UnitedHealthcare Prior Auth requirements DD Arizona

Coverage Criteria and Medical Necessity

General medical necessity and provider registration

Covered when ALL of the following are met

AHCCCS benefit and provider requirements: Service is a covered benefit per AHCCCS and the rendering provider is actively registered with AHCCCS

From policy general information

Allergy immunotherapy/testing (members <21)

Special pediatric coverage

EPSDT for members <21: Allergy immunotherapy and allergy testing is covered under EPSDT for members younger than 21 when medically necessary or when the member has sustained an anaphylactic or life‑threatening allergic reaction (examples: severe facial swelling, breathing difficulties, epiglottal swelling, extensive urticaria). Prior authorization is required when the criteria are met.

Pediatric EPSDT rules referenced

Circumcision

Covered only with documented medical necessity

Circumcision medical necessity: Routine circumcision is not a covered benefit; prior authorization is required only for cases with documented medical necessity (see listed CPT codes).

CPT codes: 54150, 54160, 54161, 54162

Durable Medical Equipment

DME authorization: Certain durable medical equipment (DME) codes require prior authorization; some DME items require prior authorization regardless of dollar amount. Contact Preferred Homecare to request DME/supplies and provide documentation establishing medical necessity.

Preferred Homecare: 800-636-2123; DME prior authorization required regardless of dollar amount for listed codes.

Age-based coverage rules

Coverage and prior authorization distinctions by member age

Members younger than 21: Follow AHCCCS AMPM Chapter 400, Section 430 (EPSDT). Use the Certificate of Medical Necessity for Commercial Oral Nutritional Supplements where applicable. Pediatric-specific allowances (e.g., vision, hearing, allergy services) apply as described in AMPM Chapter 400.

See AMPM Chapter 400, Section 430-10

Members 21 and older: Follow AMPM Chapter 300 policies. Prior authorization is required when medically necessary to diagnose or treat diseases and conditions of the eye; experimental/investigational services require prior authorization per AMPM Chapter 300, Section 320. Genetic testing and other listed services may require prior authorization when not covered by vendor contracts.

See AMPM Chapter 300, Policy 310-GG and Policy 320-B

Outpatient therapy coverage and limits

Coverage and authorization rules for outpatient occupational, physical, and speech therapy

Outpatient therapy PA and limits: Prior authorization is required for the listed outpatient therapy CPT codes. Outpatient speech therapy is not a covered benefit. Outpatient occupational and physical therapy are limited to 15 visits per benefit year to restore or maintain a skill/level of function and 15 visits per benefit year to acquire a new skill/level of function; special rules apply for members younger than 21.15 visits per benefit year

See outpatient therapy CPT code list and visit limits

Network/Geographic prior authorization rules

Authorization required for non-standard network or geographic situations

Out-of-network/out-of-state: Prior authorization is required for all out-of-network services. Out-of-state services are approved only when emergent or when the service is unavailable in Arizona.

All rendering providers must be actively registered with AHCCCS

Qualified Medicare Beneficiary (QMB) coverage

Special coverage for QMB members

QMB visits: For Qualified Medicare Beneficiaries (QMB), visits are covered for unlimited visits when medically necessary.unlimited

Applies to services when medically necessary

Pharmacy / Physician-Administered Drug Prior Authorization

PA requirements for drugs

Drug PA: Medications listed on the prior authorization list and physician‑administered drugs require prior authorization. Service requests must include J‑codes and NDC codes. Submit pharmacy prior authorization requests via UnitedHealthcare Pharmacy Prior Authorization Service (phone or fax) or use the online forms on UHCprovider.com/AZcommunity.

Pharmacy PA contact: Phone 800-310-6826; Fax 866-940-7328

Experimental and investigational services are not covered benefits. Prior authorization is required for services determined to be experimental or investigational; see AHCCCS AMPM Chapter 300, Section 320 for details and examples. Additionally, services or items furnished solely for cosmetic purposes are excluded from AHCCCS coverage and require prior authorization when codes listed in the cosmetic/reconstructive section are submitted.

Prosthetic devices are explicitly distinguished from durable medical equipment: the policy states prosthetics are not DME. Providers should follow the prosthetics authorization and documentation provisions in the orthotics/prosthetics section rather than DME pathways when requesting coverage.

Incontinence supplies are a covered benefit only when provided through the designated vendor pathway. To obtain incontinence supplies, providers and members must contact Preferred Homecare as the required benefits vendor. For DME and other supplies that require prior authorization regardless of dollar amount, contact Preferred Homecare at the number listed in the policy.

Orthotic repair and replacement are subject to limits and documentation requirements. Reasonable repairs are permitted, but replacement or component substitution may be limited when the cost to repair is less than purchasing a replacement unit or where cumulative rental thresholds apply. Authorization requests must document that existing components are not functioning and that replacement or repair meets the policy criteria.

Outpatient therapy coverage differs by discipline and member age. Outpatient speech therapy is not a covered benefit. Occupational and physical therapy in outpatient settings are covered but subject to limits: 15 visits per benefit year for restoration/maintenance and 15 visits per benefit year to acquire a new skill. For members younger than 21 follow EPSDT requirements; for members 21 and older follow AMPM Chapter 300 rules and prior authorization requirements where specified.

Routine cosmetic procedures that change or improve appearance without treating a medical condition are excluded from AHCCCS coverage. Prior authorization is required for the cosmetic/reconstructive codes listed in the policy, but services furnished solely for cosmetic purposes are not covered.

Services considered experimental or investigational require prior authorization. The policy references AMPM Chapter 300, Section 320 for criteria and lists example codes that are treated as experimental/investigational. In special circumstances described in AMPM, some such services may be reviewed for coverage when appropriate documentation is provided with the authorization request.

Code Lists and Coding Notes

Covered CPT Codes (selected surgical/procedural codes requiring prior authorization)CPTCovered

58294	Hysterectomy, removal of uterus, abdominal or vaginal — CPT listed for prior authorization
58541	Hysteroscopy, surgical; with removal of leiomyomata (fibroids) — listed
58542	Hysteroscopy, with treatment of uterine adhesion (synechiae), any method
58543	Hysteroscopy with removal of submucous leiomyoma, by resection techniques
58544	Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy
58548	Hysteroscopy, surgical; with removal of impacted foreign body
58550	Hysteroscopy, surgical; with removal of tubal ostial obstruction
58552	Hysteroscopy, surgical; with lysis of intrauterine adhesions
58553	Hysteroscopy, surgical; with endometrial ablation
58554	Hysteroscopy, surgical; with myomectomy, submucous

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Covered HCPCS / Other Codes (selected)HCPCSCovered

No codes listed

Covered CPT Codes: Bone growth, chemotherapy, cardiology, seizure monitoring (examples)CPTCovered

95700	Cerebral seizure monitoring Inpatient video
95711	Cerebral seizure monitoring
95712	Ambulatory EEG
95713	Extended EEG monitoring
95714	Chemotherapy-related monitoring
95715	Chemotherapy-related monitoring
95716	Chemotherapy-related monitoring
95718	Chemotherapy-related monitoring
E0747	Neurostimulator (bone growth stimulator)
E0748	Neurostimulator

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Neutral / Informational Codesmixed

J9000-J9999	Chemotherapy injectable drugs (range)
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin
J1950	Lupron Depot (example)

Covered CPT Codes: Gynecologic / Surgical procedures requiring prior authorization (subset)CPTCovered

58541	Hysteroscopy, surgical; with removal of leiomyomata (fibroids)
58542	Hysteroscopy, with treatment of uterine adhesion (synechiae), any method
58543	Hysteroscopy with removal of submucous leiomyoma, by resection techniques
58544	Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy
58548	Hysteroscopy, surgical; with removal of impacted foreign body
58550	Hysteroscopy, surgical; with removal of tubal ostial obstruction
58552	Hysteroscopy, surgical; with lysis of intrauterine adhesions
58553	Hysteroscopy, surgical; with endometrial ablation
58554	Hysteroscopy, surgical; with myomectomy, submucous
58570	Laparoscopy with total hysterectomy, uterus 250 g or less

1–10 of 19

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Neutral Codes: Referencemixed

No codes listed

Covered DME / Durable Medical Equipment (examples requiring prior authorization)HCPCSCovered

E0194	Stairlift, example DME requiring prior authorization through Preferred Homecare
E0265	Example DME code listed for prior authorization
E0465	Example DME code
E0745	Insulin pump (example)
E0984	Insulin pump supplies (example)

Key Notemixed

*Requires prior authorization regardless of dollar amount

DME items require prior authorization regardless of dollar amount; contact Preferred Homecare at 800-636-2123 to request DME items.

Experimental / Investigational (examples)CPTExperimental

33477	Example experimental cardiac code
A4638	Example HCPCS experimental
G0293	Example investigational
S9991	Example investigational
36514	Example investigational

Neutral: Genetic / Biomarker Codes (examples)CPT

81265	Genetic testing example
81302	Genetic testing example
81321	Genetic testing example

Provider Submission, Authorization, and Documentation Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for many services and specific CPT/HCPCS/J/NDC codes listed in this section. Submit requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone per the instructions below. Failure to obtain required prior authorization or notification may result in claim denial.

Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) — sign in with One Healthcare ID.
Phone: 800-445-1638 — use when portal is not available.
Services must be covered benefits per AHCCCS; experimental/investigational services are not covered.
Out-of-network and out-of-state services require prior authorization and supporting documentation; all providers must be actively registered with AHCCCS.

Prior Authorization

DME, Specialty Beds, Supplies and Vendor Contacts

Durable medical equipment (DME), specialty beds, orthotics/prosthetics, incontinence and enteral supplies frequently require prior authorization. Preferred Homecare is the contracted vendor for many DME and supply requests; call Preferred Homecare at 800-636-2123. For items requiring cumulative rental or regardless of dollar amount, prior authorization is required. Documentation to establish medical necessity must accompany requests.

Background and Scope

This document enumerates prior authorization requirements for services billed to the UnitedHealthcare Community Plan of Arizona Developmentally Disabled Program and aligns coverage with AHCCCS benefit determinations. It applies to inpatient and outpatient services and notes that services must be covered benefits per AHCCCS and that all rendering providers must be actively registered with AHCCCS to be eligible for prior authorization.

Key Definitions and Acronyms

AHCCCS

DefinitionAHCCCS (Arizona Health Care Cost Containment System) governs covered benefits and reimbursable services for members

ImplicationServices must be covered benefits per AHCCCS to be eligible for prior authorization

Provider requirementAll rendering providers, facilities and vendors must be actively registered with AHCCCS

EPSDT

DefinitionEPSDT (Early and Periodic Screening, Diagnostic and Treatment) — referenced for members younger than 21 for services such as allergy immunotherapy and testing

ApplicationAllergy immunotherapy and testing is covered under EPSDT for members <21 when medically necessary

OpenPayer

Prior authorization requirements for developmentally disabled Arizona members

Coverage Criteria and Medical Necessity

Code Lists and Coding Notes

Provider Submission, Authorization, and Documentation Actions

Background and Scope

Key Definitions and Acronyms