UnitedHealthcare Notification/Prior Authorization Requirements Effective October 1, 2016

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1 General Information This list contains notification/prior authorization review requirements for participating care providers for inpatient and outpatient services, as referenced in the UnitedHealthcare Physician, Health Care Professional, Facility and Ancillary Provider 2016 Administrative Guide for Commercial and Medicare Products. Updates to the list are announced routinely in the UnitedHealthcare Network Bulletin. To provide notification/request prior authorization, please submit your request online, or by phone or fax: Online: UnitedHealthcareOnline.com > Notifications/Prior Authorizations > Notification/Prior Authorization Submission Phone: Fax: ; fax form is available UnitedHealthcareOnline.com > Tools & Resources > Forms > Clinical/Pharmacy. Notification/prior authorization is not required for emergency or urgent care. Arthroplasty Arthroscopy Bariatric surgery Bariatric surgery and specific obesity-related services There is a Center of Excellence requirement for coverage of bariatric surgery and services. In certain situations, bariatric surgery and other obesity-related services aren t covered by some benefit plans. For more information, please call * 43865* T 0313T 0314T 0315T 0316T 0317T * for the

2 Bariatric surgery (cont d) following diagnosis codes: E E66.3, E66.8, E66.9, Z68.1, Z Z68.39, Z Z68.45, Z Z68.54, Z98.84 Bone growth stimulator E0747 E0748 E0749 E0760 BRCA genetic testing program DNA sequencing to identify BRCA 1 and BRCA 2 gene mutations associated with the development of breast and ovarian cancer BRCA testing requires notification/prior authorization before DNA sequencing is performed. An ordering care provider must notify the laboratory conducting the test and the laboratory will notify UnitedHealthcare. Genetic counseling is required prior to testing by a qualified provider to review the hereditary history and discuss the impact of the test on treatment. Once UnitedHealthcare receives notification for BRCA testing from the laboratory, we ll send the member a letter explaining how to access the service. Genetic testing and/or genetic counseling services are not covered in some benefit plans. More information about the BRCA genetic testing program, including the required supportive documentation and generic counseling attestation form, can be found at UnitedHealthcareOnline.com > Clinician Resources > Oncology > BRCA Testing Breast reconstruction (non-mastectomy) Reconstruction of the breast or other than following mastectomy L8600 Notification/prior authorization not required for the following diagnosis codes: C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C50.421

3 Breast reconstruction (non-mastectomy) (cont d) C C C C C C C C C C C C C C C79.81 D05.90 D05.00 D05.01 D05.02 D05.10 D05.11 D05.12 D05.80 D05.81 D05.82 D05.91 D05.92 Z85.3 Z90.10 Z90.11 Z90.12 Z90.13 Cartilage implants J7330 S2112 Clinical trials A rigorously controlled study of a new drug, medical device or other treatment on eligible human subjects that is subject to oversight by an Institutional Review Board (IRB) Z42.1 S9988 S9990 S9991 Cochlear and other auditory implants Cosmetic and reconstructive surgery Cosmetic procedures that change or improve physical appearance, without significantly improving or restoring physiological function Reconstructive procedures that either treat a medical condition or improve or restore physiologic function Durable medical equipment: more than $1,000 DME codes listed with a retail purchase or cumulative rental cost of more than $1, L8614 L8615 L8616 L8617 L8618 L8619 L8627 L8628 L8690 L8691 L8692 L Q2026 only in outpatient settings, to include patient s home Prosthetics are not DME see Orthotics and prosthetics. Some home health care services may qualify under the durable medical equipment A7025 A7026 E0194 E0265 E0266 E0277 E0296 E0297 E0300 E0302 E0304 E0328 E0329 E0445 E0471 E0472 E0483 E0601 E0620 E0745 E0764 E0770 E0784 E0984 E1002 E1003 E1004 E1005 E1006 E1007 E1008 E1010

4 Durable medical equipment: more than $1,000 (cont d) requirement but are not subject to the $1,000 retail purchase or cumulative retail rental cost threshold see Home health services. Power mobility devices and accessories, lymphedema pumps and pneumatic compressors require notification/prior authorization regardless of the cost. E1016 E1018 E1220 E1230 E1236 E1238 E1399 E1800 E1802 E1805 E1810 E1812 E1815 E1825 E1830 E1840 E2300 E2310 E2311 E2321 E2363 E2364 E2365 E2382 E2384 E2385 E2389 E2391 E2396 E2402 E2500 E2502 E2504 E2506 E2508 E2510 E2511 E2512 E2599 K0005 K0007 K0009 K0010 K0012 K0014 K0606 K0800 K0801 K0802 K0806 K0807 K0808 K0812 K0813 K0815 K0820 K0821 K0822 K0823 K0824 K0825 K0826 K0827 K0828 K0829 K0830 K0831 K0835 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 Foot surgery Functional endoscopic sinus Surgery (FESS) Home health care nonnutritional Nursing services in the home only in outpatient settings, to include patient s home T1000 T1002 T1003 T1005 S9123 S9124 Home health care nutritional Provision of nutritional therapy, whether enteral or through a gastrostomy tube in the home only in outpatient settings, to include patient s home B4159 B4162 S9208 S9433 Hysterectomy inpatient only Vaginal hysterectomies for inpatient vaginal hysterectomies Notification/prior authorization not required for outpatient vaginal hysterectomies For claims purposes:

5 Hysterectomy inpatient only (cont d) Out-of-network claims without predeterminations will be reviewed for medical necessity post service/prepayment if the member s benefit plan requires services to be medicaly necessary in order to be covered. Hysterectomy inpatient and outpatient procedures Abdominal and laparoscopic surgeries Intensity-modulated radiation therapy (IMRT) Injectable medications A drug capable of being injected intravenously through an intravenous infusion, subcutaneously or intramuscularly For claims purposes: Out-of-network claims without predeterminations will be reviewed for medical necessity post service/prepayment if the member s benefit plan requires services to be medicaly necessary in order to be covered. To provide notification/request prior authorization, please complete the appropriate UnitedHealthcare IMRT clinical form and all supporting information and fax to the number on the form. The UnitedHealthcare IMRT clinical form is available at UnitedHealthcareOnline.com > Clinician Resources > Oncology > Intensity Modulated Radiation Therapy. For drug-specific notification/ prior authorization request forms, please visit UnitedHealthcareOnline.com > Clinician Resources > Specialty Drug > Commercial Specialty Drug Prior Authorization Program G6015 G6016 Blood modifier Soliris POS 19 & 22 only J1300 Enzyme replacement therapy for Gaucher s disease J1786 J3060 Hemophilia J7178 J7180 J7181 J7182 J7183 J7185 J7186 J7187 J7188 J7189 J7190 J7191 J7192 J7193 J7194 J7195 J7198 J7199 J7200 J7201 J7205 H.P. Acthar J0800 Q9975 Immune globulin J1459 J1556 J1557 J1559 J1561 J1562 J1566 J1568 J1569 J1572 J1575 J1599

6 Injectable medications (cont d) Inflammatory POS 19 & 22 only J0129 J1602 J1745 J3262 J3380 Q5102 MR-guided focused ultrasound (MRgFUS) to treat uterine fibroid MR-guided focused ultrasound procedures and treatments MR-guided focused ultrasound is a covered service for certain benefit plans, subject to the terms and conditions of those benefit plans, which generally are as follows: A physician and/or facility must confirm coverage of the service for the member. A hospital and/or facility must be contracted with UnitedHealthcare. Members have no out-of-network benefits for MRgFUS. A member must consent in writing to the procedure acknowledging that UnitedHealthcare doesn t believe that sufficient clinical evidence has been published in peer- reviewed medical literature to conclude that the service is safe and/or effective. A member must agree in writing to not hold UnitedHealthcare responsible if they re not satisfied with the results. The consent form can be found at: UnitedHealthcareOnline.com >Tools & Resources > Forms > Patient/Member > Magnetic Resonance-Guided Focused Ultrasound Procedure Patient Acknowledgement Form. A physician and facility must have demonstrated experience and expertise in MRgFUS as determined by UnitedHealthcare. A physician and facility must follow U.S. Food and Drug Administration labeled indications for use. Multiple sclerosis J T 0072T Non-emergent air ambulance transport Non-urgent ambulance transportation by air between specified locations Orthognathic surgery Treatment of maxillofacial functional impairment A0430 A0431 A0435 A0436 S9960 S

7 Orthognathic surgery (cont d) Orthotics: more than $1,000 Orthotics codes listed with a retail purchase or cumulative rental cost of more than $1,000 Out-of-network services A recommendation from a network physician or other health care provider to a hospital, physician, or other health care provider who is not contracted with UnitedHealthcare only in outpatient settings, to include patient s home Your agreement with UnitedHealthcare may include restrictions on directing members outside the health plan service area. Your patients who use non-network physicians, health care professionals or facilities may have increased out-of-pocket expenses or no coverage. L0220 L0480 L0482 L0484 L0486 L0636 L0638 L1640 L1680 L1685 L1700 L1710 L1720 L1755 L1844 L1846 L2005 L2020 L2034 L2036 L2037 L2038 L2128 L2330 L3251 L3253 L3420 L3430 L3440 L3450 L3455 L3465 L3470 L3480 L3485 L3766 L3900 L3901 L3904 L3961 L3967 L3971 L3973 L3975 L3976 L3977 L3978 L4631 Potentially unproven services (including experimental/ investigational) Services, including medications, determined to be ineffective in treating a medical condition and/or to have no beneficial effect on health outcomes Determination made when there s insufficient clinical evidence from well-conducted randomized controlled trials or cohort studies in the prevailing published, peerreviewed medical literature T 0270T 0271T 0345T A9274 A9276 A9277 A9278 S0810 S1040 S3652 Prosthetics: more than $1,000 Prosthetic codes listed with a retail purchase or cumulative rental cost of more than $1,000 only in outpatient settings, to include patient s home L5000 L5010 L5020 L5050 L5060 L5100 L5105 L5150 L5160 L5200 L5210 L5230 L5250 L5270 L5280 L5301 L5321 L5331 L5400 L5420 L5530 L5535 L5540 L5585 L5590 L5616 L5637 L5639 L5643 L5649 L5651 L5676 L5680 L5681 L5683 L5695

8 Prosthetics: more than $1,000 (cont d) L5700 L5701 L5703 L5706 L5707 L5718 L5722 L5724 L5726 L5728 L5780 L5781 L5782 L5795 L5811 L5812 L5814 L5816 L5818 L5822 L5824 L5826 L5828 L5830 L5840 L5845 L5848 L5856 L5858 L5930 L5950 L5960 L5966 L5968 L5970 L5973 L5975 L5976 L5979 L5980 L5981 L5987 L5988 L5990 L6000 L6010 L6020 L6026 L6050 L6055 L6120 L6130 L6200 L6205 L6310 L6320 L6350 L6360 L6370 L6400 L6450 L6570 L6580 L6582 L6584 L6586 L6588 L6590 L6620 L6621 L6624 L6638 L6645 L6648 L6693 L6696 L6697 L6707 L6881 L6882 L6884 L6885 L6900 L6905 L6910 L6920 L6925 L6930 L6935 L6940 L6945 L6950 L6955 L6960 L6965 L6970 L6975 L7007 L7008 L7009 L7040 L7045 L7170 L7180 L7181 L7185 L7186 L7190 L7191 L7499 L8040 L8041 L8042 L8043 L8044 L8045 L8046 L8047 L8049 L8699 V2627 V2629 Proton beam therapy Focused radiation therapy using beams of protons Please indicate whether proton beam therapy is performed as part of a clinical trial see Clinical trials Rhinoplasty Treatment of nasal functional impairment and septal deviation Sinuplasty

9 Site of service (SOS) Notification/prior authorization only required required when requesting service in an outpatient hospital setting Abdominal paracentesis Notification/prior authorization not required if performed at a participating Ambulatory Surgery Center (ASC) Notification/prior authorization not required for care providers in Iowa, Indiana, New Jersey and Utah Cardiovascular Carpal tunnel surgery Cataract surgery Cosmetic and reconstructive Ears, nose and throat (ENT) procedures Gynecologic procedures Hernia repair Liver biopsy Miscellaneous Ophthalmologic Tonsillectomy & adenectomy Upper & lower gastrointestinal endoscopy

10 Site of service (SOS) (cont d) Urologic procedures Sleep apnea procedures and surgeries Maxillomandibular advancement or oral pharyngeal tissue reduction for teatment of obstructive sleep apnea Sleep studies Laboratory-assisted and related studies, including polysomnography, to diagnosis sleep apnea and other sleep disorders Specific medications as indicated on the prescription drug list (PDL) Applies to inpatient or outpatient procedures and surgeries including but not limited to palatopharyngoplasty oral pharyngeal reconstructive surgery that includes laserassisted uvulopalatoplasty. Applies only for surgical sleep apnea procedures and not sleep studies. Excludes sleep studies performed in the home. Not applicable to sleep apnea procedures and surgeries see Sleep apnea procedures and surgeries. for certain medications to make sure they re a covered benefit for the indication for which they re prescribed. For a list of medications requiring notification/prior authorization, please refer to the PDL at UnitedHealthcareOnline.com > Tools & Resources > Pharmacy Resources > Prescription Drug List. Please call when prescribing medications that require notification/prior authorization. You may also fax requests to: Specialty medications: Non-specialty medications: Spinal cord stimulators Spinal cord stimulators when implanted for pain management T 0283T 0284T 0285T L8680 L8682 L8685 L8686 L8687 L8688

11 Spinal surgery T 0098T 0164T 0195T 0196T 0309T 0375T

12 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 to treat venous disease and varicose veins of the extremities Other Notification and Prior Authorization Programs Procedures and Services Behavioral health services Additional Information Prior authorization required Behavioral health services through a designated behavioral health network Current Procedural Terminology (CPT) Codes and/or How to Obtain Prior Authorization Many of our benefit plans only provide coverage for behavioral health services through a designated behavioral health network. Please call the number on the member s health plan ID card to refer for mental health and substance abuse/substance services. Cardiology Chemotherapy services for participating physicians for inpatient, outpatient and office-based electrophysiology implants prior to performance for participating physicians for outpatient and office-based diagnostic catheterizations, echocardiograms and stress echoes prior to performance for injectable chemotherapy drugs administered in an outpatient setting including intravenous, intravesical and intrathecal for a cancer diagnosis Please provide notification/ request prior authorization online or by phone: Online: UnitedHealthcareOnline.com> Notifications/Prior Authorizations > Cardiology Notification & Authorization - Submission & Status Phone: For more details and the CPT codes that require notification/prior authorization, please visit UnitedHealthcareOnline.com > Clinician Resources > Cardiology > Cardiology Notification/Prior Authorization. Chemotherapy codes J0640 J0641 J9000 J9015 J9017 J9019 J9020 J9025 J9027 J9031 J9032 J9033 J9035 J9039 J9040 J9041 J9042 J9043 J9045 J9047 J9050 J9055 J9060 J9065 J9070 J9098 J9100 J9120 J9130 J9150 J9151 J9155 J9160 J9165 J9171 J9175 J9178 J9179 J9181 J9185

13 Procedures and Services Additional Information Current Procedural Terminology (CPT) Codes and/or How to Obtain Prior Authorization Chemotherapy services (cont d) J9190 J9200 J9201 J9202 J9206 J9207 J9208 J9209 J9211 J9212 J9213 J9214 J9215 J9216 J9217 J9218 J9219 J9225 J9226 J9228 J9230 J9245 J9250 J9260 J9261 J9262 J9263 J9264 J9266 J9267 J9268 J9270 J9271 J9280 J9293 J9299 J9300 J9301 J9302 J9303 J9305 J9306 J9307 J9308 J9310 J9315 J9320 J9328 J9330 J9340 J9351 J9354 J9355 J9357 J9360 J9370 J9371 J9390 J9395 J9400 J9600 J9999 Q2017 Q2043 Q2049 Q2050 In combination with the following cancer diagnosis code ranges: ICD-10 from ICD-10 to ICD-10 from ICD-10 to C00.0 C39.9 C92.90 C92.92 C40.00 C43.9 C93.00 C93.32 C4A.0 C4A.9 C93.Z0 C93.Z2 C44.00 C49.9 C93.90 C93.92 C49.A0 C49.A5 C94.00 C95.92 C49.A9 C49.A9 C96.0 C96.4 C C69.92 C96.A C96.Z C70.0 C75.9 C96.9 C96.9 C7A.00 C7B.8 D00.00 D09.9 C76.0 C79.9 D3A.00 D3A.8 C80.0 C83.99 D45 D45 C84.00 C84.79 D46.0 D46.22 C84.A0 C84.Z9 D46.A D46.C C84.90 C84.99 D46.4 D46.4 C85.10 C86.6 D46.Z D46.Z C88.2 C90.32 D46.9 D46.9 C91.00 C91.62 D47.0 D47.1 C91.A0 C91.Z2 D47.3 D47.4 C91.90 C91.92 D47.Z1 D47.Z9 C92.00 C92.62 D47.9 D47.9 C92.A0 C92.Z2 D48.0 D48.2

14 Procedures and Services Congenital heart disease Congenital heart disease-related services, including pre-treatment evaluation Current Procedural Terminology (CPT) Additional Information Codes and/or How to Obtain Prior Authorization For notification/prior authorization, please call or the notification number on the back of the member s health plan ID card. Congential heart disease codes In combination with the following ICD-10-CM codes: Q20.0 Q20.3 Q20.1 Q20.5 Q20.2 Q20.3 Q20.8 Q21.3 Q20.4 Q21.0 Q21.1 Q21.2 Q21.8 Q21.2 Q21.2 Q20.8 Q20.6 Q20.8 Q21.4 Q21.8 Q21.9 Q21.9 Q22.3 Q22.0 Q22.1 Q22.2 Q22.4 Q22.6 Q22.8 Q22.9 Q22.5 Q23.0 Q23.1 Q23.2 Q23.3 Q23.4 Q24.4 Q24.2 Q24.3 Q24.8 Q24.5 Q24.6 Q24.0 Q24.1 Q24.8 Q23.8 Q23.9 Q24.8

15 Procedures and Services Additional Information Current Procedural Terminology (CPT) Codes and/or How to Obtain Prior Authorization Congenital heart disease (cont d) Q20.9 Q24.9 Q25.0 Q25.1 Q25.2 Q25.4 Q25.4 Q25.2 Q25.3 Q25.4 Q25.8 Q25.9 Q25.5 Q25.71 Q25.72 Q25.6 Q25.79 Q26.9 Q26.2 Q26.3 Q26.4 Q26.0 Q26.1 Q26.8 Q27.0 Q27.9 Q26.5 Q26.6 Q27.33 Q27.8 Q27.1 Q27.2 Q27.34 Q27.31 Q27.32 Q27.39 Q27.8 Q28.2 Q28.3 End stage renal disease disease (ESRD) dialysis services Services for treating end stage renal disease, including outpatient dialysis services when members are referred to an outof-network care provider for dialysis services Notification/prior authorization not required for ESRD when a member travels outside of the service area Please note: Your agreement with us may include restrictions on referring members outside of the UnitedHealthcare network. For notification/prior authorization, please call To enroll or refer a member to the UnitedHealthcare ESRD Disease Management Program, please contact the Kidney Resource Service at Infertility Diagnostic and treatment services related to the inability to achieve pregnancy T 0357T S4011 S4013 S4014 S4015 S4016 S4022 S4023 S4025 S4026 S4028 S4030 S4031 S4035 S4037 The following codes only require prior authorization if the DX code is also listed: DX codes N46.01 N46.021

16 Procedures and Services Additional Information Current Procedural Terminology (CPT) Codes and/or How to Obtain Prior Authorization Infertility (cont d) N N N N N46.11 N N N N N N N N46.8 N46.9 N97.0 E23.0 N97.1 N97.2 N97.8 N97.8 N97.9 N98.1 Radiology for participating physicians who request these advanced outpatient imaging procedures: Certain CT, MRI, MRA and PET scans Nuclear medicine and nuclear cardiology procedures Care providers ordering an advanced outpatient imaging procedure are responsible for providing notification/requesting prior authorization before scheduling the procedure. Please provide notification/request prior authorization online or by phone: Online: UnitedHealthcareOnline.com > Notifications/Prior Authorizations > Radiology Notification & Authorization - Submission & Status Phone: For more details and the CPT codes that require notification/prior authorization, please visit UnitedHealthcareOnline.com > Clinician Resources > Radiology > Radiology Notification/Prior Authorization. Transplant Organ or tissue transplant or transplant related services before pre-treatment or evaluation for transplant or transplant-related services before pre-treatment or evaluation For transplant services, please call or the notification number on the back of the member s health plan ID card. Evaluation for transplant Bone marrow harvest Heart/lung Heart Lung S2060 S2061

17 Procedures and Services Transplant (cont d) Additional Information Current Procedural Terminology (CPT) Codes and/or How to Obtain Prior Authorization Kidney Pancreas Liver Intestine Ventricular assist devices (VAD) A mechanical pump that takes over the function of the damaged ventricle of the heart and restores normal blood flow Services related to transplants S2152 Please call the notification number on the back of the member s ID card. Then, fax the form provided by the nurse to the Optum VAD Case Management Team at T 0052T 0053T Voluntary Notification for Case and Disease Management Enrollment Please provide us with voluntary notification of the following diagnoses so we can enroll UnitedHealthcare members in our case and disease management programs. As part of these programs, we ll contact members to explain their benefits and other available resources. Voluntary notification doesn t indicate or imply coverage, which is determined according to the member s benefit plan. Diagnosis Additional Information ICD-10-CM Codes Pregnancy Notification allows UnitedHealthcare to enroll a pregnant member in the Healthy Pregnancy Program before their baby s arrival. Please notify us only once per pregnancy. We re not requesting notification for ancillary services such as ultrasound and lab work. After notification, please contact us if the member is no longer appropriate for the Healthy Pregnancy Program for Upon confirmation of pregnancy, please notify us for ICD-10-CM : O09.00 O09.01 O09.02 O09.03 O09.10 O09.11 O09.12 O09.13 O O O O O O O O O09.30 O09.31 O09.32 O09.33 O09.40 O09.41 O09.42 O09.43 O O O O O O O O O O O O09.619

18 Pregnancy (cont d) example, if a pregnancy is terminated. O O O O O09.70 O09.71 O09.72 O09.73 O O O O O09.90 O09.91 O09.92 O09.93 O12.00 O12.01 O12.02 O12.03 O12.10 O12.11 O12.12 O12.13 O12.20 O12.21 O12.22 O12.23 O21.0 O21.1 O21.8 O21.9 O O O O O O O O O O O O O O O O26.00 O26.01 O26.02 O26.03 O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O30.91 O30.92 O30.93 O47.00 O47.02 O47.03 O47.1 O47.9 O60.00 O60.02 O60.03 O O O O O99.89 Z32.01 Z33.1 Z34.00 Z34.01 Z34.02 Z34.03 Z34.80 Z34.81 Z34.82 Z34.83 Z34.90 Z34.91 Z34.92 Z34.93 Z36