Prior Authorization Requirements - Effective Oct. 1, 2021 ...

1 Prior Authorization Requirements for Michigan Medicaid, Healthy Michigan Plan (HMP), and Children's Special Health Care Services (CSHCS). Effective Oct. 1, 2021. General Information This list contains Prior Authorization Requirements for UnitedHealthcare Community Plan in Michigan's participating care providers for inpatient and outpatient services. To request Prior Authorization , please submit your request online, or by phone or fax: Online: Use the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal. Go to and click on the UnitedHealthcare Provider Portal button in the top right corner. Then, select the Prior Authorization and Notification tile on your Provider Portal dashboard. Phone: 800-903-5253.

2 Fax: 855-225-9847 A fax form is available at > Prior Authorization and Notification Resources > Prior Authorization Paper Fax Forms. Prior Authorization is not required for emergency or urgent care. Out-of-network physicians, facilities and other health care providers must request Prior Authorization for all procedures and services, excluding emergent or urgent care. Exceptions to this process are orthopedic physician services, medically necessary obstetric physician services and 23-hour observation where Prior Authorization is not needed. Procedures and Additional CPT or HCPCS Codes and/or Services Information How to Obtain Prior Authorization Abortion Prior Authorization is 59840 59841 59850 59851. required 59852 59855 59856 59857.

3 59866. Bariatric surgery Prior Authorization is 43644 43645 43659 43770. Bariatric surgery and specific required obesity-related services 43775 43842 43845 43846. 43847 43848 43860. Bone growth stimulator Prior Authorization is 20975. Electronic stimulation or required ultrasound to heal fractures Breast reconstruction Prior Authorization is 19316 19318 19325 19328. (non-mastectomy) required Reconstruction of the breast 19330 19340 19342 19350. except when following 19357 19361 19364 19367. mastectomy 19368 19369 19370 19371. 19380 19396. Cancer supportive care Prior Authorization is Injectable colony-stimulating factor drugs that require required for colony- Prior Authorization : stimulating factor drugs and Filgrastim (Neupogen ).

4 Bone- modifying agents administered in an J1442*. outpatient setting for a Filgrastim-aafi (NivestymTM). cancer diagnosis *Codes J1442, J1447 Q5110*. J2505, Q5101, Q5108, Filgrastim-sndz (Zarxio ). Q5110, Q5111, Q5120 and CPT is a registered trademark of the American Medical Association. PCA-1-20-00295-Clinical-WEB_03012020. 2021 United HealthCare Services, Inc Procedures and Additional CPT or HCPCS Codes and/or Services Information How to Obtain Prior Authorization Cancer supportive care Q5122 also require Prior Q5101*. (continued) Authorization for non- Pegfilgrastim (Neulasta ). oncology DX. See Injectable medications J2505*. section below. Pegfilgrastim-apgf (NyvepriaTM). Q5122. Pegfilgrastim-bmez (Ziextenzo ). Q5120*.

5 Pegfilgrastim-cbqv (UDENYCATM). Q5111*. Pegfilgrastim-jmdb (FulphilaTM). Q5108*. Sargramostim (Leukine ). J2820. Tbo-filgrastim (Granix ). J1447*. Anti-emetic Drugs that require Prior Authorization : Akynzeo (palonosetron/fosnetupitant). J1454. Aloxi (palonosetron). J2469. CinvantiTM (aprepitant). J0185. Emend (fosaprepitant). J1453. Sustol (granisetron extended release). J1627. Bone-modifying agent that requires Prior Authorization : Denosumab (Xgeva ). J0897. For Prior Authorization , please submit requests online by using the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal. Go to and click on the UnitedHealthcare Provider Portal button in the top right corner. Then, select the Prior Authorization and Notification tile on your Provider Portal dashboard.

6 Or, call 888-397-8129. Cardiovascular Prior Authorization is 37220 37221 37224 37225. required 37226 37227 37228 37229. 75710* 75716*. * Prior Authorization is required for the following diagnosis codes: CPT is a registered trademark of the American Medical Association. PCA-1-20-00295-Clinical-WEB_03012020. 2021 United HealthCare Services, Inc. Procedures and Additional CPT or HCPCS Codes and/or Services Information How to Obtain Prior Authorization Cardiovascular (continued) CPT is a registered trademark of the American Medical Association. PCA-1-20-00295-Clinical-WEB_03012020. 2021 United HealthCare Services, Inc. Procedures and Additional CPT or HCPCS Codes and/or Services Information How to Obtain Prior Authorization Cardiovascular (continued) I96 Centers for Medicare & Services determined by Medicaid Services (CMS) CMS to be inpatient only inpatient only procedures must be requested as inpatient.

7 If performed as outpatient procedures, they're not payable according to CMS. Outpatient Prospective Payment System guidelines. For a list of inpatient only CPT is a registered trademark of the American Medical Association. PCA-1-20-00295-Clinical-WEB_03012020. 2021 United HealthCare Services, Inc. Procedures and Additional CPT or HCPCS Codes and/or Services Information How to Obtain Prior Authorization Centers for Medicare & codes, please visit Medicaid Services (CMS) > Medicare > Medicare Fee inpatient only procedures for Service Payment >. (continued) Hospital Outpatient PPS >. Addendum A and Addendum B Updates >. Addendum B (most recent copy) > Status Indicator (SI). C in column D. Chemotherapy Prior Authorization is Injectable chemotherapy drugs that require Prior required for injectable Authorization : chemotherapy drugs Chemotherapy injectable drugs (J9000 - J9999), Leucovorin administered in an (J0640), Levoleucovorin (J0641, J0642), Lupron Depot.

8 Outpatient setting including (J1950). intravenous, intravesical and Chemotherapy injectable drugs that have a Q code intrathecal for a cancer Chemotherapy injectable drugs that have not yet received an diagnosis assigned code and will be billed under a miscellaneous Healthcare Common Procedure Coding System (HCPCS). code Please submit Prior Authorization requests online by using the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal. Go to and click on the UnitedHealthcare Provider Portal button in the top right corner. Then, select the Prior Authorization and Notification tile on your Provider Portal dashboard. Or, call 888-397-8129. Cochlear implants and Prior Authorization is 69710 69714 69715 69718.

9 Other auditory implants required A medical device within the 69930 L8619 L8691 L8692. inner ear with an external portion that helps persons with profound sensorineural deafness achieve conversational speech Continuous Glucose Prior Authorization required A9276 A9277 A9278 K0553. Monitor with Type 2 and Gestational Diabetes Diagnosis K0554. Cosmetic and Prior Authorization is 11960 11971 14020 14021. reconstructive required 14041 14061 15820 15821. Cosmetic procedures that change or improve physical 15822 15823 15830 15847. appearance without 17106 17107 17108 17999. significantly improving or 21137 21138 21139 21172. restoring physiological function 21175 21179 21180 21181. Reconstructive procedures 21182 21183 21184 21230.

10 That treat a medical condition 21235 21256 21275 21280. or improve or restore 21282 21295 21740 21742. physiologic function 21743 28344 30620 67900. 67901 67902 67903 67904. 67906 67908 67909 67911. 67912 67914 67915 67916. 67917 67921 67922 67923. 67924 67950 67961 67966. Q2026. CPT is a registered trademark of the American Medical Association. PCA-1-20-00295-Clinical-WEB_03012020. 2021 United HealthCare Services, Inc. Procedures and Additional CPT or HCPCS Codes and/or Services Information How to Obtain Prior Authorization Durable medical Prior Authorization is A9900 E0194 E0265 E0266. equipment (DME) required only for the codes E0277 E0328 E0329 E0457. listed with a retail purchase or cumulative rental cost of E0460 E0465 E0466 E0470.