CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Indiana MLTSS Pathways

Lists services and CPT/HCPCS/DME codes that require prior authorization for participating UnitedHealthcare Community Plan of Indiana providers and describes how to submit requests. Applies to providers participating in Indiana MLTSS Pathways.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Indiana MLTSS Pathways

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 1, 2024

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleservice categories listed

dozensCPT/HCPCS/DME codes enumerated

1phone number provided

1online portal described

multipleentries noting 'Prior authorization is required'

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Services and Coverage Criteria Requiring Prior Authorization

Coverage criteria summary

Coverage requires prior authorization for the listed services and codes. Some services include additional notes such as Center of Excellence requirements or network routing.

Prior authorization is required for the services and CPT/HCPCS/DME codes listed below.

Examples of service categories requiring prior authorization

Bariatric surgery (e.g., CPT 43644, 43645, 43659, 43770, 43771-43775, 43842-43847) — Center of Excellence requirement for coverage noted.
Behavioral health services — Many plans route behavioral health through a designated behavioral health network; prior authorization is required.
Breast cancer (BRCA) genetic testing (e.g., CPT 81162–81166, 81212, 81215–81217) — notification/prior authorization required.
Durable medical equipment (DME) — prior authorization required only for the DME codes listed in the policy.
Enteral services (e.g., HCPCS B4149–B4161) — prior authorization required.
Experimental and investigational procedures (examples include CPT 33477, 96002 and listed HCPCS A9274–A9278, E1831) — prior authorization required.
Gender dysphoria treatment (listed CPT codes such as 15832–15839, 54660, 55970) — prior authorization required.

Prior authorization and notification requirements

Coverage stance for listed services in this excerpt

Prior authorization is required for the HCPCS/CPT codes and services enumerated (examples include enteral services, genetic testing, home health, hysterectomy, and listed injectable medications).

For certain genetic and molecular tests (including BRCA), the ordering health care professional must notify the laboratory and the laboratory will notify UnitedHealthcare; notification/prior authorization workflow applies.

Home health services (e.g., G0151–G0153) require prior authorization.

Hysterectomy procedures listed (examples shown) require prior authorization.

Prior authorization is required for the injectable medications listed (multiple J-codes shown in the policy).

Summary criteria

Prior authorization requirements by service category and code.

Neurostimulators — Prior authorization required (example code 61850).

Non-emergent air ambulance transport — Prior authorization required (codes A0430, A0431).

Occupational and physical therapy services listed require prior authorization (examples: 97012, 97016, 97110, 97112, 97530, etc.).

Orthotics and prosthetics — Prior authorization required for listed codes when retail purchase or cumulative rental cost exceeds $500.

Unclassified/temporary J-codes (J3490, J3590) — Prior authorization required only for specific drugs named in the policy (Casgevy, Lantidra, Nulibry, Revcovi, Rivfloza, Ryplazim, Scenesse, Uplizna, Vabysmo).

Prior authorization criteria (partial)

Prior authorization and notification requirements

Orthotics and prosthetics: codes listed with a retail purchase or cumulative rental cost of more than $500 require prior authorization.

Advanced outpatient imaging (selected CT, MRI/MRA, PET, nuclear medicine): participating physicians must provide notification prior to scheduling; prior authorization is required for certain advanced outpatient imaging procedures.

Remote patient monitoring — prior authorization required for the listed CPT codes (e.g., 98975–98981 and related codes).

Rhinoplasty and speech therapy: listed codes require prior authorization (speech therapy examples include 92507, 92508, 92526).

Prior authorization requirements

The following services are subject to prior authorization before being provided:

Speech therapy — Prior authorization required (CPT 92507, 92508, 92526).

Spinal surgery — Prior authorization required (examples: CPT 22856, 22860, 22867, 22868).

Stimulators — Prior authorization required (examples: CPT 61863, 61864, 61867, 61868).

Transplants and transplant-related pre-treatment/evaluation — Prior authorization required; transplant and CAR T‑cell therapy referral/authorization handled via Optum (policy references Optum contact). Codes include L8688, L8689 and related CPTs (e.g., 32851–32854).

Prior authorization requirement (codes)

Codes listed require prior authorization for pre‑treatment or evaluation and for organ/tissue transplant related services.

Prior authorization is required for the CPT/HCPCS codes listed for related pre‑treatment/evaluation services (examples include 32851–32854 and additional transplant‑related procedure codes).

Multiple CPT/HCPCS procedure codes enumerated for organ or tissue transplant and transplant‑related services require prior authorization before pre‑treatment or evaluation.

Prior authorization criteria for transplant services

Prior authorization is required for listed transplant-related CPT/HCPCS codes prior to pre‑treatment or evaluation.

Organ or tissue transplant and transplant‑related services require prior authorization prior to pre‑treatment or evaluation.

The policy lists specific CPT codes associated with transplant‑related procedures (examples include 44136, 44137, 44715, 44720, 47135–47147, 48550–48556 and others) that are included in the prior authorization listing.

Prior authorization codes (incomplete)

Codes listed for prior authorization; specific coverage criteria not present in this fragment.

The document enumerates multiple CPT/HCPCS codes (examples shown: 48554, 50325, 50300, 50327, 50320, 50323) tied to prior authorization, but detailed coverage criteria or submission steps are not present in this excerpt.

Prior authorization codes

This section enumerates procedure codes for which prior authorization instructions are provided elsewhere in the policy.

A listing of CPT/HCPCS procedure codes (examples include 48554, 50300, 50320, 48552) appears under the heading 'how to obtain prior authorization'; the excerpt shows code enumeration but detailed instructions are not included in this fragment.

CPT / HCPCS / DME / Other Codes (Examples and Groups)

Bariatric surgery codes (examples)CPTCovered

43644	Bariatric surgery code listed as requiring prior authorization
43645	Bariatric surgery code listed as requiring prior authorization
43659	Bariatric surgery code listed as requiring prior authorization
43770	Bariatric surgery code listed as requiring prior authorization

BRCA genetic testing codes (examples)CPTCovered

81162	BRCA genetic testing code requiring prior authorization
81163	BRCA genetic testing code requiring prior authorization
81164	BRCA genetic testing code requiring prior authorization
81165	BRCA genetic testing code requiring prior authorization

Durable Medical Equipment / DME codes (examples)HCPCSCovered

E0270	DME code requiring prior authorization
E0300	DME code requiring prior authorization
K0821	DME/orthotics/prosthetics code requiring prior authorization
Q0481	DME/procedure code requiring prior authorization

Cochlear implants and experimental procedure codes (examples)mixedCovered

69930	Cochlear implant procedure code requiring prior authorization
L8615	Cochlear implant device code requiring prior authorization
33477	Procedure listed under experimental and investigational requiring prior authorization

Injectable medications and related HCPCS/CPT codesHCPCS | CPTCovered

J0179	Berinert
J0597	Bivigam
J1556	Botox
J0585	Brineura
J0567	Briumvi
J2329	Byooviz
Q5124	Cerezyme
J1786	Cimerli
Q5128	Cimzia
J0717	Cinqair

1–10 of 91

1/10

Genetic and molecular testing codesCPTCovered

81269	Genetic testing (listed)
81270	Genetic testing (listed)
81276	Genetic testing (listed)
81277	Genetic testing (listed)
81278	Genetic testing (listed)
81279	Genetic testing (listed)
81292	Genetic testing (listed)
81293	Genetic testing (listed)
81294	Genetic testing (listed)
81295	Genetic testing (listed)

1–10 of 36

1/4

Selected injectable HCPCS/CPT codesHCPCSCovered

J3397	Mepsevii
J3490	Unclassified (see exceptions)
J3590	Unclassified (see exceptions)

Air ambulance codesHCPCSCovered

A0430	Non-emergent air ambulance transport
A0431	Non-emergent air ambulance transport

Orthotics/prostheticsHCPCSCovered

L3252	Orthotic/prosthetic supply
L3649	Orthotic/prosthetic supply

Orthotics and prosthetics (partial)HCPCS

L3252	Orthotics/prosthetics HCPCS code listed in orthotics/prosthetics section
L3649	Orthotics/prosthetics HCPCS code listed in orthotics/prosthetics section
L2006	Orthotics/prosthetics HCPCS code listed in orthotics/prosthetics section

Radiology (examples)CPT

52441	Radiology CPT code listed
52442	Radiology CPT code listed

Remote patient monitoringCPT

98975	Remote patient monitoring CPT code
98976	Remote patient monitoring CPT code
98977	Remote patient monitoring CPT code
98980	Remote patient monitoring CPT code
98981	Remote patient monitoring CPT code

RhinoplastyCPT

30400	Rhinoplasty CPT code
30410	Rhinoplasty CPT code
30420	Rhinoplasty CPT code
30430	Rhinoplasty CPT code

Speech therapyCPT

92507	Speech therapy CPT code
92508	Speech therapy CPT code
92526	Speech therapy CPT code

Speech therapy CPT codesCPTCovered

92507	Speech therapy
92508	Speech therapy
92526	Speech therapy

Spinal surgery CPT codesCPTCovered

22856	Spinal surgery
22860	Spinal surgery
22867	Spinal surgery
22868	Spinal surgery

Stimulator CPT codesCPTCovered

61863	Stimulators
61864	Stimulators
61867	Stimulators
61868	Stimulators

Transplant and related service codesmixedCovered

L8688	Transplant-related HCPCS
L8689	Transplant-related HCPCS
32851	Related services before pre-treatment or evaluation
32852	Related services before pre-treatment or evaluation
32853	Related services before pre-treatment or evaluation
32854	Related services before pre-treatment or evaluation

Transplant and related procedures (partial)CPT | HCPCS

32855	transplant related
33933	transplant related
33935	transplant related
33944
38241
38232
38240
38206
38242
38243

1–10 of 15

1/2

Transplant-related CPT codesCPT

44136
44721
44137
38230
44715
44720
47144
47135
48550
47145

1–10 of 16

1/2

Procedure codes (fragmented)CPT

48550
48554
48556
50300
50320
50323
50325
50327
50328
50329

Explicitly listed CPT codesCPT

50325
50327
50328
50329

Extracted CPT codesCPT

50325	Listed in the prior authorization code list
50327	Listed in the prior authorization code list
50328	Listed in the prior authorization code list
50329	Listed in the prior authorization code list

Procedure codes shownCPT

50325
50327
50328
50329

Procedure codes referenced for authorizationCPT

48554
50325
50327
50320
50323

Referenced CPT/HCPCS codes (partial)CPT

48554
50300
50320
48552
50323

Procedure codes referencedCPT

48550
48554
50300
48551
48552

Surgical CPT examples presentCPT

48550
48556
48551
47147

Additional CPT exampleCPT

47146

More CPT codesCPT

47144
47145
47143

Orthotics/prosthetics prior authorization threshold

ThresholdRetail purchase or cumulative rental cost greater than $500 requires prior authorization for orthotics/prosthetics.

Applies toOrthotics and prosthetics HCPCS codes listed in the policy (examples: L3252, L3649, L2006).

Action requiredSubmit prior authorization before providing items when the retail purchase or total rental cost exceeds $500.

Retail purchase or cumulative rental cost threshold

Threshold amountMore than $500 (retail purchase or cumulative rental cost).

ScopeCertain orthotics/prosthetics codes listed in the policy (see orthotics/prosthetics code group).

TriggerPrior authorization is triggered when single purchase or cumulative rentals exceed the $500 threshold.

How Providers Request Authorization and Operational Requirements

Prior Authorization

How to request prior authorization — Submit requests online or by phone.

Submit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by phone at 877-610-9785. Prior authorization is not required for emergency or urgent care. Providers are required to request approval before rendering services. Advance notification is required for prospective, concurrent and retrospective care review.

Online: Use the Prior Authorization and Notification tool at UHCprovider.com (sign in with One Healthcare ID).
Phone: Call 877-610-9785.
Prior authorization is required before non-emergent services are rendered; advance notification supports prospective, concurrent and retrospective review.

Prior Authorization

CPT/HCPCS codes and prior authorization (consolidated list)

The following CPT and HCPCS codes, and grouped code blocks from the source, require prior authorization or notification. This consolidated list represents all fragmented and repeated entries from the source and highlights code groups and notable operational notes. Providers must obtain prior authorization for these services and codes per UnitedHealthcare requirements.

Bariatric surgery: 43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847
Breast cancer (BRCA) genetic testing and related molecular/genetic testing: 81162–81166, 81212, 81215, 81218–81219, 81228–81232, 81235, 81238, 81243–81254, 81309–81311, 81315–81319, 81321–81323, 81328, 81330, 81335, 81346, 81504, 81519, 81522
Breast reconstruction: 19316, 19318, 19325, 19340, 19342, 19350, S2067
Cochlear implants and auditory devices: 69930, L8615–L8619, L8618
Durable medical equipment (selected): A9279, A9999, E0265, E0266, E0424, E0441
Enteral services: B4149, B4150, B4152–B4155, B4158–B4161
Experimental / investigational items: 33477, 96002, A9274, A9276–A9278, E1831
Gender dysphoria treatment (selected): 15832–15839, 54660, 55970
Home health care: G0151–G0153
Hysterectomy procedures: 51925, 58152, 58200, 58210, 58240, 58263, 58267, 58270, 58275, 58280, 58285, 58292, 58294, 58548, 59897
Injectable medications: (extensive J/Q codes list) examples include J3397, J1437, J0587, J1458, J0219, J2796, J2182, Q5122, J2350, J1568, J2354, J2267, J0222, J0129, J0224, J1576, J0606, J1203, J0897, J0802, J1304, J1301, J0896, Q5125, J1745, Q5104, Q5123, J9312, J9311, J1449, J0596, Q5119, J2998, J9333, J2353, J0491, J7352, J1602
Unclassified/temporary J-codes: J3490/J3590 require prior authorization only for specific drugs: Casgevy, Lantidra, Nulibry, Revcovi, Rivfloza, Ryplazim, Scenesse, Uplizna, Vabysmo
Neurostimulators / Stimulators: 61850, 61860, 61863, 61864, 61867, 61868
Non-emergent air ambulance: A0430, A0431
Occupational and physical therapy / related services: extensive list including 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97129, 97130, 97139, 97140, 97150, 97530, 97533, 97535, 97537, 97542, 97760–97763, 97799, G0281–G0283

Note

Special operational notes for transplants, CAR T-cell therapy, specialty drugs and genetic testing

When arranging transplant or CAR T-cell therapy services (including Carvykti, Kymriah, Yescarta), contact Optum at 888-936-7246 or the number on the member ID card to coordinate prior authorization. For other listed services, use the Prior Authorization and Notification tool or the general phone line.

Transplant/CAR T-cell coordination: Optum 888-936-7246.
For injectable medications and specialty drugs see the detailed J/Q code list above; for unclassified J3490/J3590 only specific drugs require authorization (see list).
Order genetic/molecular testing only after completing the ordering/provider and laboratory notification steps; laboratories will notify UnitedHealthcare as required.

Terms and Definitions

Prior authorization (definition)

DefinitionPrior authorization is the required approval from UnitedHealthcare Health Services before rendering certain services to enable prospective, concurrent, and retrospective care review.

PurposeTo provide UnitedHealthcare timely communication of services so the plan can perform care review and determine coverage before services are rendered.

Provider responsibilityProviders are required to request approval before rendering services (advance notification is required).

Services for which prior authorization is not required

Not subject to prior authorizationEmergency or urgent care services do not require prior authorization.

Out-of-network noteOut-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services.

Submission methodsRequests can be submitted online via the UnitedHealthcare Provider Portal or by phone at 877-610-9785 (see 'How to request prior authorization').

Enteral services

DefinitionEnteral services are listed with specific HCPCS codes (examples include B4149, B4150, B4152, B4153, B4155, B4158, B4159, B4160, B4161).

RequirementPrior authorization is required for the enteral services and HCPCS codes listed in the policy.

ActionObtain prior authorization for enteral supplies and products identified by the listed HCPCS codes before provision.

Experimental and investigational

ClassificationCertain codes and items are labeled as experimental and investigational in the policy (examples shown: 33477, 96002, A9274, A9277, A9278, E1831).

RequirementPrior authorization is required for items identified as experimental or investigational.

ImplicationThese items may be subject to denial risk if not pre-authorized per policy guidance.

BRCA testing

Specific serviceBRCA genetic testing (multiple CPT codes listed such as 81309–81311, 81315–81318, 81319, 81321–81323, 81328, 81330, 81335, 81346).

RequirementNotification/prior authorization is required for BRCA testing; the ordering provider must notify the laboratory and the laboratory will notify UnitedHealthcare for certain tests.

Provider actionFollow the policy's prior authorization/notification workflow when ordering listed genetic/molecular tests.

J3490/J3590 — unclassified J-code exceptions

CodesUnclassified/temporary J-codes J3490 and J3590 are included in the listing.

ExceptionPrior authorization for J3490/J3590 is required only for specific drugs named in the policy (Casgevy, Lantidra, Nulibry, Revcovi, Rivfloza, Ryplazim, Scenesse, Uplizna, Vabysmo).

ActionCheck the policy's named-drug exceptions before seeking authorization for unclassified J-codes.

Advanced outpatient imaging

ServiceAdvanced outpatient imaging (selected CT, MRI/MRA, PET, nuclear medicine).

Notification requirementHealth care professionals ordering an advanced outpatient imaging procedure are responsible for providing notification prior to scheduling the procedure.

Prior authorizationPrior authorization is required for participating physicians who request certain advanced outpatient imaging procedures.

Optum contact for transplant and CAR T-cell therapy

ContactFor transplant and CAR T-cell therapy services (e.g., Carvykti, Kymriah, Yescarta) call Optum at 888-936-7246 or the number on the member ID card.

ScopeThis contact applies to transplant and CAR T-cell therapy referral and authorization coordination per the policy.

Provider actionCall Optum at the specified number prior to pre-treatment or evaluation for transplant/CAR T authorization instructions.

Prior authorization required

RequirementPrior authorization is required for the services and codes listed in this policy before rendering services (prospective, concurrent and retrospective care review).

How to requestSubmit requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by phone at 877-610-9785.

Exceptions/notesEmergency or urgent care do not require prior authorization; out-of-network providers must request prior authorization for all procedures and services.

Organ or tissue transplant related services

ScopeOrgan or tissue transplant and transplant-related procedures and related pre-treatment/evaluation services are listed with CPT/HCPCS codes in the policy.

RequirementPrior authorization is required before pre-treatment or evaluation for organ/tissue transplant and transplant-related services.

ExamplesPolicy lists multiple CPT/HCPCS codes associated with transplant-related services (examples include 44136, 44137, 44715, 44720 and others).

Transplant-related services

DefinitionTransplant-related services are procedures and services associated with transplantation that must receive prior authorization before pre-treatment or evaluation.

Provider actionObtain prior authorization for listed transplant-related CPT/HCPCS codes prior to scheduling pre-treatment or evaluation.

Additional supportFor CAR T-cell and some transplant services, contact Optum as directed in the policy (see Optum contact).

CPT/HCPCS code list (partial)

ContentPartial list of CPT/HCPCS procedure codes referenced in the policy for prior authorization purposes (many entries in the excerpt are incomplete or placeholders).

Examples shownExamples of CPT codes included in the excerpt: 48550, 48551, 48552, 48554, 48556, 50300, 50320, 50323, 50325, 50327–50329.

NoteDetailed 'how to obtain prior authorization' instructions are paired with these codes elsewhere in the policy; this excerpt contains repeated/fragmented listings.

How to obtain prior authorization

Primary methodsOnline via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by phone at 877-610-9785.

TimingProviders must request approval before rendering services; advance notification is required for prospective, concurrent and retrospective care review.

NotesSome CPT/HCPCS entries in the policy include specific 'how to obtain prior authorization' pairing; follow the code-specific instructions in the full policy.

CPT/HCPCS codes (prior authorization section)

Codes referencedCPT/HCPCS codes shown in the prior authorization sections include examples such as 50325, 50327, 50328, 50329 (repeated across the excerpt).

ContextThese codes appear under the header 'CPT ® or HCPCS codes and how to obtain prior authorization' paired with instructions elsewhere in the policy.

CompletenessThe excerpt contains many blank placeholders; consult the full policy for complete code/instruction mappings.

CPT/HCPCS prior authorization instructions

Instruction headerSections titled 'CPT ® or HCPCS codes and how to obtain prior authorization' list procedure codes alongside the prior authorization instruction fields.

ExamplesCodes explicitly repeated in these sections include 50325, 50327, 50328, 50329 and others shown across fragments.

Provider guidanceWhen a CPT/HCPCS code is listed under these sections, follow the associated prior authorization process indicated in the complete policy and use the Provider Portal or phone number provided to request authorization.

CPT/HCPCS prior authorization list (fragmented)

PurposeThese entries enumerate CPT/HCPCS procedure codes and indicate they are tied to the prior authorization process; many entries in the excerpt are placeholders or repeated fragments.

Representative codesExamples shown repeatedly include 50325, 50327, 50328, 50329 and 48554, 50320, 50323 in different fragments.

Follow-upProviders should reference the full policy mapping for code-specific prior authorization steps and submit requests via portal or phone.