CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Indiana Hoosier Care Connect

This document lists services, CPT/HCPCS/ICD-10 codes, and instructions that require prior authorization for participating UnitedHealthcare Community Plan of Indiana providers effective April 1, 2026.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Indiana Hoosier Care Connect

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or call 877-610-9785.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=1Effective date listed

1State-specific plan referenced

partialDocument part

selectedExamples requiring PA

20+Injectable codes listed

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 is not required for emergency or urgent care. Providers should submit prior authorization requests for non-emergent services using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) with a One Healthcare ID, or by phone at 877-610-9785. Out-of-network requests must be made by a network care provider.

Items designated as experimental or investigational in the document are explicitly listed and flagged as Prior authorization required. Examples in this category include CPT/HCPCS entries such as 33477, 96002, A9274, A9276, A9277, A9278, E1831, and the listing indicates that prior authorization is required for these experimental/investigational items.

The excerpt contains several entries marked as Unclassified or placeholder items and does not provide detailed coverage or exclusion criteria for those entries within this segment. Where the document shows Unclassified labels, no explicit coverage determination or additional exclusion text is provided in this excerpt.

This section predominantly lists procedure and HCPCS/J-code groups and indicates prior authorization requirements rather than providing explicit coverage criteria. For example, multiple injectable medications, neurostimulator procedures, transport codes for occupational/physical therapy, and orthognathic surgery entries are shown with Prior authorization required, but detailed medical necessity text is not included in this excerpt.

For procedures performed by participating physicians the document repeatedly states that prior authorization is required. The policy notes that the absence of required prior authorization for those participating physician procedures may result in denial or exclusion of coverage for the service.

Unclassified drug codes J3490 and J3590 used for transplant-related services require prior authorization routed through Optum Transplant. The document specifies that for these unclassified codes an Optum Transplant prior authorization is required.

CPT / HCPCS / ICD-10 Codes

Bariatric CPT codesCPTCovered

43644	Bariatric (listed as prior authorization required)
43645	Bariatric
43659	Bariatric
43770	Bariatric

Breast cancer (BRCA) genetic testing codesCPTCovered

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

Breast reconstructionmixedCovered

19316	Breast reconstruction
19342	Breast reconstruction
19318	Breast reconstruction
19350	Breast reconstruction
19340	Breast reconstruction
S2068	Breast reconstruction

Cochlear implants and auditory device codesmixedCovered

69930	Cochlear implants and other auditory
L8615	Cochlear implant device
L8616	Cochlear implant device
L8617	Cochlear implant device
L8618	Cochlear implant device
L8619	Cochlear implant device
L8627	Cochlear implant
L8628	Cochlear implant
L8691	Implant
L8692	Implant

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Cosmetic and reconstructive procedure codesCPTCovered

11921	Cosmetic and reconstructive procedures
11922	Cosmetic and reconstructive procedures
15780	Cosmetic/reconstructive tissue expander
15781	Cosmetic/reconstructive
15782	Reconstructive
15783	Reconstructive
15820	Reconstructive
15821	Reconstructive
15822	Reconstructive
15830	Reconstructive

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Ophthalmic/reconstructive codesCPT|HCPCSCovered

67900	Eyelid surgery / ophthalmic reconstructive
67901	Eyelid surgery
67902	Eyelid surgery
67903	Eyelid surgery
67904	Eyelid surgery
67906	Eyelid surgery
67908	Eyelid surgery
67912	Eyelid surgery
S2066	Ophthalmic supply

Miscellaneous surgical codesCPTCovered

29800	Arthroscopy (listed)
96921	Neonatal/pediatric (listed)
96922	Neonatal/pediatric (listed)

Durable Medical Equipment (DME) and related HCPCS codesHCPCSCovered

A9279	Durable medical equipment
A9999	DME miscellaneous
E0265	DME
E0266	DME
E0270	DME
E0274	DME
E0277	DME
E0296	DME
E0297	DME
E0300	DME

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Durable medical equipment (DME) and other general codesHCPCS

E1089	How to obtain prior authorization = E1089.
E1090	How to obtain prior authorization = E1090.
E1130	How to obtain prior authorization = E1130.
E1140	How to obtain prior authorization = E1140.
E1161	How to obtain prior authorization = E1161.
E1220	How to obtain prior authorization = E1220.
E1226	How to obtain prior authorization = E1226.
E1229	How to obtain prior authorization = E1229.
E1231	How to obtain prior authorization = E1231.
E1232	How to obtain prior authorization = E1232.

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Additional K-codes (DME/other)HCPCS

K0108	How to obtain prior authorization = K0108.
K0606	How to obtain prior authorization = K0606.
K0730	How to obtain prior authorization = K0730.
K0800	How to obtain prior authorization = K0800.
K0801	How to obtain prior authorization = K0801.
K0812	How to obtain prior authorization = K0812.
K0821	How to obtain prior authorization = K0821.
K0822	How to obtain prior authorization = K0822.
K0823	How to obtain prior authorization = K0823.
K0824	How to obtain prior authorization = K0824.

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Q-codes (DME/related)HCPCS

Q0479	How to obtain prior authorization = Q0479.
Q0480	How to obtain prior authorization = Q0480.
Q0481	How to obtain prior authorization = Q0481.
Q0482	How to obtain prior authorization = Q0482.
Q0483	How to obtain prior authorization = Q0483.
Q0484	How to obtain prior authorization = Q0484.
Q0495	How to obtain prior authorization = Q0495.
Q0502	How to obtain prior authorization = Q0502.
Q0503	How to obtain prior authorization = Q0503.
Q0504	How to obtain prior authorization = Q0504.

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V-codes (DME/supplies)HCPCS

V2786	How to obtain prior authorization = V2786.
V5269	How to obtain prior authorization = V5269.
V5270	How to obtain prior authorization = V5270.
V5271	How to obtain prior authorization = V5271.
V5272	How to obtain prior authorization = V5272.
V5274	How to obtain prior authorization = V5274.
V5281	How to obtain prior authorization = V5281.
V5282	How to obtain prior authorization = V5282.
V5283	How to obtain prior authorization = V5283.
V5286	How to obtain prior authorization = V5286.

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Supply and equipment codesHCPCS

L1001	How to obtain prior authorization = L1001.
L8694	How to obtain prior authorization = L8694.
E0424	How to obtain prior authorization = E0424.
E0441	How to obtain prior authorization = E0441.
K0738	How to obtain prior authorization = K0738.

Enteral servicesHCPCS

B4100	Enteral services code
B4102	Enteral services code
B4103	Enteral services code
B4161	Enteral services code
B4149	Enteral services code
B4150	Enteral services code
B4152	Enteral services code
B4153	Enteral services code
B4155	Enteral services code
B4158	Enteral services code

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Gender dysphoria and related surgical codesCPT

15832	Gender dysphoria-related code listed under prior authorization section
15833	Gender dysphoria-related code listed under prior authorization section
15834	Gender dysphoria-related code listed under prior authorization section
15835	Gender dysphoria-related code listed under prior authorization section
15836	Gender dysphoria-related code listed under prior authorization section
15837	Gender dysphoria-related code listed under prior authorization section
15838	Gender dysphoria-related code listed under prior authorization section
15839	Gender dysphoria-related code listed under prior authorization section
54660	Gender dysphoria-related code
55970	Gender dysphoria-related code

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Genetic and molecular testing codesCPT

81161	Genetic testing code (listed under Genetic testing)
81167	Genetic testing code
81200	Genetic testing code
81201	Genetic testing code
81202	Genetic testing code
81203	Genetic testing code
81206	Genetic testing code
81207	Genetic testing code
81208	Genetic testing code
81218	Genetic testing code

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Injectable medications (partial list)HCPCS

J3262	Acthar (injectable medication)
J0801	Adzynma
J7171	Aldurazyme
J1931	Alyglo
J1575	Hympavzi
J7172	Ilaris
J0638	Ilumya
J3245	Imaavy
Q5098	Inflectra
Q5103	Injectafer

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Injectable HCPCS/J-code mappingsHCPCS

J3241	Tezspire / Tepezza (listed in excerpt)
J2356	Tofidence (listed in excerpt)
Q5133	Trelstar (listed in excerpt)
J3315	Tremfya IV (listed in excerpt)
J1628	Triptodur (listed in excerpt)
J3316	Truxima (listed in excerpt)
Q5115	Tyenne (listed in excerpt)
Q5135	Tzield (listed in excerpt)
J9381	Tzield (J-code also) / listed
J1303	Ultomiris (listed in excerpt)

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Referenced HCPCS codesHCPCS

Q5138	HCPCS code Q5138 (repeated reference in section)
Q5101	HCPCS code Q5101 (repeated reference in section)
Q5120	HCPCS code Q5120
J1442	HCPCS code J1442 (medication-related)
J0218	J0218 (Xenpozyme) mapped in prior authorization example
J0588	J0588 (Xeomin) mapped in prior authorization example

Procedure and therapy CPT codes referencedCPT

61850	Neurostimulator-related CPT code
61860	Neurostimulator-related CPT code
97012	Occupational/physical therapy transport code
97016	Occupational/physical therapy transport code
97018	Occupational/physical therapy transport code
97022	Occupational/physical therapy transport code

Orthognathic and associated therapy codesCPT|HCPCS

21121	Orthognathic surgery CPT code
21127	Orthognathic surgery CPT code
21206	Orthognathic surgery CPT code
21215	Orthognathic surgery CPT code
21247	Orthognathic surgery CPT code
21193	Orthognathic surgery CPT code
21208	Orthognathic surgery CPT code
21244	Orthognathic surgery CPT code
21248	Orthognathic surgery CPT code
21299	Orthognathic surgery CPT code

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Prostate procedure codesCPT

52441	Prostate procedure CPT code
52442	Prostate procedure CPT code

Prostate procedures (radiology) CPT codesCPT

52441	CPT code cited for prostate procedures
52442	CPT code cited for prostate procedures

Referenced codes for prior authorizationmixed

CPT/HCPCS

Radiology CPT ® or HCPCS codes (specific codes not listed in this excerpt)

Selected CPT codes requiring prior authorizationCPTCovered

98975	Remote patient monitoring - initial set-up (as listed)
98976	Remote patient monitoring
98977	Remote patient monitoring
98980	Remote patient monitoring
98981	Remote patient monitoring
30400	Rhinoplasty
30435	Rhinoplasty
30410	Rhinoplasty
30450	Rhinoplasty
30420	Rhinoplasty

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Transplant / CAR T / related CPT/HCPCS codesmixedCovered

32851
32855
33944
38241
38206
44136
44721
47144
48550
48554

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Other device/testing codes requiring prior authorizationmixedCovered

G0482	Urine drug testing
G0483	Urine drug testing
33927	Ventricular assist device
Q0508
33928
33929
Q0507
E2402	Wound vac

Provider Actions / Prior Authorization Instructions

Prior Authorization

Prior Authorization Required

Prior authorization is required for many services listed in this section. Submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com; sign in with One Healthcare ID) or by phone. Failure to obtain required prior authorization may result in claim denial for participating providers. Prior authorization is not required for emergency or urgent care.

Online: UHCprovider.com (Prior Authorization and Notification tool)
By phone: 877-610-9785

Billing Rule

Use Listed HCPCS/J‑codes When Obtaining Prior Authorization

When requesting prior authorization for injectable medications or biologics, use the HCPCS/J‑codes listed in this section to map the drug name to the appropriate billing code. This crosswalk is informational to assist with accurate prior authorization submissions; it does not replace clinical authorization criteria.

Examples: Xenpozyme — J0218; Xeomin — J0588; many other J‑codes listed in the Injectable medications lists

Prior Authorization

Transplant and CAR T‑cell Therapy Prior Authorization

Organ or tissue transplants and transplant‑related services (including CAR T‑cell therapies) require prior authorization before pretreatment or evaluation. For transplant and CAR T‑cell therapy services (for example Carvykti, Kymriah, Yescarta) providers must call Optum at 888‑936‑7246 or the number on the back of the member's health plan ID card. Unclassified drug codes J3490 and J3590 used for transplant‑related products require prior authorization routing through Optum Transplant.

Call Optum for transplant/CAR T prior authorization: 888‑936‑7246
Unclassified J‑codes (J3490, J3590) require Optum Transplant prior authorization routing
Examples of listed transplant procedure CPT/HCPCS codes are included in the Transplants list

Prior Authorization

Home Health Care Prior Authorization

Prior authorization is required for home health care services. Obtain authorization using the Provider Portal or the listed phone numbers and include applicable service codes (for example G0151, G0152, G0153, 99600) with your request.

Home health care example codes: G0151, G0152, G0153, 99600
Submit via UHCprovider.com or phone per portal instructions

Prior Authorization

Hysterectomy Prior Authorization

Hysterectomy procedures require prior authorization. Include the applicable CPT codes (examples: 51925, 58152, 58200, 58210, 58240, 58263, 58267, 58270, 58275, 58280, 58285, 58292, 59897, 58548) when submitting your request.

Example hysterectomy codes: 51925, 58152, 58200, 58210, 58240, 58263, 58267, 58270, 58275, 58280, 58285, 58292, 59897, 58548
Prior authorization required before scheduling elective hysterectomy

Documentation Required

Documentation Note

This section is primarily an informational crosswalk and list of services/codes used when obtaining prior authorization. It does not list every clinical approval criterion or appeal pathway; follow the Provider Portal prompts and any clinical documentation requests during the authorization process.

Crosswalks map drug/product names to HCPCS/J‑codes for submission accuracy
Laboratory or clinical documentation may be requested during review

Denial Risk

Denial Risk if No Prior Authorization / Documentation

No single explicit denial trigger is listed in each line item in this excerpt; however, failure to obtain required prior authorization or to provide requested documentation may result in denial or payment delay. Participating providers are responsible for obtaining authorization when required — especially for advanced outpatient imaging, transplants/CAR T, select surgeries, home health, hysterectomy, neurostimulators, and listed injectable medications.

Not obtaining prior authorization when required may result in claim denial
Providing complete documentation and correct HCPCS/J‑codes reduces risk of denial

OpenPayer

Prior authorization requirements for Indiana Hoosier Care Connect

Coverage Criteria

CPT / HCPCS / ICD-10 Codes

Provider Actions / Prior Authorization Instructions