ModifiedUnitedHealthcarePolicy N/A

Prior authorization requirements for Indiana Hoosier Care Connect

Lists prior authorization requirements and codes for participating UnitedHealthcare Community Plan of Indiana providers; describes how to submit requests and notes exceptions for emergency/urgent care and out-of-network requests.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Indiana Hoosier Care Connect

Policy CodePolicy N/A

Change TypeMaterial updates to injectable code requirements and code-specific applicability

Effective DateJan. 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID, or by phone at 877-610-9785.

SourceLink

POLICY UPDATE CHANGES

Effective Oct. 1, 2024: Prior authorization required for Q5133, Q5135.

Effective Jan. 1, 2023: prior authorization required for J0897 for nononcology Dx.

877-610-9785Provider phone

UHCprovider.comOnline portal

ExemptEmergency/urgent care

NotedBariatric COE

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Injectable codes listed

Notification/PABRCA testing

Coverage and Prior Authorization Criteria

Prior authorization coverage stance

Prior authorization is required for listed services and codes except where noted (emergency/urgent care). Submit requests via the Provider Portal or by phone.

ALL of the following

Prior authorization is required for the services and CPT/HCPCS codes listed in this document.
Exceptions
- Emergency or urgent care (prior authorization not required).
- Out-of-network requests must be made by a network care provider.

ALL of the following

Submit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID.
Or submit by phone at 877-610-9785.

ALL of the following

Certain service categories have additional requirements (for example, bariatric surgery has a Center of Excellence requirement). See individual entries for code-specific rules and routing.

ALL of the following

Effective date: see individual code entries for any newly added effective prior authorization dates or code-specific applicability (e.g., J0897 applicability by diagnosis, Q5133/Q5135 effective dates).

ALL of the following

Providers must follow the submission and routing instructions in each specific entry (some services require special routing or contact numbers).

Genetic testing PA criteria (partial)

Genetic and molecular testing prior authorization and notification requirements

Prior authorization is required for genetic and molecular testing performed in an outpatient setting.

Health care professionals requesting laboratory genetic testing will be required to complete the prior authorization/notification process, including indicating the laboratory and test name as requested.

Notification or prior authorization is required for BRCA testing.

The ordering health care professional must notify the laboratory conducting the test and the laboratory will notify UnitedHealthcare as part of the process.

Home health and hysterectomy

Home health and hysterectomy prior authorization notes

Home health care requires prior authorization (codes G0151, G0152, G0153 listed).

Hysterectomy procedures require prior authorization; multiple CPT codes are listed for hysterectomy (examples include 51925, 58152, 58200, 58210, 58240, 58263, 58267, 58270, 58275, 58280, 58285, 58292, 58294, 59897, 58548).

Injectable medications

Injectable medications prior authorization requirements

An extensive list of injectable medications (by HCPCS/CPT) require prior authorization as listed in this document (see individual code entries for specifics).

Unclassified code exception: For unclassified and temporary codes J3490 and J3590, prior authorization is required only for a specified subset of drugs (Casgevy, Lantidra, Lyfgenia, Nulibry, Revcovi, Rivflosa, Ryplazim, Scenesse, Uplizna, and Vabysmo).

Effective Oct. 1, 2024: prior authorization required for Q5133 (Tofidence) and Q5135 (Tyenne).

Effective Jan. 1, 2023: prior authorization required for J0897 for non‑oncology diagnoses.

Prior authorization coverage criteria

Prior authorization is required for the following services and codes as listed below. See individual entries for special routing or effective dates.

Injectable medications: specific HCPCS/J-codes listed in the document require prior authorization; unclassified codes J3490/J3590 require prior authorization only for the specified subset of products noted in the listing.

Orthotics and prosthetics: prior authorization is required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500.

Ventricular assist devices (VAD): prior authorization is required for VAD-related codes (including Q0507, 33927–33929). For Q0508, call the number on the member's ID card and fax the completed form to the Optum VAD Case Management team at 855-282-8929.

Transplants and CAR‑T/gene therapy: prior authorization required for organ/tissue transplant and transplant-related services before pre-treatment or evaluation; certain gene therapy/unclassified products require transplant routing or Optum Transplant prior authorization (see entries).

CPT / HCPCS / Code-specific Rules

Bariatric CPT/HCPCS codesCPTCovered

43644	Bariatric procedure code listed for prior authorization
43645	Bariatric procedure code listed for prior authorization
43659	Bariatric procedure code listed for prior authorization
43770	Bariatric procedure code listed for prior authorization

Cochlear implants and auditory device codesHCPCSCovered

69930	Cochlear implant procedure code
L8615	Implantable hearing device HCPCS
L8616	Implantable hearing device HCPCS

Genetic testing, gender dysphoria and other listed codesmixedCovered

81162	BRCA genetic testing
81163	BRCA genetic testing
81164	BRCA genetic testing
81165	BRCA genetic testing
15832	Gender dysphoria related surgical code
15833	Gender dysphoria related surgical code

Notable code-specific PA rulesHCPCSCovered

J0897

Prolia — prior authorization required for nononcology diagnosis effective Jan. 1, 2023

Newly required PA codes (effective dates)HCPCSCovered

Q5133	Prior authorization required effective Oct. 1, 2024
Q5135	Prior authorization required effective Oct. 1, 2024

Highlighted injectable medication codes with effective prior authorization datesHCPCSCovered

Q5133	Tofidence (effective Oct. 1, 2024 prior auth required)
Q5135	Tyenne (effective Oct. 1, 2024 prior auth required)
J0897	Prior authorization required for nononcology diagnosis (effective Jan. 1, 2023)

VAD codesCPTCovered

Q0507	Ventricular assist device related code requiring prior authorization
33927	VAD implant/related codes
33928	VAD implant/related codes
33929	VAD implant/related codes

Unclassified code (J3490/J3590) prior authorization exceptions

Unclassified J-codes exceptionPrior authorization is required for J3490 and J3590 only when used for specific products: Casgevy, Lantidra, Lyfgenia, Nulibry, Revcovi, Rivflosa, Ryplazim, Scenesse, Uplizna, and Vabysmo.

Examples of affected unclassified productsDocument specifically lists Casgevy; Lantidra; Lyfgenia; Nulibry; Revcovi; Rivflosa; Ryplazim; Scenesse; Uplizna; Vabysmo.

Transplant routing noteSome unclassified products (e.g., Hemgenix, Amtagvi, Lenmeldy, Tecelra) require prior authorization through Optum Transplant as noted separately.

Orthotics and prosthetics prior authorization threshold

Provider Submission, Notifications, and Actionable Items

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) by signing in with a One Healthcare ID, or by phone at 877-610-9785. Prior authorization is not required for emergency or urgent care; out-of-network requests must be made by a network care provider.

Online: UHCprovider.com → Sign In → One Healthcare ID
By phone: 877-610-9785

Prior Authorization

Categories requiring prior authorization

Prior authorization is required for many service categories including bariatric surgery (coverage requires a Center of Excellence), behavioral health, cochlear implants, durable medical equipment, enteral services, experimental/investigational services, and gender dysphoria treatment, among others listed with specific CPT/HCPCS codes.

Bariatric surgery — Center of Excellence requirement for coverage (multiple CPT/HCPCS codes listed)
Behavioral health — refer to number on member ID card for specific code routing

Key Terms and Definitions

Definition of Prior Authorization

DefinitionPrior authorization is the process by which providers must obtain approval before performing certain services.

Emergency/urgent carePrior authorization is not required for emergency or urgent care.

Submission methodsRequests may be submitted online via the Prior Authorization and Notification tool on UHCprovider.com (One Healthcare ID) or by phone at 877-610-9785.

Center of Excellence requirement

Center of Excellence requirementCoverage of bariatric surgery and related services requires care at designated Centers of Excellence.

Applicable servicesBariatric surgery and certain obesity‑related services are subject to the Center of Excellence requirement and prior authorization (multiple CPT/HCPCS codes listed).

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Indiana Hoosier Care Connect

Policy CodePolicy N/A

Change TypeMaterial updates to injectable code requirements and code-specific applicability

Effective DateJan. 1, 2025

Next Review DateN/A

SourceLink

On This Page

Radiology/Advanced Imaging and other procedures: prior authorization or notification is required for listed advanced imaging and procedural codes; ordering clinicians are responsible for notification prior to scheduling where indicated.

Wound vac (E2402) requires prior authorization.

Providers must consult individual code entries for additional requirements, special routing, and effective dates for newly added prior authorization requirements.

Orthotics/prosthetics PA thresholdPrior authorization is required only for orthotics and prosthetic codes with a retail purchase or cumulative rental cost of more than $500.

Scope of requirementApplies to orthotics and prosthetic HCPCS codes listed in the document (examples: L3215, L3216, L3217, L3219, L3221, L3222, L3250, L3251, L3252, L3649, L8659, L2006).

Provider responsibilityObtain prior authorization before furnishing items that meet the > $500 retail or cumulative rental threshold.

Cochlear implants — prior authorization required (e.g., 69930, L8615, L8616)

Enteral services, DME, experimental/investigational services, gender dysphoria treatment — prior authorization required

Prior Authorization

General prior authorization listing (partial)

The policy includes multiple CPT/HCPCS codes requiring prior authorization for general services (examples include enteral services B4103, B4161 and many others listed in the document).

Enteral service examples: B4103, B4161, B4149, B4150, B4152, B4153, B4155, B4158, B4159, B4160
Experimental/investigational examples: A9274, A9276, A9277, A9278

Prior Authorization

Genetic testing prior authorization requirements

Genetic and molecular testing performed in an outpatient setting requires prior authorization; ordering health care professionals must notify the laboratory conducting the test and the laboratory will notify UnitedHealthcare. BRCA testing requires notification or prior authorization as indicated in the genetic testing entries.

Outpatient genetic/molecular testing requires prior authorization (multiple CPT/HCPCS codes listed, e.g., 81161, 81200, 81207).
Ordering professional must notify the laboratory; the lab will notify UnitedHealthcare.
BRCA testing entries included (notification/prior authorization applies)

Prior Authorization

Home health care and lab notification requirements

Home health care requires prior authorization. For certain laboratory tests, the ordering health care professional must notify the laboratory, which will then notify UnitedHealthcare.

Home health CPT/HCPCS examples: G0151, G0152, G0153
Ordering provider responsibility: notify the laboratory conducting the test

Prior Authorization

Injectable medications prior authorization list

An extensive list of injectable medications (HCPCS/CPT/J-codes) require prior authorization; the list includes many named products and notes special handling for unclassified codes and effective dates for newly added codes.

Examples of listed products: Avsola (J1554), Benlysta (Q5121), Entyvio (J1302), Ilumya (J0638), Rituxan (J9312), Ryplazim (J2998)
Unclassified codes J3490/J3590: prior authorization required only for a specified subset of products (see note in list)
Effective Oct. 1, 2024: prior authorization required for Q5133 and Q5135

Prior Authorization

Injectable medications prior authorization list (codes and exceptions)

The injectable medication listing specifies individual CPT/HCPCS codes (including unclassified codes J3490 and J3590) and identifies which products require prior authorization; it also documents effective dates (e.g., Q5133 and Q5135 effective Oct. 1, 2024) and code-specific clarifications.

Unclassified J-codes: prior authorization only for named drugs (Casgevy, Lantidra, Lyfgenia, Nulibry, Revcovi, Rivflosa, Ryplazim, Scenesse, Uplizna, Vabysmo).
J0897 (Prolia): prior authorization required for nononcology diagnosis effective Jan. 1, 2023.
Newly required: Q5133 (Tofidence) and Q5135 (Tyenne) require prior authorization effective Oct. 1, 2024.

Prior Authorization

Procedures and services prior authorization list

Various procedures and services require prior authorization and are listed with associated CPT/HCPCS codes — this includes therapies (OT/PT/speech), orthognathic surgery, orthotics/prosthetics, radiology/advanced imaging, remote patient monitoring, rhinoplasty, spinal surgery, stimulators, transplants (including CAR-T/gene therapy routing), VADs, urine drug testing, and wound vacs.

Therapies: multiple CPTs (e.g., 97110, 97112, 97139) require prior authorization.
Orthotics/prosthetics: prior authorization required only when retail purchase or cumulative rental cost > $500 (examples: L3215, L3221).
Radiology: ordering clinicians must provide notification prior to scheduling certain advanced outpatient imaging (CT/MRI/MRA/PET).
Transplants/CAR-T/gene therapy: prior authorization required before pre-treatment or evaluation; CAR T-cell therapy Q2056 and gene therapy J3490/J3590 flagged for special routing.
VADs: codes Q0507, 33927-33929 require prior authorization; for Q0508 follow contact instructions.
Wound vac: E2402 requires prior authorization.

Documentation Required

VAD authorization contact instructions (Q0508)

For VAD code Q0508, call the number on the member's ID card and then fax the form provided by the nurse to the Optum VAD Case Management team at 855-282-8929 as instructed.

Call the phone number on the member's ID card first.
Fax the Optum VAD Case Management form to 855-282-8929.

Noncoverage noteIn certain situations, bariatric surgery and other obesity‑related services aren’t covered by some benefit plans — confirm plan benefits.

Injectable medications — definition

DefinitionAn injectable medication is a drug capable of being injected intravenously (including intravenous infusion), subcutaneously, or intramuscularly.

Authorization stanceInjectable medications listed in the document require prior authorization.

ExamplesThe list includes many J‑codes and HCPCS entries (examples in document: J3262, J0801, J0172, J0225, J0256, J0739).

Ventricular assist device (VAD) — definition and PA instructions

VAD definitionA ventricular assist device (VAD) is a mechanical pump that takes over the function of the damaged ventricle of the heart and restores normal blood flow.

Associated codesVAD‑related codes listed include Q0507 and CPT codes 33927, 33928, 33929; Q0508 is used for VAD admission/authorization processing.

Authorization contactFor Q0508, call the number on the member's ID card and fax the provided form to the Optum VAD Case Management team at 855‑282‑8929.