Louisiana Revised Prior Authorization Requirements

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Louisiana Revised Prior Requirements Contact: Ann Kay Logarbo, M.D. Chief Medical Officer, a_logarbo@uhc.com All non-emergency inpatient admissions, including planned surgeries, require prior authorization. Procedure Codes not listed in this document may not be covered. Please check your Medicaid Fee Schedule. 17 P (17 Hydroxyprogesterone Capraote) Bill as J3490 with a TH modifier. A low level office visit (99211) may be billed for the administration of the injection if a higher level visit has not been submitted for the recipient on that date. Physician is responsible for obtaining the compounded medication from a compounding pharmacy. Makena product is not a covered benefit. Abortions No Must meet state/federal guidelines. Must submit paper claim. Must be accompanied by state consent and written provider letter of medical necessity. 59840, 59841 Acupuncture Ambulance and Air Transport s Emergency No Not required for emergencies CAT Scan Submit claim to UnitedHealthcare SPECT Submit claim to UnitedHealthcare 78451, 78452 Cardiac Rehabilitation/ Pulmonary Rehabilitation Chemotherapy No Submit claim to UnitedHealthcare Chiropractic s No Must be referred by PCP, members through age 20 only, see Professional s Manual at lamedicaid.com 98940 Chronic Pain Management Clinical Trials Cochlear Implants Device covered by Louisiana Department of Health & Hospitals (DHH); see age-specific, medical and social requirements in Professional s Manual 69930 Dental s Dialysis No Submit claim to UnitedHealthcare Drugs Botox Review for medical necessity; not a covered benefit for cosmetic services Drugs Synagis EEG No Submit claim to UnitedHealthcare Elective Inpatient Admissions Submit claim to UnitedHealthcare Endometrial Ablation Submit claim to UnitedHealthcare Experimental s Family Planning No s provided through OB-GYN through preventive care and covered contraceptives

Louisiana Revised Prior Requirements Genetic Testing No Please see Covered Codes in column Covered Codes: 81265,81267,81380, 81382,88245,88248, 88249,88261,88262, 88263,88264,88267, 88269,88271,88272, 88273,88274,88275, 88280,88283,88285, 88289,88291,88299 Genetic Testing (Prolonged QT Syndrome) Requires prior authorization/paper claim submission 81280 and 81282 Home Health s Submit claim to UnitedHealthcare; Skilled Nursing/Aide Submit claim to UnitedHealthcare limited to 50 visits per calendar year/adults; one visit/day G0154 OT/PT/Speech Therapy Submit claim to UnitedHealthcare PT-G0151, OT-G0152, ST-G0153 Extended Skilled Nursing (Pediatric Day Health Care/Private Duty Nursing) Hospice s Infertility Tests/Treatment Submit claim to UnitedHealthcare; younger than age 21 only; requires medical necessity review LTAC Submit claim to UnitedHealthcare Mammography, Screening No Ages 40 and older; one/year Mental Health Refer to Magellan MRI Submit claim to UnitedHealthcare Nuclear Cardiac Imaging Submit claim to UnitedHealthcare 78499 Nursing Facilities/SNF Contact DHH at 225-342-5774 Nutrition s. Enteral nutrition only; routine counseling is not a covered benefit. Observation No Obstetrical s No Two ultrasounds allowed per pregnancy; additional ultrasounds require medical necessity review Orthotic/Prosthetic s 97760, 97761, 97762 Outpatient Drug/Alcohol Treatment Refer to Magellan Outpatient OT/PT/Speech Therapy Ages 21 and Older Submit claim to UnitedHealthcare; covered benefit (with Provider Type Exclusions) Younger Than Age 21 No prior authorization required for evaluation

Louisiana Revised Prior Requirements Speech Therapy Submit claim to UnitedHealthcare 92521, 92522, 92523, 92524,92507, 92508, 92626, 92627, 92630, 92633 Occupational Therapy Submit claim to UnitedHealthcare 97003, 97530 Physical Therapy Submit claim to UnitedHealthcare 97001, 97110, 97530 Pediatric Day Health Care Submit claim to UnitedHealthcare Must meet medical criteria PET Scans ; exceptions must be handled individually Sigmoidoscopy With Ultrasound Submit claim to UnitedHealthcare 45341 Sleep Study No Submit claim to UnitedHealthcare Sterilization No See Professional s Manual for specifics; waiting times apply between consent and procedure Hysterectomy Tubal Ligation Vasectomy Transfers Between Facilities (Non-Emergency) s Manual s Manual s Manual Submit claim to UnitedHealthcare Transplant s Submit claim to UnitedHealthcare Refer to specific CPT codes for coverage Vagus Nerve Stimulators Specific state criteria apply; see Professional s Manual 64568, 64569, 64570 Vascular Procedures Submit claim to UnitedHealthcare 37191, 37192, 37193, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785 Vision s Only covered up to age 21; corrective eyewear requires prior authorization through DHH. s for ages 21 and older limited to eye diseases, infections. Surgical Procedures Abdominoplasty, Panniculectomy, Body Contouring Submit claim to UnitedHealthcare; includes procedures to remove fat 15830, 15847 Arthrodesis (Bone Fusing) Submit claim to UnitedHealthcare 22633 Artifical Urinary Sphincter Removal/Replacement Submit claim to UnitedHealthcare 53446, 53447, 53448 Anal Sphincteroplasty Submit claim to UnitedHealthcare 46762

Louisiana Revised Prior Requirements Auditory Canal (EXT) Reconstruction Submit claim to UnitedHealthcare 69310, 69399 Baclofan Pump, Intrathecal Must meet state requirements in Professional s Manual; prior authorization needed for ages 4 and older with specific diagnoses Bariatic Surgery State-specific criteria applies 43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888 Bone Graft Submit claim to UnitedHealthcare 20955, 20962, 20969, 20970, 20972, 20973, 21208, 21209 Breast Procedures Breast Reconstruction Submit claim to UnitedHealthcare 11970, 11971, 19295, 19340, 19342, 19350, 19357, 19361, 19364, 19366, 19367, 19368, 19369 Breast Reduction Weight/height restrictions apply; see Professional s Manual 19318 Implant Removal Submit claim to UnitedHealthcare 19328 Mastopexy Inverted Nipples Gynecomastia-Mastectomy Submit claim to UnitedHealthcare 19300 Chest Procedure Miscellaneous Submit claim to UnitedHealthcare 32999 Circumcision unless deemed medically necessary Cystourethroscopy For treatment of congenital conditions 54150, 54160, 54161 52400 Endometrial Ablation Submit claim to UnitedHealthcare 58353 Eyelid Procedures Submit claim to UnitedHealthcare 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911, 67914, 67916, 67917, 67921, 67923, 67924, 67961, 67966, 67971, 67973, 67974, 67975 Forehead and Brow Procedures Submit claim to UnitedHealthcare 15820, 15821,15822, 15823 Hair Transplant Lipectomy/Removal of Excess Skin Submit claim to UnitedHealthcare Only covered as Ambulatory Surgical Procedure 15832, 15833, 15834, 15835, 15876, 15877, 15878, 15879

Louisiana Revised Prior Requirements Neurostimulator/Receiver For implantation, removal or revision 61885, 61888, 64568, 64569, 64570 Nose Procedures Submit claim to UnitedHealthcare 30120, 30400, 30410, 30420, 30430, 30435, 30450, 30520, 30620, 30630, 30999 Osteocutaneous Flap Applies to multiple sites 20969, 20970, 20972, 20973 Osteoplasty Refers to facial 21208, 21209 Otoplasty (Repair of Visible Ear Defects) Pancreatectomy Refers to autologous transplantation 48160 Pectus Excavatum/Carinatum Submit claim to UnitedHealthcare 21742, 21743 Penile Surgeries Submit claim to UnitedHealthcare 54162, 54163, 54300, 54304, 54360, 54440 Prostate Laser Enuclation Ablation Submit claim to UnitedHealthcare 52649, 53446, 53447, 53448 Removal of Excessive Skin/ Fat Submit claim to UnitedHealthcare 15830, 15847 Nasal Reconstruction Procedures See code limitation 30465 Sex Change Surgery Submit claim to UnitedHealthcare 55970, 55980 Spinal/Intrathecal Catheter Submit claim to UnitedHealthcare 62350, 62351, 62355, 62360, 62361, 62362, 62365 Tissue Expanders For use other than in the breast 11960, 11970, 11971 Vaginal Procedures Vaginal Construction Submit claim to UnitedHealthcare 57291, 57292 Vaginal Dilitation With Anesthesia Submit claim to UnitedHealthcare 57400 Pelvic Exam With Anesthesia Submit claim to UnitedHealthcare 57410 Vein Stripping/Ligation Submit claim to UnitedHealthcare 37650, 37700, 37718, 37722, 37735, 37760, 37780, 37785 Outpatient procedures not listed above do not require prior authorization. Highlighted services represent revised prior authorization requirements. Updated 3/4/2014.

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