofacial/maxillofacial related CPT code
21296	Craniofacial/maxillofacial related CPT code

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Therapy and related codes listedCPTCovered

92507
92508
92526
J3399

Pharmacy/physician-administered drug J-codesHCPCSCovered

J0224
J0717
J1290
J1300
J1303
J1427
J1428
J1429
J1786
J2326

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Various surgical/spinal/cranial procedure codesCPTCovered

30400
30410
30420
30430
30435
30450
30460
30462
30465
31295

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Device and implantable stimulatorsHCPCSCovered

E0747	Neurostimulator
E0748
E0749
E0760
L8680
L8682
L8685
L8686
L8687
L8688

Pregnancy termination, prostate, and proton beam codesCPTCovered

59840
59852
59841
59855
59850
59851
59857
37243
53852
52441

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Transplant-related procedure codesCPTCovered

64555
64568
64570
64590

Sterilization / Stimulator implantation codesCPT | HCPCSCovered

63307
52601
52649
55831
58611
63308
52630
55250
58565
0098T

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Transplant / Neurostimulation / related device codesCPT | HCPCSCovered

64555
64568
64570
64590
L8680
L8682
L8685
L8686
L8687
L8688

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Various surgical, transplant, CAR-T and associated codesCPT | HCPCS | mixedCovered

32854
32855
32856
33930
33933
33935
33940
33944
33945
38208

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CAR-T / biologic temporary and HCPCS codesCPT | HCPCSCovered

0537T
0538T
0539T
0540T
J9999
Q2041
Q2042
Q2053
Q2054
Q2055

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Temporary/unclassified codes and VAD/wound vac related codesCPT | HCPCS | TemporaryCovered

C9399
J3490
J3590
33927
33928
33929
33975
33976
33979
33981

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Age-based coverage for allergy immunotherapy — EPSDT coverage note

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

Prior Authorization Steps, Documentation, and Denial Risks

Prior Authorization

Cardiovascular codes requiring prior authorization

Prior authorization is required for the cardiovascular diagnosis codes listed (I70.*). When requesting authorization, reference the specific I70.* code(s) involved and submit supporting clinical documentation via the UnitedHealthcare Provider Portal or by phone. Failure to obtain prior authorization for these listed cardiovascular codes may result in denial.

Affected codes: I70.268, I70.269, I70.321, I70.322, I70.323, I70.329, I70.331, I70.332, I70.333, I70.334, I70.335, I70.338, I70.339, I70.341, I70.342, I70.343, I70.344, I70.345, I70.348, I70.349, I70.35, I70.361, I70.362, I70.363, I70.369, I70.421, I70.422, I70.423, I70.428, I70.429, I70.431, I70.432, I70.433, I70.434, I70.435, I70.438, I70.439, I70.441, I70.442, I70.443, I70.444, I70.445, I70.448, I70.449, I70.461, I70.462, I70.463, I70.468, I70.469, I70.521, I70.522, I70.523, I70.528, I70.529, I70.531, I70.532, I70.533, I70.534, I70.535, I70.538, I70.539, I70.541, I70.542, I70.543, I70.544, I70.545, I70.548, I70.549, I70.561
When submitting: include specific I70.* code(s) and clinical rationale

Denial Risk

Covered Indications and Lab/Genetic Testing Guidance

BRCA and other genetic testing requests

Prior authorization is required; LabCorp handles review and processing for designated tests.

BRCA and genetic testing requests: Prior authorization is required for BRCA and specified genetic testing CPT/HCPCS codes. Providers should direct all lab requests for these tests to LabCorp (800‑533‑0567) for review and processing.

BRCA/genetic testing PA and LabCorp routing required.

Genetic testing not covered by LabCorp

Prior authorization is required for genetic testing services that are not processed by the designated laboratory:

Genetic testing not covered by LabCorp: Genetic testing services that are not covered by LabCorp require prior authorization before services are rendered.

Contact LabCorp or submit PA as specified.

How to Request Prior Authorization and Contact Points

Note

Excluded Services

Experimental and investigational services are not covered benefits and are excluded from payment under this policy.

No specific laboratory tests are explicitly listed as 'not covered' in these excerpts. However, genetic testing services that are not processed by LabCorp require prior authorization and may be subject to different review; providers should direct BRCA and other genetic test requests to LabCorp per the document's instruction for review/processing.

Background and Scope

This policy documents administrative prior authorization requirements and references AHCCCS coverage rules. It notes that allergy immunotherapy for members 21 and older is not a covered benefit, while allergy immunotherapy and testing may be covered under EPSDT for members younger than 21 when medically necessary. Prior authorization requests must be submitted via the UnitedHealthcare Provider Portal or by phone as specified in the policy.

Definitions and Key Terms

EPSDT coverage — Early and Periodic Screening, Diagnostic and Treatment coverage for members younger than 21 (allergy immunotherapy/testing).

EPSDT — summaryEarly and Periodic Screening, Diagnostic and Treatment (EPSDT) may cover allergy immunotherapy and testing for members younger than 21 when medically necessary.

PA exceptions for emergenciesEmergency services do not require prior authorization; EPSDT coverage still requires medical necessity as defined by AHCCCS.

Provider registration requirementAll rendering health care professionals, facilities, and vendors must be actively registered with AHCCCS to request EPSDT‑covered services.

Cochlear and other auditory implants — Definition note for implants.

Definition — cochlear and auditory implantsCochlear and other auditory implants are medical devices within the inner ear with an external portion to help persons with profound sensorineural hearing loss; prior authorization is required for the listed codes.

Policy Revision History

2024-08-01policy_effectiveLatest

Policy became effective for UnitedHealthcare Community Plan of Arizona Long Term Care.

OpenPayer

Prior authorization requirements for Arizona Long Term Care

Coverage Criteria and Prior Authorization Conditions

Codes and Coding Notes

Prior Authorization Steps, Documentation, and Denial Risks

Covered Indications and Lab/Genetic Testing Guidance

How to Request Prior Authorization and Contact Points

Excluded Services

Background and Scope

Definitions and Key Terms

Policy Revision History