CurrentUnitedHealthcarePolicy N/A

Non-covered and covered CPT/HCPCS codes policy for Medicaid

Defines UnitedHealthcare Community Plan reimbursement stance on CPT and HCPCS codes for Medicaid markets, including state-specific covered and non-covered code lists and applicability to claims filed on CMS1500/UB04 where specified.

Policy Summary

PayerUnitedHealthcare

PolicyNon-covered and covered CPT/HCPCS codes policy for Medicaid

Policy CodePolicy N/A

Change TypeDocumentation updates to attachments

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a prior authorization request when a non-covered code is medically necessary to request coverage.

SourceLink

POLICY UPDATE CHANGES

Attachments Section: Covered Codes Lists updated Arizona, Indiana, New Mexico, Ohio, and Texas.

Non-Covered Codes Lists updated California.

Multiple dates in 2024–2025: Attachments Section entries updating Covered and Non-Covered Codes Lists across many states (examples include Indiana, Texas, Arizona, Ohio, Wisconsin, Kansas, New Mexico).

multiplestates with state-specific covered/non-covered lists referenced

Category IInot payable in Medicaid markets (general rule)

manyrecent policy version changes listed in history

CMS1500

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Coverage Criteria and State Attachments

General coverage criteria

UnitedHealthcare Community Plan applies the following general rules for coverage of CPT and HCPCS codes in Medicaid markets.

Codes on a state's Medicaid fee schedule or the CMS NPFS are considered covered for that state's Medicaid market, subject to all UnitedHealthcare Community Plan reimbursement policies (may still be denied under another policy).

Any CPT and HCPCS codes that are not on a state Medicaid fee schedule are considered not covered for that state's Medicaid market unless there are benefit or contractual agreements with negotiated rates.

Any code not covered in any UnitedHealthcare Community Plan market will be placed on the UnitedHealthcare Community Plan NonCovered Codes List.

Some states utilize a Covered Codes List; for those states, only codes on the Covered Codes List will be accepted as covered and any code not on that list will deny as not covered.

Services must be reviewed against the enrollee's benefit document; when the enrollee's benefit definitions differ from UnitedHealthcare's definitions (e.g., Experimental/Investigational or Unproven Services), the enrollee's benefit document prevails.

Medical necessity override

A non-covered code for a covered service may be reviewed for medical necessity and covered if approved through prior authorization.

A 'non-covered' or 'non-listed' procedure code (a code not on the state fee schedule) that represents a covered service may be approved if found to be medically necessary through a prior authorization request.

States may have specific language clarifying this process (example: Ohio will not deny coverage solely because a code is not on the Ohio fee schedule and allows prior authorization review).

State-specific Covered/Non-Covered Codes Attachments

Attachments list state-specific Covered and Non-Covered Codes; these lists are periodically updated and documented in the Resources/History sections.

Attachments include state-specific Covered Codes Lists and Non-Covered Codes Lists; updates are documented in the Resources/History sections with dates and affected states (examples: Covered Codes Lists updated for Arizona, Indiana, New Mexico, Ohio, Texas; Non-Covered Codes Lists updated for California).

History entries and older attachment entries are routinely archived (see Resources/History for archived dates).

Providers must reference the state-specific attachments and provider manuals for definitive coverage and billing guidance for their provider type, specialty and the member.

Code Lists and Classification

Category II codesCPTNot Covered

Category II (xxxxF)

CPT Category II procedure codes ending in 'F' are identified as Category II codes; not payable in UnitedHealthcare Community Plan Medicaid markets.

Attachments — state code list updatesmixed

Covered and Non-Covered Codes Lists updated for multiple states (examples include Indiana, DC Washington, Arizona, Idaho, New Mexico, Colorado, Mississippi, Texas, Kentucky, New York, Virginia, Kansas, Ohio, Missouri, Nebraska, New Jersey, Wisconsin, Washington).

Archive cutoff (archived entries prior to listed dates)

Archive summaryPolicy history includes multiple archived-entry actions: entries prior to 6/29/2023, 3/16/2023, and 3/9/2023 (examples cited in 2025 history entries).

Examples of archived datesEntries prior to 6/29/2023; entries prior to 3/16/2023; entries prior to 3/9/2023.

PurposeArchive actions consolidate prior history entries when attachments or state lists are updated to keep the history concise.

Referenced updatesArchive entries are documented alongside attachments updates for Covered and Non-Covered Codes Lists across multiple states (Indiana, Arizona, Ohio, Texas, etc.).

Provider Actions, Prior Authorization, and Attachments

Prior Authorization

Prior authorization can override non-covered code status

A non-covered code for a covered service may be considered for payment if a prior authorization request documents medical necessity; UnitedHealthcare will not deny coverage solely because a code is not listed on a state Medicaid fee schedule (example language referencing Ohio).

Submit a prior authorization request that documents medical necessity for the non-covered code.
Include supporting clinical documentation tying the procedure to a covered service and the applicable diagnosis. (See Ohio example in policy text.)

Documentation Required

Updated state Covered Codes Lists (AZ, IN, NM, OH, TX) — check attachments

Attachments were updated to revise Covered Codes Lists for multiple states — providers should reference the current attachments for state-specific covered code lists (examples: Arizona, Indiana, New Mexico, Ohio, Texas) when billing.

Definitions and Policy Implementation

Category II codes (definition and policy)

DefinitionCPT Category II procedure codes are identified by the procedure code ending with 'F' (format: xxxxF).

Medicare stanceCategory II codes are used primarily for performance measurement and, per CMS, are not payable by Medicare.

UnitedHealthcare Community Plan policyUnitedHealthcare Community Plan has determined Category II codes are not payable in their Medicaid markets (not payable in any UnitedHealthcare Community Plan markets), except where state regulations allow specific exceptions.

State exceptions exampleSome states allow or cover specific Category II codes (examples: Tennessee covers 0500F and 0503F; Wisconsin covers 3008F under specified conditions).

Non-covered codes (definition and implementation)

Definition of non-covered codes