ModifiedUnitedHealthcarePolicy N/A

Prior authorization requirements for Indiana MLTSS Pathways

Lists prior authorization requirements and submission methods for participating UnitedHealthcare Community Plan of Indiana providers for inpatient and outpatient services under Indiana MLTSS Pathways.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Indiana MLTSS Pathways

Policy CodePolicy N/A

Change TypeMaterialadded HCPCS Q5133/Q5135 and retro Q0138

Effective DateEffective August: 1, 2025

Next Review Date

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone at 877-610-9785.

SourceLink

POLICY UPDATE CHANGES

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

*** Retro prior auth effective July. 1,2024 for code Q0138.

PortalOnline submission

877-610-9785Phone

ExcludedEmergency/Urgent

Bariatric notedCenter of Excellence

Oct 1, 2024

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.

New Q-codes effective

Jul 1, 2024Retroactive Q0138

Prior Authorization Coverage Criteria

inv-01: Prior authorization coverage criteria (summary)

Prior authorization requirement and applicable exceptions/notes by service category

ALL of the following

Submission method
Requests must be submitted via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone at 877-610-9785.
Emergency/urgent care
Prior authorization is not required for emergency or urgent care.
Out-of-network requests
Out-of-network requests must be made by a network care provider.

Bariatric surgery

Specific bariatric CPT/HCPCS codes listed require prior authorization; a Center of Excellence requirement applies for coverage in certain situations.

Behavioral health

Prior authorization is required; providers should call the number on the member's health plan ID card for mental health and substance use referrals; many plans use a designated behavioral health network.

Cochlear and auditory implants

Listed cochlear and auditory implant CPT/HCPCS codes require prior authorization.

Cosmetic and reconstructive procedures

Listed cosmetic/reconstructive CPT codes require prior authorization.

inv-02: Partial criteria sets — authorization and notification

Authorization/notification requirements present for multiple service types; specific clinical or documentation criteria are referenced elsewhere in the policy.

Genetic and molecular testing

Notification/prior authorization required for listed genetic CPT codes; for BRCA testing the ordering provider must notify the laboratory before DNA sequencing is performed.

Gender‑affirming and related surgical procedures

Listed CPT codes require prior authorization when indicated; some procedures reference diagnosis codes F64.* (gender dysphoria) as part of authorization criteria.

Durable medical equipment (DME)

DME codes listed require prior authorization in certain circumstances (for example when purchase or cumulative rental cost exceeds the plan threshold).

Enteral services

Listed enteral HCPCS codes (B41xx series) require prior authorization.

inv-03: Prior authorization requirements

Prior authorization or notification is required for the listed CPT/HCPCS codes and injectable medications.

Genetic testing and BRCA-specific rules

Multiple CPT genetic testing codes (e.g., 81315–81323, 81328, 81330, 81335, 81346, 81504, 81519, 81522 and others) require authorization or notification; BRCA testing specifically requires notification/prior authorization before DNA sequencing and the ordering provider must notify the laboratory.

Injectable medications (HCPCS/J-codes)

Extensive list of injectable HCPCS/J-codes require prior authorization (examples include J3262, J0801, J7171, J1931 and many others listed in the document).

Effective-date exceptions

Q-code effective-date changes
Effective Oct. 1, 2024: prior authorization required for Q5133 and Q5135.
Retroactive Q-code

inv-04: Prior authorization requirements (partial list)

Prior authorization is required for the listed services and codes; special contact and routing instructions apply for transplants and VADs.

Transplant and transplant‑related services

Organ or tissue transplant and transplant-related services require authorization before pre-treatment or evaluation; providers should call the number on the member's ID card (Optum contact referenced) for routing and authorization.

CAR T‑cell and gene therapy codes

CAR T‑cell and gene therapy codes (for example Q2042, Q2053, Q2056, Q2057, Q2058 and certain J-codes) require prior authorization; when billed under unclassified codes specific products require prior authorization.

Ventricular assist devices (VAD)

VAD procedure/device codes (for example 33927–33929, Q0507, Q0508) require prior authorization; providers should call the number on the member's health plan ID card and fax the nurse-provided form to the Optum VAD Case Management team at 855-282-8929.

Advanced outpatient imaging

CPT / HCPCS / Other Codes Requiring Prior Authorization

Selected bariatric codes (partial list)CPTCovered

43644	Bariatric procedure code listed in document
43775	Bariatric procedure code listed in document

Cochlear/auditory implant codes (example)CPT | HCPCSCovered

69930	Cochlear implant related procedure
L8615	Cochlear implant device code

Cosmetic and reconstructive codes (examples)CPTCovered

11921	Cosmetic/reconstructive procedure code
19301	Breast reconstruction/reconstruction-related code

DME and supply codes appearing in listHCPCSCovered

A9279	DME code listed in document
A999G	DME code listed in document
E0265	DME code listed in document
E0266	DME code listed in document
E0270	DME code listed in document
E0274	DME code listed in document
E0277	DME code listed in document
E0296	DME code listed in document
E0297	DME code listed in document
E0300	DME code listed in document

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Surgical and procedure CPT codes listedCPTCovered

19316	Surgical/procedure code listed in document
19318	Surgical/procedure code listed in document
19325	Surgical/procedure code listed in document
19340	Surgical/procedure code listed in document
19350	Surgical/procedure code listed in document
15821	Surgical/procedure code listed in document
15822	Surgical/procedure code listed in document
15823	Surgical/procedure code listed in document
15830	Surgical/procedure code listed in document
15832	Surgical/procedure code listed in document

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Genetic/molecular testing CPT codes requiring authorization/notificationCPTCovered

81161	Genetic/molecular testing CPT code listed in document
81167	Genetic/molecular testing CPT code listed in document
81168	Genetic/molecular testing CPT code listed in document
81200	Genetic/molecular testing CPT code listed in document
81201	Genetic/molecular testing CPT code listed in document
81202	Genetic/molecular testing CPT code listed in document
81203	Genetic/molecular testing CPT code listed in document
81206	Genetic/molecular testing CPT code listed in document
81207	Genetic/molecular testing CPT code listed in document
81208	Genetic/molecular testing CPT code listed in document

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Sample codes from genetic testing and home health sectionsmixedCovered

81315	Genetic testing CPT code listed under authorization requirements
G0151	Home health care HCPCS/CPT code listed under authorization requirements

Injectable medication codes (partial)HCPCSCovered

J3262	Injectable medication HCPCS code listed
Q5121	Injectable medication HCPCS code listed

Recent/Effective date-specific codesHCPCSExperimental

Q5133	Effective Oct. 1, 2024 prior authorization required
Q5135	Effective Oct. 1, 2024 prior authorization required
Q0138	Retro prior auth effective July 1, 2024

CAR T-cell / Gene / UnclassifiedmixedCovered

Q2042	CAR T-cell therapy
Q2053	CAR T-cell therapy
Q2056	Gene/CAR T-related code listed in section
Q2057	CAR T-cell therapy
Q2058	CAR T-cell/gene therapy
J3490	Unclassified/temporary code — prior auth only required for certain products
J3590	Unclassified/temporary code — prior auth only required for certain products

DME purchase/rental cost threshold

Threshold rulePrior authorization is required when a DME item's retail purchase price or the cumulative rental cost exceeds the specified threshold (amount not shown in excerpt).

Applies toDurable medical equipment codes listed in the DME section (examples: A9279, A999G, E0265, E0266, E0270).

How it is appliedThreshold applies per item — purchase or cumulative rental cost triggers prior authorization requirement as noted in DME entries.

Where to find detailsSee DME list and 'Additional information' notes in the DME section for items and threshold language (chunk 21).

What Providers Must Do

Prior Authorization

Submission methods and exceptions

Submit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (sign in with 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 the network care provider.

Online: UHCprovider.com > Sign In (One Healthcare ID) > Prior Authorization and Notification tab
Phone: 877-610-9785

Prior Authorization

Behavioral health prior authorization and network routing

Many UnitedHealthcare benefit plans provide behavioral health services through a designated behavioral health network. Prior authorization may be required for behavioral health services — for specific codes and referral/network routing, call the number on the member's health plan ID card to refer for mental health and substance use services.

For behavioral health prior authorization and network routing, call the phone number on the member's ID card

Definitions and Notes

Prior authorization — definition and exceptions

DefinitionPrior authorization: a required pre-service approval for certain services; requests must be submitted via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone (877-610-9785).

Exception — emergency/urgent carePrior authorization is not required for emergency or urgent care (chunk 1).

Out-of-network requestsOut-of-network requests must be made by a network care provider (chunk 1).

Center of Excellence — bariatric surgery context

Definition/contextCenter of Excellence requirement: Certain bariatric procedures and services have a Center of Excellence requirement for coverage under some benefit plans (chunk 2).

Applies toBariatric CPT/HCPCS codes listed in the bariatric section (examples: 43644, 43645, 43659, 43770–43775, 43843–43848).

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Indiana MLTSS Pathways

Policy CodePolicy N/A

Change TypeMaterialadded HCPCS Q5133/Q5135 and retro Q0138

Effective DateEffective August: 1, 2025

Next Review Date

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone at 877-610-9785.

SourceLink

On This Page

Retroactive prior authorization effective July 1, 2024 for code Q0138.

Unclassified/temporary J-codes

For J3490 and J3590, prior authorization is required only for a specified subset of products (examples named in the document).

Advanced outpatient imaging procedures require notification prior to scheduling by the ordering provider.

Other service categories requiring prior authorization

Physical therapy
Physical therapy codes listed require prior authorization.
Speech therapy
Speech therapy codes listed require prior authorization.
Rhinoplasty and cosmetic procedures
Rhinoplasty and other cosmetic procedure codes listed require prior authorization.
Spinal surgery and neurostimulators
Spinal surgery and neurostimulator procedure codes listed require prior authorization.

Effective date changes for selected Q-codes

Q5133 and Q5135 effective datePrior authorization required effective Oct. 1, 2024.

Q0138 retroactive effective dateRetroactive prior authorization effective July 1, 2024 for code Q0138.

Where notedEffective-date notations appear in the Q-code section and change log (chunk 55).

Orthotics and prosthetics prior authorization threshold

Orthotics & prosthetics threshold rulePrior authorization is required only for orthotics and prosthetic codes listed with retail purchase or cumulative rental cost of more than the specified threshold (amount not shown in excerpt).

Example codesExamples of listed O&P codes include L3215, L3216, L3217, L3219, L3221, L3222, L3250, L3251, L3252, L3649 (chunk 59).

Application noteThreshold language repeats across O&P entries — PA applies when purchase or cumulative rental cost exceeds the indicated amount.

Prior Authorization

Prior authorization required — surgical/cosmetic codes (partial)

Certain surgical and cosmetic procedures require prior authorization. A range of CPT codes for cosmetic and reconstructive procedures are listed and require prior authorization before scheduling or performing services.

Examples of CPT codes requiring prior authorization (partial list): 11921, 11922, 15780, 15781, 15782, 15783, 15820, 15821, 15822, 15823, 15830, 15847, 17999, 19300, 19301, 21137, 21138, 21139, 21230, 21270, 21295, 30120, 67900–67904, 30400–30430, 30435, 30450
Providers should obtain prior authorization as indicated in the Provider Portal or by calling the number on the member ID card

Prior Authorization

Genetic and molecular testing — authorization/notification requirements (partial)

Genetic and molecular testing codes require authorization or notification. Tests must follow the authorization/notification process and, when indicated, be performed in an outpatient setting by an authorized laboratory. The ordering provider may need to indicate the laboratory and follow the program/process for authorization/notification.

Authorization/notification required for many genetic and molecular CPT codes (examples): 81161, 81167, 81168, 81200–81208, 81218–81219, 81228–81232, 81235, 81238, 81243–81244, 81251–81259, 81269, 81270, 81276–81279, 81292–81299, 81300–81311, 81315–81323, 81328, 81330, 81335, 81346, 81504, 81519, 81522, 81315–81318, 81319, 81321–81323, 81328, 81330, 81335, 81346, 81504, 81519, 81522
Ordering health care professional must follow the program/process and provide required laboratory information

Prior Authorization

Genetic testing codes and BRCA notification

BRCA testing requires notification/prior authorization before DNA sequencing is performed. The ordering health care professional must notify the laboratory conducting testing and the laboratory will notify UnitedHealthcare as required by the authorization/notification process.

Prior authorization/notification required for BRCA testing before DNA sequencing
The ordering provider must notify the laboratory; the laboratory will notify UnitedHealthcare per program requirements

Prior Authorization

Home health care codes

Prior authorization is required for a range of home health care services and related CPT/HCPCS codes. Obtain authorization before initiating home health services.

Examples of home health care codes requiring prior authorization: G0151, G0152, G0153, 97161–97167, 97162, 97163, 97165, 97166, 97167, 92521–92524, 99600–99602
Providers should request authorization via the Provider Portal or by phone

Prior Authorization

Injectable medications and HCPCS/J-codes

Many injectable medications (J-/Q-/unclassified HCPCS codes) require prior authorization. A long list of specific product codes and unclassified/temporary codes are subject to authorization — verify individual product requirements before administration.

Examples of injectable medication codes requiring prior authorization (partial): J3262, J0801, J7171, J1931, J1552, J0256, J1554, J1786, J0717, J2786, J0598, J3247, J0584, J1551, J1555, J0589, J0586, J1743, J3060, J2508, J1302, J3380, J1305, J3111, J0180, J0517, J1951, Q0138 (retro to July 1, 2024), Q5130, Q5133, Q5135 (effective Oct 1, 2024)
Unclassified/temporary codes J3490/J3590 require prior authorization only for specified products (e.g., Casgevy, Lantidra, Nulibry, Zunovo, Revcovi, Rivfloza, Ryplazim, Scenesse, Uplizna, Vabysmo)
For complete list and exceptions, use the Provider Portal or contact prior authorization phone support

Prior Authorization

Maxillofacial / Orthotics & Prosthetics

Orthognathic (maxillofacial) surgery and selected orthotics/prosthetics require prior authorization. For orthotics and prosthetics, prior authorization is required only when the retail purchase or cumulative rental cost exceeds the plan-specified threshold.

Selected maxillofacial and orthognathic CPT codes requiring prior authorization (partial): 21121, 21122, 21123, 21125, 21127, 21110, 21196, 21199, 21206, 21208–21210, 21215, 21244–21249, 21255, 21296, 21299
Orthotics & prosthetics HCPCS examples (prior auth when purchase/rental threshold exceeded): L3215, L3216, L3217, L3219, L3221, L3222, L3250, L3251, L3252, L3649

Prior Authorization

CAR T-cell / Gene therapy / Unclassified codes

CAR T-cell therapy, gene therapy, and certain unclassified codes require prior authorization. Contact Optum or the number on the member ID card for transplant/advanced therapy pre-treatment authorization and follow specified code-level requirements for CAR T/gene therapies.

CAR T-cell and related HCPCS codes requiring prior authorization (examples): Q2042, Q2053, Q2056, Q2057, Q2058
Gene therapy/unclassified codes requiring prior authorization (examples): J3490*, J3590*, J1411**, J1412**, J3391, J3392, J3394 (products vary by code — confirm product-level requirements)
For transplant, CAR T-cell or gene therapy authorization/pre-treatment evaluation, call Optum Transplant at 888-936-7246 or the number on the member's health plan ID card

Coverage noteIn certain situations, bariatric surgery and other obesity-related services aren’t covered by some benefit plans — Center of Excellence requirement affects coverage (chunk 2).

Durable medical equipment (DME)

DefinitionDurable medical equipment (DME): equipment items listed in the DME section for which prior authorization may be required when purchase or cumulative rental cost thresholds are exceeded (chunk 21).

Examples of DME codesExamples include A9279, A999G, E0265, E0266, E0270, E0274, E0277, E0296, E0297 (chunk 21).

PA applicabilityPA is required only for certain DME items as noted (see DME entries and 'Additional information' threshold notes).

Genetic testing — notification and prior authorization

Program requirementAuthorization/Notification program applies to genetic and molecular testing CPT codes; prior authorization or notification is required for listed genetic testing codes (chunks 33, 36).

BRCA-specific noteNotification/prior authorization is required for BRCA testing before DNA sequencing is performed; the ordering health care professional must notify the laboratory conducting the test (chunk 36).

ScopeExtensive lists of genetic CPT codes (e.g., 81161, 81167–81168, 81200–81208, 81315–81346, 81504, 81519, 81522) are covered by the program (chunks 33, 36).

F64.* diagnosis requirement for gender-affirming procedures

Triggering diagnosis codesDiagnosis codes F64.* (specifically F64.0, F64.1, F64.2) are referenced as diagnoses that require prior authorization for certain gender-affirming surgical CPT codes (chunk 33).

ContextF64.* codes appear in the gender-affirming/experimental services section tied to listed surgical CPT codes (chunks 30–33).

Action requiredWhen procedures are billed for these diagnoses, prior authorization is required per the listed CPT entries and notes (chunks 30–33).

Ordering provider responsibilities for genetic tests requiring PA/notification

RequirementPrior authorization or notification is required for certain genetic tests before testing is performed; ordering provider responsibilities include notifying the laboratory and following the authorization/notification program (chunks 36, 33).

BRCA testing specificFor BRCA testing, notification/prior authorization is required before DNA sequencing is performed; the ordering provider must notify the laboratory conducting the test (chunk 36).

Code scopeApplies to the genetic/molecular CPT code lists provided in the policy (examples: 81161, 81200 series, 81315–81346, 81504, 81519, 81522).

Ventricular assist device (VAD) — definition

DefinitionVentricular assist device (VAD): a mechanical pump that takes over the function of the damaged ventricle of the heart and restores normal blood flow (chunk 71).

PA requirementMultiple VAD procedure/device codes require prior authorization and case management; providers instructed to contact the number on the member's ID and fax required forms to Optum VAD Case Management (see coverage section).

Related itemsVAD entries appear with device/procedure codes (e.g., 33927, 33928, 33929, Q0507, Q0508) in the VAD section of the policy (brief and coverage modules).