Procedures and Services Additional Information Current Procedural Terminology (CPT) Codes
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1 General Information The following list represents our prior authorization requirements for UnitedHealthcare Community Plan in Florida, participating/contracted providers (inpatient and outpatient). All services rendered by a non-contracted physician, facility or other health care provider must receive prior authorization. Please use the following for prior authorization review for coverage: Products: Medicaid, Florida Healthy Kids Phone: Fax: Online: UHCCommunityplan.com Bariatric surgery Bone growth stimulator Inpatient and outpatient bariatric surgery and specific obesity-related services Electronic stimulation or ultrasound to heal fractures T 313T 314T 315T 316T 317T E747 E748 E749 E76 BRCA genetic testing Breast reconstruction (non-mastectomy) Cataract surgery Reconstruction of the breast except when following mastectomy Prior authorization is required if performed in an outpatient hospital setting for members 18 years and older. Prior authorization is not required if performed at a participating ambulatory surgery center L Cochlear and other auditory implants Colonoscopy Excludes procedures performed in Monroe County. A medical device within the inner ear and with an external portion to help persons with profound sensorineural deafness achieve conversational speech Prior authorization is required if performed in an outpatient hospital setting for members 18 years and older. Prior authorization is not required if performed at a participating ambulatory surgery center. Excludes procedures performed in Monroe County L8614 L8615 L8616 L8617 L8618 L8619 L8627 L8628 L869 L8691 L AHCA-3/16-1/18-519
2 Cosmetic and reconstructive Durable medical equipment (DME) more than $5 Advance notification required for inpatient and outpatient cosmetic and reconstructive services Cosmetic procedures that change or improve physical appearance without significantly improving or restoring physiological function Reconstructive procedures that treat a medical condition or improve or restore physiologic function DME codes listed with a retail purchase or rental cost of more than $5 outpatient only Prosthetics are not DME (see Prosthetics and Orthotics) Some home health care services may qualify but are not subject to the cost threshold (see Home Health Care Services) Q226 A9275 A9279 A928 A99 E265 E27 E3 E34 E445 E457 E46 E465 E466 E47 E471 E472 E483 E485 E486 E62 E65 E651 E652 E666 E667 E668 E675 E691 E692 E693 E694 E745 E762 E764 E782 E783 E784 E786 E947 E948 E984 E986 E12 E13 E14 E15 E16 E17 E18 E11 E13 E135 E136 E185 E186 E189 E19 E113 E114 E1161 E122 E1226 E1231 E1232 E1233 E1234 E1235 E1236 E1237 E1238 E125 E126 E1285 E129 E13 E131 E1399 E1825 E183 E184 E224 E2227 E2228 E231 E2311 E2312 E2321 E2322 E2325 E2327 E2328 E2329 E233 E2343 E2351 E237 E2373 E2375 E2376 E251 E2511 E2512 E2599 E2614 E2616 E262 E2621 E2626 E2627 E2628 E2629 E263 K5 K7 K8 K11
3 Durable medical equipment (DME) more than $5 (cont d.) Enteral services DME codes listed with a retail purchase or rental cost of more than $5 outpatient only Prosthetics are not DME (see Prosthetics and Orthotics) Some home health care services may qualify but are not subject to the cost threshold (see Home Health Care Services). In home nutritional therapy either enteral or through a gastrostomy tube K13 K14 K18 K73 K8 K81 K82 K86 K87 K88 K821 K822 K823 K824 K825 K826 K827 K828 K829 K836 K837 K838 K839 K84 K841 K842 K843 K848 K849 K85 K851 K852 K853 K854 K855 K856 K857 K858 K859 K86 K861 K862 K863 K864 K899 Q479 Q48 Q481 Q482 Q483 Q484 Q488 Q489 Q49 Q491 Q495 Q496 Q52 Q53 Q54 Q56 T1999 T5999 V2786 V5268 V5269 V527 V5271 V5272 V5281 V5282 V5283 V5284 V5285 V5286 V5287 V5288 V5289 V529 B434 B435 B436 B41 B413 B414 B4149 B415 B4152 B4153 B4154 B4155 B4157 B416 B4161 B4162 B9998 Experimental and investigational Functional enterprise sinus surgery (FESS) T 191T 269T 27T 271T 282T 283T 285T A4638 A6 A9274 A9276 A9277 A9278 E231 E1831 S81 S13 S131 S14 S3652 S8262 S9988 S999 S Home health services G151 G152 G153 G157 G158 G159 G16 G299 G3 S9122 S9123 S9124 S9128 S9129 T121 T13 T131
4 Hospice Injectable medications Authorization required inpatient place of service only Prior notification is obtained through OptumRx prior notifications services at for Makena, Synagis, and Xolair T242 T243 T244 T245 Acthar J8 Botox J585 J586 J587 J588 Cerezyme J1786 Elelyso J36 IVIG J1459 J1556 J1557 J1559 J1561 J1566 J1568 J1569 J1572 J1575 J1599 Makena* J1725 Synagis* J2675 Joint replacement Non-emergent air ambulance transport Orthognathic surgery Outpatient and inpatient joint and total hip and knee replacement procedures Non-emergent Air Ambulance Transport requires prior authorization. Nonemergent Ground Ambulance Transport does NOT require prior authorization Treatment of maxillofacial (jaw) functional impairment 9378 Xolair* J J733 S2112 A43 A431 A435 A436 S996 S
5 Orthotics/prosthetics more than $5 Orthotics and prosthetics codes listed with a retail purchase or a rental cost of more than $5 outpatient only L17 L456 L458 L46 L462 L464 L47 L48 L482 L484 L486 L488 L491 L624 L629 L631 L7 L71 L81 L82 L83 L859 L1 L15 L12 L13 L131 L1499 L168 L1685 L1686 L169 L17 L171 L172 L173 L1755 L181 L1812 L182 L1832 L1834 L184 L1843 L1844 L1845 L1846 L1847 L185 L186 L1932 L1945 L195 L1951 L197 L2 L25 L21 L22 L23 L234 L236 L237 L238 L26 L216 L218 L2114 L2116 L2126 L2128 L2132 L2134 L2136 L235 L251 L2525 L2526 L2627 L2628 L2999 L3 L31 L32 L331 L321 L322 L323 L324 L326 L327 L3215 L3216 L3217 L3219 L3221 L3222 L323 L3251 L3253 L3649 L3671 L372 L373 L374 L3763 L3764 L3765 L3766 L39 L391 L394 L395 L396 L3961 L3962 L3967 L3971 L3973 L3975 L3976 L3977 L3978 L3999 L4 L41 L42 L421 L435 L436 L4392 L4394 L4396 L5 L51 L52 L55 L56 L51 L515 L515 L516 L52 L521 L522 L523 L525 L528 L531 L5321 L5331 L5341 L54 L542 L546 L553 L5535 L554 L556 L558 L5585 L559 L5595 L56 L561 L5611 L5613 L5614 L5616 L5639 L564 L5642 L5643 L5644 L5645 L5646 L5647 L5648 L5649 L5651 L5653 L5661 L5673 L5679
6 Orthotics/prosthetics more than $5 (cont d.) Orthotics and prosthetics codes listed with a retail purchase or a rental cost of more than $5 outpatient only L5681 L5682 L57 L571 L572 L575 L576 L577 L5716 L5718 L5722 L5724 L5726 L5728 L578 L5781 L5782 L579 L5795 L5811 L5812 L5814 L5816 L5818 L5822 L5824 L5826 L5828 L583 L584 L5845 L5848 L5856 L5857 L5858 L593 L595 L596 L5961 L5962 L5964 L5966 L5968 L5973 L5976 L5979 L598 L5981 L5982 L5984 L5986 L5987 L5988 L599 L5999 L6 L61 L62 L65 L655 L61 L611 L612 L613 L62 L625 L625 L63 L631 L632 L635 L636 L637 L638 L6382 L6384 L64 L645 L65 L655 L657 L658 L6582 L6584 L6586 L6588 L659 L6621 L6623 L6624 L6648 L6686 L6687 L6689 L669 L6692 L6693 L674 L677 L678 L679 L6715 L688 L6881 L6882 L69 L695 L691 L6915 L692 L6925 L693 L6935 L694 L6945 L695 L6955 L696 L6965 L697 L6975 L77 L78 L79 L74 L745 L717 L718 L7181 L7185 L7186 L719 L7191 L745 L7499 L835 L84 L841 L842 L843 L844 L845 L846 L847 L8499 L85 L869 L861 L8612 L8631 L8659 V2623 Proton beam therapy V2627
7 Rehabilitative services (physical, speech and occupational therapy) Septoplasty/rhinoplasty 15 minutes equals 1 unit. For unites (1 hour) equal 1 visit. Therapy will be reviewed & approved per Medical Necessity and using clinical guidelines for all determinations. For Florida Healthy Kids: 15 minutes equals 1 unit. Four units (1 hour) equal 1 visit. Total 24 visits (96 units)/6 months Treatment of nasal functional impairment and septal deviation G129 S899 S Sinuplasty Sleep apnea procedures and surgeries Spinal stimulator for pain management Maxillomandibular advancement and oral-pharyngeal tissue reduction for treating obstructive sleep apnea Spinal cord stimulators when implanted for pain management Spinal surgery Inpatient and outpatient spinal surgeries T 98T 164T
8 Tonsillectomy/adenoidectomy Upper gastrointestinal endoscopy Vagus nerve stimulation Vein procedures Prior authorization is required if performed in an outpatient hospital setting for members 5 years and older. Prior authorization is not required if performed at a participating ambulatory surgery center. Excludes procedures performed in Monroe County. Prior authorization is required if performed in an outpatient hospital setting for members 18 years and older. Prior authorization is not required if performed at a participating ambulatory surgery center. Excludes procedures performed in Monroe County. Implantation of a device that sends electrical impulses into one of the cranial nerves Removal and ablation of the main trunks and named branches of the saphenous veins for treating venous disease and varicose veins of the extremities L868 L8682 L8685 L8686 L8687 L Additional Advance Notification and Prior Authorization Programs or How to Obtain Prior Authorization Behavioral health services Chemotherapy Behavioral health services through a designated behavioral health network Many of our benefit plans provide coverage for behavioral health services through a designated behavioral health network. Please call the number on the member s identification (ID) card when referring for mental health and substance abuse/substance use services. Prior authorization is required for injectable chemotherapy drugs administered in an outpatient setting (including intravenous, intravesical and intrathecal) for a cancer diagnosis. Injectable Chemotherapy Drugs That Require a Prior Authorization Chemotherapy injectable drugs (J9 - J9999), Leucovorin (J64), Levoleukovorin (J641) Chemotherapy injectable drugs that have a Q code
9 Additional Advance Notification and Prior Authorization Programs or How to Obtain Prior Authorization Chemotherapy (cont d.) Chemotherapy injectable drugs that have not yet received an assigned code and will be billed under a miscellaneous Healthcare Common Procedure Coding System (HCPCS) code will require prior authorization To submit, please use the Cancer- Oncology Authorization Submission & Status to begin the process at Inpatient services Notification only: Routine Obstetrics (OB)/Deliveries Elective Inpatient Admissions Acute Inpatient Rehabilitation Skilled Nursing Facility (SNF), transitional and sub-acute care OB and newborn confinements exceeding two day length of stay (LOS) for Vaginal and four day LOS for Cesarean. All Neonatal Intensive Care (NICU) admissions (including newborns, regardless of LOS) Out-of-network services Referral to a health care provider who is not contracted with UnitedHealthcare All out-of-network services require prior authorization. Radiology prior authorization Transplants Prior authorization required for participating physicians for certain CT, MRI, MRA, PET scan and nuclear medicine and cardiology procedures. Advanced imaging procedures that require prior authorization are called advanced outpatient imaging procedures. Physicians ordering advanced outpatient imaging procedures are responsible for requesting prior authorization before scheduling the procedure by calling For more information about this prior authorization requirement, including a list of the CPT codes that require prior authorization, go to UHCCommunityPlan.com > Radiology > CPT Code List. For transplant services, call OptumHealth at or the notification number on the back of the member s ID card.
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