Prior authorization requirements for Massachusetts OneCare
Lists prior authorization requirements and submission instructions for participating UnitedHealthcare Community Plan of Massachusetts OneCare providers for inpatient and outpatient services; includes contact methods and codes for specific services. Affects OneCare network providers and out-of-network providers seeking authorization.
Policy Summary
PayerUnitedHealthcare
PolicyPrior authorization requirements for Massachusetts OneCare
Policy CodePolicy N/A
Change TypeNo material change
Effective DateNov 1, 2025
Next Review DateN/A
Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by phone (866-633-4454), or by fax (888-840-6450).
No material clinical or coverage changes in this revision.
Online/Phone/Faxsubmission methods
Optum:800-632-2206behavioral health contact
866-633-4454general PA phone
888-840-6450PA fax
$1,000DME cost threshold
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20+distinct codes listed
Prior Authorization Coverage Criteria
Prior authorization stance and examples
Submit prior authorization requests as described below. Prior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all procedures and services.
ALL of the following
Accepted submission methods
Online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com).
Phone: Call 866-633-4454.
Fax: 888-840-6450 using the Prior Authorization Paper Fax Form.
Behavioral health prior authorization routing: Behavioral health services prior authorization is handled through Optum Behavioral Health; call 800-632-2206.
ALL of the following
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.
Examples of services that require prior authorization (representative list): bone growth stimulators (CPT 20974, 20975, 20979), BRCA testing (81163, 81164), breast reconstruction (CPT 19316, 19318, 19325, 19355; HCPCS L8600), auditory implants and CGM devices/supplies (A4226, A9277, E2103, A4238, A4239, E0787, A9276, E2102), selected cardiovascular/vascular procedures and implant/device codes (e.g., 93653, 33285, 37220–37231; 69714; L8690; L8691), and selected cosmetic/reconstructive CPT codes (11950–11954, 15820–15822).
Prior authorization coverage criteria (excerpt)
Prior authorization is required for the following categories and codes as listed below; some DME/prosthetic codes are subject to a cost threshold.
Representative CPT codes include 55970 and related surgical codes; applicable diagnosis codes F64.x are referenced.
ALL of the following
Prior authorization requirements (partial list)
Services and codes listed below require prior authorization as noted.
Hysterectomy (inpatient/outpatient; abdominal and laparoscopic): Prior authorization is required for listed CPT codes, including 58553, 58554, 58570–58573 and related entries.
Injectable medications: Prior authorization is required for multiple J- and Q-codes as listed (see injectable medication lists and J-code entries).
Orthotics and prosthetics: Prior authorization is required only when the retail purchase or cumulative rental cost exceeds $1,000 for the specified orthotic/prosthetic codes.
Prior authorization coverage criteria (section 5 of 6)
Services and codes listed below are subject to prior authorization or notification per the payer; some have additional instructions or cost thresholds.
Advanced outpatient imaging (prior authorization/notification required): Providers ordering certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures must notify prior to scheduling and submit PA requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call 866-889-8054.
Rhinoplasty and treatment of nasal functional impairment: Prior authorization required for listed CPT codes (30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465).
Sleep apnea and spinal surgery: Maxillomandibular advancement and oral‑pharyngeal tissue reduction for OSA and numerous spinal surgery CPT codes require prior authorization (see lists including CPTs such as 21685, 22100–22633, 22800–22869, 63001–63197, 63200, etc.).
Prior authorization criteria (partial)
Items listed below require prior authorization or notification as specified; some require additional provider actions.
Ventricular assist devices (VAD): Prior authorization/notification required. Providers must call the notification number on the member's health plan ID card, then fax the form provided by the nurse to the Optum VAD Case Management team at 855-282-8929.
Vein procedures (saphenous): Prior authorization required for listed CPT codes including 37735, 37799, 37765, 37766, 37785.
Specific drugs/products tied to unclassified/temporary codes: Products such as Amtagvi and Lantidra associated with HCPCS/J‑codes C9399, J3490, J3590 require prior authorization.
Code 38232: Will require prior authorization only under conditions noted elsewhere in the full document (see 38232 references).
Submission Instructions and Provider-Facing Requirements
Prior Authorization
Submission methods and general rules
Submit prior authorization requests using the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, by phone, or by fax. Prior authorization is required for many non-emergent services listed below; emergency and urgent care do not require prior authorization. Out-of-network providers must request prior authorization for all procedures and services.
Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal for online submission.
Phone submission for general PA: 866-633-4454. For advanced outpatient imaging PA/notification call: 866-889-8054.
Fax submissions: 888-840-6450 (use Prior Authorization Paper Fax Form).
Behavioral health PAs: call Optum Behavioral Health at 800-632-2206.
Transplant and CAR-T services: contact UnitedHealthcare Community and State Transplant Case Management at 888-936-7246 (or the number on the member ID card).
VAD notifications: fax provided form to Optum VAD Case Management at 855-282-8929 after calling the member ID notification number.
Prior Authorization
Key Definitions and Terms
Prior authorization — definition and submission
DefinitionPrior authorization: A requirement that providers submit and receive approval before providing certain services; requests can be submitted online, by phone or by fax as specified.
Submission methodsUse the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, or call 866-633-4454, or fax 888-840-6450.
ExceptionsPrior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all procedures and services.
Behavioral health routing
DefinitionBehavioral health routing: Behavioral health prior authorization requests are handled through Optum Behavioral Health.
ContactFor behavioral health prior authorization call Optum Behavioral Health at 800-632-2206.
Policy Summary
PayerUnitedHealthcare
PolicyPrior authorization requirements for Massachusetts OneCare
Policy CodePolicy N/A
Change TypeNo material change
Effective DateNov 1, 2025
Next Review DateN/A
Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by phone (866-633-4454), or by fax (888-840-6450).
Inpatient-only vaginal hysterectomy CPT codes: 58260, 58262, 58263, 58267; inpatient and outpatient abdominal and laparoscopic hysterectomy CPT codes: 58150, 58152, 58180, 58541–58544, 58552–58554, 58570–58573, 58290–58294, etc.
ALL of the following
Representative J- and Q-codes (partial list): J0791, J7171, J0225, J0739, J1414, Q5152, J0585, J2329, J3247, J0584, J1551, J0589, J0586, J1413, J3403, J1302, J3380, J1303 (Ultomiris) and many others listed in the injectable medication sections.
Neurostimulator/device implantation: Implantation of electrical stimulators and related device codes (e.g., E0747, E0748, E0749, E0760; CPTs 64555, 63650, 63655, 63685, etc.) require prior authorization.
Transplant and CAR‑T therapies: Prior authorization and case management required; providers must call the UnitedHealthcare Community and State Transplant Case Management team at 888-936-7246 or use the notification number on the member's health plan ID card for coordination.
Temporary/unclassified codes and specific drug products: Temporary/unclassified HCPCS/J‑codes (C9399, J3490, J3590) and associated products (e.g., Amtagvi, Lantidra) require prior authorization when applicable.
Vein procedures: Removal and ablation of saphenous trunks and named branches for venous disease/varicose veins require prior authorization (examples include CPT 37735, 37799, 37765, 37766, 37785).
Orthotics/Prosthetics PA thresholdPrior authorization is required only for orthotics and prosthetics codes listed when the retail purchase or cumulative rental cost is more than $1,000.
Examples of affected itemsOrthotics codes L3216–L3222 and numerous prosthetic L-codes (see prosthetics code lists) are subject to the $1,000 threshold.
Related requirementPrivate duty nursing and select prosthetics/orthotics require PA under the same cost-threshold rule.
Prosthetic purchase/rental cost thresholdPrior authorization is required for listed prosthetic L‑codes only when the retail purchase or cumulative rental cost exceeds $1,000.
How appliedThe threshold applies per retail purchase or cumulative rental cost calculation as noted in the document for the specified L‑codes.
Behavioral health prior authorization routing
Behavioral health services are managed through the designated behavioral health network; prior authorization requests should be routed to Optum Behavioral Health.
All behavioral health prior authorization requests: call Optum Behavioral Health at 800-632-2206.
Prior Authorization
Examples of services requiring prior authorization and related codes
Examples of services that require prior authorization are listed below. This is an illustrative (non-exhaustive) set of codes — consult the portal/tool for the full list and any plan-specific exceptions.
Bone growth stimulators (electronic stimulation/ultrasound) — CPT: 20974, 20975, 20979
Continuous glucose monitors (CGMs) and cosmetic/reconstructive procedures require prior authorization. CGM device and supply HCPCS codes and common cosmetic/reconstructive CPTs are listed.
Cosmetic and reconstructive procedures (including listed CPTs like 11950–11954, 15820–15822) require prior authorization.
Prior Authorization
DME cost-threshold prior auth
Durable medical equipment (DME), orthotics and prosthetics may require prior authorization depending on code and cost thresholds. Certain DME codes always require prior authorization regardless of billed amount.
Some DME codes require prior authorization regardless of billed amount (see Provider Portal for the definitive list).
For specified orthotics (e.g., L3216, L3217, L3219, L3221, L3222, etc.) and prosthetics (numerous L-codes listed), prior authorization is required only when retail purchase or cumulative rental cost exceeds $1,000.
Examples of mapped device codes referenced in source: E0466, E1230, E1239, E2510 and K-codes K0859, K0877, K0884, K0890–K0899.
Prior Authorization
Enteral and In-home Nutritional Services
Enteral nutrition and in-home nutritional services require prior authorization. Codes for enteral formulas, supplies and in-home nutrition are listed below.
Services and procedures identified as experimental, investigational or unproven require prior authorization and review. Representative CPT/T codes that may be considered experimental/investigational are listed.
Experimental/investigational examples requiring prior authorization: 64722; 64744; 66180; 95965; 95966; temporary codes 0200T, 0201T — verify via Portal for full list.
Prior Authorization
Gender Dysphoria Treatment
Gender dysphoria treatments, including related surgical procedures, require prior authorization. Diagnosis codes and multiple surgical CPTs listed in policy apply.
Prior authorization required for gender dysphoria treatment and associated surgical CPTs listed in the policy.
Include appropriate diagnosis code (e.g., F64.x) when submitting PA requests.
Prior Authorization
Hysterectomy - Prior Authorization
Hysterectomy procedures (inpatient vaginal hysterectomies and many inpatient/outpatient abdominal and laparoscopic hysterectomies) require prior authorization. Listed CPTs cover vaginal, abdominal and laparoscopic approaches.
Prior authorization required for listed vaginal hysterectomy CPTs.
Prior authorization required for listed abdominal and laparoscopic hysterectomy CPTs (see full CPT list above).
Prior Authorization
Hearing Aids and Devices
Hearing aids and related devices, including replacements when billed with specified modifiers, require prior authorization. A broad set of V-codes are subject to PA.
Hearing aid devices and many V-codes listed in policy require prior authorization; replacements may require PA when billed with modifiers.
Confirm specific V-codes and modifier requirements via the Provider Portal.
Prior Authorization
Joint replacement prior authorization
Total joint replacement (hip and knee) procedures require prior authorization. Multiple CPTs related to joint replacement surgeries are included in the PA list.
Total hip and knee replacement procedures require prior authorization — use the Provider Portal to confirm the exact CPT(s) for the planned procedure.
PA also applies to inpatient admissions for acute, AIR, LTAC and SNF levels of care.
Billing Rule
Unclassified/temporary codes rule
Use of temporary or unclassified HCPCS/CPT codes (for example C9399, J3490, J3590) requires notification/prior authorization only when used for specified drug products. Check the policy list to determine which drugs trigger PA/notification.
For C9399, J3490, J3590: prior authorization/notification required only when billing for specific drug products named in the policy (e.g., Amtagvi, Lantidra, Nulibry, Yimmugo).
When in doubt, include product-level NDC or HCPCS/J-code details in the PA submission.
Advanced outpatient imaging (selected CT/MRI/MRA/PET and certain nuclear medicine procedures) requires prior authorization or notification before scheduling. Submit requests via the Provider Portal or call the imaging line.
Health care professionals ordering advanced outpatient imaging must provide notification prior to scheduling and obtain PA when required.
For prior authorization use the Prior Authorization and Notification tool on the Provider Portal or call 866-889-8054.
See the Radiology resource on UHCprovider.com for the specific CPT codes that require notification/PA.
Prior Authorization
Sleep apnea and spinal surgery prior authorization
Sleep apnea procedures (including maxillomandibular advancement and certain oral-pharyngeal tissue reductions) and many spinal surgeries require prior authorization. Multiple CPTs are listed for these procedures.
Prior authorization required for maxillomandibular advancement and oral-pharyngeal tissue reduction for OSA — example CPTs: 21685, 41512, 41599, 42145.
Prior authorization required for a broad list of spinal surgery CPTs — confirm specific codes and criteria in the Provider Portal.
Prior Authorization
Transplant and CAR-T prior authorization and case management
Transplant and CAR-T therapies require prior authorization and coordination with the UnitedHealthcare transplant/CAR-T case management team. Call the transplant case management team for pre-service authorization and care coordination.
Before scheduling transplant or CAR-T services, contact the Transplant Case Management team at 888-936-7246 (or use the notification number on the member's ID card).
Transplant/CAR-T services require prior authorization and case management coordination; include therapy/drug names when submitting PA.
Prior Authorization
Vein procedures prior authorization
Vein procedures for treatment of venous disease and varicose veins (removal/ablation of saphenous trunks and named branches) require prior authorization. Specific CPTs are listed below.
Prior authorization required for saphenous vein removal/ablation and related procedures: CPTs 37735, 37799, 37765, 37766, 37785.
Prior Authorization
Drug HCPCS/J-code prior auth
Certain drug products billed with HCPCS (J-/Q-/C-codes) require prior authorization. A wide list of specific injectable medications is subject to PA — include the J- or Q-code when submitting requests.
Prior authorization required for the injectable medications and their associated J-/Q-/C-codes listed in the policy (provide the exact J/Q/C code in the PA request).
Unclassified/temporary codes (C9399, J3490, J3590) require PA/notification only for specific products — include product identifiers.
ScopeApplies to behavioral health services identified in the document requiring prior authorization routing to the behavioral health network.
Auditory implant — definition and codes
DefinitionAuditory implant: A medical device within the inner ear with an external portion that helps persons with profound sensorineural deafness achieve conversational hearing.
AuthorizationPrior authorization is required for auditory implant devices and related supplies as listed.
Durable medical equipment (DME)
DefinitionDurable medical equipment (DME): Medical equipment items listed with CPT/HCPCS codes that may require prior authorization per payer rules.
Cost-threshold noteCertain DME/prosthetic/orthotic codes require prior authorization only when retail purchase or cumulative rental cost exceeds $1,000; some DME codes require PA regardless of billed amount.
ExamplesSelected DME HCPCS/E/K codes appear in the document (e.g., E0221, E0692, K0831 and others) and may be subject to PA requirements.
Enteral services
DefinitionEnteral services: Enteral nutrition and in-home nutritional therapy (including gastrostomy tube feeding) that require prior authorization.
Example codesIncludes HCPCS codes such as B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4155, B4158, B4159, B4160.
RequirementPrior authorization is required for enteral services and associated in-home nutritional therapy as listed.
Experimental / Investigational
DefinitionExperimental/Investigational: Procedures identified as experimental or investigational in the document require prior authorization.
ExamplesNoted codes include 64722, 95966, 64744, 0200T, 66180, 0201T, 95965 as examples of procedures classified this way.
Provider actionSubmit PA requests for experimental/investigational procedures per the listed process; see codes in the document for specifics.
Hearing aid replacements
DefinitionHearing aid replacements: Replacement of hearing aids and devices billed with a modifier require prior authorization.
Code seriesApplies to V5xxx series hearing aid HCPCS codes (examples: V5030, V5040, V5050, V5060, V5070, V5080, V5100, V5130, etc.).
ConditionPrior authorization required for replacements and when specific billing modifiers are used, as noted in the code list.
ScopeApplies to inpatient admission types listed; associated transportation codes (non-emergent air transport) also require PA.
Provider actionProviders must request prior authorization for these admission types before services are rendered except in emergency/urgent situations.
DefinitionC9399, J3490, J3590: Unclassified/temporary HCPCS and J-codes that may require notification or prior authorization only for specific drugs/products.
ExamplesDocument notes these codes and indicates notification/PA is required only for specified drugs (examples include Nulibry, Yimmugo, Amtagvi, Lantidra and others referenced).
RuleUse of these unclassified codes for certain products requires PA/notification as detailed in the policy; check the listed product examples in the document.
Advanced outpatient imaging
DefinitionAdvanced outpatient imaging: Certain CT, MRI, MRA, PET scans and selected nuclear medicine/nuclear cardiology procedures that require notification or prior authorization.
Provider responsibilityProviders ordering advanced outpatient imaging must notify prior to scheduling and submit PA requests via the UnitedHealthcare Provider Portal or call 866-889-8054.
Where to find codesFor specific CPT codes that require notification/prior authorization, see the Radiology section referenced in the document.
Prosthetics (cost-threshold)
DefinitionProsthetics (cost-threshold): Prosthetic L‑codes listed in the document require prior authorization only when the retail purchase or cumulative rental cost exceeds $1,000.
Listed examplesIncludes numerous L‑codes such as L5540, L5560, L5570, L5580, L5590, L5600, L5610, L5611, L5613, L5614, L5616, L5639, etc.
ApplicationThis threshold-based PA requirement applies specifically to the L‑codes enumerated in the prosthetics sections of the document.
Transplant Case Management
DefinitionTransplant Case Management: Contact UnitedHealthcare Community and State Transplant Case Management team for transplant and CAR‑T services prior authorization and coordination.
ContactCall the Transplant Case Management team at 888-936-7246 or use the notification number on the back of the member's health plan ID card.
ScopeApplies to transplant and CAR‑T therapies including listed products (Abecma, Breyanzi, Carvykti, Kymriah, Yescarta, etc.).
Ventricular assist device (VAD)
DefinitionVentricular assist device (VAD): A mechanical pump that takes over the function of the damaged ventricle and restores normal blood flow; prior authorization/notification is required.
Provider actionCall the notification number on the back of the member's health plan ID card, then fax the form provided by the nurse to the Optum VAD Case Management team at 855-282-8929.
Example codesAssociated CPT codes include 33927, 33976, 33928, 33929, 33975, 33983, 33979, 33981, 33982.
Vein procedures (saphenous)
DefinitionVein procedures (saphenous): Removal and ablation of the main trunks and named branches of the saphenous veins for treating venous disease and varicose veins of the extremities require prior authorization.
Example CPT codesExamples listed include 37735, 37799, 37765, 37766, 37785.
RequirementPrior authorization is required for the listed vein procedures as noted in the document.