Advance Notification Requirements for STAR Kids, Effective January 1, 2017

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1 Advance Notification Requirements for STAR Kids, Effective January 1, 217 General Information This list contains prior authorization requirements for UnitedHealthcare Community Plan STAR Kids 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 Authorizations > Notification/Prior Authorization Submission Phone: Fax: ; fax form is available at UHCCommunityPlan.com > For Health Care Professionals > Texas > Provider Forms > Standard Prior Authorization Form: Texas Department of Insurance. Prior authorization is not required for emergency or urgent care. Out-of-network physicians, facilities and other health care providers must request prior authorization for all procedures and services, excluding emergent or urgent care. Bariatric surgery Bariatric surgery and specific obesityrelated services Bone growth stimulator Electronic stimulation or ultrasound to heal fractures Prior authorization required Prior authorization required E747 E748 E76 BRCA genetic testing Prior authorization required Breast reconstruction (non-mastectomy) Reconstruction of the breast except when following mastectomy Prior authorization required Circumcision Prior authorization required 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 procedures Cosmetic procedures that change or improve physical appearance without significantly improving or restoring physiological function Prior authorization required L8614 L8619 L869 L8691 L8692 Prior authorization required

2 Effective January 1, 217 Cosmetic and reconstructive procedures (cont d) Reconstructive procedures that treat a medical condition or improve or restore physiologic function Durable medical equipment (DME): more than $5 DME codes listed with a retail purchase or a cumulative rental cost of more than $5 Prior authorization required only in outpatient settings, to include patient s home Prior authorization required for continuous positive airway pressure therapy (CPAP) and bilevel positive airway pressure (BiPAP) Prosthetics are not DME see Orthotics and prosthetics Q226 A9279 A99 E193 E194 E265 E277 E3 E34 E328 E329 E445 E457 E46 E465 E466 E47 E471 E472 E483 E61 E636 E637 E638 E641 E642 E65 E651 E652 E667 E668 E669 E673 E7 E71 E745 E762 E764 E782 E783 E784 E786 E12 E13 E14 E15 E16 E17 E18 E19 E11 E111 E118 E135 E185 E186 E189 E19 E113 E114 E1161 E122 E1229 E123 E1231 E1232 E1233 E1234 E1235 E1236 E1237 E1238 E1239 E125 E126 E1285 E129 E13 E131 E1399 E1825 E183 E184 E21 E224 E2227 E2228 E23 E231 E2311 E2312 E2321 E2325 E2327 E2328 E2329 E233 E2343 E2351 E237 E2373 E2375 E2376 E251 E2511 E2512 E2599 E2616 E2626 E2627 E2628 E2629 E263 E81 K5 K7 K8 K11 K13 K18 K66 K73 K8 K81 K82 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

3 Effective January 1, 217 Durable medical equipment (DME): more than $5 (cont d) DME codes listed with a retail purchase or a cumulative rental cost of more than $5 Enteral services In-home nutritional therapy, either enteral or through a gastrostomy tube K859 K86 K861 K862 K863 K864 K868 K869 K87 K871 K877 K878 K879 K88 K884 K885 K886 K89 K891 K898 K899 T1999 Prior authorization required B434 B435 B436 B41 B413 B414 B4149 B415 B4152 B4153 B4155 B4158 B4159 B416 B4161 B9 Experimental and investigational Prior authorization required Femoroacetabular impingement syndrome (FAI) Functional endoscopic sinus surgery (FESS) Home health services B92 B A9274 E1831 S14 Prior authorization required Prior authorization required Prior authorization required only in outpatient settings, to include member s home Injectable medications Prior authorization required Acthar 9953 G151 G152 G153 G155 G156 G162 G299 G3 S9122 S9123 S9124 S9127 S9128 S9129 S9131 S9474 J8 Botox J585 J586 J587 J588 IVIG 9284 J1459 J1556 J1557 J1559 J1561 J1566 J1568 J1569 J1572 J1575 J1599 Makena J1725 Synagis* J Xolair* J2357 *Please obtain prior notification for Synagis and Xolair through OptumRx prior notifications services at

4 Effective January 1, 217 Joint replacement Joint, total hip and knee replacement procedures Prior authorization required Non-emergent air ambulance transport Prior authorization required A43 A431 A435 A436 Non-emergent ground ambulance Prior authorization required A382 A398 A42 A422 A424 A425 A426 A428 A433 A434 Orthognathic surgery Treatment of maxillofacial/jaw functional impairment Orthotics and prosthetics: more than $5 Orthotic and prosthetics with a retail purchase or a cumulative rental cost of more than $5 Prior authorization required Prior authorization required only in outpatient settings, to include member s home L112 L17 L456 L462 L464 L48 L482 L484 L486 L624 L629 L631 L632 L634 L636 L637 L638 L64 L7 L71 L81 L82 L83 L859 L1 L15 L12 L13 L131 L1499 L168 L1685 L17 L171 L172 L173 L1755 L1832 L1834 L184 L1844 L1845 L1846 L186 L1945 L195 L197 L2 L25 L21 L22 L23 L234 L236 L237 L238 L26 L216 L218 L2126 L2128 L2136 L235 L251 L2525 L2526 L2627 L2628 L2999 L3 L316 L321 L322 L323 L324 L326 L327 L3212 L3213 L3214 L3215 L3216 L3217 L3219 L3221 L3222 L323 L325 L3251 L3252 L3253 L3265

5 Effective January 1, 217 Orthotics and prosthetics: more than $5 (cont d) Orthotic and prosthetic codes with a retail purchase or a cumulative rental cost of more than $5 L3649 L3671 L3674 L372 L373 L374 L3763 L3764 L3765 L3766 L39 L391 L394 L395 L3961 L3967 L3971 L3973 L3975 L3976 L3977 L3978 L3999 L4 L41 L42 L4631 L51 L52 L55 L56 L51 L515 L515 L516 L52 L521 L522 L523 L525 L527 L528 L531 L5312 L5321 L5331 L5341 L54 L542 L546 L55 L555 L551 L552 L553 L5535 L554 L556 L557 L558 L5585 L559 L5595 L56 L561 L5611 L5613 L5614 L5616 L5639 L564 L5642 L5643 L5644 L5645 L5646 L5647 L5648 L5649 L5651 L5653 L5661 L5673 L5681 L5682 L5683 L57 L571 L572 L573 L575 L576 L577 L5716 L5718 L5722 L5724 L5726 L5728 L578 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 L626 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 L6646 L6648 L6686 L6687 L6689 L669

6 Effective January 1, 217 Orthotics and prosthetics: more than $5 (cont d) Orthotic and prosthetic codes with a retail purchase or a cumulative rental cost of more than $5 L6692 L6693 L6694 L6695 L6696 L6697 L674 L677 L678 L679 L6711 L6712 L6713 L6714 L6715 L688 L6881 L6882 L6883 L6884 L6885 L6895 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 L861 V2623 Personal care service Prior authorization required S5125 V2627 Prescribed pediatric extended care (PPEC) Prior authorization required T125 T126 Private duty nursing Prior authorization required T1 T12 T13 Proton beam therapy Focused radiation therapy using beams of protons, which are tiny particles with a positive charge Rehabilitative services physical, speech and occupational therapy Prior authorization required Prior authorization required G129 S Rhinoplasty and septoplasty Treatment of nasal functional impairment and septal deviation Prior authorization required Sinuplasty Prior authorization required Sleep apnea procedures and surgeries Maxillomandibular advancement and oral-pharyngeal tissue reduction for treatment of obstructive sleep apnea Prior authorization required Spinal stimulator for pain management Spinal cord stimulators when implanted for pain management Prior authorization required

7 Effective January 1, 217 Spinal surgery Prior authorization required 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 Prior authorization required L868 L8682 L8685 L8686 L8687 L8688 Prior authorization required Wound vac Prior authorization required E242

8 Effective January 1, 217 Additional Advance Notification and Prior Authorization Programs (CPT) Codes and/or How to Obtain Prior Authorization Cardiology Prior authorization required for participating physicians for inpatient, outpatient and office-based 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. For prior authorization, please submit requests online at UnitedHealthcareOnline.com > Notifications/Prior Authorizations > Cardiology Notification & Authorization Submission & Status, or call For more details and the CPT codes that require prior authorization, please visit UHCCommunityPlan.com > For Health Care Professionals > Texas > Cardiology > Cardiology Prior Authorization CPT Code Crosswalk. Chemotherapy Prior authorization required for injectable chemotherapy drugs administered in an outpatient setting including intravenous, intravesical and intrathecal for a cancer diagnosis Injectable chemotherapy drugs that require prior authorization: Chemotherapy injectable drugs (J9 - J9999), Leucovorin (J64), Levoleukovorin (J641) Chemotherapy injectable drugs that have a Q code 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 Long term services and supports (LTSS)/home and community-based services (HCBS) Prior authorization obtained by the member s UnitedHealthcare Community Plan Service Coordinator during the person-centered care planning process, which includes an assessment and determination of needs To submit a prior authorization online request for injectable chemotherapy drugs, please log on to UnitedHealthcareOnline.com > Notifications/Prior Authorizations > Oncology Authorization Submission and Status > Submit or Look Up Chemotherapy Prior Authorization Request.

9 Effective January 1, 217 Additional Advance Notification and Prior Authorization Programs (CPT) Codes and/or How to Obtain Prior Authorization Mental health (MH)/substance use disorder (SUD) Prior authorization required for services including: Inpatient/residential Partial hospitalization program Intensive outpatient Home health services Nursing facility services Psychological testing Electroconvulsive therapy Prior authorization not required for crisis evaluations, code H211 To request prior authorization, please call the number on the back of the member s health plan ID card. Or, fax prior authorization request to Fax form is available at UHCCommunityPlan.com > For Health Care Professionals > Texas > Provider Forms > Standard Prior Authorization form: Texas Department of Insurance G177 H12 H14 H16 H34 H46 H47 H5 H214 H217 H235 H236 T17 T117 Radiology Prior authorization required for participating physicians who request these advanced outpatient imaging procedures prior to performance: Certain CT, MRI, MRA and PET scans Nuclear medicine and nuclear cardiology procedures Care providers ordering an advanced outpatient imaging procedure are responsible for obtaining authorization prior to scheduling the procedure. For prior authorization, please submit requests online at UnitedHealthcareOnline.com > Notifications/Prior Authorizations > Radiology Notification & Authorization Submission & Status, or call For more details and the CPT codes that require prior authorization, please visit UHCCommunityPlan.com > For Health Care Professionals > Texas > Radiology > CPT Code List. Transplants Prior authorization required For transplant services, please call the UnitedHealthcare Community and State Transplant Case Management Team at or the notification number on the back of the member s ID card

10 Effective January 1, 217 Additional Advance Notification and Prior Authorization Programs (CPT) Codes and/or How to Obtain Prior Authorization Transplants (cont d) Ventricular assist devices (VAD) A mechanical pump that takes over the function of the damaged ventricle of the heart and restores normal blood flow Prior authorization required S26 S261 S2152 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 T 52T 53T Q57 Q58 Q59