CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Indiana Hoosier Care Connect

Lists services and CPT/HCPCS/diagnosis codes that require prior authorization (or are exempt) for participating UnitedHealthcare Community Plan of Indiana providers; includes submission methods and special program requirements.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Indiana Hoosier Care Connect

Policy CodePolicy N/A

Change TypeAdministrative — no material changes

Effective DateJul 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

No material clinical or coverage changes in this revision.

online, phonesubmission methods

877-610-9785prior auth phone

7/1/2025effective

bariatricCOE requirement

prior authgenetic testing

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.

transplant/CAR-T routing

Coverage and Authorization Criteria

Extracted coverage criteria (partial)

Service-level coverage notes and examples in this extract:

Bariatric surgery and related services: Prior authorization is required; a Center of Excellence requirement applies for coverage in certain situations.

Cochlear implants and other auditory implants: Prior authorization is required for listed cochlear/implant codes.

Behavioral health services: Prior authorization is required for specified behavioral health/substance use codes; providers should call the number on the member's health plan ID card for specifics.

Breast reconstruction and related procedures: Prior authorization is required except when performed with specific diagnosis codes listed in the document (notification/prior authorization not required for those diagnosis codes).

Cosmetic and reconstructive procedures: Prior authorization is required for many listed procedure codes; some procedure–diagnosis pairings are exempt as noted in the document.

Surgery/procedure authorization criteria

Surgical/procedural codes may be exempt from prior authorization when billed with specific diagnosis codes; otherwise prior authorization required.

Notification/prior authorization not required when billed with listed Dx codes

Codes 19340, 19316, 19318, 19325 (and others listed) — notification/prior authorization is NOT required when paired with the specific diagnosis codes listed in the document.

All other surgical/procedural code and diagnosis combinations not meeting the listed exemptions require prior authorization.

DME authorization criteria

Durable medical equipment (DME) rules and how to obtain prior authorization.

DME HCPCS codes enumerated in the document (E02xx, E03xx, E04xx, E04xx, etc.) — some items require prior authorization; certain items are 'required only for DME.'

Rental cost threshold: items with a retail purchase or cumulative rental cost above the documented threshold (rental cost of more than $500) require prior authorization.

Note: Prosthetics are not considered DME — prosthetics are handled separately (see orthotics/prosthetics policy sections).

Genetic testing authorization criteria

Genetic and molecular testing requires prior authorization for listed CPT codes.

Prior authorization is required for genetic and molecular testing for the CPT codes enumerated in the document (examples include 81161, 81167, 81168, 81200, and many additional CPT codes listed).

The authorization/notification process must be completed by the ordering health care professional and/or the requesting laboratory as described in the document.

Authorization requirements

Authorization/notification requirements

Genetic testing authorization: Prior authorization is required for genetic and molecular testing; the ordering provider must notify the laboratory and the laboratory will notify UnitedHealthcare.

BRCA testing notification: Notification or prior authorization is required for BRCA testing before DNA sequencing is performed.

Injectable medications: Prior authorization is required for the injectable medications listed in the document (extensive J‑code and HCPCS listing).

Coverage requirements — prior authorization

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

Non-emergent air ambulance transport: Prior authorization is required for codes A0430 and A0431.

Remote patient monitoring (RPM): Prior authorization is required for CPT codes 98975, 98976, 98977 and 98980.

Transplant and CAR T-cell therapy: Prior authorization is required for transplant and CAR T-cell therapy services; for CAR T and gene therapy services call Optum at 888-936-7246 or the number on the member ID card. Certain unclassified codes (eg, J3490, J3590) for specific products require Optum Transplant authorization.

Orthotics and prosthetics threshold: Prior authorization is required only for orthotics/prosthetic codes with retail purchase or cumulative rental cost above the documented threshold.

Wound vacuum devices: Prior authorization is required for wound vac services (for example E2402) as listed.

Relevant CPT / HCPCS / DME Codes

Bariatric CPT codesCPTCovered

43644	Listed bariatric procedure code
43645	Listed bariatric procedure code
43659	Listed bariatric procedure code
43770	Listed bariatric procedure code
43771	Listed bariatric procedure code
43772	Listed bariatric procedure code
43773	Listed bariatric procedure code
43774	Listed bariatric procedure code
43775	Listed bariatric procedure code
43842	Listed bariatric procedure code

1–10 of 15

1/2

BRCA genetic testing CPT/HCPCS codesCPTCovered

81162	BRCA testing code
81163	BRCA testing code
81164	BRCA testing code
81165	BRCA testing code
81166	BRCA testing code
81212	BRCA testing code
81215	BRCA testing code
81216	BRCA testing code
81217	BRCA testing code
81167	BRCA testing code

Cochlear and auditory device codesmixedCovered

69930	Cochlear implant procedure code
L8615	Cochlear implant device code
L8616	Cochlear implant device code
L8617	Cochlear implant device code
L8618	Cochlear implant device code
L8619	Cochlear implant device code
L8627	Cochlear implant device code
L8628	Cochlear implant device code
L8691	Implant device code
L8692	Implant device code

1–10 of 11

1/2

Cosmetic/reconstructive and breast procedure codes (examples and many diagnosis-code exceptions shown)CPTCovered

19316	Breast reconstruction/mastopexy related code (listed among many breast procedure codes)
19342	Breast procedure code
19318	Breast procedure code
19325	Breast procedure code
19340	Breast procedure code
S2067	Breast procedure add-on or supply code
S2068	Breast procedure add-on or supply code
15781	Cosmetic/reconstructive code
15782	Reconstructive code
15783	Reconstructive code

1–10 of 23

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Selected DME HCPCS examplesHCPCS

E0442	DME - oxygen system, rental
E0439	DME - oxygen concentrator

Genetic testing CPT examplesCPTCovered

81161	Genetic testing CPT example
81200	Genetic testing CPT example

Sample genetic CPT codes (document lists many)CPT

81161	Genetic testing (listed in document)
81167	Genetic testing (listed in document)
81168	Genetic testing (listed in document)
81200	Genetic testing (listed in document)

Injectable HCPCS/J-codes (partial list)HCPCSCovered

J3262	Actemra
J0801	Acthar
J7171	Adzynma
J1931	Aldurazyme

Injectable medications (continued)HCPCS

J1558	Injectable medication (listed)
J0218	Injectable medication (listed)
J0588	Injectable medication (listed)
Q5100	Yesintek IV
J9202	Injectable medication (listed)

Occupational/physical therapy codesCPTCovered

97012	Occupational/physical therapy
97110	Therapeutic exercises
97116	Gait training
G0281	Supervised physical therapy

Wound vacHCPCSCovered

E2402

Wound VAC

Center of Excellence requirement

Applies toBariatric surgery and related obesity services

RequirementCenter of Excellence (COE) designation required for coverage of bariatric surgery and services in certain situations

Relevant codes (examples)43644, 43645, 43659, 43770–43775, 43842–43848

rental cost threshold

Threshold

How Providers Should Submit Requests and Where to Route

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com — 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 a network care provider.

Prior Authorization

Examples of services requiring prior authorization and program notes

Certain services require prior authorization and may have additional program requirements (for example, bariatric surgery has a Center of Excellence requirement). Examples include bariatric procedures, cochlear implants, and many cosmetic/reconstructive procedures — see the listed CPT/HCPCS codes for details.

Bariatric surgery: prior authorization required; Center of Excellence requirement applies in some situations (codes include 43644, 43645, 43659, 43770–43775, 43842–43848).
Cochlear implants and other auditory implants: prior authorization required (examples include 69930, L8615–L8693).
Cosmetic/reconstructive and breast procedures: many listed codes require prior authorization unless billed with specified diagnosis codes.

Definitions and Policy Terms

Prior authorization

How to submitUse the Prior Authorization and Notification tool on UHCprovider.com (sign in with One Healthcare ID) or call 877-610-9785

When requiredPrior authorization is required for services and codes listed in this document unless specific diagnosis-code exceptions apply or the service is emergency/urgent care

Special routingTransplant, CAR T-cell and some gene therapies require Optum routing/authorization as noted (see transplant/CAR T sections)

Center of Excellence requirement

ScopeCOE requirement applies to bariatric surgery and related obesity services

EffectCoverage for bariatric surgery may require treatment at an accredited Center of Excellence; some obesity-related services may not be covered in certain situations

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Indiana Hoosier Care Connect

Policy CodePolicy N/A

Change TypeAdministrative — no material changes

Effective DateJul 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

Rental cost of more than $500 may require prior authorization

Applies toDurable medical equipment (DME) listed with rental charges

Document noteSee DME HCPCS listing (examples include E0439, E0442, E0443, etc.)

Orthotics/prosthetics prior authorization threshold

Prior authorization rulePrior authorization is required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost above the specified threshold

Applies toOrthotics and prosthetic HCPCS/L-codes (examples: L3215, L3216, L3221, L3250, L3251, L3252)

Threshold contextThreshold referenced as retail purchase or cumulative rental cost (see orthotics/prosthetics section for details)

Prior Authorization

Behavioral health prior authorization routing

For behavioral health and substance use/mental health referrals, contact the phone number on the member's health plan ID card for specifics on which codes require prior authorization and for referral routing.

Many plans provide behavioral health coverage through a designated behavioral health network; use the member ID card number for authorization details.

Prior Authorization

Surgical/procedural prior authorization notes

Notification/prior authorization is not required for certain listed surgical/reconstructive CPT/HCPCS codes when billed with specified diagnosis codes; otherwise prior authorization is required for those surgical/procedural services.

Examples of surgical/reconstructive codes with diagnosis-based exceptions include 19316, 19318, 19325, 19340 (see document for full list and associated diagnosis codes).
When the listed diagnosis exceptions do not apply, prior authorization must be obtained.

Prior Authorization

DME prior authorization list

Durable medical equipment (DME) HCPCS codes listed in the document require prior authorization per the notes; some items are marked 'required only for DME' and rental-cost thresholds apply.

Selected DME examples include E0439 and E0442.
A rental cost of more than $500 may trigger prior authorization requirements; prosthetics are not DME and are handled separately.

Prior Authorization

Enteral services prior authorization

Enteral services HCPCS/B codes listed (for example B4100, B4102, B4103, B4161) require prior authorization as indicated in the document.

Enteral codes shown include B4100, B4102, B4103, B4161, B4149, B4150, B4152, B4153, B4155, B4158, B4159, B4160.
Additional information in the document indicates prior authorization is required for certain enteral services.

Prior Authorization

Genetic/molecular testing prior authorization

Prior authorization is required for genetic and molecular testing CPT codes listed in the document; the requesting health care professional must notify the laboratory conducting the test and the laboratory will notify UnitedHealthcare as part of the authorization/notification process.

Numerous genetic/molecular CPT codes are listed (examples include 81161, 81167, 81168, 81200 and many others).
BRCA testing requires notification/prior authorization before DNA sequencing is performed.

Prior Authorization

Gender dysphoria treatment prior authorization

Gender dysphoria treatment and related surgical procedure codes listed (for example 15832–15839, 54660, 55970, 55980, 58150, 58541–58554, 58570–58573, 69300) require prior authorization as noted.

Prior authorization is required for the enumerated gender dysphoria treatment and surgical procedure codes.
See the document for the full code list and any procedure-specific notes.

Documentation Required

Genetic testing prior authorization/notification

The ordering health care professional must notify the laboratory conducting genetic tests; the laboratory will notify UnitedHealthcare. Prior authorization is required for genetic/molecular testing and must follow the authorization/notification process.

This process applies to the many CPT codes listed for genetic testing (see document for full list).
BRCA testing specifically requires notification/prior authorization before DNA sequencing.

Prior Authorization

BRCA testing notification

Notification/prior authorization is required for BRCA testing before DNA sequencing is performed; the ordering provider must follow the program's notification/prior authorization process.

BRCA CPT codes listed include 81162–81167, 81212, 81215–81217, 81167 (see document for full code list).
Obtain prior authorization/notification prior to DNA sequencing.

Prior Authorization

Injectable medications prior authorization

Prior authorization is required for the injectable medications listed in the document; review the listed J-/HCPCS codes and obtain authorization before administration.

The document lists many injectable medications and their codes (examples include Actemra J3262, Acthar J0801, Adzynma J7171, Aldurazyme J1931).
Unclassified/temporary codes J3490 and J3590 have special prior authorization instructions (see separate block).

Prior Authorization

Prior authorization required for listed services

Prior authorization is required for the services and codes shown in the 'Coverage requirements — prior authorization' section, including non-emergent air ambulance transport and listed occupational/physical therapy and advanced imaging services.

Non-emergent air ambulance transport (A0430, A0431) requires prior authorization.
Occupational/physical therapy codes (for example 97012, 97110, 97116) require prior authorization.
Advanced outpatient imaging requires notification prior to scheduling.

Prior Authorization

Transplant and CAR T-cell prior authorization routing

Transplant and CAR T‑cell therapy services require prior authorization; for CAR T and gene therapy services call Optum at 888-936-7246 or the number on the member's health plan ID card. Certain unclassified codes (e.g., J3490, J3590) for specified products require prior authorization through Optum Transplant.

For Carvykti, Kymriah, Yescarta and similar CAR T services, call Optum at 888-936-7246 or use the number on the member ID.
Unclassified codes J3490/J3590 for products such as Aucatzyl, Hemgenix, Amtagvi, Ryoncil require prior authorization through Optum Transplant.

Prior Authorization

Remote patient monitoring and VAD prior authorization

Prior authorization is required for remote patient monitoring CPT codes (98975, 98976, 98977, 98980) and for ventricular assist devices (VAD); for VAD coordination, call the number on the member's ID card and fax the form provided by the nurse to the Optum VAD Case Management team at 855-282-8929.

Remote patient monitoring codes listed include 98975, 98976, 98977, 98980 — obtain prior authorization.
VAD codes include 33927 and Q0508; call the member ID card number and fax required VAD forms to 855-282-8929.

Billing Rule

Unclassified/temporary drug codes

For unclassified and temporary drug codes J3490 and J3590, prior authorization is required for certain therapies and products; authorization for specific products may be handled through Optum Transplant.

Prior authorization applies to J3490 and J3590 when used for specified gene therapies or unclassified products.
Some products (Aucatzyl, Hemgenix, Amtagvi, Ryoncil) require Optum Transplant prior authorization.

Example codes43644, 43770, 43842 (see bariatric code list)

DME / Prosthetics distinction

Definition distinctionDME refers to durable medical equipment; prosthetics are not DME and are handled under orthotics/prosthetics policy sections

Examples — DMEE0297, E0300, E0302, E0328, E0439, E0442

Examples — Prosthetics/OrthoticsL3215, L3216, L3221, L3250, L3251

Genetic testing prior authorization

Authorization requirementPrior authorization is required for genetic and molecular testing CPT codes listed in the document

Process noteOrdering health care professional must notify the laboratory; the laboratory will notify UnitedHealthcare as part of the authorization/notification process

Example codes81161, 81167, 81168, 81200 (document includes many additional genetic CPT codes)

Injectable medications

DefinitionInjectable medications: drugs administered intravenously, subcutaneously, or intramuscularly

Authorization requirementPrior authorization is required for the injectable medications listed in this section

Example J-/HCPCS codesJ3262 (Actemra), J0801 (Acthar), J7171 (Adzynma), J1931 (Aldurazyme) — see full injectable list

Ventricular assist device (VAD)

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

Prior authorizationPrior authorization is required for VAD services and codes (e.g., 33927, Q0508); contact the number on the member's ID card and fax required forms to the Optum VAD Case Management team at 855-282-8929

Example codes33927, 33928, Q0507, Q0508