ModifiedUnitedHealthcarePolicy N/A

Prior authorization requirements for Indiana MLTSS Pathways

Provides prior authorization requirements and submission instructions for participating UnitedHealthcare Community Plan of Indiana providers for a variety of services (inpatient, outpatient, DME, genetic testing, behavioral health, etc.). Applies to providers participating in Indiana MLTSS Pathways.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Indiana MLTSS Pathways

Policy CodePolicy N/A

Change TypeMaterial updates (routing for Lenmeldynew PA for Aucatzyl)

Effective DateApr 1, 2025

Next Review DateN/A

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 July 1, 2024: For unclassified codes J3490, J3590 Lenmeldy will require prior authorization through Optum Transplant.

Effective April 1, 2025: Prior authorization required for Aucatzyl (C9301**).

PortalOnline submission

877-610-9785Phone

No PAEmergency/Urgent

$500DME threshold

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.

2025-04-01New PA effective

~150+Codes referenced

Coverage and Prior Authorization Criteria

High-level coverage requirements

Covered when ALL of the following apply:

Prior authorization is required for many non-emergency inpatient and outpatient services listed in this document (see specific categories and codes).

Prior authorization is NOT required for emergency or urgent care.

Out-of-network requests must be made by a network care provider.

Prior authorization criteria (summary)

Prior authorization/notification is required for the following categories and specific codes:

Genetic testing and molecular testing — prior authorization/notification required; BRCA testing requires notification/prior authorization before DNA sequencing is performed; the ordering provider must notify the laboratory.

Hysterectomy procedures — prior authorization required for listed hysterectomy CPT codes (examples shown in the document).

Injectable medications — prior authorization required for the comprehensive list of injectable medications identified by CPT/HCPCS (extensive J-/Q-code lists).

Prior authorization coverage criteria (partial)

Services and codes listed in this section require prior authorization as indicated.

Non-emergent air transport — prior authorization required.

Occupational/physical therapy services — prior authorization required; specific CPT codes are listed in the document.

Orthognathic surgery and impairment-related procedures — prior authorization required; specific CPT/HCPCS codes are listed.

Prostate procedures and related HCPCS/L-codes — prior authorization required; items with retail purchase or cumulative rental cost over $500 require prior authorization.

Injectable medications — prior authorization required for multiple J/Q-codes and named biologic/agents listed throughout the injectable medication sections.

Prior Authorization Coverage Criteria

Coverage stance for listed CPT/HCPCS codes

Prior authorization is required for the prostate CPT/HCPCS codes listed (examples include 52441 and 52442); participating physicians must obtain prior authorization before performing these services.

Prior authorization is required for radiology CPT/HCPCS codes listed in the radiology sections for participating physicians.

Radiology prior authorization requirement

Radiology coverage stance:

Prior authorization is required for participating physicians for the radiology CPT® or HCPCS codes listed in this section.

Radiology prior authorization

Radiology prior authorization note:

Radiology CPT/HCPCS codes shown in the document require prior authorization for participating physicians as noted in the radiology sections.

Radiology prior authorization requirement

Radiology prior authorization requirement:

Radiology services listed by CPT/HCPCS codes in the radiology sections require prior authorization for participating physicians.

Prior authorization requirement

Operational requirement:

Prior authorization is required for participating physicians for the radiology CPT/HCPCS codes referenced in this document.

Radiology prior authorization

Radiology prior authorization:

Prior authorization is required for participating physicians submitting radiology CPT® or HCPCS codes listed in this section.

Prior authorization criteria and codes (partial)

Prior authorization requirement and code lists referenced in this section:

Advanced outpatient imaging (certain CT, MRI, MRA, PET and nuclear medicine) — prior authorization is required for participating physicians for these advanced imaging procedures.

Remote patient monitoring — prior authorization is required for listed CPT codes (examples include 98975–98981; 98976, 98977, 98980 are listed in the document).

Note: Many radiology CPT/HCPCS code lines in this section are placeholders or repeated in the excerpt and should be referenced in the full document for exact code lists.

Prior authorization coverage stance

Services and codes requiring prior authorization (examples in this section):

Radiology: Certain advanced outpatient imaging procedures (CT, MRI, MRA, PET) require prior authorization for participating physicians.

Remote patient monitoring: CPT codes 98975–98981 (and listed related codes) require prior authorization.

Rhinoplasty: Codes 30400–30430 require prior authorization.

Speech therapy: Codes such as 92507, 92508, 92526 require prior authorization.

Spinal surgery: Codes 22856, 22860, 22867–22868 require prior authorization.

Stimulator implantation procedures (examples include 61885, 63650, 63685, 64555) require prior authorization.

Prior authorization code list

Codes and prior authorization instructions (excerpted):

Multiple HCPCS/Q/J codes are listed in the document and associated with prior authorization (examples include Q2056, Q2057, J3392, J3590, J3490, C9301); several are annotated as gene therapy or have asterisks in the source.

The document repeatedly references how to obtain prior authorization alongside listed codes (placeholders in the excerpt indicate refer to the full document or the provider portal/phone for submission).

Prior authorization requirements (partial)

Coverage actions and requirements noted in this section:

Effective July 1, 2024: Unclassified codes J3490 and J3590 (Lenmeldy) require prior authorization through Optum Transplant.

Effective April 1, 2025: Prior authorization required for Aucatzyl (C9301) as noted in the document.

Urine drug testing: Prior authorization is required for codes G0482 and G0483.

Ventricular assist devices (VAD) 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.

Prior authorization requirements (excerpt)

Prior authorization is required for the following services and codes; see listed codes and contact instructions.

Transplants and related services: prior authorization required; for CAR T-cell and certain transplant services contact Optum at the number provided or follow Optum routing instructions in the document.

Unclassified biologic/drug codes associated with Lenmeldy (J3490, J3590) require prior authorization through Optum Transplant effective July 1, 2024.

Aucatzyl (C9301) requires prior authorization effective April 1, 2025.

Urine drug testing codes G0482 and G0483 require prior authorization.

Wound VAC (HCPCS E2402) requires prior authorization.

CPT / HCPCS / J / Q Code Lists

Bariatric surgery CPT codesCPTCovered

43644	Bariatric surgery code example
43645	Bariatric surgery code example
43659	Bariatric surgery code example
43770	Bariatric surgery code example

Cochlear implants and auditory device codesmixedCovered

69930	Cochlear implant procedure
L8615	Cochlear device HCPCS
L8616	Cochlear device HCPCS
L8617	Cochlear device HCPCS

Durable Medical Equipment (DME) codesHCPCSCovered

A9279	DME/related code
E0265	DME HCPCS example
E0300	DME HCPCS example
K0108	DME/k-code example

Genetic testing codesCPTCovered

81162	BRCA genetic testing
81163	BRCA genetic testing
81164	BRCA genetic testing
81217	Genetic testing example

Examples of genetic and injectable codes requiring prior authorizationCPT | HCPCS | mixedCovered

81161	Genetic testing — listed
81318	Genetic testing — BRCA (BRCA sequencing prior auth required)
J3262	Actemra (example injectable listed)
J2182	Nucala
J2350	Ocrevus
J9312	Rituxan

Injectable medication HCPCS/J-codes (examples)HCPCS

J1747	HCPCS code listed for injectable medication (Somatuline Depot mentioned nearby)
J3358	HCPCS code listed for injectable medication
J9334	HCPCS code listed
Q5127	HCPCS code (Stimufend) listed
J9226	HCPCS code (Supprelin) listed
J2781	HCPCS code (Syfovre) listed
90378	Code listed for Synagis
J3241	HCPCS code (Tepezza) listed
J2356	HCPCS code (Tezspire) listed
J3315	HCPCS code (Trelstar) listed

1–10 of 15

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Therapy and prostate CPT codes (examples)CPT

97016	Therapeutic exercise/modalities code referenced under non-emergent air/therapy section
97018	Therapeutic procedure code
97022	Application of a modality
97116	Therapeutic procedure (gait training)
97139	Unlisted therapeutic procedure
97533	Sensory integrative techniques
52441	CPT for prostate procedure
52442	CPT for prostate procedure

Prostate proceduresCPT

52441	Prostate procedures (example listed in document)
52442	Prostate procedures (example listed in document)

Radiology codesCPT | HCPCS

No codes listed

Radiology CPT/HCPCS codes (listed repetitively)mixed

No codes listed

Radiology CPT/HCPCS codes (listed but not captured in this excerpt)CPT | HCPCS

No codes listed

Radiology CPT/HCPCS codes (placeholders)CPT | HCPCS

No codes listed

Radiology CPT/HCPCS codes (listed but not present in extracted chunks)CPT | HCPCS

No codes listed

Radiology CPT®/HCPCS codes listedmixed

No codes listed

Remote patient monitoring CPT codesCPT

98975
98976
98977
98980
98981

Examples of CPT/HCPCS codes requiring prior authorization in this sectionCPT

98975-98981	Remote patient monitoring setup and services
30400-30430	Rhinoplasty procedures
92507,92508,92526	Speech therapy evaluation and treatment codes
22856,22860,22867-22868	Spinal surgery codes
32852-32856,44136-44139,44715-44721,47135-47147,48550-48556,50300-50365	Selected organ/tissue transplant and related procedure codes

HCPCS/Q/J codes mentionedHCPCS

Q2056
J3392
Q2057
Q2042
J3394

HCPCS codes referencedHCPCS

Q2056	Listed and annotated as gene therapy
Q2057	Listed
J3392	Listed repeatedly
J3590	Listed (appears with an asterisk in several places)
J3490	Listed as gene therapy J3490*
C9301	Listed with double asterisks C9301**

Highlighted unclassified/gene therapy codesHCPCSCovered

J3490	Unclassified biologics / gene therapy J-code (Lenmeldy referenced)
J3590	Unclassified biologics / J-code
C9301	Code referenced for Aucatzyl prior authorization (C9301**)

Urine drug testing codesHCPCSCovered

G0482	Urine drug testing code
G0483	Urine drug testing code

VAD codesmixedCovered

33927	VAD-related CPT code
33928	VAD-related CPT code
33929	VAD-related CPT code
Q0507	VAD device HCPCS code

Transplant/unclassified drug codesHCPCS

J3490	Unclassified drug code (Lenmeldy)
J3590	Unclassified drug code (Lenmeldy)
Aucatzyl	Drug requiring PA (name referenced)

Urine drug testingHCPCS

G0482	Urine drug testing panel
G0483	Urine drug testing panel

Ventricular assist device codesCPT|HCPCS

33927	VAD procedure code
33928	VAD procedure code
33929	VAD procedure code
Q0507	VAD device code

Wound VAC codesHCPCS

E2402

Wound VAC device code

Submission Instructions and Provider Requirements

Note

Submission methods and exceptions

Submit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) using your One Healthcare ID and password, or call 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 -> Prior Authorization and Notification tab (One Healthcare ID required).
Phone: 877-610-9785
Prior authorization not required for emergency or urgent care.
Out-of-network requests must be submitted by a network care provider.

Prior Authorization

Injectable medications - prior authorization

Many injectable medications require prior authorization. Providers must obtain prior authorization before administering or billing for the listed injectable drugs and associated J-/Q-codes.

Prior authorization required for numerous injectable medications (selected examples): Actemra, Brineura, Brimvii, Byooviz, Cerezyme, Cimzia, Cinqair, Cinryze, Cosentyx, Crysvita, Cutaquig, Cuvitru, Daxxify, Dysport, Elaprase, Elelyso, Elfabrio, Enjaymo, Entyvio, Evkeeza, Evenity, Eylea, Fasenra, Fensolvi, Feraheme, Firmagon, Flebogamma DIF, Fylnetra, Gamifant, Gammagard, Gammaplex, Gamunex-C, Givlaari, Glassia, Hizentra, Hyqvia, Ilaris, Ilumya, Inflectra, Injectafer, IVIG (90283, 90284), J1459, J1599.

Key Terms and Thresholds

inv-75: Prior authorization

DefinitionA requirement to obtain approval from UnitedHealthcare before providing certain non-emergency services to ensure coverage eligibility and medical necessity.

ScopeApplies to participating UnitedHealthcare Community Plan of Indiana providers for specified inpatient and outpatient services (emergency and urgent care are excluded).

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

inv-76: DME prior authorization threshold

ThresholdPrior authorization is required for listed DME codes when the retail purchase or cumulative rental cost exceeds $500.

Applies to

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Indiana MLTSS Pathways

Policy CodePolicy N/A

Change TypeMaterial updates (routing for Lenmeldynew PA for Aucatzyl)

Effective DateApr 1, 2025

Next Review DateN/A

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

Transplants and transplant-related services (including CAR T-cell therapies) require prior authorization; contact Optum for transplant and CAR T-cell therapy authorizations as directed in the document.

Extensive list continues with many J-/Q-codes (see full policy coding list).

Providers should confirm the member's benefit coverage and obtain authorization prior to service.

Prior Authorization

Prior authorization requirement (radiology)

Prior authorization is required for many advanced radiology and imaging services (participating physicians). This includes certain advanced outpatient imaging procedures such as select CT, MRI, MRA, PET scans and nuclear medicine studies. Obtain authorization before scheduling these studies.

Prior authorization required for certain computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance angiography (MRA) and positron emission tomography (PET) scans.
Includes select nuclear medicine procedures and other advanced outpatient imaging.
Prior authorization applies to participating physicians — confirm requirements and obtain authorization before imaging.

Documentation Required

CPT/HCPCS codes referenced for prior authorization

This section lists CPT® and HCPCS codes referenced throughout the prior authorization requirements. Providers must use these codes when submitting prior authorization requests and follow any program-specific submission instructions.

Genetic testing examples: 81161, 81167, 81168, 81200–81208, 81218–81231, 81232, 81302–81311, 81315–81323, 81328, 81330, 81335, 81346, 81504, 81519, 81522.
Radiology and remote monitoring examples: select advanced imaging CPT/HCPCS (see policy), Remote patient monitoring: 98975–98981, 98976–98980.
Speech/therapy examples: 92507, 92508, 92526. Occupational/physical therapy examples: 97024, 97033, 97039, 97116, 97139, 97533, 97026, 97028, 97032.
Spinal/surgical/stimulator examples: 22856, 22860, 22867, 22868, 30400–30430 (rhinoplasty), 61885, 63650, 63685, 64555.
Transplant and CAR T-cell services: multiple CPT codes listed; contact Optum for CAR T-cell and some transplant authorizations (Optum: 888-936-7246).
Urine drug testing: G0482, G0483.
Ventricular assist device (VAD) codes: 33927, 33928, 33929, Q0507.
Prostate procedures and DME lists include numerous L- and E- codes (see policy).
Unclassified drug codes and gene therapies: J3490, J3590 (Lenmeldy — PA via Optum Transplant effective July 1, 2024); Aucatzyl (C9301) — PA required effective April 1, 2025.

Prior Authorization

Wound VAC prior authorization

Wound VAC (negative pressure wound therapy) requires prior authorization. Use HCPCS code E2402 when submitting a prior authorization request for wound VAC therapy.

Wound VAC prior authorization required.
Relevant HCPCS: E2402.
Obtain authorization before providing or billing Wound VAC supplies/services.

Durable medical equipment codes explicitly listed in the DME section of the document.

NoteProsthetics are not categorized as DME per the document notes.

inv-77: Prior Authorization/Notification

Program definitionPrior Authorization/Notification: a program requiring notification or prior authorization for each specified genetic test and other listed services.

Ordering provider obligationFor genetic tests, the ordering health care professional must notify the laboratory and the laboratory will notify UnitedHealthcare.

ExceptionsPrior authorization is not required for emergency or urgent care; out-of-network requests must be made by a network care provider.

inv-78: BRCA testing prior authorization

RequirementNotification/prior authorization is required for BRCA testing before DNA sequencing is performed.

ScopeBRCA testing is listed within the genetic testing section and is subject to the Prior Authorization/Notification program.

Provider actionOrdering provider must follow the program procedures and ensure laboratory notification as instructed.

inv-79: purchase_or_cumulative_rental_cost_threshold

Threshold value> $500 retail purchase or cumulative rental triggers prior authorization.

ContextApplies to durable medical equipment items listed in the DME section.

Document referenceReferenced repeatedly in DME/prostate sections where purchase/rental costs are discussed.

inv-80: Prior authorization

RequirementPrior authorization is required for the listed CPT/HCPCS prostate procedures before performing the service.

ExamplesDocument lists prostate CPT examples such as 52441 and 52442 as subject to prior authorization.

Related DME thresholdSome prostate-related HCPCS/L-codes note that items with retail purchase or cumulative rental cost > $500 require prior authorization.

inv-81: Prior authorization (radiology)

RequirementPrior authorization is required for participating physicians for the listed radiology CPT® or HCPCS codes, including certain advanced outpatient imaging procedures.

Advanced imaging examplesIncludes certain CT, MRI, MRA and PET scans as noted under advanced outpatient imaging.

Instruction placeholdersMany radiology code lines include placeholder 'how to obtain prior authorization' entries in the excerpt.

inv-82: Prior authorization

Requirement statementPrior authorization is required for participating physicians for radiology services listed in the document.

Operational noteThe document repeats the operational note that participating physicians must obtain prior authorization for radiology codes.

PlaceholdersSpecific 'how to obtain prior authorization' entries appear as placeholders in many radiology lines within the excerpt.

inv-83: Prior authorization

RequirementPrior authorization is required for participating physicians for the radiology CPT/HCPCS codes referenced in this section.

RepetitionThe requirement statement is repeated across multiple radiology code group chunks in the document.

Next stepsProviders should consult the full radiology section or portal for code-specific authorization instructions due to placeholders in the excerpt.

inv-84: CPT® or HCPCS codes and how to obtain prior authorization

Placeholder entriesThe document includes CPT® or HCPCS code lines that reference 'how to obtain prior authorization' but many appear as '.' placeholders in this excerpt.

Examples presentSeveral Q- and J-codes (e.g., Q2056, J3392) appear alongside placeholder instructions for authorization.

Action for providersWhen placeholders are present, providers should use the Provider Portal or the contact numbers listed to submit prior authorization requests.

inv-85: Prior authorization (radiology)

RequirementPrior authorization is required for participating physicians for the radiology CPT® or HCPCS codes listed in this section.

Document patternRadiology entries are repeated across multiple chunks indicating broad prior authorization coverage for radiology services.

Provider guidanceUse the Provider Portal or contact the plan when radiology 'how to obtain prior authorization' details are not specified in-line.

inv-86: Advanced outpatient imaging

ScopeAdvanced outpatient imaging procedures include certain CT, MRI, MRA, PET scans and nuclear medicine studies.

Authorization requirementPrior authorization is required for participating physicians for these advanced outpatient imaging procedures.

ReferenceSee the radiology and advanced imaging sections for code-level listings and submission instructions.

inv-87: Optum contact for transplant and CAR T-cell therapy

Contact for referral/authorizationFor transplant and CAR T-cell therapy services (including Carvykti, Kymriah, Yescarta), contact Optum at 888-936-7246 or the number on the member's health plan ID card.

ScopeApplies to transplant and CAR T-cell therapy prior authorization and routing as specified in the transplants section.

ExamplesTransplant CPT codes (e.g., 32852, 32856) are listed in the transplant section and require prior authorization.

inv-88: how to obtain prior authorization (placeholder)

Placeholder statusEntries labeled 'how to obtain prior authorization' appear throughout the document but many are not populated in this excerpt (appear as '.' placeholders).

ImplicationWhen an entry is a placeholder, providers should rely on the Provider Portal or plan contact numbers for submission details.

ExamplesPlaceholders are present notably in radiology and other code lists across the excerpted chunks.

inv-89: Gene therapy

DefinitionGene therapy: referenced in the document as a category requiring prior authorization for associated codes (e.g., Q2056, J3490 with annotations).

Code examplesDocument references gene therapy entries and associated annotations such as J3490* and Q2056 in the gene therapy section.

Provider actionFollow transplants/gene therapy prior authorization routing and contact Optum as directed for CAR T-cell and related therapies.

inv-90: Lenmeldy

Lenmeldy routingEffective July 1, 2024: Unclassified codes J3490 and J3590 for Lenmeldy require prior authorization through Optum Transplant.

Impacted codesJ3490, J3590 (unclassified J-codes) associated with Lenmeldy.

Effective dateJuly 1, 2024 for Optum Transplant prior authorization requirement for Lenmeldy unclassified codes.

inv-91: Ventricular assist device (VAD)

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

CodesVAD-related CPT/HCPCS codes listed include 33927, 33928, 33929 and Q0507.

Provider processCall the number on the member's health plan ID card and fax the nurse-provided form to Optum VAD Case Management at 855-282-8929 for prior authorization submission.

inv-92: Ventricular assist device (VAD) duplicate

Definition (duplicate)Ventricular assist device (VAD): a mechanical pump that takes over the function of the damaged ventricle and restores normal blood flow.

Submission instructionsPrior authorization required; providers should call the number on the member's ID card and fax the provided form to Optum VAD Case Management at 855-282-8929.

Codes listed33927, 33928, 33929, Q0507 are cited as VAD-related codes requiring prior authorization.