CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Indiana Hoosier Care Connect

Lists procedures, services and HCPCS/CPT/DME codes that require prior authorization for UnitedHealthcare Community Plan of Indiana providers and explains how to request authorization; applies to participating health care professionals rendering inpatient and outpatient services under Indiana Hoosier Care Connect.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Indiana Hoosier Care Connect

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 877-610-9785 before rendering non-emergent services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

May 1, 2024effective date

Emergency/urgent careno prior authorization required for

Many codesitems enumerated requiring prior authorization

20+injectable medications listed

PA required

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transplants/CAR T/VAD

Prior Authorization Coverage Criteria

Prior authorization coverage stance

The policy lists categories and many specific CPT/HCPCS/DME codes that require prior authorization. Some categories have additional coverage rules noted (for example, Center of Excellence for bariatric).

ALL of the following

Bariatric procedures
- Prior authorization required for bariatric procedures listed (examples include CPT 43644, 43645, 43659, 43770, 43771–43775, 43842–43848, 44799, 44705).
Cosmetic, reconstructive and related procedures
- Prior authorization required for cosmetic and reconstructive procedure codes listed (examples include CPT 11921, 11922, 15780–15783, 15820–15823, 15830–15833).
Inner ear / auditory devices and cochlear implants
- Prior authorization required for inner ear and cochlear implant related HCPCS/CPT codes (examples include V5050, V5060, V5140, V5256, V5257, V5260, V5261, 92640, L8690).
Enteral nutrition and supplies
- Prior authorization required for enteral services and supplies (examples include B4100, B4102, B4103, B4149, B4150, B4152, B4153, B4155, B4158, B4159, B4160, B4161).
Experimental / investigational services
- Prior authorization required for codes identified as experimental or investigational (examples include CPT 33477, 96002; HCPCS A9274, A9276, A9277, A9278, E1831).
Gender dysphoria treatment
- Prior authorization required for gender dysphoria treatment codes (examples include CPT 15832–15839 and related procedure codes listed).

ALL of the following

Orthotics/prosthetics and DME
- Prior authorization required for orthotics/prosthetics and DME listed; prosthetics are not DME and purchase or cumulative rental cost thresholds may apply (see DME/orthotics thresholds).
Other listed categories
- Prior authorization required for the many additional categories and codes enumerated throughout the policy (see full code lists in document).

ALL of the following

Provider obligations and special rules
- Some services have special coverage rules noted (for example, bariatric services may require Center of Excellence affiliation). Providers should follow the submission process indicated for each category.

Prior authorization criteria (enumerated services)

Notification or prior authorization is required for specific services and tests as listed below.

ALL of the following

Genetic and molecular testing
- Notification/prior authorization required for genetic testing; testing must follow the prior authorization/notification process which includes indicating the laboratory and test name; payment is authorized only for CPT codes registered with the Genetic and Molecular Testing Prior Authorization/Notification Program; BRCA testing requires notification/prior authorization before DNA sequencing is performed.

ALL of the following

Home health care
- Prior authorization required for home health care services (examples include CPT G0151, G0152, G0153).

ALL of the following

Prior authorization coverage criteria (excerpt)

Prior authorization is required for the following categories and listed codes; select unclassified codes require prior authorization only for enumerated products and some gene therapies/transplants require PA via Optum Transplant.

ALL of the following

Injectable medications
- Prior authorization required for the injectable HCPCS/J-codes listed in the policy (examples in excerpt include J3316, Q5115, J9381, J1303, J1823, J9376, J1322, J3032, J9332, J9334).
- Unclassified codes J3490 and J3590 require prior authorization only for specific products (Casgevy, Lantidra, Lyfgenia, Nulibry, Revcovi, Ryplazim, Scenesse, Uplizna, Vabysmo); effective April 1, 2024 Omvoh and Adzynma use temporary/assigned codes as noted.

ALL of the following

Procedures and devices

Codes Requiring Prior Authorization

Sample bariatric CPT codes requiring prior authorizationCPTCovered

43644	Bariatric procedure code listed
43770	Bariatric procedure code listed
43842	Bariatric procedure code listed

Sample reconstructive/auditory codes requiring prior authorizationmixedCovered

19316	Breast reconstruction
69930	Cochlear implant procedure
L8615	Cochlear implant, internal device

Selected additional HCPCS/CPT/DME codes across categories that require prior authorizationmixedCovered

A9279	DME/Hcpcs code listed
E1008	DME/Hcpcs code listed
K0861	Orthotics/prosthetics code listed
B4100	Enteral nutrition supply
33477	Experimental/investigational example code listed
15832	Gender dysphoria treatment example CPT

Selected injectable HCPCS/J-codes from listHCPCSCovered

J0177	Fabrazyme
J1300	Soliris
J3316	Truxima

Selected procedure codesCPTCovered

G0151	Home health skilled nursing per 15 minutes
51925	Hysterectomy-related CPT example from list

Selected special-case codes and notesHCPCSCovered

J3490	Unclassified drug code — prior authorization only for specified products; gene therapies and designated drugs require PA via Optum/Transplant for some products
J3590	Unclassified drug code — see J3490 note
C9167	Temporary code noted for Adzynma use with J3490/J3590 (effective Apr 1, 2024)
C9168	Temporary code noted for Omvoh use with J3490/J3590 (effective Apr 1, 2024)
J0897	Prior authorization required for non-oncology diagnosis (effective Jan 1, 2023)
J0174	Prior authorization required (effective Aug 1, 2023)

DME prior authorization threshold

ThresholdRetail purchase or cumulative rental cost of more than $500 requires prior authorization for DME.

ScopeApplies only to DME codes listed in the policy (not all DME).

Exclusion noteProsthetics are not considered DME for this threshold (see prosthetics notes).

Genetic and Molecular Testing Prior Authorization/Notification Program

RequirementPayment will be authorized only for CPT codes registered with the Genetic and Molecular Testing Prior Authorization/Notification Program.

How Providers Request Prior Authorization and Required Notifications

Prior Authorization

How to request prior authorization

This list contains prior authorization requirements for health care professionals participating with UnitedHealthcare. To request prior authorization, submit your request using one of the following: Online: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) and sign in with your One Healthcare ID and password. By phone: Call 877-610-9785. Note: Prior authorization is not required for emergency or urgent care. Out-of-network providers must request prior authorization for all procedures and services except emergent or urgent care. Advance notification is required to allow UnitedHealthcare to perform prospective, concurrent and retrospective care review.

Note

Notification purpose

Notification is required to give UnitedHealthcare timely communication of services so we can do prospective, concurrent and retrospective care review. Providers are required to request approval before rendering services when prior authorization is indicated.

Prior Authorization

Key Definitions and Thresholds

Definition of Prior Authorization

DefinitionPrior authorization is the required approval from UnitedHealthcare Health Services before rendering non-emergent services; providers must request approval in advance.

PurposeAdvance notification enables prospective, concurrent and retrospective care review by UnitedHealthcare Health Services.

ExceptionEmergency and urgent care do not require prior authorization; out-of-network providers must request prior authorization for all non-emergent procedures and services.

DME prior authorization threshold and prosthetics note

DME thresholdRetail purchase or cumulative rental cost of more than $500 requires prior authorization for listed DME items.

Prosthetics classification

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Indiana Hoosier Care Connect

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 877-610-9785 before rendering non-emergent services.

SourceLink

On This Page

Hysterectomy

Prior authorization required for hysterectomy procedures listed (examples include CPT 51925, 58152, 58200, 58210, 54660 where indicated).

ALL of the following

Injectable medications
- Prior authorization required for the extensive list of injectable drugs and associated HCPCS/J-codes provided in the policy (examples include Actemra J0801, Aduhelm J0172, Aldurazyme J1931, and many others).

ALL of the following

Other enumerated services
- Prior authorization is required for other enumerated services noted in the policy (for example, home health, hysterectomy and gender dysphoria treatment as listed).

Prior authorization required for neurostimulators (examples CPT 61850, 61860), non-emergent air ambulance transport (A0430, A0431), occupational/physical therapy codes (examples 97012, 97016, 97018–97039), stimulators and related device codes (E0748, L8682, E0749, L8685, E0760, L8686, L8680, L8687).

Orthotics and prosthetics require prior authorization when purchase or cumulative rental cost exceeds $500.

ALL of the following

Transplants, CAR T and VAD services
- Prior authorization required for organ or tissue transplants and transplant-related services before pre-treatment or evaluation; for transplant and CAR T-cell therapy services (including Carvykti, Kymriah, Yescarta) providers must call Optum at 888-936-7246 or the number on the member's ID card and follow Optum submission/fax instructions.

Process detailRegistration is per specified genetic test and includes indicating the laboratory and test name as part of the prior authorization/notification process.

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

Orthotics/prosthetics prior authorization threshold

ThresholdPurchase or cumulative rental cost of more than $500 for orthotics and prosthetics requires prior authorization.

ScopePrior authorization is required only for orthotics and prosthetic codes listed in the policy.

Example codesExamples of listed HCPCS codes include L3215, L3216, L3221, L3250 and others cited in the orthotics/prosthetics section.

Genetic / BRCA testing notification and prior authorization

Certain genetic and molecular tests require notification or prior authorization. Payment will be authorized only for CPT codes registered with the Genetic and Molecular Testing Prior Authorization/Notification Program. Notification/prior authorization is required for BRCA testing before DNA sequencing is performed. When requesting authorization for genetic testing, indicate the performing laboratory and the specific test name.

Prior Authorization

Injectable medications requiring prior authorization (examples)

Many injectable medications require prior authorization. The following HCPCS/J‑codes (examples listed) require prior authorization before administration. When submitting requests, include drug name, HCPCS/J‑code, dose, frequency, diagnosis, member clinical history and any prior treatments tried.

J0597 - Bivigam
J1556 - Botox
J0585 - Brineura
J0567 - Briumvi
J2329 - Cerezyme
J1786 - Cimzia
J0717 - Cinqair
J2786 - Cinryze
J0598 - Crysvita
J0584 - Cutaquig
J1551 - Cuvitru
J1555 - Daxxify
J0589 - Dysport
J0586 - Elaprase
J1743 - Elelyso
J3060 - Elfabrio
J2508 - Enjaymo
J1302 - Entyvio
J3380 - Evkeeza
J1305 - Evenity
J3111 - Eylea HD
J0177 - Fabrazyme
J0180 - Fasenra
J0517 - Feraheme
Q0138 - Firmagon
J9155 - Flebogamma DIF
J1572 - Fylnetra
Q5130 - Gamifant
J9210 - Gammagard
J1569 - Gammaplex
J1557 - Gamunex/Gammaked
J1561 - Givlaari
J0223 - Glassia
J0257 - Hizentra
J1559 - Hyqvia
J1575 - Ilaris
J0638 - Ilumya
J3245 - Inflectra
Q5103 - Injectafer
J1439 - IVIG 90283
J1599 - Izervay
J2782 - 90284
J1459 - J1566
J1290 - Kalbitor
J2840 - Kanuma
J0879 - Korsuva
J2507 - Krystexxa
J0217 - Lamzede
J1932 - Lanreotide
J0202 - Lemtrada
J0174 - Leqembi
J1306 - Leqvio
J0221 - Lumizyme
J1950 - Lupron Depot
J9217 - Lupron Depot Eligard
J1726 - Makena/17P
J3397 - Mepsevii
J0587 - Myobloc
J1458 - Naglazyme
J0219 - Nexviazyme
J2796 - Nplate
J2182 - Nucala
Q5122 - Nyvepria
J2350 - Ocrevus
J3316 - Truxima
Q5115 - Tzield
J9381 - Ultomiris
J1303 - Unclassified (see J3490/J3590/C9167/C9168 guidance)
J3490 - Unclassified
J3590 - Unclassified
C9167 - Unclassified
C9168 - Unclassified
J1823 - Uplizna
J9376 - Vimizim
J1322 - Vyepti
J3032 - Vyvgart
J9332 - Vyvgart Hytrulo
J9334 - Xembify

Billing Rule

Injectable medications — prior authorization and coding notes

When billing for injectable medications, do not use J3490 or J3590 as a substitute for specific HCPCS/J‑codes when a specific code exists. If using unclassified codes (J3490/J3590/C9167/C9168) provide complete documentation: drug name, NDC, dose, strength, units, route, frequency, and clinical rationale. Missing documentation or lack of a specific code when one applies may result in claim denial.

Prior Authorization

Transplant, CAR T and VAD authorization pathway

Organ or tissue transplants, transplant‑related services (including pre‑treatment and evaluation), ventricular assist device (VAD) services and CAR T‑cell therapies require specialized authorization pathways. For transplant and CAR T‑cell therapy services (including Carvykti, Kymriah, Yescarta and similar therapies) please call Optum at 888‑936‑7246 or the number on the back of the member's health plan ID card to initiate the review. For VAD services, call the number on the member's ID card and then fax the form provided by the Optum nurse to the Optum VAD Case Management team at 855‑282‑8929.

Prosthetics are not classified as DME for this threshold; separate orthotics/prosthetics rules apply.

Referenced codesPolicy lists specific DME and HCPCS codes subject to the $500 threshold (examples included in the DME and orthotics sections).

Genetic and Molecular Testing Prior Authorization/Notification Program

Program requirementCPT codes must be registered with the Genetic and Molecular Testing Prior Authorization/Notification Program to be payable.

Registration detailsThe prior authorization/notification process requires indicating the laboratory and test name for each specified genetic test.

BRCA sequencingSpecific requirement that BRCA testing requires notification/prior authorization before DNA sequencing is performed.

Ventricular assist devices (VAD)

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

Prior authorizationPrior authorization is required for VADs and associated codes (e.g., 33927, 33928, 33929, Q0508).

Authorization pathwayProviders should call the number on the member's ID card and fax required forms to the Optum VAD Case Management team (fax number provided in policy).

CAR T-cell therapy / Gene therapy — authorization pathway overview

Authorization pathwayCAR T-cell therapies and certain gene therapies require prior authorization and must be routed through Optum (providers should call Optum at 888-936-7246 or the number on the member's ID card).

Covered therapies examplesPolicy specifically references Carvykti (ciltacabtagene autoleucel), Kymriah (tisagenlecleucel) and Yescarta (axicabtagene ciloleucel) as CAR T-cell therapies requiring this pathway.

Unclassified code handlingCertain gene therapies billed with unclassified codes J3490/J3590 (and specified products like Zynteglo) require Prior Authorization through Optum Transplant per effective dates noted in the policy.