CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization requirements for Massachusetts OneCare

Lists services, CPT/HCPCS and ICD-10 codes, and instructions for submitting prior authorization requests for UnitedHealthcare Community Plan of Massachusetts OneCare providers; applies to participating Massachusetts OneCare network providers and specifies behavioral health routing and exceptions for emergency/urgent care and out-of-network providers.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Massachusetts OneCare

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by phone at 866-633-4454, or by fax at 888-840-6450.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Online/Phone/Faxsubmission methods

866-633-4454prior auth contact

800-632-2206behavioral health contact

Extensive listscoded entries

$1,000

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.

prosthetics threshold

Requiredfacility-level prior auth

Services Requiring Prior Authorization

Prior authorization coverage criteria (partial)

Services and codes listed require prior authorization as indicated.

ALL of the following

Bone growth stimulators (electronic stimulation or ultrasound for fracture healing) require prior authorization.
CPT codes: 20974, 20975, 20979
BRCA genetic testing requires prior authorization.
CPT codes: 81163, 81164
Continuous glucose monitors and supplies require prior authorization.
HCPCS codes: A4226, A4238, A4239, A9276 (additional A9277/A9278/E0787/E2102/E2103 listed)
Cochlear and other auditory implants require prior authorization.
CPT/HCPCS codes: 69714, 69930, L8614, L8619 (additional L8690–L8692 listed)
Breast reconstruction (non-mastectomy) requires prior authorization.
CPT codes: 19316, 19318, 19325, 19355

Prior authorization coverage criteria

The following codes and service categories require prior authorization as specified:

DME rules

Certain DME items require prior authorization regardless of billed amount.
Examples: codes referenced with E- and K- series (E0466, E1230, E1239, E2510; K0831, K0835, K0837, K0838)
For specified DME/K-codes prior authorization is required only if retail purchase or cumulative rental cost exceeds $1,000.
K-codes examples: K0839, K0841, K0842; threshold: $1,000

Enteral & nutritional therapy: Enteral services and in‑home nutritional therapy require prior authorization.

HCPCS examples: B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4155, B4158–B4161

Experimental/Investigational procedures:

Surgical procedures

Procedures requiring prior authorization

ALL of the following

Hysterectomy procedures require prior authorization (inpatient-only and inpatient/outpatient abdominal and laparoscopic surgeries).
See listed CPT examples: 58260, 58262, 58263, 58267, 58150, 58541–58573
Joint replacement (total hip and knee) procedures require prior authorization.
Example CPTs include 27120, 27447 and multiple joint replacement codes listed in section

Injectables

Injectable medications

The injectable medications listed require prior authorization.

Selected examples: J0791 (Adakveo), J0739 (Apretude), J1306 (Leqvio), 90284 (IVIG); unclassified/temporary codes (J3490/J3590 and others) require notification/PA only for specified drugs

Prosthetics/Orthotics

Prosthetics and orthotics

ANY of the following

Prior authorization is required for prosthetic codes listed when retail purchase or cumulative rental cost exceeds $1,000.$1,000
Examples of L-codes listed: L5010, L5020, L5050, L5060, L5100–L5220, L5230, L5250–L5331, L5341, L5500–L5560, L5570–L5700
Orthotics require prior authorization as specified; some orthotics are subject to the same purchase/rental threshold requirement.
Examples: L3216, L3217, L3219, L3221

Private duty nursing requires prior authorization.

Procedure/service codes: T1000, T1002, T1003

HCBS prior authorization

Long-term services and support (HCBS)

Prior authorization for Home‑and‑Community‑Based Services (HCBS) must be obtained through the member's case manager during care planning and needs determination.

Contact One Care Member Engagement Center: 866-633-4454

Radiology notification/prior authorization

Advanced outpatient imaging

Health care professionals ordering advanced outpatient imaging are responsible for providing notification prior to scheduling; for prior authorization submit requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

Applies to certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures; see Radiology Prior Authorization and Notification for CPT code details.

Rhinoplasty

Rhinoplasty and nasal functional procedures

Rhinoplasty and treatment of nasal functional impairment and septal deviation require prior authorization.

CPT examples: 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462

Spinal surgery

Spinal surgeries listed require prior authorization; additional information is required for many listed codes.

Examples of CPT codes: 22100–22102, 22110, 22112, 22206, 22220, 22532, 22533, 22551, 22554, 22556, 22600–22633, 22800–22802, 63001, 63003, 63017, 63064

Transplants / CAR T-cell therapy

Transplants and CAR T-cell therapy

Transplant and CAR T‑cell therapy services require prior authorization/notification and must be coordinated with the UnitedHealthcare Community and State Transplant Case Management team.

Call Transplant Case Management at 888-936-7246; referenced CPT/HCPCS examples include 32850–32856, 33930–33940, 38208–38215, 38232*, and CAR‑T related codes (temporary/HCPCS)

Prior authorization and notification requirements

Prior authorization/notification requirements in this section include:

ALL of the following

Transplant and CAR T‑cell therapy: contact Transplant Case Management for prior authorization/notification and coordination.
Call 888-936-7246 for Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta
Code 38232 requires prior authorization only when billed for oncology services.
Reference note: 38232 will only require prior authorization for an oncology.
Vein procedures for treatment of venous disease and varicose veins require prior authorization.
Examples: CPT codes 37735, 37799, 37765, 37766, 37785
Ventricular assist devices require prior authorization and notification per the member's ID card instructions; fax required forms as instructed.

CPT/HCPCS/ICD-10 Codes and Coding Rules

Sample CPT/HCPCS/genetic codes requiring prior authorization (partial list)mixedCovered

81163	BRCA testing
81164	BRCA testing
20974	Bone growth stimulator
19316	Breast reconstruction (non-mastectomy)
A4226	Continuous glucose monitor supplies
L8614	Cochlear implant device

Facial/craniofacial and related procedure codesCPTCovered

21181
21182
21183
21184
21230
21235
21256
21260
21261
21263

1–10 of 18

1/2

Hysterectomy and related surgical CPT codesCPTCovered

58260	Hysterectomy CPT example
58262	Hysterectomy CPT example
58150	Hysterectomy - abdominal/laparoscopic
58541	Laparoscopic hysterectomy

Joint replacement (hip and knee) CPT codesCPTCovered

27120	Total hip arthroplasty
27447	Total knee arthroplasty
29870	Arthroscopic procedures (examples listed)

Injectable medications (selected examples)HCPCSCovered

J0791	Adakveo
J0739	Apretude
J1306	Leqvio
90284	IVIG

Prosthetics and orthotics L-codesHCPCSCovered

L5010	Prosthetic codes (examples)
L5600	DME/orthotic L-code example
L5987	DME/orthotic L-code example
L6026	DME/orthotic L-code example

Unclassified/temporary HCPCS codesHCPCS

J3490	Unclassified/temporary code (notification/PA for specific drugs only)
J3590	Unclassified/temporary code (notification/PA for specific drugs only)

Long-term services / prosthetics HCPCS codesHCPCSCovered

L5830	HCPCS/prosthetics-related code listed in long-term services
L5840	HCPCS/prosthetics-related code
L5845	HCPCS/prosthetics-related code
L5848	HCPCS/prosthetics-related code
L5856	HCPCS/prosthetics-related code
L5857	HCPCS/prosthetics-related code
L5858	HCPCS/prosthetics-related code

Spinal surgery CPT codesCPTCovered

22100	Spinal surgery (CPT)
22532	Spinal fusion (CPT)
63001	Spinal decompression/laminectomy (CPT)
63003	Spinal decompression (CPT)

Transplant/Hematopoietic CPT codesCPTCovered

38208	Bone marrow harvest or related (CPT)
38209	Bone marrow transplant codes
38210	Bone marrow/peripheral stem cell transplant
38232	Related hematopoietic cell transplantation code (noted with *)

Codes referenced in this sectionmixed

64590	Transplant/CAR T-cell related code referenced
32850-32856	Listed surgical codes (range)
38232	Stem cell harvest code — prior auth only for oncology
0537T-0540T	CAR-T cell therapy related temporary CPT codes
Q2041,Q2042,Q2053,Q2054,Q2055,Q2056	HCPCS/Q-codes listed
37735,37765,37766,37785,37799	Vein procedure codes
33927-33933,33935,33940,33944-33945,33975-33983	Cardiac and VAD related CPT codes
C9399	Temporary and Unclassified

DME retail purchase / cumulative rental cost threshold — $1,000

Threshold amount$1,000

Applies toDME retail purchases or cumulative rentals for specified K-/E-/other DME codes

Trigger rulePrior authorization required only when retail purchase or cumulative rental cost is more than $1,000

Reference examplesK0839, K0841, K0842 referenced in threshold guidance

How Providers Submit Requests and Operational Requirements

Prior Authorization

How to submit prior authorization requests

Submit prior authorization and notification requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by phone, or by fax. To use the portal, go to UHCprovider.com, click Sign In and log in with your One Healthcare ID and password, then select the Prior Authorization and Notification tab on your dashboard. If you do not have a One Healthcare ID, visit UHCprovider.com/access. Phone: 866-633-4454. Fax: 888-840-6450 (use the Prior Authorization Paper Fax Form). Prior authorization is not required for emergency or urgent care. Out-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services.

Prior Authorization

Behavioral health prior authorization routing

Behavioral health services are managed through the designated behavioral health network and require separate routing for prior authorization.

Behavioral health prior authorizations must be obtained through Optum Behavioral Health
Call Optum Behavioral Health: 800-632-2206

Key Terms and Contacts

Prior authorization — Definition and scope (not required for emergency/urgent care)

DefinitionA process requiring providers to obtain approval from the health plan before performing certain services

Emergency/urgent carePrior authorization is not required for emergency or urgent care

Submission methodsSubmit requests online via the Prior Authorization and Notification tool on UHCprovider.com, by phone (866-633-4454) or by fax (888-840-6450)

Out-of-network ruleOut-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services

Behavioral health prior authorization — Behavioral health services authorized through Optum Behavioral Health

RoutingBehavioral health services must be authorized through the designated behavioral health network (Optum Behavioral Health)

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Massachusetts OneCare

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by phone at 866-633-4454, or by fax at 888-840-6450.

SourceLink

On This Page

Experimental or investigational procedures require prior authorization.

Examples: 64722, 64744, 66180, 95965, 95966, 0200T, 0201T; FAI codes 29914–29916

Hearing aids and devices: Hearing aids and related devices require prior authorization for replacements and certain modifier-billed situations.

Examples: V5030–V5172 listed

Home health care (outpatient/member's home): Home health care services require prior authorization when provided in outpatient/home settings.

Examples: 99503, G0151–G0159, G0299, G0300, G0493–G0496, S9122–S9128

Hysterectomy procedures require prior authorization; some codes are marked inpatient-only.

Examples: 58260, 58262, 58263, 58267, 58150, 58541 and related codes

Example CPT codes: 33927, 33928, 33929, 33975–33976, 33979, 33981–33983; follow notification number on member ID card

Prosthetic prior authorization purchase/rental threshold — $1,000 retail purchase or cumulative rental cost

Threshold amount$1,000 retail purchase or cumulative rental cost

Applies toProsthetic codes (selected L‑codes listed such as L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160)

Trigger rulePrior authorization required only for prosthetic codes listed with a retail purchase or cumulative rental cost exceeding $1,000

Where to find detailsLong-term services and support / Prosthetics section lists specific L‑codes requiring PA when cost threshold exceeded

Prior Authorization

Enteral and in-home nutritional therapy

Enteral services and in-home nutritional therapy require prior authorization. This includes gastrostomy-related supplies and specified HCPCS codes for enteral nutrition and in-home therapy.

Enteral services: B4100, B4102, B4103, B4104
In-home nutritional therapy (enteral or other): B4149, B4150, B4152, B4153
Gastrostomy tube supplies: B4155, B4158, B4159, B4160, B4161

Prior Authorization

Experimental/Investigational procedure prior authorization

Experimental, investigational or unproven procedures require prior authorization. Specific procedure codes that are considered experimental/investigational are listed and must be authorized before services are rendered.

Examples of codes requiring prior authorization as experimental/investigational: 64722, 64744, 66180, 95965, 95966, 0200T, 0201T
Prior authorization required for potentially unproven services and linked services

Prior Authorization

Hearing aids prior authorization

Hearing aids and related devices require prior authorization for replacements billed with modifiers and in specified situations.

Hearing aid device codes: V5030, V5040, V5050
Prior authorization required for replacements when billed with modifier

Prior Authorization

Hysterectomy prior authorization

Hysterectomy procedures (inpatient-only and inpatient/outpatient abdominal and laparoscopic surgeries) require prior authorization. Vaginal and other hysterectomy codes listed also require authorization where indicated.

Inpatient-only hysterectomy examples: 58260, 58262, 58263, 58267
Vaginal hysterectomy examples: 58270, 58290, 58291, 58292, 58294
Abdominal/laparoscopic hysterectomy examples: 58150

Prior Authorization

Home- and Community-Based Services prior authorization

Home- and Community-Based Services (HCBS) prior authorization must be obtained through the member's case manager during the care planning assessment and determination of needs.

HCBS authorization is coordinated via the member's case manager during care planning
Call One Care Member Engagement Center: 866-633-4454 for assistance

Prior Authorization

Neurostimulator/stimulator implantation prior authorization

Neurostimulator and other electrical stimulator implantation procedures require prior authorization. Specific CPT/HCPCS and device codes are listed and must be authorized prior to implantation.

Common neurostimulator CPT codes: 64555, 63650, 63655, 63685, 61885, 64568, 61850, 61863, 61864, 61867, 61868, 61886, 64590
Device HCPCS examples: E0747, E0748, E0749, E0760

Prior Authorization

Transplant and CAR T‑cell therapy notification/prior authorization

For transplant procedures and CAR T‑cell therapies, providers must contact UnitedHealthcare Community and State Transplant Case Management for prior authorization or notification. Several CAR T‑cell products are listed and require case management engagement.

Contact transplant case management for services including Abecma®, Breyanzi®, Carvykti™, Kymriah™, Tecartus™, and Yescarta™
Transplant prior authorization is required

Prior Authorization

Code-specific prior authorization

Certain codes have specific prior authorization rules; ensure you check code-specific guidance before scheduling services.

Code 38232 requires prior authorization only for oncology indications
Temporary and unclassified codes (e.g., C9399 and other Temporary/Unclassified codes) may require prior authorization or special handling

Prior Authorization

Ventricular assist devices notification/prior authorization

Ventricular assist devices (VADs) require prior authorization and a notification workflow. Call the notification number on the back of the member's health plan ID card and fax the form provided by the nurse as instructed.

Examples of related CPT codes: 33927, 33928, 33929, 33975, 33976
Call the notification number shown on the member's ID card and follow fax instructions provided by the nurse

Behavioral health prior auth phoneCall Optum Behavioral Health at 800-632-2206 for prior authorization

ScopeApplies to behavioral health CPT/HCPCS codes as indicated in the behavioral health section

Prosthetics vs DME — Prosthetics are separate from DME and categorized under orthotics and prosthetics

CategorizationProsthetics are not considered DME and are handled under orthotics and prosthetics

ImplicationRefer to the orthotics and prosthetics section for prosthetic code requirements and thresholds

ExamplesSee L‑codes listed under prosthetics/orthotics for specific PA rules

Retail purchase/cumulative rental threshold — Prior authorization applies when retail purchase or cumulative rental exceeds $1,000 for certain DME/K-codes

Threshold amount$1,000 — retail purchase or cumulative rental cost

Applies toCertain DME/K-codes (examples: K0839, K0841, K0842) where PA is required only if cost exceeds threshold

Rule textPrior authorization is required only for a retail purchase or cumulative rental cost of more than $1,000

Reference placementSee DME section for listed K- and E- series codes and threshold notes

Home health care outpatient prior auth — Home health care prior authorization applies only to outpatient/home settings

ScopeHome health care prior authorization is required only for outpatient settings (member's home)

Examples of codesIncludes codes such as 99503, G0151–G0159 and related home health CPT/HCPCS codes listed

How to submitSubmit prior authorization requests via the standard portal/phone/fax channels

Prior authorization for facility admissions — Requirement to obtain approval before certain services or admissions (acute inpatient, AIR, LTAC, SNF)

RequirementPrior authorization is required before coverage for certain facility admissions and services

Affected facilitiesAcute inpatient, acute inpatient rehabilitation (AIR), long-term acute care (LTAC) and skilled nursing facilities (SNF)

Action for providersObtain PA in advance of admissions to these facility levels to ensure coverage

HCBS prior authorization pathway — For long-term services and support under HCBS, prior authorization must be obtained through the member's case manager

PathwayFor Home- and Community-Based Services (HCBS), prior authorization must be obtained through the member's case manager during care planning and needs determination

Contact for informationOne Care Member Engagement Center: 866-633-4454

ApplicabilityApplies to long-term services and supports arranged under HCBS care planning

Prior authorization/notification — Providers must notify or obtain prior authorization before scheduling certain advanced outpatient imaging procedures and other listed services

RequirementHealth care professionals ordering advanced outpatient imaging must provide notification prior to scheduling and may need prior authorization

Submission methodFor prior authorization, submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com)

Imaging typesCertain CT, MRI, MRA, PET scans, nuclear medicine and nuclear cardiology procedures are included

Transplant case management contact — Call UnitedHealthcare Community and State Transplant Case Management at 888-936-7246 for transplant/CAR-T services

ContactCall UnitedHealthcare Community and State Transplant Case Management at 888-936-7246 for transplant and CAR-T services

When to callFor all transplant and CAR-T therapy services (including listed CAR-T products) to obtain prior authorization or notification

AlternateUse the notification number provided as instructed in the transplants section when applicable

Ventricular assist devices — Definition and requirement for prior authorization/notification

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

RequirementPrior authorization is required for VADs and related CPT/HCPCS codes

Notification processCall the notification number on the back of the member's health plan ID card and fax the form provided by the nurse as instructed

CAR-T cell therapy — Definition and product examples referenced (Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta)

DefinitionCAR-T cell therapy: chimeric antigen receptor T‑cell treatments referenced by product names (examples listed) and associated CPT/HCPCS codes

Product examplesAbecma (idecabtagene vicleucel), Breyanzi (lisocabtagene), Carvykti (ciltacabtagene autoleucel), Kymriah (tisagenlecleucel), Tecartus (brexucabtagene autoleucel), Yescarta (axicabtagene ciloleucel)

Administrative actionCall Transplant Case Management at 888-936-7246 or use the notification number for CAR-T prior authorization/notification