Colorado Rocky Mountain Health Plans Prior Auth

Policy at a Glance

This document applies to participating providers in the UnitedHealthcare Community Plan of Massachusetts Senior Care Options program and lists services, CPT/HCPCS and diagnosis codes that require prior authorization. It also explains how to submit requests (online via the UnitedHealthcare Provider Portal, by phone at 888-867-5511, or by fax at 888-840-6450) and notes special routing for behavioral health and other services.

Policy dates and scope

Effective date2024-11-01

Last reviewN/A

Next reviewN/A

Scope summaryLists services, CPT/HCPCS and diagnosis codes that require prior authorization for participating UnitedHealthcare Community Plan of Massachusetts Senior Care Options providers; includes how to submit requests and behavioral health routing. Applies to participating providers in Massachusetts Senior Care Options.

Policy numberN/A

Which services and codes require prior authorization

This document enumerates numerous CPT, HCPCS, ICD-10 and V-code groups that require prior authorization, including items such as bone growth stimulators, BRCA testing, cochlear implants, continuous glucose monitors, DME/prosthetics, enteral nutrition, advanced imaging, inpatient admissions, transplants, neurostimulators, and many injectable medications. It also highlights that some DME and orthotics/prosthetics codes require authorization regardless of billed amount and that other orthotics/prosthetics require prior authorization only when retail purchase or cumulative rental cost exceeds $1,000.

Authorization thresholds

Retail purchase or cumulative rental cost threshold$1,000 (prior authorization required only when retail purchase or cumulative rental cost exceeds $1,000 for certain DME/orthotics)

Orthotics/Prosthetics prior authorization thresholdRetail purchase or cumulative rental cost > $1,000

Grouped code lists and billing stance

Bone growth stimulators (electronic stimulation/ultrasound to heal fractures)CPT|HCPCSCovered

20974
20975
20979

BRCA genetic testingCPTCovered

81163
81164

Breast reconstruction (non-mastectomy)CPTCovered

19316	Reconstruction of the breast except when following mastectomy
19318
19325
19355

Cardiovascular — selected procedures and device codesCPT|HCPCS|ICD-10Covered

93653
93656
33285
E0616
37220
37221
37224
37225
37226
37227

1–10 of 14

1/2

Cardiovascular — diagnosis codes requiring prior authorization (partial list in this part)ICD-10Covered

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

1–10 of 52

1/6

Extended ICD-10 cardiovascular and related diagnosis codes (continued)ICD-10Covered

I70.369
I70.421
I70.422
I70.423
I70.428
I70.429
I70.431
I70.432
I70.433
I70.434

1–10 of 16

1/2

Large listing of I70.*, I72.*, I74.*, I75.*, I77.*, T82.*, S81.*, S91.* and related codes (vascular/complication codes)ICD-10Covered

I70.528
I70.529
I70.531
I70.532
I70.533
I70.534
I70.535
I70.538
I70.539
I70.541

1–10 of 64

1/7

Miscellaneous ICD-10 vascular, infection, device and other related codes (selected)ICD-10Covered

I72.8
I72.3
I72.4
I72.9
I77.70
I74.4
I77.77
I77.79
I74.3
I74.5

1–10 of 37

1/4

Osteomyelitis and bone infection ICD-10 codes (M86.* series)ICD-10Covered

M86.051
M86.052
M86.059
M86.061
M86.079
M86.08
M86.09
M86.1
M86.10
M86.151

1–10 of 14

1/2

Cochlear and other auditory implantsCPT|HCPCSCovered

69714
69930
L8614
L8619
L8690
L8691
L8692

Continuous glucose monitor and related suppliesHCPCSCovered

A4226
A4238
A4239
A9276
A9277
A9278
E0787
E2102
E2103

Cosmetic and reconstructive procedure codes (require prior authorization)CPTCovered

11950
11951
11952
11954
15820
15821
15822
15823
15830
15832

1–10 of 58

1/6

Durable medical equipment / Prosthetics HCPCS requiring prior authorization (selected)HCPCSCovered

E0466	DME prior authorization required regardless of billed amount
E1230
E1239
E2510
E8000
E8001
E8002
K0831
K0835
K0837

1–10 of 19

1/2

Other miscellaneous codes present in this partICD-10|HCPCS|CPTCovered

I96.
L03.115
L03.116
Q27.30
Q27.32
Q27.39
Q27.8
Q27.9
Q87.2
S35.511A

1–10 of 12

1/2

Orthotics / Prosthetics / Durable Medical Equipment (examples)HCPCSCovered

K0831	Orthotic/prosthetic item listed (requires prior authorization regardless of billed amount)
K0835	Orthotic/prosthetic item (prior authorization required regardless of billed amount)
K0837	Orthotic/prosthetic item (prior authorization required regardless of billed amount)
K0838	Orthotic/prosthetic item (prior authorization required regardless of billed amount)
K0839	Orthotic/prosthetic item (prior authorization required regardless of billed amount)
K0841	Orthotic/prosthetic item (prior authorization required regardless of billed amount)
K0842	Orthotic/prosthetic item (prior authorization required regardless of billed amount)
K0843	Orthotic/prosthetic item (prior authorization required regardless of billed amount)
K0857	Orthotic/prosthetic item (prior authorization required regardless of billed amount)
K0859	Orthotic/prosthetic item (prior authorization required regardless of billed amount)

1–10 of 27

1/3

Enteral nutrition and gastrostomy related HCPCS/B- codesHCPCSCovered

B4100	Enteral services (prior authorization required regardless of billed amount)
B4102	Enteral services (prior authorization required)
B4103	Enteral services (prior authorization required)
B4104	Enteral services (prior authorization required)
B4149	In-home nutritional therapy (prior authorization required)
B4150	In-home nutritional therapy (prior authorization required)
B4152	In-home nutritional therapy (prior authorization required)
B4153	In-home nutritional therapy (prior authorization required)
B4155	Gastrostomy tube (prior authorization required)
B4158	Gastrostomy tube (prior authorization required)

1–10 of 13

1/2

Hearing aids and device V-codesHCPCSCovered

V5030	Hearing aid/device (prior authorization required for replacements when billed with specific modifier)
V5040	Hearing aid/device
V5050	Hearing aid/device
V5060	Hearing aid/device
V5070	Hearing aid/device
V5080	Hearing aid/device
V5100	Hearing aid/device
V5130	Hearing aid/device
V5140	Hearing aid/device
V5150	Hearing aid/device

1–10 of 40

1/4

Home health care / skilled services (examples)CPT|HCPCSCovered

99503	Home health care (prior authorization required only in outpatient settings including member's home)
G0151	Home health/home infusion (prior authorization conditionally required)
G0152	Home health/home infusion
G0153	Home health/home infusion
G0155	Home health/home infusion
G0156	Home health/home infusion
G0157	Home health/home infusion
G0158	Home health/home infusion
G0159	Home health/home infusion
G0299	Home health code

1–10 of 23

1/3

Hysterectomy and gynecologic procedures (inpatient/outpatient)CPTCovered

58260	Hysterectomy - inpatient only (prior authorization required)
58262	Hysterectomy - inpatient only
58263	Hysterectomy - inpatient only
58267	Hysterectomy - inpatient only
58270	Vaginal hysterectomy
58290	Vaginal hysterectomy
58291	Vaginal hysterectomy
58292	Vaginal hysterectomy
58294	Vaginal hysterectomy
58150	Abdominal/laparoscopic hysterectomy (prior authorization required)

1–10 of 18

1/2

Joint replacement and orthopedics (examples)CPTCovered

23470	Joint procedure (prior authorization required)
23472	Joint procedure
24360	Shoulder procedure
24361	Shoulder procedure
24362	Shoulder procedure
24363	Shoulder procedure
27120	Hip procedure
27122	Total hip
27125	Hip procedure
27130	Hip procedure

1–10 of 24

1/3

Injectable medications (J-codes and others)HCPCS|CPT|unclassified

J0791	Adakveo (prior authorization required)
J0739	Apretude (prior authorization required)
J3247	Cosentyx IV
J0584	Crysvita
J1551	Cutaquig
J1413	Elevidys
J3380	Entyvio
J1305	Evkeeza
J0223	Givlaari
J1411	Hemgenix

1–10 of 42

1/5

Gender dysphoria surgical and related CPT/diagnosis codesCPT|ICD-10

F64.0	Gender dysphoria diagnosis (prior authorization required for related treatments)
F64.1	Gender dysphoria diagnosis
F64.2	Gender dysphoria diagnosis
F64.8	Other gender identity disorders
F64.9	Gender identity disorder, unspecified
Z87.890	Personal history code referenced in gender dysphoria section
14000	Surgical code listed under gender dysphoria treatments (various reconstructive/reductive/plastic procedures)
14001	Surgical code listed under gender dysphoria treatments
14041	Surgical code listed under gender dysphoria treatments
15734	Surgical code listed under gender dysphoria treatments

1–10 of 62

1/7

Experimental/investigational and linked services (examples)CPT

64722	Listed under experimental/investigational (prior authorization required)
64744	Listed under experimental/investigational (prior authorization required)
66180	Listed under experimental/investigational (prior authorization required)
95965	Listed under experimental/investigational (prior authorization required)
95966	Listed under linked services (prior authorization required)
0200T	Temporary/unlisted code - linked services
0201T	Temporary/unlisted code - linked services

Orthognathic / maxillofacial surgery codesCPTCovered

21120	Orthognathic surgery
21121
21122
21123
21125-21143	Range of orthognathic/maxillofacial procedure codes
21127
21141
21142
21143-21150
21145-21147

1–10 of 18

1/2

OrthoticsHCPCSCovered

L3216
L3222
L3217
L3765
L3219
L3221
21255
21244
21248
21249

ProstheticsHCPCSCovered

L5301
L5987
L5856
L8629
L5968
L5981

Potentially unproven / investigational codes (require prior auth)CPTExperimental

28890
33289
36514
64405

Non-emergent air transportHCPCSCovered

A0140	Air ambulance mileage (non-emergent)
A0430	Basic life support air ambulance
A0431	Advanced life support air ambulance
A0435	Fixed wing air ambulance

Radiology / advanced outpatient imagingCPT|HCPCSCovered

see payer list

Certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures require prior authorization — providers must notify prior to scheduling

Rhinoplasty (functional nasal surgery)CPTCovered

30400-30435	Rhinoplasty functional codes
30410
30420
30430

Sleep apnea surgery / maxillomandibular advancementCPTCovered

21685	Maxillomandibular advancement
42299	Unlisted procedure, maxillofacial
41512
41599
42145

Spinal surgery (extensive list)CPTCovered

22100-22222	Various spinal decompression/arthrodesis codes listed
22548,22551,22554,22556,22558,22590,22595
22600,22610,22612,22630,22633
22800,22802,22804,22808,22810,22812,22818,22819,22830,22849,22850,22852,22855,22856,22861,22867
63005-63197 (many)	Numerous laminectomy, discectomy and related codes listed (see payor list)

Neurostimulators / implantable stimulatorsHCPCS|CPTCovered

E0747	Spinal cord neurostimulator, external pulse generator
E0748	Implantable neurostimulator pulse generator
E0749
E0760
64555	Insertion of neurostimulator electrode array
63650,63655,63685	Spinal neurostimulator lead/device implantation codes
61885,64568,61850,61863,61864,61867,61868,61886	Cranial/neuromodulation codes
64590

Transplant and CAR-T related codesCPT|HCPCSCovered

32850-32856	Cardiac transplant-related codes listed
33930,33933,33935,33940,33944,33945	Cardiothoracic transplant/perfusion codes
38208-38215,38232*,38240-38242	Stem cell collection/processing codes
44132-44137	Bowel/intestinal transplant-related codes
44715-44721	Small bowel/intestinal codes
47133-47147	Liver transplant/hepatic codes
48551-48554	Pancreas transplant codes
50300-50370,50547	Renal transplant and related codes; includes drugs J3393, J9999, C9098 and Q2041-Q2055 in list
0537T-0540T	Category III codes listed
J3490,J3590,C9399,C9399	Unclassified drug codes require prior auth/notification

Vein procedures (saphenous trunk removal/ablation)CPTCovered

37735	Ligation, stripping of saphenous veins
37765	Ablation of incompetent veins
37766
37785

Ventricular assist devices (VAD)CPT|Operational instructionsCovered

33927,33928,33929,33975,33983

VAD implant/explant and related codes

Private duty nursingHCPCSCovered

T1000	Private duty nursing
T1002
T1003

Miscellaneous / unclassified codesHCPCS|CPTCovered

C2624
S2060,S2061,S2152
J3393	Drug code included in transplant list
Q2041,Q2042,Q2053,Q2054,Q2055	Supply/implant codes referenced
C9098,J9999	Temporary/unclassified codes require special handling/prior auth notes

The coverage stance in this document is centered on billing rules: most listed procedures, devices, implants, transports and supplies require prior authorization before services are provided. Behavioral health prior authorization is routed to Optum Behavioral Health at 800-632-2206. Health care professionals ordering advanced outpatient imaging must notify prior to scheduling and may submit prior authorization requests online or call 866-889-8054 for assistance.

What providers must do (submission, routing, authorizations)

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests online 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 via UnitedHealthcare Provider Portal — Prior Authorization and Notification tool
Phone: 888-867-5511
Fax: 888-840-6450 — use the Prior Authorization Paper Fax Form

Prior Authorization

Behavioral health prior authorization routing

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

Call Optum Behavioral Health: 800-632-2206

Key definitions

Definitions

Prior authorizationApproval obtained from the plan before a service or item is provided to ensure coverage.

Senior Care OptionsUnitedHealthcare Community Plan of Massachusetts Senior Care Options program (as referenced in this document).

Unclassified/temporary codesHCPCS/CPT codes used for new or unclassified drugs/devices requiring separate notification/prior authorization procedures.

Cumulative rental costTotal rental payments aggregated toward threshold that triggers prior authorization requirement (used for orthotics/prosthetics).

Prior authorizationA process by which a provider must obtain approval from the payer before delivering the listed service or item for coverage to be considered.

OpenPayer

Prior authorization requirements for Massachusetts Senior Care Options

Policy at a Glance

Which services and codes require prior authorization

Grouped code lists and billing stance

What providers must do (submission, routing, authorizations)

Key definitions

Document updates