Prior Authorization Requirements for Florida Effective March 1, 2015

for Florida Effective March 1, 215 General Information The following list represents our prior authorization requirements for UnitedHealthcare in Florida. 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: 866-64-3267 Fax: 866-67-5975 Online: UHCCommunityplan.com Bariatric Surgery Inpatient and outpatient bariatric surgery and specific obesity-related services Bone Growth Stimulator Electronic stimulation or ultrasound to heal fractures 43644 43645 43647 43648 43659 4377 43771 43772 43773 43774 43775 43842 43843 43845 43846 43847 43848 4386 43865 43881 43882 43886 43887 43888 6459 9598 95981 95982 2975 E747 E748 BRCA Genetic Testing 81211 81212 81214 81215 81216 81217 Breast Reconstruction (Non Mastectomy) Reconstruction of the breast except when following mastectomy Cochlear and Other Auditory Implants A medical device within the inner ear and with an external portion to help persons with profound sensorineural deafness achieve conversational speech. Cosmetic and Reconstructive 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 Advance notification required for inpatient and outpatient cosmetic and reconstructive services 19316 19318 19324 19325 19328 1933 1934 19342 1935 19357 19361 19364 19366 19367 19368 19369 1937 19371 1938 19396 69717 69718 6993 9261 9262 9263 9264 L8615 L8616 L8617 L8618 L8619 L8621 L8622 L8623 L8624 L8627 L8628 L8691 L8692 L8693 1192 11922 1196 11971 1582 15821 15822 15823 1583 15847 1716 1717 1718 17999 21137 21138 21139 21172 21175 21179 2118 21181 21182 21183 21184 2123 21235 21256 2126 21261 21263 21267 21268 21275 2128 21282 21295 2174 28344 354 3545 356 362 45 679 6791 6792 6793 6794 6796 6798 6799 67911 67912 67914 67915 67916 67917 67921 67922 PCA_214mmdd

for Florida Effective March 1, 215 Cosmetic and Reconstructive (Continued) Durable Medical Equipment (DME) More Than $5 DME with a retail purchase or rental cost of more than $5 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). 67923 67924 6795 67961 67966 6932 Q226 A9999 E193 E194 E265 E266 E274 E277 E296 E297 E32 E34 E328 E329 E445 E45 E457 E46 E461 E463 E464 E47 E471 E483 E61 E636 E637 E638 E641 E642 E65 E651 E652 E656 E666 E667 E668 E669 E67 E671 E672 E673 E7 E71 E784 E947 E948 E984 E986 E12 E13 E14 E15 E16 E17 E18 E19 E11 E111 E118 E13 E1161 E1226 E1229 E123 E1231 E1232 E1233 E1234 E1235 E1236 E1237 E1238 E1239 E21 E224 E223 E23 E231 E231 E2311 E2312 E2321 E2325 E2327 E2328 E2329 E233 E2331 E2343 E2351 E237 E2373 E2375 E2376 E242 E251 E2511 E2512 E2599 E2614 E2616 E262 E2621 E2626 E8 E81 E82 K5 K7 K18 K66 K69 K8 K81 K82 K86 K87 K88 K812 K821 K822 K823 K824 K825 K826 K827 K828 K829 K83 K831 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 K868 K869 K87 K871 K877 K878 K879 K88 K884 K885 K886 K89 K891 K898 V5274

for Florida Effective March 1, 215 Enteral Services In home nutritional therapy either enteral or through a gastrostomy tube B434 B435 B436 B412 B4149 B415 B4152 B4153 B4154 B4155 B4157 B4158 B4159 B416 B4161 B4162 B9 B92 B9998 Experimental and Investigational 36514 5424 55866 61863 61864 61867 61868 61886 62264 6229 62291 62292 64555 64566 64722 6618 9525 95251 95965 95966 95967 95978 962 191T S14 S212 Home Health Services 9953 G151 G152 G153 G154 G155 G156 G157 G158 G159 G16 G161 G162 G163 G164 S9122 S9123 S9124 S9127 S9128 S9129 S9131 S9474 T1 T12 T13 Injectable Medications Acthar J8 Botox J585 J586 J587 J588 IVIG 9283 9284 J1459 J1556 J1557 J1559 J1561 J1566 J1568 J1569 J1572 J1599 Makena J1725 Synagis* 9378 Joint Replacement Outpatient and inpatient joint and total hip and knee replacement procedures Non-Emergent Ambulance Transport Non-emergent Air Ambulance Transport requires prior authorization. Xolair* J2357 *Prior notification is obtained through OptumRx prior notifications services at 8-31-6826 for Synagis and Xolair 2347 23472 23473 23474 2436 24361 24362 24363 2437 24371 2712 27122 27125 2713 27132 27134 27137 27138 27412 27446 27447 27486 27487 29866 29867 29868 A43 A431 A435 A436

for Florida Effective March 1, 215 Non-Emergent Ambulance Transport (Continued) Non-emergent Ground Ambulance Transport does NOT require prior authorization Orthognathic Surgery Treatment of maxillofacial (jaw) functional impairment Orthotics/Prosthetics Greater Than $5 Orthotics and prosthetics with a retail purchase or a rental cost of more than $5 21121 21122 21123 21125 21127 21141 21142 21143 21145 21146 21147 2115 21151 21154 21155 21159 2116 21188 21193 21194 21195 21196 21198 21199 2126 2128 2129 2121 21215 2124 21242 21244 21245 21246 21247 21248 21249 21255 21296 21299 3465 L112 L17 L456 L458 L46 L462 L464 L47 L48 L482 L484 L486 L488 L491 L624 L629 L631 L632 L634 L635 L636 L637 L638 L639 L64 L7 L71 L1 L15 L12 L13 L1499 L168 L169 L17 L171 L172 L173 L1755 L1832 L1834 L184 L1843 L1844 L1845 L1846 L186 L1945 L195 L197 L2 L21 L22 L23 L234 L236 L237 L238 L26 L216 L218 L2114 L2116 L2128 L2136 L235 L251 L2627 L2628 L2999 L3 L31 L32 L316 L321 L322 L323 L324 L326 L327 L3212 L3213 L3214 L3215 L3216 L3217 L3219 L3221 L3222 L323 L325 L3251 L3252 L3253 L3265 L3649 L3674 L372 L373 L374 L39 L394 L396 L3962 L3999 L4 L41 L42 L4631 L5 L51 L52 L55 L56 L51 L515 L515 L516 L52 L521 L522 L523 L525 L527 L528 L531 L5312 L5321 L5331

for Florida Effective March 1, 215 Orthotics/Prosthetics Greater Than $5 (Continued) Rehabilitative Services (Physical, Speech and Occupational Therapy) Septoplasty/Rhinoplasty Treatment of nasal functional impairment and septal deviation For Medicaid: 15 minutes equals 1 unit. Four units (1 hour) equals 1 visit. Total 36 visits (144 units)/6 months For Florida Healthy Kids: 15 minutes equals 1 unit. Four units (1 hour) equal 1 visit. Total 24 visits (96 units)/6 months L5341 L55 L555 L551 L552 L553 L5535 L554 L556 L557 L558 L559 L5595 L56 L561 L5611 L5613 L5616 L5639 L564 L5642 L5644 L5646 L5648 L5653 L5673 L5679 L5681 L5682 L5683 L57 L571 L572 L573 L575 L576 L577 L5716 L5718 L5722 L5724 L5726 L5728 L578 L5812 L5816 L5818 L5822 L5824 L5828 L583 L584 L5845 L5962 L5964 L5966 L5976 L5979 L598 L5981 L5982 L5984 L599 L5999 L6 L61 L62 L65 L61 L611 L612 L613 L62 L625 L63 L635 L64 L645 L65 L655 L657 L6646 L6692 L6693 L6694 L6695 L6696 L6697 L677 L678 L679 L6711 L6712 L6713 L6714 L6881 L6883 L6884 L6885 L6895 L6935 L7186 L7499 L8499 L865 V2623 V2627 9256 9257 9258 92526 971 972 973 974 971 9712 9714 9716 9718 9722 9726 9728 9733 9734 9739 9711 97112 97113 97116 97124 9714 97799 G129 G151 G152 G153 G157 G158 G159 G16 S899 S9128 S9129 S9152 34 341 342 343 3435 345 346 3462 Sleep Apnea Procedures and Surgeries Maxillomandibular advancement and oral-pharyngeal tissue reduction for treating obstructive sleep apnea 21685 4153 42145 41599 Sleep Studies 9585 9587 9588 9581 95811

for Florida Effective March 1, 215 Spinal Stimulator for Pain Management Spinal cord stimulators when implanted for pain management Spinal Surgery Inpatient and outpatient spinal surgeries Vagus Nerve Stimulation Implantation of a device that sends electrical impulses into one of the cranial nerves Vein Procedures Removal and ablation of the main trunks and named branches of the saphenous veins for treating venous disease and varicose veins of the extremities Wound Vac 6365 63655 63685 221 2211 2212 2211 22112 22114 2226 2227 2221 22212 22214 2222 22224 22532 22533 22548 22551 22554 22556 22558 22586 2259 22595 226 2261 22612 2263 22633 228 2282 2284 2288 2281 22812 22818 22819 2283 22849 2285 22852 22855 22856 22861 22864 22865 631 633 635 6311 6312 6315 6316 6317 632 633 634 6342 6345 6346 6347 635 6355 6356 6364 6375 6377 6381 6385 6387 639 6311 6312 6317 63172 63173 6318 63182 63185 6319 63191 63194 63195 63196 63198 63199 632 6325 63251 63252 63265 63267 63268 6327 63271 63272 63286 633 6331 6332 6333 6334 6335 6336 6337 6338 6457 61885 64568 36468 36475 36478 377 37718 37722 3778 E242

for Florida Effective March 1, 215 Additional Advance Notification and Prior Authorization Programs Codes for UnitedHealthcare Benefit Plans Behavioral Health Services Behavioral health services through a designated behavioral health network Cardiology Prior Authorization Program 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 Radiology Prior Authorization Referral to a health care provider who is not contracted with UnitedHealthcare 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 required for participating physicians for inpatient, outpatient and office-based and electrophysiology implants prior to performance. Prior authorization required for participating physicians for outpatient and office-based diagnostic catheterizations, echocardiograms and stress echoes prior to performance. Request prior authorization by calling 866-889-854. For more information, including a list of the CPT codes that require prior authorization, please visit UHCCommunityPlan.com > Cardiology > Cardiology Prior Authorization CPT Code Crosswalk. All out of network services require prior authorization. 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.

for Florida Effective March 1, 215 Additional Advance Notification and Prior Authorization Programs Codes for UnitedHealthcare Benefit Plans Radiology Prior Authorization (Continued) Transplants Ventricular Assist Devices A mechanical pump that takes over the function of the damaged ventricle of the heart and restores normal blood flow. Physicians ordering advanced outpatient imaging procedures are responsible for requesting prior authorization before scheduling the procedure by calling 866-889-854. For more information about this prior authorization requirement, including a list of the CPT codes that require prior authorization, go to UHCCommunityPlan.com > Radiology > 214 CPT Code List. For transplant services, call OptumHealth at 8-418-4994 or the notification number on the back of the member s ID card. Fax OptumHealth at 877-814-488 or call the notification number on the back of the member s ID card.