CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for participating UnitedHealthcare Community Plan of Indiana providers

Lists services and CPT/HCPCS/DME codes requiring prior authorization for in-network participating UnitedHealthcare Community Plan of Indiana providers and describes submission methods (online or phone) and contact instructions.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for participating UnitedHealthcare Community Plan of Indiana providers

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

phone & onlinesubmission methods listed

no prior authemergency or urgent care

>$500DME cost threshold

manycodes listed across sections

888-936-7246Transplant/CAR T contact

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.

Prior Authorization Coverage Criteria

Prior authorization coverage criteria (partial)

The following categories and listed CPT/HCPCS/DME codes require prior authorization; additional program-specific requirements may apply (e.g., Center of Excellence for bariatric surgery).

ALL of the following

Examples of bariatric CPT codes requiring prior authorization: 43644, 43645, 43659, 43770-43775, 43842-43848, 44799, 44705.

ALL of the following

Examples of DME/HCPCS codes requiring prior authorization: A9279, A9999, E0265, E0266, E0270, E0274, E0277, E0296, E0297, E0300, E0302, E0304, E0328, E0329, E0439, E0442, E0443, E0455, E0457, etc.

ALL of the following

Examples: CPT 69930; HCPCS L8615, L8616 (cochlear implant procedure and device codes).

ALL of the following

Examples: B4149, B4150, B4152, B4153, B4155, B4158, B4159, B4160, B4161.

ALL of the following

Examples: 33477, 96002, A9274, A9276, A9277, A9278, E1831.

ALL of the following

Examples: 15832-15839 and related CPT codes.

ALL of the following

Examples: 19316, 19318, 19325, 19340, 19342, 19350, S2067 and related reconstruction codes.

Provider and network rules: prior authorization is not required for emergency or urgent care; out-of-network physicians, facilities and other professionals must request authorization for all procedures and services.

Prior authorization coverage criteria (partial)

Services and codes listed require prior authorization or notification before outpatient testing, administration, outpatient facility billing, or home health/hysterectomy procedures.

ALL of the following

Examples of genetic/molecular testing CPT codes requiring authorization/notification: 81161, 81167, 81168, 81200-81208, 81218, 81228-81238, 81243-81244, 81251-81259, 81269-81270, 81276-81279, 81292-81296, 81298-81311, 81315-81319, 81321-81323, 81328, 81330, 81335, 81346, 81504, 81519, 81522; BRCA testing requires prior authorization/notification.

ALL of the following

Examples include many J/Q codes such as J0179, J0597, J1556, J0585, J0567, J2329, Q5124, J1786, Q5128, J0717, J2786 and numerous additional J-codes listed in the injectable medications section.

ALL of the following

Examples include home health codes GO151-GO153 and GO151/GO152/GO153, and hysterectomy-related CPT codes such as 51925, 58152, 58200-58210, 58240, 58263, 58267-58275, 58280-58285.

Prior authorization categories (selected)

Prior authorization is required for the following selected categories and examples of CPT/HCPCS codes:

ALL of the following

Examples: A0430, A0431.

ALL of the following

Examples: occupational and physical therapy codes 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032-97039, 97110-97113, 97116, 97124, 97129.

ALL of the following

Examples include rhinoplasty (30400, 30410, 30420), orthognathic and maxillofacial procedure codes (e.g., 21110, 21121-21123, 21125, 21127, 21137-21270 series), spinal surgery and stimulator codes (22856, 22860, 22867, 22868), and prosthetics/orthotics codes (E0747-E0760, L8680, L8686-L8687).

ALL of the following

Prior authorization requirements and actions

Prior authorization is required for the following categories and specific codes; follow the noted contact or submission instructions (Optum or the number on the member's ID card) when requesting prior authorization.

ALL of the following

Sample listed transplant CPT codes: 32851-32856, 33933, 33935, 33944-33945, 38205-38243, 44132-44140, 44715-44720, 47144-47147, 48550-48554, 50300-50380 and others. Action: Call Optum at 888-936-7246 or the number on the member's health plan ID card for prior authorization.

ALL of the following

Sample codes and references: Category III codes 0537T-0540T and gene therapy/J-code references; products referenced include Carvykti, Kymriah, and Yescarta. Action: Call Optum at 888-936-7246 or the number on the member's health plan ID card.

ALL of the following

Examples: J3490, J3590 and other gene therapy-related HCPCS/J-codes per the gene therapy section; follow prior authorization contact instructions.

Codes and Coding Examples

Bariatric CPT/HCPCS examplesCPT | HCPCS | mixedCovered

43644	Bariatric surgery-related code listed as requiring prior authorization
43770	Bariatric surgery-related code listed as requiring prior authorization

DME HCPCS examplesHCPCSCovered

A9279	Example DME/HCPCS code listed for prior authorization
E0265	Example DME/HCPCS code listed for prior authorization

Cochlear implant examplesCPT | HCPCSCovered

69930	Cochlear implant procedure code listed for prior authorization
L8615	Cochlear implant device HCPCS codes listed for prior authorization

Injectable medications (sample)HCPCS

J0179	Beovu
J0597	Berinert
J1556	Bivigam
J0585	Botox
J0567	Brineura
J2329	Briumvi
Q5124	Byooviz

Genetic / Molecular testing codes (sample)CPT

81161	Genetic testing (example listed)
81292	Genetic testing (example listed)
81319	BRCA testing (notification/prior authorization required)

injectable medications and selected J/C codesHCPCSCovered

J1930	Somatuline Depot
J1747	Spevigo
J3358	Stelara (as listed)
J9226	J9226 (listed)
J2779	Susvimo
90378	Synagis (listed as 90378)
J3241	J3241 (listed)
J3315	Trelstar
J3316	J3316 (listed)
J9381	Tzield

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Transplant/CAR T-cell/VAD/Gene therapy related codesmixedCovered

32851	CPT code listed for transplant-related service
32852	CPT code listed for transplant-related service
32853	CPT code listed for transplant-related service
32854	CPT code listed for transplant-related service
32855	CPT code listed for transplant-related service
32856	CPT code listed for transplant-related service
33933	CPT code listed for transplant-related service
33935	CPT code listed for transplant-related service
33944	CPT code listed for transplant-related service
33945	CPT code listed for transplant-related service

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Wound vac codesHCPCSCovered

E2402

Wound vac device code

Urine drug testingHCPCSCovered

G0482	Urine drug testing code
G0483	Urine drug testing code

DME cost threshold for prior authorization — retail purchase or cumulative rental cost > $500

DME prior authorization thresholdRetail purchase or cumulative rental cost > $500

Applies to listed DME HCPCS codesPrior authorization required for DME codes specifically listed in the policy (examples include A9279, E0265, E0297, E0328)

When to request authorizationRequest prior authorization before rendering services or billing when the purchase/rental cost exceeds the threshold

Submission methodsSubmit prior authorization requests online via the Provider Portal or by phone (see policy for contact details)

How to Submit and Provider Responsibilities

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 (sign in with your One Healthcare ID) or by phone at 877-610-9785. Prior authorization is required before rendering non-emergency services; it is not required for emergency or urgent care. Out-of-network providers must request authorization for all procedures and services.

Online: Prior Authorization and Notification tool on UnitedHealthcare Provider Portal (One Healthcare ID)
Phone: Call 877-610-9785

Prior Authorization

Bariatric services — prior authorization required

Bariatric surgery procedures require prior authorization. There is a Center of Excellence requirement for coverage of bariatric surgery and related services in certain situations. Examples of CPT codes that require prior authorization include 43644, 43645, 43659, 43770–43775, 43842–43848 (list not exhaustive).

Center of Excellence requirement for coverage of bariatric surgery

Definitions and Notes

Authorization required prior to service — definition of Prior authorization

DefinitionPrior authorization: Authorization required prior to service; providers are required to request approval before rendering services to allow prospective, concurrent, or retrospective review.

ExceptionsPrior authorization is not required for emergency or urgent care.

Who must requestOut-of-network physicians, facilities and other health care professionals must request authorization for all procedures and services.

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

DME requiring prior authorization when listed codes or cost threshold apply — definition of Durable Medical Equipment (DME)

Definition

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for participating UnitedHealthcare Community Plan of Indiana providers

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

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

SourceLink

On This Page

Examples: transplant-related CPT codes and HCPCS (see transplant section); contact Optum at 888-936-7246 or the number on the back of the member's health plan ID card for authorization.

ALL of the following

Examples: 98975, 98976, 98977, 98980, 98981.

ALL of the following

Examples: CPT 33927-33929 and HCPCS Q0507. Action: Fax the VAD form to Optum VAD Case Management at 855-282-8929 after calling the number on the member's ID card.

ALL of the following

Examples: G0482, G0483.

ALL of the following

Example: HCPCS E2402.

Example CPT codes: 43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848

Prior Authorization

Devices, implants, cosmetic and reconstructive procedures — prior authorization required

Device, implant, cosmetic and reconstructive procedures and related surgical/ancillary services require prior authorization. This includes cochlear implants and a range of cosmetic and reconstructive procedures.

Cochlear implant codes: 69930, L8615, L8616, L8679, L8690
Breast reconstruction and related codes: 19316, 19318, 19325, 19340, 19342, 19350, S2067
Cosmetic/reconstructive example codes: 11921, 11922, 15780–15783, 15820–15823, 15830, 15847, 17999, 19300, 19301

Prior Authorization

Durable Medical Equipment (DME) — prior authorization rules

Durable medical equipment (DME) requires prior authorization only for the codes listed and when a retail purchase or cumulative rental cost exceeds $500. Prosthetics are not classified as DME for this purpose (see orthotics/prosthetics rules).

Prior authorization required for listed DME/HCPCS codes (examples: A9279, A9999, E0265–E0304, E0328–E0329, E0439, E0442, E0443, E0455, E0457, E0465, E0466, E0470–E0472)
Applies when retail purchase or cumulative rental cost > $500

Prior Authorization

Enteral, experimental/investigational, gender dysphoria and other procedures — prior authorization required

Prior authorization is required for certain enteral services, experimental/investigational procedures, gender dysphoria treatment and various listed surgical procedures. See the specific code lists for each category when preparing authorization requests.

Enteral service examples: B4149, B4150, B4152–B4161, B4153, B4155, B4158, B4159
Experimental/investigational examples: 33477, 96002, A9274–A9278, E1831
Gender dysphoria treatment example codes: 15832–15839

Prior Authorization

Injectable medications — prior authorization required

A wide range of injectable medications require prior authorization before administration or coverage. Refer to the full injectable drug list when submitting requests; many specialty agents and J-/Q-codes are included.

Examples of injectable drugs and codes requiring prior authorization: Actemra (Jxxxx), Acthar, J0801, Aduhelm (J0172), Beovu (J0179), Brineura (J0567), Briumvi (J2329), Entyvio (J3380), Eylea (J0177/J0178), Hizentra (J1559), Nplate (J2796), Ocrevus (J2350), Rituxan (J9312), Soliris, Stelara, Ultomiris (J1303)
Full list includes many J- and Q-codes; check policy list before billing

Prior Authorization

Home health care and hysterectomy — prior authorization required

Home health care services and hysterectomy procedures require prior authorization. Ensure authorization is obtained before starting care or scheduling surgery.

Home health care example codes: GO151, GO152, GO153, 99600
Hysterectomy example codes: 51925, 58152, 58200, 58210, 58240, 58263, 58267, 58270, 58275, 58280, 58285, 58292

Prior Authorization

Unclassified J‑codes (J3490, J3590) — prior authorization note

Unclassified and temporary J-codes (J3490, J3590) require prior authorization only for a specified subset of products. Prior authorization is required for Casgevy, Lantidra, Nulibry, Revcovi, Rivfloza, Ryplazim, Scenesse, Uplizna, Vabysmo and other named agents — verify the policy list when submitting.

Unclassified J-codes: J3490, J3590 — prior authorization required only for specific drugs (e.g., Casgevy, Lantidra, Nulibry, Revcovi, Rivfloza, Ryplazim, Scenesse, Uplizna, Vabysmo)
When billing J3490/J3590 for these agents, include prior authorization reference

Prior Authorization

Wound VAC — prior authorization required

Wound VAC therapy requires prior authorization. Use HCPCS code E2402 when requesting authorization for negative pressure wound therapy.

Wound vac (negative pressure wound therapy) HCPCS code: E2402

Durable Medical Equipment (DME): Equipment subject to prior authorization when specific HCPCS codes are listed or when retail purchase/cumulative rental cost exceeds $500.

Examples of listed codesExamples in the policy include A9279, A9999, E0265, E0297, E0328

Prosthetics noteProsthetics are not considered DME per the policy (see related sections).

Laboratory notification requirement

RequirementOrdering health care professional must notify the laboratory conducting the genetic test; the laboratory will notify UnitedHealthcare as part of the prior authorization/notification process.

Example codeReference example: 81257 (and other listed genetic/molecular testing codes).

PurposeEnsures laboratory and UnitedHealthcare coordination for prior authorization/notification of genetic tests.

Optum transplant/CAR T authorization — contact definition/short note

Contact instructionFor transplant and CAR T-cell therapy services, providers should call Optum at 888-936-7246 or use the number on the back of the member's health plan ID card for authorization.

ScopeApplies to transplant and CAR T-cell therapy services (authorization routed via Optum).

Examples referencedPolicy cites Carvykti, Kymriah and Yescarta as CAR T-cell therapies covered by this contact process.

CAR T-cell therapy — definition and examples

DefinitionCAR T-cell therapy: Cellular immunotherapy requiring prior authorization under the policy.

Product examplesExamples listed in the policy: Carvykti (ciltacabtagene autoleucel), Kymriah (tisagenlecleucel), Yescarta (axicabtagene ciloleucel).

Related codesCategory III codes (e.g., 0537T–0540T) and specific CAR T-related CPT/HCPCS codes require authorization as indicated.

Ventricular assist device (VAD) — definition and VAD case management note

DefinitionVentricular assist device (VAD): A mechanical pump that takes over the function of the damaged ventricle.

Authorization processPrior authorization is required; call the number on the member's health plan ID card and fax the form provided by the nurse to the Optum VAD Case Management team at 855-282-8929.

Related codesPolicy lists VAD-related CPT/HCPCS codes such as 33927, 33928, 33929 and Q0507.