CurrentUnitedHealthcarePolicy PCA -2-25-00398-Clinical -QRG_022125

Prior authorization requirements for Indiana Hoosier Care Connect

Defines prior authorization requirements and submission methods for participating UnitedHealthcare Community Plan of Indiana providers for inpatient and outpatient services under the Hoosier Care Connect program.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Indiana Hoosier Care Connect

Policy CodePolicy PCA -2-25-00398-Clinical -QRG_022125

Change TypeNo material changes

Effective DateFeb 1, 2026

Next Review Date

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com using One Healthcare ID) or by phone at 877-610-9785.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Feb 1, 2026effective date stated

MultipleService categories with PA

~200+Codes listed

YesHome health PA

YesEnteral services PA

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Coverage and Prior Authorization Criteria

Coverage criteria by service category

Coverage stance and prior authorization requirements for specific service categories and codes.

Covered when prior authorization is obtained as specified below; services listed require prior authorization per member plan terms.

Bariatric surgery

Prior authorization required; Center of Excellence requirement for coverage.
See CPT codes 43644, 43645, 43659, 43770 listed in the policy.

Behavioral health

Prior authorization required; refer via the number on the member's health plan ID card for specific codes and referrals to the designated behavioral health network.

BRCA genetic testing

Prior authorization required for BRCA genetic testing; CPT/HCPCS codes listed include 81162, 81166, 81217.

Cochlear implants and auditory devices

Prior authorization required for cochlear implants and related auditory device codes (examples include 92640, L8690).

Cosmetic and reconstructive procedures

Prior authorization required for cosmetic and reconstructive procedures; numerous CPT codes are listed in the policy.

Durable medical equipment (DME)

Prior authorization required for listed DME codes; certain items require authorization when retail purchase or cumulative rental cost exceeds $500.
Examples of listed DME codes include A9279, A9999, E0265, E0300 and Q0495/Q0504 shown in the policy.

Prior authorization criteria by service category

Authorization requirements enumerated by service category and code lists in this excerpt:

Enteral services: Prior authorization required for enteral products and services; examples of codes listed include B4100, B4102, B4103, B4161, B4149, B4150, B4152, B4153, B4155, B4158, B4159, B4160.

Home health care: Prior authorization required for home health care services; example codes include G0151, G0152, G0153, 99600.

Hysterectomy procedures: Prior authorization required for specified hysterectomy procedures; example CPT codes include 51925, 58240, 58275, 58152, 58263, 58280, 59897, 58200, 58267, 58285, 58548, 58210, 58270, 58292.

Genetic testing: Prior authorization/notification required for genetic and molecular testing; listed CPT codes include 81161, 81167, 81168, 81200, 81201, 81202, 81203, 81206. Ordering provider and laboratory notification are required for certain tests (e.g., BRCA sequencing).

Prior authorization coverage stance

Services and procedures listed in these sections require prior authorization as indicated; specific codes and provider actions are listed with each service.

Neurostimulators and related procedures: Prior authorization required for neurostimulator procedures; example CPT code 61850 is listed.

Non-emergent air ambulance transport: Prior authorization required for non-emergent air ambulance transport; example HCPCS codes include A0430 and A0431.

Occupational and physical therapy: Prior authorization required for many occupational/physical therapy services; example CPT/HCPCS codes include 97012, 97016, 97018-97028, 97110-97113, 97116, 97124, 97129.

Transplants and CAR T-cell therapy: Prior authorization required for organ or tissue transplants and transplant-related services before pretreatment or evaluation. For transplant and CAR T-cell therapies (e.g., Carvykti, Kymriah, Yescarta), providers must call Optum at 888-936-7246 or the number on the member's ID card.

Code Lists and Coding Rules

Selected procedure and genetic test codesCPTCovered

43644	Bariatric procedure code listed as requiring prior authorization
43645	Bariatric procedure code listed as requiring prior authorization
43659	Bariatric procedure code listed as requiring prior authorization
43770	Bariatric procedure code listed as requiring prior authorization
81162	BRCA genetic testing code listed
81166	BRCA genetic testing code listed
81217	BRCA genetic testing code listed

Durable Medical Equipment (examples)HCPCSCovered

A9279	Durable medical equipment (DME) code listed
A9999	Durable medical equipment (DME) code listed
E0265	DME code listed
E0300	DME code listed
E1390	DME code listed

Durable Medical Equipment (examples)HCPCSCovered

Q0495	DME item (example code listed)
Q0504	DME item (example code listed)

Injectable medications (examples)CPT | HCPCS | mixedCovered

J1557	Gamunex-C/Gammaked (injectable requiring prior auth)
J1459	Izervay (injectable requiring prior auth)
J0175	Korsuva (injectable requiring prior auth)

Genetic and Molecular TestingCPT | HCPCS | mixedCovered

81161	Genetic test code (requires prior auth for listed Dx)
81201	Genetic/molecular testing code (requires prior auth/notification)

Drug and unclassified HCPCS codesHCPCSCovered

J2357	Xolair
Q5100	Yesintek IV
J9202	Zoladex
J3490/J3590	Unclassified/temporary codes (PA only for specified products)
J1954	Injectable med code with Cancer DX exclusion from PA

Representative procedure and device codesCPT | HCPCS | mixedCovered

61850	Neurostimulator procedure code (example)
A0430	Non-emergent air ambulance base code
97012	Physical therapy code (example)
L3215	Orthotics/prosthetics example code
33927	Ventricular assist device code / related
E2402	Wound vac code

DME cumulative rental threshold

ThresholdSome DME items require prior authorization when cumulative rental cost exceeds $500.

Applicable codes (examples)E0300, E0302, E0304, E0328, E0329 (see DME list).

Action requiredSubmit prior authorization for listed DME items when cumulative rental cost > $500 or when code is listed as requiring PA.

Orthotics/prosthetics retail/rental cost threshold

ThresholdPrior authorization required for prosthetic codes when retail purchase or cumulative rental cost is more than $500.

Applicable codes (examples)L3215, L3216, L3217, L3219, L3221 (orthotics/prosthetics examples listed).

NoteProsthetic codes listed with a retail purchase or cumulative rental cost > $500 require prior authorization; orthotics-only rules also specified.

How to Obtain Authorization and Provider Responsibilities

Prior Authorization

How to obtain prior authorization

Submit prior authorization requests online via 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

Categories requiring prior authorization (examples)

Many categories of services require prior authorization. Examples include (but are not limited to): bariatric surgery (specific CPT/HCPCS codes such as 43644, 43645, 43659, 43770), behavioral health services (follow the number on the member's ID card for mental health/substance use referrals), genetic testing (BRCA and other molecular/genetic tests), home health care (e.g., G0151, G0152, G0153, 99600), hysterectomy (multiple CPT codes listed), durable medical equipment/DME and related supplies (various HCPCS like Q0495, Q0504, Q0506, S1040, V2786, V5269–V5281, V5274), neurostimulators (e.g., 61850, 61860), non-emergent air ambulance (A0430, A0431), occupational/physical therapy services (selected CPT codes), transplants and CAR T-cell therapies, urine drug testing (G0482, G0483), ventricular assist devices (e.g., 33927, 33928, 33929, Q0507, Q0508), wound VACs (e.g., E2402), and other specialty devices and procedures. For transplant and CAR T-cell therapies, authorization is routed via Optum (see Optum contact below).

Prior Authorization

How to obtain prior authorization for injectable medications

For drugs administered intravenously, subcutaneously, or intramuscularly (injectable medications), prior authorization requests should be submitted through the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone at 888-397-8129 when indicated. Examples of injectable drugs that require prior authorization include (but are not limited to) J3262, J0801, J7171, J1931, J0597, J1556, J2357 (Xolair), Q5100 (Yesintek IV), J9202 (Zoladex) and others listed in the plan-specific injectable drug list. For transplant-related injectable therapies and certain specialty injectables, follow the transplant/CAR T routing to Optum when specified.

Billing Rule

Unclassified/temporary codes rules

Unclassified and temporary HCPCS codes J3490/J3590: prior authorization is required only when these codes are used to bill for specific products listed by name. The following products billed under J3490/J3590 require prior authorization: Casgevy, Lantidra, Lyfgenia, Revcovi, Rivflosa, Ryplazim, Scenesse, Starjemza, Uplizna, and Vabysmo. Note: J1954 is excluded from the injectable-medication prior authorization requirement when billed with a cancer diagnosis (Cancer DX excluded).

Definitions and Policy Terms

Definition of prior authorization

DefinitionPrior authorization is the requirement to obtain approval from UnitedHealthcare before providing certain services.

ExemptionPrior authorization is not required for emergency or urgent care.

Submission methodsRequests may be submitted online via the UnitedHealthcare Provider Portal (UHCprovider.com using One Healthcare ID) or by phone at 877-610-9785.

Center of Excellence requirement

RequirementCoverage of bariatric surgery includes a Center of Excellence requirement.

Prior authorizationBariatric procedures (examples: CPT 43644, 43645, 43659, 43770) require prior authorization.

Behavioral health noteBehavioral health services also require prior authorization; refer via the number on the member's health plan ID card as indicated.

prior authorization (policy note)

TermPrior authorization (policy note): listed services and many drugs require approval before provision; submit via portal or phone.

OverlapSeveral sections reference 'prior authorization' as the required approval step for specified codes and services throughout the document.

Provider instructionOut-of-network requests must be made by a network care provider; emergency/urgent care exempt.

DME (durable medical equipment)

TermDurable medical equipment (DME): equipment items listed in the DME sections require prior authorization.

ExamplesCodes include Q0495, Q0504, Q0496, Q0506, Q0502, S1040, V2786, V5269, V5270 (see DME lists).

NoteSome DME items have special rules (retail purchase or cumulative rental thresholds) that trigger PA requirements.

Ventricular assist devices (VAD)

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

Authorization stepsCall the number on the member's ID card, then fax the form provided by the nurse to the Optum VAD Case Management team at 855-282-8929 for prior authorization.

Example codeCPT/HCPCS example listed: 33929 and Q0507 appear in the VAD section.

CAR T-cell therapy

TermCAR T-cell therapy: specified cellular immunotherapies requiring special authorization routing via Optum.

ExamplesDocument lists Carvykti (ciltacabtagene autoleucel), Kymriah (tisagenlecleucel), and Yescarta (axicabtagene ciloleucel).

Authorization routeFor transplant and CAR T-cell therapy services, call Optum at 888-936-7246 or the number on the member's ID card before pretreatment or evaluation.