CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization requirements for Massachusetts Senior Care Options

Lists services, codes and instructions for submitting prior authorization (PA) requests for UnitedHealthcare Community Plan of Massachusetts Senior Care Options providers. Applies to participating in-network and out-of-network clinicians (out-of-network must request PA); emergency/urgent care is exempt.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Massachusetts Senior Care Options

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2025

Next Review Date

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal, by phone at 888-867-5511, or by fax at 888-840-6450 using the Prior Authorization Paper Fax Form.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Multiplecategories requiring PA (e.g., cardiovascular, cosmetic, cochlear, CGM, BRCA, bone growth stimulators)

Phone/Fax/Onlineaccepted submission methods for PA requests

Optumbehavioral health PA vendor and phone

~40CPT/HCPCS procedure codes referenced in this part

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orthotics cost threshold requiring PA

Requiredprior authorization required for transplant, spinal surgery, advanced imaging, VADs, etc.

Policy snapshot & scope

This document lists prior authorization (PA) requirements and submission instructions for UnitedHealthcare Community Plan of Massachusetts Senior Care Options providers effective October 1, 2025. It applies to participating in‑network clinicians and facilities and to out‑of‑network providers (who must request PA), and it explicitly states that prior authorization is not required for emergency or urgent care.

PayerUnitedHealthcare Community Plan of Massachusetts (Colorado Rocky Mountain Health Plans)

PolicyPrior authorization requirements for Massachusetts Senior Care Options

Policy CodeN/A

Effective Date2025-10-01

StatusCURRENT

Key ActionProviders must submit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by phone (888-867-5511) or by fax (888-840-6450). Emergency/urgent care is exempt; out-of-network providers must request PA.

Prior authorization coverage rules

This policy establishes billing rules describing services, CPT/HCPCS codes and instructions for obtaining prior authorization; many clinical and equipment categories listed in the document require PA before services are scheduled or billed. Providers should submit PA requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, by phone at 888-867-5511, or by fax at 888-840-6450; behavioral health services are managed through Optum Behavioral Health and require authorization via 800-632-2206. The policy reiterates that PA is required for numerous categories (for example, advanced outpatient imaging, injectable medications, many cosmetic/reconstructive procedures, DME/orthotics/prosthetics above cost thresholds and inpatient admissions) while emergency/urgent care is exempt.

Codes referenced in this policy

Bone growth stimulatorCPTCovered

20974
20975
20979

BRCA genetic testingCPTCovered

81163
81164

Breast reconstruction (non-mastectomy)CPT|HCPCSCovered

19316
19318
19325
19355
L8600

Cardiovascular (selected CPTs)CPTCovered

37220
37221
37224
37225
37227
37228
37229
37230
37231

Cardiovascular (ICD-10 dx codes where PA NOT required)ICD-10Not Covered

E08.52
E09.52
E10.52
E11.52
E13.52
I70.221
I70.222
I70.223
I70.228
I70.229

1–10 of 203

1/21

Cochlear and other auditory implantsCPT|HCPCSCovered

69714
69930
L8690
L8691
L8614
L8692
L8619

Continuous Glucose Monitor (CGM)HCPCSCovered

A4226
A4238
A4239
A9276
A9277
A9278
E2103
E2102
E0787

Cosmetic and reconstructive procedures (selected)CPTCovered

11950
11951
11952
11954
15820
15821
15822
15823
15830
15832

1–10 of 16

1/2

Cosmetic procedures — codes mentionedCPT

15835
15837
15838
15839
15834

Reconstructive procedures — codes mentionedCPT

15830
15832
15833
15834
15820
15821
15822
15823
11950
11951

1–10 of 12

1/2

Additional cosmetic/reconstructive codes repeated in textCPT

11954
11950
11951
11952

Cosmetic and reconstructive — example codesCPT

11950
11951
11952
11954
15820
15877
15878
15879
17999
19300

1–10 of 52

1/6

Durable Medical Equipment (DME) — HCPCS example codesHCPCS

E0466
E1230
E1239
E2510
E8000
E8001
E8002
K0831
K0835
K0837

1–10 of 113

1/12

Experimental / linked services — CPT examplesCPTExperimental

64722
95966
64744
0200T
66180
0201T
95965

Enteral services mapping (HCPCS to revenue/procedure codes)mixed

K0849 / K0854 / K0860 / K0864	mapped to B4100 B4149
K0850 / K0855 / K0861	mapped to B4102 B4150
K0851 / K0856 / K0862	mapped to B4103 B4152
K0852 / K0858 / K0863	mapped to B4104 B4153 B4160

Femoroacetabular impingement (FAI) — example CPTCPT

29914
29915
29916

Gender dysphoria treatment — surgical CPTs and DX codesmixed

55970	surgical code used for gender dysphoria treatment (requires specific DX codes)
55980	surgical code used for gender dysphoria treatment (requires specific DX codes)
F64.0
F64.9
F64.1
Z87.890
F64.2
F64.8

Hysterectomy — CPT examples (vaginal, abdominal, laparoscopic)CPT

58260
58270
58294
58262
58290
58263
58291
58267
58292

Hysterectomy — vaginal (inpatient only)CPTCovered

58260	Vaginal hysterectomy
58270	Vaginal hysterectomy (other)
58294	Radical vaginal hysterectomy
58262	Vaginal hysterectomy with removal of adnexal structures
58290	Vaginal hysterectomy (other)
58263	Vaginal hysterectomy with repair
58291	Vaginal hysterectomy (other)
58267	Vaginal hysterectomy with colpopexy
58292	Vaginal hysterectomy (other)

Hysterectomy — abdominal and other (inpatient and outpatient)CPTCovered

58150	Subtotal abdominal hysterectomy
58542	Laparoscopic hysterectomy
58552	Laparoscopic hysterectomy w/ removal of tube(s)/ovary(ies)
58152	Total abdominal hysterectomy
58543	Laparoscopic hysterectomy (other)
58553	Laparoscopic hysterectomy w/ removal of tube(s)/ovary(ies) (other)
58180	Total abdominal hysterectomy, with repair of prolapse
58544	Laparoscopic supracervical hysterectomy
58554	Laparoscopic supracervical hysterectomy w/ removal of tube(s)/ovary(ies)
58541	Laparoscopic-assisted vaginal hysterectomy

1–10 of 12

1/2

Injectable medications (prior authorization required)HCPCS|CPT|mixed

J0791	Adakveo
J0739	Apretude
J1414	Beqvez
Q5152	Bkemv
J3247	Cosentyx IV
J0584	Crysvita
J1551	Cutaquig
J1413	Elevidys
J3403	Encelto
J3380	Entyvio

1–10 of 52

1/6

Home health care (selected G/S codes)HCPCS|G-codes|S-code

99503
G0155
G0159
G0494
G0151
G0156
G0299
G0495
G0152
G0157

1–10 of 16

1/2

Private duty nursingHCPCS|CPTCovered

T1000	Private duty nursing
T1002	Private duty nursing
T1003	Private duty nursing

Prostate proceduresCPTCovered

53850

Prostate procedure (example code listed)

Prosthetics (prior auth only if retail purchase or cumulative rental > $1,000)HCPCSCovered

L5301	Prosthetic code (example)
L5987	Prosthetic code (example)
L5856	Prosthetic code (example)
L8629	Prosthetic code (example)
L5968	Prosthetic code (example)
L5981	Prosthetic code (example)

Radiology — advanced outpatient imaging (prior authorization required)mixedCovered

CT/MRI/MRA/PET	Certain advanced outpatient imaging procedures require prior authorization (no exhaustive CPT list in this part)
Nuclear medicine/nuclear cardiology	Require prior authorization

Rhinoplasty (functional/septal deviation)CPTCovered

30400	Rhinoplasty, primary
30435	Rhinoplasty, with other procedures
30465	Rhinoplasty, revision
30410	Rhinoplasty, other
30450	Rhinoplasty, other
30420	Rhinoplasty, other
30460	Rhinoplasty, other
30430	Rhinoplasty, other
30462	Rhinoplasty, other

Sleep apnea surgeries (maxillomandibular advancement, oral-pharyngeal tissue reduction)CPTCovered

21685	Mandibular/maxillary osteotomy (listed for sleep apnea procedures)
42299	Unlisted procedure, pharynx/larynx (used for oral-pharyngeal tissue reduction)
41512	Unlisted procedure, nose (listed)
41599	Unlisted procedure, pharynx (listed)
42145	Palate surgery (listed)

Spinal surgery (prior authorization required)CPTCovered

22100	Spinal fusion, anterior instrumented
22112	Spinal procedure
22210	Spinal fusion, other
22101	Spinal procedure
22114	Spinal procedure
22102	Spinal procedure
22206	Spinal procedure
22110	Spinal procedure
22207	Spinal procedure
22548	Spinal fusion, posterior

1–10 of 75

1/8

Neurostimulators / Implantation of devices that send electrical impulses (prior authorization required)CPT|HCPCSCovered

E0747	External spinal cord neurostimulator (example HCPCS)
E0748	External neurostimulator
E0749	External neurostimulator
E0760	Neurostimulation device
63650	Percutaneous implantation of neurostimulator electrode array
63655	Open implantation of neurostimulator
63685	Insertion or replacement of spinal neurostimulator pulse generator or receiver
61885	Placement of cranial neurostimulator
64568	Insertion/placement of peripheral neurostimulator lead
61850	Neurostimulator-related code

1–10 of 16

1/2

Transplants and CAR T-cell therapy (prior authorization required; call transplant case management)mixedCovered

32850	Thoracic transplant-related code (example)
32851	Thoracic transplant-related code
32852	Thoracic transplant-related code
32853	Thoracic transplant-related code
32854	Thoracic transplant-related code
32855	Thoracic transplant-related code
32856	Thoracic transplant-related code
33930	Cardiac transplant-related code
33933	Cardiac transplant-related code
33935	Cardiac transplant-related code

1–10 of 28

1/3

Vein procedures (removal/ablation of main trunks/branches; prior authorization required)CPTCovered

37735	Vein procedure
37799	Unlisted procedure, veins
37765	Saphenous stripping/ligation
37766	Vein procedure
37785	Endovenous ablation

Ventricular assist devices (VADs) — prior authorization requiredCPT|HCPCSCovered

33927	VAD related code
33928	VAD related code
33929	VAD related code
33975	VAD related code
33976	VAD related code
33979	VAD related code
33981	VAD related code
33982	VAD related code
33983	VAD related code

Ventricular assist device procedure codes (CPT/HCPCS)CPT/HCPCS

33927	Ventricular assist device procedure (listed in document)
33928	Ventricular assist device procedure (listed in document)
33929	Ventricular assist device procedure (listed in document)
33975	Ventricular assist device procedure (listed in document)
33976	Ventricular assist device procedure (listed in document)
33979	Ventricular assist device procedure (listed in document)
33981	Ventricular assist device procedure (listed in document)
33982	Ventricular assist device procedure (listed in document)
33983	Ventricular assist device procedure (listed in document)

What providers must do

Prior Authorization

How to submit a prior authorization request

Submit PA requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, by phone at 888-867-5511, or by fax at 888-840-6450 using the Prior Authorization Paper Fax Form.

Online: Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com)
Phone: 888-867-5511
Fax: 888-840-6450 (use Prior Authorization Paper Fax Form)

Prior Authorization

Behavioral health prior authorization vendor

Behavioral health services are managed through a designated behavioral health network; prior authorization is obtained by calling Optum Behavioral Health at 800-632-2206.

Optum Behavioral Health: 800-632-2206

Defined terms

Prior authorization (PA)A requirement to obtain approval from the plan before performing certain procedures or services to ensure coverage.

Prior authorizationA requirement that certain services or items must be reviewed and approved by the payer before they are rendered or billed in order for coverage to be allowed.

Pre-service approvalPre-service approval required by the plan before the service is rendered to be considered for coverage.

Pre-approval from the health planPre-approval from the health plan required before the service is performed or scheduled; several service categories and codes in this section explicitly require it.

Advanced outpatient imagingCertain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures that require prior authorization and pre-notification before scheduling.

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

Policy updates

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Massachusetts Senior Care Options

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2025

Next Review Date

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal, by phone at 888-867-5511, or by fax at 888-840-6450 using the Prior Authorization Paper Fax Form.

SourceLink

On This Page

Prior Authorization

Emergency/urgent care exemption

Prior authorization is not required for emergency or urgent care services.

Prior Authorization

Out-of-network requirement

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

Prior Authorization

Prior authorization required for cosmetic and reconstructive procedures

Prior authorization is required for the cosmetic and reconstructive CPT/HCPCS procedure codes listed in this part of the document.

11950
11951
11952
11954
15820
15821
15822
15823
15830
15832
15833
15834
15835
15837
15838
15839

Prior Authorization

Prior authorization required for listed services

Prior authorization is required for the listed cosmetic/reconstructive CPT codes, many DME/HCPCS items, enteral services, experimental/ investigational services, femoroacetabular impingement procedures, gender dysphoria surgical procedures (with specified diagnosis codes), hearing aid replacements billed with modifiers, home health in outpatient settings, hysterectomy procedures, and the injectable medications listed.

Cosmetic / reconstructive CPT codes (listed above)
Durable medical equipment / HCPCS items
Enteral nutritional services
Potentially experimental/investigational services
Femoroacetabular impingement (FAI) procedures
Gender dysphoria surgeries (with required DX codes)
Hearing aid replacements billed with modifier(s)
Home health services in outpatient settings (including member's home)
Hysterectomy procedures
Selected injectable medications

Prior Authorization

Hearing aid replacements

Prior authorization is required for hearing aid/device replacements when billed with the specified modifier(s).

V5030
V5040
V5050
V5060
V5070
V5080
V5100
V5130
V5140
V5190
V5211
V5212

Prior Authorization

Home health prior authorization

Prior authorization is required for home health services provided in outpatient settings (including member's home).

99503
G0155
G0159
G0494
G0151
G0156
G0299
G0495
G0152
G0157
G0300
G0496
G0153
G0158
G0493
S9122

Prior Authorization

Enteral services prior authorization

Prior authorization is required for in-home enteral nutritional therapy and mapped HCPCS codes listed in this part.

K0849
K0850
K0851
K0852
K0854
K0855
K0856
K0858
K0860
K0861
K0862
K0863
K0864

Documentation Required

Gender dysphoria surgical procedures

When submitting gender dysphoria surgical codes (e.g., 55970, 55980), include the appropriate diagnosis code (examples listed: F64.0, F64.9, F64.1, Z87.890, F64.2, F64.8) to support prior authorization.

55970
55980
F64.0
F64.9
F64.1
Z87.890
F64.2
F64.8

Prior Authorization

Obtain prior authorization for listed services

Prior authorization is required for the listed categories and codes, including injectable medications, inpatient admissions (acute inpatient, AIR, LTAC, SNF), hysterectomy procedures, joint replacements, orthognathic surgery, orthotics over the cost threshold, and potentially unproven services.

Prior Authorization

Orthotics specific action

Prior authorization is required only for orthotics codes listed when the retail purchase or cumulative rental cost is more than $1,000.

L3216
L3222
L3217
L3765
L3219
L3221
Orthotics threshold: retail purchase or cumulative rental cost > $1,000

Prior Authorization

Inpatient admission action

Prior authorization is required for acute inpatient, acute inpatient rehabilitation (AIR), long-term acute care (LTAC) and skilled nursing facility (SNF) admissions.

Prior Authorization

Prior authorization required for listed potentially unproven services

Prior authorization is required for the potentially unproven services and the CPT/HCPCS codes listed in this section (examples: 28890, 33289, 36514, 64405, C2624).

28890
33289
36514
64405
C2624

Prior Authorization

General prior authorization requirement

Prior authorization is required for the listed categories and codes (examples include advanced outpatient imaging, transplants/CAR T-cell therapies, spinal surgery, stimulator implantation, VADs, vein procedures, rhinoplasty for function, sleep apnea surgeries, prosthetics over $1,000 and private duty nursing).

Prior Authorization

Prior authorization required for VAD procedures

Prior authorization is required for ventricular assist device procedures. To obtain prior authorization, call the notification number on the back of the member's health plan ID card and fax the form provided by the nurse to the Optum VAD Case Management team.

33927
33928
33929
33975
33976
33979
33981
33982
33983

Documentation Required

Fax prior auth form to Optum VAD Case Management

Fax the form provided by the nurse to the Optum VAD Case Management team at 855-282-8929.

Optum VAD Case Management fax: 855-282-8929

Authorization thresholds

DME prior authorization thresholdPrior authorization required regardless of billed amount for some DME; for other DME PA required only when retail purchase or cumulative rental cost exceeds a threshold (unspecified in this part).

Orthotics prior authorization cost thresholdPrior authorization required for orthotics when retail purchase or cumulative rental cost is more than $1,000 retail purchase or cumulative rental cost.

Prosthetics prior authorization thresholdPrior authorization required only for prosthetic codes listed when retail purchase or cumulative rental cost is more than $1,000.