Prior Authorization Requirements for AZ Children s Rehabilitative Services (CRS) Effective July 1, 2017

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1 General This list contains prior authorization requirements for UnitedHealthcare Community Plan of Arizona Children s Rehabilitative Services (CRS) participating care providers for inpatient and outpatient services. To request prior authorization, please submit your request online, or by phone or fax: Online: UnitedHealthcareOnline.com > Notifications/Prior s > Notification/Prior Submission Phone: Fax: ; fax form is available at UHCCommunityPlan.com > For Health Care Professionals > Arizona > Provider Forms. Important Specialty care services are those provided for a specific CRS condition listed on the Master Diagnosis List at UHCCommunityPlan.com > For Health Care Professionals > Arizona > Provider Forms > CRS Master Diagnosis List. Specialty care services rendered outside the Multi-Specialty Interdisciplinary Clinic (MSIC) for conditions listed on the Master Diagnosis List require prior authorization, with the exception of certain radiology services. If the specific CPT code is listed on the radiology list of codes, then it requires prior authorization. Please visit UHCCommunityPlan.com > For Health Care Professionals > Arizona > Radiology > CPT Code List. Primary care services for and Acute members don t require prior authorization when provided by a CRS contracted care provider. Primary care services for Behavioral and CRS Only that aren t related to a CRS condition should be redirected to the member s Acute Medicaid health plan. Services provided by non-network health and out-of-state care providers require prior authorization and documentation supporting the out-of-network request. All rendering providers, facilities and vendors must be actively registered with Arizona Health Cost Containment Care System (AHCCCS). Members must be eligible at the time a covered service is rendered. isn t a guarantee of payment billing guidelines must be met. Only medically necessary, cost effective, and federally- and state-reimbursable services are covered services, as outlined by AHCCCS. Important Reminders Out-of-network physicians, facilities and other health care providers must request prior authorization for all services. All services must be covered benefits as outlined and defined by AHCCCS for one of the four CRS plan types in the following list. Children s Rehabilitative Services (CRS) Plan Type Definitions Acute (BH) Members receive all CRS and acute health plan benefits, and behavioral health services provided by UnitedHealthcare Community Plan. American Indian (AI) members receive all CRS and acute health plan benefits from UnitedHealthcare Community Plan, but get behavioral health services from a Tribal Regional Authority (T/RBHA). Comprehensive Medical and Dental Program (CMDP) and Developmentally Disability (DD) members receive CRS benefits and behavioral health services from UnitedHealthcare Community Plan. Acute health services are covered by the primary program of enrollment. For DD members, the primary program may be UnitedHealthcare Community Plan or another contractor. Coverage: CRS and behavioral health conditions only; please contact the member s primary Acute Medicaid health plan for other medical services.

2 CRS Only Members receive all CRS benefits from UnitedHealthcare Community Plan, acute health services from the primary program of enrollment, and behavioral health services from: A T/RBHA for CMDP and DD members A T/RBHA for AIHP members. CRS Only also includes ALTCS/EPD and American Indian Fee for Service members Coverage: CRS conditions only; please contact the member s primary Acute Medicaid health plan for other medical services. Procedures and Services Behavioral health services Behavioral health services through a contracted behavioral health network & How to for the following services: Acute inpatient admission Residential treatment center Level 1 Residential behavioral health facility Level II group home Out-of-state services Neuropsychological testing Services provided by a non-contracted provider Home Care Training Client S5109 For prior authorization, please call or fax Fax forms are available at UHCCommunityPlan.com > For Health Care Professionals > Arizona > Provider Forms > CRSPrior Services Request Form. Acute & CRS Only For prior authorization, please call the appropriate Regional Authority (RBHA) or Tribal Regional Authority (T/RBHA) Member Services number. RBHA: Cenpatico Care (CIC) Cochise, Gila, Graham, Greenlee La Paz, Pima, Pinal, Santa Cruz, Yuma Counties: Mercy Maricopa Care (MMIC) - Maricopa County: Health Choice Care (HCIC) Apache, Coconino, Mohave, Navajo - Yavapai Counties: UnitedHealthcare Community Plan CRS - All Counties: UnitedHealthcare Community Plan Medicaid/Medicare enrolled members - All Counties: T/RBHA: Apache White Mountain: Colorado River: Gila River: , ext Navajo Nation: Pascua Yaqui:

3 & CRS Acute Prior (CPT) Codes and/or Prior for All Plan Types Abdominal paracentesis Allergy immunotherapy for the code not if performed at a participating ambulatory surgery center For members younger than age for CRS 21: Allergy immunotherapy and allergy testing is covered under Early and Periodic Screening, Diagnostic and Treatment (EPSDT) when medically necessary. For members age 21 and older: Allergy immunotherapy, including desensitization treatments administered by subcutaneous injections (allergy shots), sublingual immunotherapy (SLIT) or another route of administration, is not a covered benefit. Allergy testing, including testing for common allergens, is a covered benefit when the member has:

4 & CRS Acute Prior (CPT) Codes and/or Prior for All Plan Types Allergy immunotherapy (cont d) Sustained an anaphylactic reaction to an unknown allergen Exhibited such a severe allergic reaction where it s reasonable to assume further exposure to the unknown allergen may result in a life-threatening situation. Examples include severe facial swelling, breathing difficulties, epiglottal swelling, extensive urticaria, etc. Prior authorization is for these situations. Bariatric surgery Bariatric surgery and specific obesity-related services Bone growth stimulator Electronic stimulation or ultrasound to heal fractures BRCA genetic testing for CRS for CRS for CRS E0747 E0748 E0749 E Please contact the member s primary Acute Medicaid health plan for any other requests.

5 & CRS Acute Prior (CPT) Codes and/or Prior for All Plan Types Breast reconstruction (non-mastectomy) Reconstruction of the breast except for post mastectomy Cardiology Carpal tunnel surgery for CRS for participating physicians for inpatient, outpatient and officebased electrophysiology implants prior to performance for participating physicians for outpatient and office-based diagnostic catheterizations, echocardiograms and stress echos prior to performance for the code not if performed at a participating ambulatory surgery center L8600 For prior authorization, please submit requests online at UnitedHealthcareOnline.com > Notifications/Prior s > Cardiology Notification & Submission & Status, or call For more details and the CPT codes that require prior authorization, please visit UHCCommunityPlan.com > For Health Care Professionals > Arizona > Cardiology > Cardiology Prior CPT Code Crosswalk Cataract surgery for the code Chiropractic care not if performed at a participating ambulatory surgery center For members Please contact the younger than age member s assigned 21: MSIC when related to a CRS condition only. not For members age 21 and older: Chiropractic care is not a covered benefit.

6 & CRS Acute Prior (CPT) Codes and/or Prior for All Plan Types Circumcision Routine circumcision is not a covered benefit. only for cases with documented medical necessity. for CRS If not related to a CRS condition, please contact the member s primary Acute Medicaid health plan Cochlear and other auditory implants A medical device within the inner ear with an external portion to help persons with profound sensorineural deafness achieve conversational speech for CRS L8614 L8619 L8690 L8691 L8692 Colonoscopy for the codes not if performed at a participating ambulatory surgery center Cosmetic and reconstructive procedures 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 For codes with an asterisk: if performed in an outpatient hospital not if performed at a participating ambulatory surgery center for CRS For codes with an asterisk: if performed in an outpatient hospital not if performed at a participating ambulatory surgery center * 13132* 14040* 14060* 14301* * *

7 & CRS Acute Prior (CPT) Codes and/or Prior for All Plan Types Dental services Dental CRS benefit conditions: Cleft lip or palate Cerebral spinal fluid diversion shunt where the member is at risk for sub-acute bacterial endocarditis Cardiac condition where the member is at risk for sub-acute bacterial endocarditis Dental complications arising as a result of treatment for a CRS condition Documented significant functional malocclusion For prior authorization requirements for routine dental services and CRS conditions with dental only, please call UnitedHealthcare Dental at For prior authorization requirements for CRS conditions with dental only, please call UnitedHealthcare Dental at Diabetic supplies Diabetic supplies are provided by the local pharmacy. for talking glucometers available through the medical prior authorization process for talking glucometers for CRS conditions only available through the medical prior authorization process To locate contracted care providers or vendors, please visit UHCCommunityPlan.com > For Health Care Professionals > Arizona > Claims and Member. Durable medical equipment (DME): more than $500 DME codes listed with a retail purchase or a cumulative rental cost of more than $500 Prosthetics are not DME see Orthotics and prosthetics. To request DME items, please call Preferred Homecare at Please see exceptions below. Please call Numotion for the following items: Acute specialty power wheelchairs Gait trainers Specialty car seats Activity chairs Feeder seats Standers To request DME items, please call Preferred Homecare at Please see exceptions below. Please call Numotion for the following items: Acute specialty power wheelchairs Gait trainers Specialty car seats Activity chairs Feeder seats Standers Numotion Phoenix A9900 A9999 E0193 E0194 E0265 E0266 E0270 E0277 E0300 E0302 E0304 E0328 E0329 E0445 E0457 E0460 E0465 E0466 E0470 E0471 E0472 E0483 E0485 E0486 E0601 E0620 E0636 E0637 E0638 E0641 E0642 E0650 E0651 E0652 E0656 E0667 E0668 E0669 E0670 E0673 E0675 E0691 E0692 E0693 E0694 E0700 E0710 E0745 E0766 E0782 E0783 E0784 E0947 E0948 E0984 E0986

8 & CRS Acute Prior (CPT) Codes and/or Prior for All Plan Types Durable medical equipment (DME): more than $500 (cont d) DME codes listed with a retail purchase or a cumulative rental cost of more than $500 Numotion Phoenix Office Phone: Fax: Numotion Tucson Office Phone: Fax: The CRS Prior Services Request fax form is available at UHCCommunityPlan.com > For Health Care Professionals > Arizona > Provider Forms. Please call to use a UnitedHealthcare participating care provider for the following services: Bone stimulators Diabetic supplies Enclosed beds Specialty beds Wound vacs Office Phone: Fax: Numotion Tucson Office Phone: Fax: The CRS Prior Services Request fax form is available at UHCCommunityPlan. com > For Health Care Professionals > Arizona > Provider Forms. Please call to use a UnitedHealthcare participating care provider for the following services: Bone stimulators Diabetic supplies Enclosed beds Specialty beds Wound vacs If not related to a CRS condition, please contact the member s primary Acute Medicaid health plan. E1002 E1003 E1004 E1005 E1006 E1007 E1008 E1009 E1010 E1011 E1018 E1030 E1035 E1036 E1085 E1086 E1089 E1090 E1130 E1140 E1161 E1220 E1229 E1230 E1231 E1232 E1233 E1234 E1235 E1236 E1237 E1238 E1239 E1250 E1260 E1285 E1290 E1300 E1310 E1825 E1830 E1840 E2100 E2204 E2227 E2228 E2230 E2300 E2301 E2310 E2311 E2312 E2321 E2322 E2325 E2327 E2328 E2329 E2330 E2331 E2343 E2351 E2370 E2373 E2375 E2376 E2510 E2511 E2512 E2599 E2616 E2626 E2627 E2628 E2629 E2630 E8000 E8001 E8002 K0005 K0007 K0008 K0011 K0013 K0014 K0108 K0606 K0730 K0800 K0801 K0802 K0806 K0807 K0808 K0812 K0821 K0822 K0823 K0824 K0825 K0826 K0827 K0828 K0829 K0830 K0831 K0836 K0837 K0838 K0839 K0840 K0841 K0842 K0843 K0848 K0849 K0850 K0851 K0852 K0853 K0854 K0855 K0856 K0857 K0858 K0859 K0860 K0861 K0862 K0863 K0864 K0868 K0869 K0870 K0871 K0877 K0878 K0879 K0880 K0884 K0885 K0886 K0890 K0891 K0898 K0899

9 & CRS Acute Prior (CPT) Codes and/or Prior for All Plan Types Ear, nose and throat (ENT) procedures for the codes not if performed at a participating ambulatory surgery center Enteral services/ parenteral/oral In-home nutritional therapy either enteral or through a gastrostomy tube, total parenteral nutrition (TPN), and/or lipids and oral supplements To request services and/or supplies, please call Preferred Homecare at To request services and /or supplies for CRS, please call Preferred Homecare at Clinical documentation and oral supplement Certificate of Medical Necessity as applicable must accompany and establish medical necessity for this service request. For members younger than age 21: For more information, please review the AHCCCS Medical Policy Manual (AMPM) Chapter 400 Policy at AZAHCCCS.gov > Resources > Guides- Manuals-Policies > AHCCCS Medical Policy Manual > Chapter 400: Medical Policy for Maternal and Child Health > Policy The Certificate of Medical Necessity for Commercial Oral Nutritional Supplements can be found at AZAHCCCS.gov > Resources > Guides-Manuals-Policies > AHCCCS Medical Policy Manual > Chapter 400: Medical Policy for Maternal and Child Health > Exhibit For members age 21 and older: Please review AMPM Chapter 300, Policy 310-GG at AZAHCCCS.gov > Resources> Guides-Manuals-Policies > AHCCCS Medical Policy Manual > Chapter 300: Medical Policy for Covered Services > Policy The Certificate of Medical Necessity for Commercial Oral Nutritional Supplements can be found at AZAHCCCS.gov > Resources > Guides-Manuals-Policies > AHCCCS Medical Policy Manual > Chapter 300: Medical Policy for Covered Services > Attachment C.

10 & CRS Acute Prior (CPT) Codes and/or Prior for All Plan Types Experimental or investigational services Eye care/optometry for the codes identified For more information, please refer to AMPM Chapter 300, Policy 320 B at AZAHCCCS.gov > Resources > Guides-Manuals-Policies > AHCCCS Medical Policy Manual > Chapter 300: Medical Policy for Covered Services > Policy 320-B. For member eye care services, please call Nationwide Vision at Please contact the member for their assigned MSIC for a CRS-related eye condition. Please contact the member for their assigned MSIC for a CRS-related eye condition. 0191T A4638 A9274 A9276 A9277 A9278 E1831 S1040 Benefits provided for members younger than age 21: One routine eye exam every 12 months Regular single vision bifocal or trifocal polycarbonate lenses Frame for up to $79.99 retail price One replacement pair of glasses if lost, stolen or damaged Members may pay the difference for a more expensive pair of glasses, but must sign a waiver provided by Nationwide Vision. For members age 21 and older: when medically necessary to diagnose or treat diseases and conditions of the eye Femoroacetabular impingement syndrome (FAI) for CRS Functional endoscopic sinus surgery (FESS) for CRS Genetic testing for all services not covered by LabCorp. for all services not covered by LabCorp To determine prior authorization requirements, please call LabCorp at To determine prior authorization requirements for CRS, please call LabCorp at

11 & CRS Acute Prior (CPT) Codes and/or Prior for All Plan Types Gynecologic procedures for the codes Hearing aids and services Hearing evaluations and hearing aids when completed outside the MSIC require prior authorization Hernia repair Home health care Hospice not if performed at a participating ambulatory surgery center for hearing evaluations and hearing aids when completed outside the MSIC Please contact the member s assigned MSIC for CRS. All other conditions: For members younger than age 21: not For members age 21 and older: this is not a covered benefit unless medically necessary. for the codes not if performed at a participating ambulatory surgery center for CRS for CRS S0618 V5010 V5011 V5014 V5030 V5040 V5050 V5060 V5095 V5100 V5120 V5170 V5180 V5190 V5220 V5230 V5242 V5243 V5244 V5245 V5246 V5247 V5248 V5249 V5250 V5251 V5252 V5253 V5254 V5255 V5256 V5257 V5258 V5259 V5260 V5261 V5262 V5263 V5267 V G0299 G0300 S9123 S9124 T2042 T2043 T2044 T2045 This is not a covered benefit if it isn t related to a CRS condition. Incontinence supplies To request services and/or supplies, please call Preferred Homecare at To request services and/or supplies for CRS, please call Preferred Homecare at T4521 T4522 T4523 T4524 T4525 T4526 T4527 T4528 T4529 T4530 T4531 T4532 T4533 T4534 T4543

12 & CRS Acute Prior (CPT) Codes and/or Prior for All Plan Types Infusion in-home services for all services not covered by Preferred Homecare. for all services not covered by Preferred Homecare. Injectable medications for in-home use To request services and/or supplies, please call Preferred Homecare at for all services not covered by Preferred Homecare. To request services and/or supplies for CRS, please call Preferred Homecare at for all services not covered by Preferred Homecare. To request medications, please call Preferred Homecare at To request medications for CRS, please call Preferred Homecare at Injectable medications for CRS Acthar J0800 Botox J0585 J0586 J0587 J0588 Cerezyme J1786 Cinqair J2786 Elelyso J3060 IVIG J1459 J1556 J1557 J1559 J1561 J1566 J1568 J1569

13 & CRS Acute Prior (CPT) Codes and/or Prior for All Plan Types Injectable medications (cont d) J1572 J1575 J1599 Makena * J1725 J2675 Nucala J2182 Probuphine J0570 Synagis ** Unclassified*** J3490 J3590 VPRIV J3385 Xolair ** J2357 *For Makena prior authorization, please fax Fax forms are available at UHCCommunityPlan.com > For Health Care Professionals > Arizona > Provider Forms > Forms > Makena Prior Form. **For Synagis and Xolair prior authorization, please call the Pharmacy Prior Service at ***For Unclassified codes J3490 and J3590, prior authorization is only for Exondys 51, Ocrevus and Spinraza. Inpatient admission Prior notification for CRS conditionrelated Please contact the member s primary Acute Medicaid health plan for medical admissions not directly related to a CRS condition.

14 & CRS Acute Prior (CPT) Codes and/or Prior for All Plan Types Joint replacement Joint, total hip and knee replacement procedures for CRS Laboratory services To determine prior authorization requirements, please call LabCorp at To determine prior authorization requirements for CRS, please call LabCorp at Liver biopsy for the code not if performed at a participating ambulatory surgery center Miscellaneous hardware removal for the code not if performed at a participating ambulatory surgery center Neuropsychological testing Please contact the member s assigned MSIC for CRS. Please contact the member s assigned MSIC for CRS. Neurobehavioral status exam Behavioral health assessments for all other conditions Non-emergent air ambulance transport for CRS service only A0430 A0431 A0435 A0436

15 & CRS Acute Prior (CPT) Codes and/or Prior for All Plan Types Ophthalmologic Orthognathic surgery Treatment of maxillofacial/jaw functional impairment for the code not if performed at a participating ambulatory surgery center for CRS Orthotics and prosthetics: more than $500 Orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500 For members younger than age 21: for the codes identified Please contact the member s assigned MSIC for CRS condition only. For members younger than age 21: for the codes identified Please contact the member s assigned MSIC for CRS condition only. L0112 L0170 L0456 L0462 L0464 L0480 L0482 L0484 L0486 L0624 L0629 L0631 L0632 L0634 L0636 L0637 L0638 L0640 L0700 L0710 L0810 L0820 L0830 L0859 L0861 L1000 L1005 L1200 L1300 L1310 L1499 L1680 L1685 L1700 L1710 L1720 For members younger than age 21 with orthotic limitation: Reasonable repairs or adjustments of purchased orthotics are covered for all members to make the orthotic serviceable and/or when the repair cost is less than purchasing For members age 21 and older: Medical documentation must accompany the request for orthotic services. L1730 L1755 L1810 L1812 L1820 L1830 L1831 L1832 L1834 L1836 L1840 L1844 L1845 L1846 L1847 L1850 L1860 L1945 L1950 L1970 L2000 L2005 L2010 L2020 L2030 L2034 L2036 L2037 L2038 L2060 L2106 L2108 L2126 L2128 L2136 L2350 L2510 L2525 L2526 L2627 L2628 L2999 L3000 L3160 L3201 L3202 L3203 L3204 L3206 L3207 L3212 L3213 L3214 L3215 L3216 L3217

16 & CRS Acute Prior (CPT) Codes and/or Prior for All Plan Types Orthotics and prosthetics: more than $500 (cont d) Orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500 another unit. The component will be replaced if, at the time authorization is requested, documentation is provided to establish that the component is not operating effectively. For members age 21 and older: L3219 L3221 L3222 L3230 L3250 L3251 L3252 L3253 L3265 L3649 L3671 L3674 L3720 L3730 L3740 L3763 L3764 L3765 L3766 L3900 L3901 L3904 L3905 L3961 L3967 L3971 L3973 L3975 L3976 L3977 L3978 L3999 L4000 L4010 L4020 L4350 L4360 L4361 L4386 L4387 L4392 L4394 L4396 L4631 L5010 L5020 L5050 L5060 AHCCCS orthotics coverage applies if: L5100 L5105 L5150 L5160 L5200 L5210 L5220 L5230 The use of the orthotic is medically necessary as the preferred treatment option consistent with Medicare guidelines. The orthotic is less expensive than all other treatment options or surgical procedures to treat the same diagnosed condition. The orthotic is ordered by a physician or primary care provider. L5250 L5270 L5280 L5301 L5312 L5321 L5331 L5341 L5400 L5420 L5460 L5500 L5505 L5510 L5520 L5530 L5535 L5540 L5560 L5570 L5580 L5585 L5590 L5595 L5600 L5610 L5611 L5613 L5614 L5616 L5639 L5640 L5642 L5643 L5644 L5645 L5646 L5647 L5648 L5649 L5651 L5653 L5661 L5673 L5681 L5682 L5683 L5700 L5701 L5702 L5703 L5705 L5706 L5707 L5716 L5718 L5722 L5724 L5726 L5728 L5780 L5781 L5782 L5790 L5795 L5811 L5812 L5814 L5816 L5818 L5822 L5824 L5826 L5828 L5830 L5840 For members age 21 and older with orthotic limitation: L5845 L5848 L5856 L5857 L5858 L5930 L5950 L5960 L5961 L5962 L5964 L5966 Reasonable repairs or adjustments of L5968 L5976 L5979 L5980 L5981 L5982 L5984 L5986 L5987 L5988 L5990 L5999

17 & CRS Acute Prior (CPT) Codes and/or Prior for All Plan Types Orthotics and prosthetics: more than $500 (cont d) Orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500 purchased orthotics are covered for all members to make the orthotic serviceable and/or when the repair cost is less than purchasing another unit. The component will be replaced if, at the time authorization is requested, documentation is provided to establish that the component is not operating effectively. L6000 L6010 L6020 L6026 L6050 L6055 L6100 L6110 L6120 L6130 L6200 L6205 L6250 L6300 L6310 L6320 L6350 L6360 L6370 L6380 L6382 L6384 L6400 L6450 L6500 L6550 L6570 L6580 L6582 L6584 L6586 L6588 L6590 L6621 L6623 L6624 L6646 L6648 L6686 L6687 L6689 L6690 L6692 L6693 L6694 L6695 L6696 L6697 L6704 L6707 L6708 L6709 L6711 L6712 L6713 L6714 L6715 L6881 L6882 L6883 L6884 L6885 L6895 L6900 L6905 L6910 L6915 L6920 L6925 L6930 L6935 L6940 L6945 L6950 L6955 L6960 L6965 L6970 L6975 L7007 L7008 L7009 L7040 L7045 L7170 L7180 L7181 L7185 L7186 L7190 L7191 L7405 L7499 L8035 L8040 L8041 L8042 L8043 L8044 L8045 L8046 L8047 L8499 L8500 L8609 L8610 L8612 L8631 Outpatient physical therapy Benefit limits for participating and nonparticipating care providers: For members younger than age 21: after the 12 th visit outside the MSIC For CRS members younger than age 21 or QMB members: after the 12 th visit outside the MSIC For CRS members age 21 and older (excluding QMB): not for CRS For CRS members younger than age 21 or QMB members: after the 12 th visit L8659 V2623 V G0129 S8990

18 & CRS Acute Prior (CPT) Codes and/or Prior for All Plan Types Outpatient physical therapy (cont d) Physical therapy is covered in an inpatient or outpatient. No benefit limits apply. For CRS members age 21 and older (excluding QMB): not For members age 21 and older: not Please contact the member s primary Acute Medicaid health plan if not related to a CRS condition. Physical therapy is covered in an inpatient or outpatient. Outpatient physical therapy is: Limited to 15 visits per contract year, Oct. 1 Sept. 30, to help an individual restore and maintain a particular skill or function that was lost due to injury or disease Limited to 15 visits per contract year, Oct. 1 Sept. 30, to help an individual attain and maintain a particular skill or function that was never learned or acquired Occupational and speech therapy For CRS members younger than age 21 or QMB members: after the 12 th visit for CRS S For CRS members age 21 and older: Occupational and speech therapy is not a covered benefit.

19 & CRS Acute Prior (CPT) Codes and/or Prior for All Plan Types Pharmacy drugs Pregnancy termination A list of medications requiring prior authorization is available at UHCCommunityPlan.com > For Healthcare Professionals > Arizona > Pharmacy Program. Service requests must include J Codes and NDC Codes for the medication requested. The following hemophilia factor/biotech drugs are included on the prior authorization list: Acthar gel Aldurazyme Ceprotin Cerezyme Cinryze Elaprase Elelyso Fabrazyme Juxtapid Kalydeco Kuvan Kynamro Lumizyme Myozyme Orfadin VPRIV for the codes identified includes Mifepristone, Mifeprex or RU-486 Clinical documentation and the Certificate of Medical Necessity for pregnancy termination must accompany the prior authorization request form. For more information, please review AMPM Chapter 400 Policy Please contact the member s primary Acute Medicaid health plan. For pharmacy prior authorization, please contact UnitedHealthcare Pharmacy Prior Service by: Phone: Fax: For specialty pharmacy prior authorization, please fax Fax forms are available at UHCCommunityPlan.com > For Healthcare Professionals > Arizona > Pharmacy Program

20 & CRS Acute Prior (CPT) Codes and/or Prior for All Plan Types Pregnancy termination (cont d) at AZAHCCCS.gov > Resources > Guides- Manuals-Policies > AHCCCS Medical Policy Manual > Chapter 400: Medical Policy for Maternal and Child Health > Policy The Certificate of Medical Necessity For Pregnancy Termination can be found at AZAHCCCS.gov > Resources > Guides- Manuals-Policies > AHCCCS Medical Policy Manual > Chapter 400: Medical Policy for Maternal and Child Health > Exhibit Private duty nursing for CRS T1002 T1003 Proton beam therapy Focused radiation therapy using beams of protons, which are tiny particles with a positive charge for CRS Radiology for participating physicians who request the following advanced outpatient imaging procedures: CT, MRI, MRA, PET scan, nuclear medicine and nuclear cardiology procedures Care providers ordering an advanced outpatient imaging procedure are responsible for providing notification prior to scheduling the procedure. For prior authorization, please submit requests online at UnitedHealthcareOnline.com > Notifications/Prior s > Radiology Notification & Submission & Status, or call For more details and the CPT codes that

21 & CRS Acute Prior (CPT) Codes and/or Prior for All Plan Types Radiology (cont d) require prior authorization, please visit UHCCommunityPlan.com > For Health Care Professionals > Arizona > Radiology > CPT Code List. Rhinoplasty and septoplasty Treatment of nasal functional impairment and septal deviation for CRS Sinuplasty Sleep apnea procedures and surgeries Maxillomandibular advancement and oralpharyngeal tissue reduction for treating obstructive sleep apnea Skilled nursing facility services Specialty/enclosed beds Spinal stimulator for pain management Spinal cord stimulators when implanted for pain management for CRS Please contact the member s primary Acute Medicaid health plan. for CRS for CRS E0250 E0251 E0255 E0256 E0260 E0261 E0280 E0290 E0291 E0292 E0293 E0294 E0295 E0301 E0303 E0315 E0316 E Spinal surgery for CRS 0095T 0098T 0164T

22 & CRS Acute Prior (CPT) Codes and/or Prior for All Plan Types Spinal surgery (cont d) Sterilization For all members younger than age 21: Any member requesting sterilization must sign an appropriate Consent for Sterilization form. For more information, please review AMPM Chapter 400 Policy at AZAHCCCS.gov > Resources > Guides-Manuals-Policies > AHCCCS Medical Policy Manual > Chapter 400: Medical Policy for Maternal and Child Health > Policy The Consent for Sterilization form can be found at AZAHCCCS.gov > Resources > Guides- Manuals-Policies > AHCCCS Medical Policy Manual > Chapter 400: Medical Policy for Maternal and Child Health > Exhibit

23 & CRS Acute Prior (CPT) Codes and/or Prior for All Plan Types Tonsillectomy and adenoidectomy Transplants Transportation non-emergent: taxi, stretcher, van Upper gastrointestinal endoscopy for the codes not if performed at a participating ambulatory surgery center For transplants, please call the UnitedHealthcare Community & State Transplant Case Management Team at or the notification number on the back of the member s health plan ID card. Clinical documentation to support the need for transplants must accompany and establish medical necessity for service request. for nonemergent taxi and stretcher van To schedule transportation, please call Medical Transportation Brokerage of Arizona (MTBA) at for CRS For all other conditions please contact the member s Acute Medicaid health plan. for nonemergent taxi and stretcher van for CRS To schedule transportation, please call MTBA at for the codes not if performed at a participating ambulatory surgery center S2060 S2061 S

24 & CRS Acute Prior (CPT) Codes and/or Prior for All Plan Types Urologic procedures Vagus nerve stimulation Implantation of a device that sends electrical impulses into one of the cranial nerves for the codes not if performed at a participating ambulatory surgery center for CRS L8680 L8682 L8685 L8686 L8687 L8688 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 for CRS Ventricular assist devices A mechanical pump that takes over the function of the damaged ventricle of the heart and restores normal blood flow. Please call the notification number on the back of the member s health plan ID card. Then, fax the form provided by the nurse to the Optum VAD Case Management Team at for CRS 0051T 0052T 0053T Q0507 Q0508 Q0509 Wound vac E2402