CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Massachusetts OneCare

Lists prior authorization requirements and submission methods for UnitedHealthcare Community Plan of Massachusetts OneCare participating providers for inpatient and outpatient services; includes behavioral health routing and many CPT/HCPCS/ICD-10 codes that require authorization.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Massachusetts OneCare

Policy Code (N/A)N/A

Change TypeNo material change

Effective DateEffective July 1, 2024

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Jul 1, 2024policy effective date

866-633-4454provider phone

888-840-6450fax

Optum 800-632-2206behavioral health contact

>$1,000DME threshold

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Manycodes in excerpt

Prior Authorization Coverage Criteria

Prior authorization criteria by service type

Prior authorization is required for the following service types and settings. Behavioral health services are routed separately through the designated behavioral health network. Emergency and urgent care services are exceptions — see operational guidance for emergent care.

Services requiring prior authorization

Behavioral health services through the designated behavioral health network; prior authorization and authorizations are obtained via Optum Behavioral Health at 800-632-2206.
Behavioral health routing: contact Optum Behavioral Health for all BH prior auths.
Bone growth stimulators / electronic stimulation or ultrasound to heal fractures (CPT/HCPCS: 20974, 20975, 20979).
BRCA genetic testing (CPT: 81163).
Cochlear and other auditory implants (CPT/HCPCS: 69714, 69930, L8614, L8619, L8690, L8691, L8692).
Continuous glucose monitors and related supplies (HCPCS: A4226, A4238, A4239, A9276, A9277, A9278, E0787, E2102).
Cosmetic and reconstructive procedures (selected CPT/HCPCS listed); prior authorization required for specified reconstructive codes (examples include 15832-15835, 67912, 67961).
Durable medical equipment (DME) — prior authorization required; for some items prior auth required regardless of billed amount; certain retail purchases or cumulative rentals > $1,000 require prior authorization (examples HCPCS: E0466, E1230, E1239, E2510, E8001, E8002, K0891, K0898, K0899, A9280, E0170, E0194, E0203, E0220, E0221, E0230, E0231).
Enteral and in-home nutritional therapy (HCPCS/CPT examples: B4100-B4104, B4160, 64722, 95966, 66180, 0200T).
Femoroacetabular impingement syndrome (FAI) and gender dysphoria treatment when listed codes apply (examples: 29914, 55970, F64.0, 287.890, 14001, 15750).
Hearing aids and related devices (examples: V5100, V5171, V5211, V5215, V5245, V5251, V5060, V5130, V5172, V5212, V5221).
Home health care services provided in outpatient settings including the member's home — prior authorization required for outpatient/home-based home health (examples: 99503, G0151-G0159, G0299, G0493-G0496, G0300).
Prior authorization required only in outpatient settings, including member's home.
Acute inpatient, acute inpatient rehabilitation (AIR), long-term acute care (LTAC) and skilled nursing facility (SNF) admissions — prior authorization required for acute inpatient and post-acute facility levels of care.
Joint replacement procedures (total hip and knee and other joint replacements) — prior authorization required for listed joint replacement procedure codes (examples include a wide range of joint procedure codes and implants; see operative code list).
Long-term services and supports for Home- and Community-Based Services (HCBS/ LTSS) — prior authorization required through the member's case manager during care planning and needs determination; call One Care Member Engagement Center at 866-633-4454 for more information.
Orthognathic surgery and maxillofacial/jaw procedures for functional impairment — prior authorization required (examples: A0140, A0436, A0430, A0431, A0435 and numerous CPT codes such as 21120-21249 series).
Orthotics — prior authorization is required for listed orthotics when a retail purchase is involved (examples: L3216, L3222, L3217, L3219, L3221).
Select high-cost or specialty pharmaceuticals and gene therapies (examples: Zolgensma; for certain unclassified/temporary codes and J-codes notification or prior authorization is required; see pharmacy/vendor guidance for J3399 and specific temporary codes).
For specific specialty drug prior authorization and notification rules refer to the medical pharmacy prior auth processes; some J-codes and temporary codes require case management or notification.
Potentially unproven services and linked services — prior authorization required for listed potentially unproven codes (examples include 28890, C2624, 33289, 36514, 64405).
Private duty nursing (T1002, T1003) — prior authorization required.
Prostate procedures where specified — prior authorization required for listed prostate procedure codes (example: 53850).
Radiology: advanced outpatient imaging procedures (certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology) — providers must obtain prior authorization or provide notification prior to scheduling; submit requests online via the UnitedHealthcare Provider Portal or call 866-889-8054.
Rhinoplasty for nasal functional impairment — prior authorization required for listed CPT codes (30400, 30410, 30420, 30430).
Sleep apnea surgical procedures such as maxillomandibular advancement and oral-pharyngeal tissue reduction— prior authorization required (examples: 21685, 42299, 41512, 41599, 42145).
Spinal surgery — prior authorization is required for listed spinal procedure codes (examples include 22100-22114 series, 22206-22214, 22548, 22556, 22610 and others).
Transplants and CAR T-cell therapies — prior authorization is required; contact UnitedHealthcare Community and State Transplant Case Management at 888-936-7246 or the notification number on the member's ID card for pre-service coordination (examples: codes associated with transplant and CAR-T services).
Ventricular assist devices (VAD) — prior authorization required; follow the notification process on the member's health plan ID card and fax the form provided by the nurse to the Optum VAD Case team.

Exceptions and routing

Emergency and urgent care services: prior authorization is not required for emergency care; obtain retrospective authorization/notification as required by plan and submit relevant documentation.
Behavioral health: all behavioral health prior authorization requests must be routed to Optum Behavioral Health at 800-632-2206 as noted above.

Codes and Coding Rules

Injectable medications — Prior authorization requiredmixed

J0791	Adakveo
J0739	Apretude
J3247	Cosentyx IV
J0584	Crysvita
J1551	Cutaquig
J0589	Daxxify
J1413	Elevidys
J3380	Entyvio
J1305	Evkeeza
J0223	Givlaari

1–10 of 33

1/4

Unclassified and temporary codes / Additional injectablesmixed

C9086	Unclassified/temporary
C9149	Unclassified/temporary
C9151-	Unclassified/temporary
C9157-	Unclassified/temporary
C9167	Unclassified/temporary
C9168*	Unclassified/temporary
C9399	Unclassified/temporary
J1823	Uplizna
J3032	Vyepti
J3401	Vyjuvek

1–10 of 11

1/2

Additional single HCPCS/J-codeHCPCS

J3332

Prior authorization required (intranasal corticosteroid)

How to Request Prior Authorization and Provider Responsibilities

Prior Authorization

How to request prior authorization

Submit authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-633-4454; fax requests to 888-840-6450 using the Prior Authorization Paper Fax Form. Prior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all procedures and services.

Documentation Required

Behavioral health prior authorization routing

Behavioral health services are routed through the designated behavioral health network; obtain prior authorization by contacting Optum Behavioral Health at 800-632-2206.

Prior Authorization

Examples of services requiring prior authorization

Definitions and Key Terms

inv-46: Cochlear and other auditory implants

DefinitionCochlear and other auditory implants: a medical device within the inner ear with an external portion that helps persons with profound sensorineural deafness achieve auditory function.

Representative codesCommon CPT/HCPCS codes include 69714, 69930, L8614, L8619, L8690–L8692.

AuthorizationThese implants require prior authorization as noted in the policy.

inv-47: Bone growth stimulator

DefinitionBone growth stimulator: electronic stimulation or ultrasound device used to promote healing of fractures.

Representative CPT codesCPT 20974, 20975, 20979.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Massachusetts OneCare

Policy Code (N/A)N/A

Change TypeNo material change

Effective DateEffective July 1, 2024

Next Review DateN/A

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

SourceLink

On This Page

The policy lists multiple specific services that require prior authorization, including bone growth stimulators (20974, 20975, 20979), BRCA genetic testing (81163), cochlear and other auditory implants (69714, 69930, L8614, L8619, L8690–L8692), continuous glucose monitors (A4226, A4238, A4239, A9276–A9278, E0787, E2102), and cosmetic/reconstructive procedures.

Bone growth stimulator codes: 20974, 20975, 20979
BRCA testing: 81163
Cochlear/auditory implant codes: 69714, 69930, L8614, L8619, L8690, L8691, L8692
Continuous glucose monitor codes: A4226, A4238, A4239, A9276, A9277, A9278, E0787, E2102

Prior Authorization

Durable medical equipment prior authorization

Prior authorization is required for many durable medical equipment items; listed HCPCS/E/K codes include E0466, E1230, E1239, E2510, E8001, E8002, K0831, K0835, K0837 and K0838. Some DME require prior authorization regardless of billed amount; others require prior authorization only for retail purchase or if cumulative rental cost exceeds $1,000.

Example DME HCPCS/E codes: E0466, E1230, E1239, E2510, E8001, E8002
Retail purchase or cumulative rental cost > $1,000 triggers prior authorization per policy

Prior Authorization

Enteral services prior authorization

In-home enteral nutritional therapy requires prior authorization. Billing codes listed include B4100, B4102, B4103, B4104 and related CPTs such as 64722 and 95966.

Enteral codes: B4100, B4102, B4103, B4104
Related CPTs: 64722, 95966

Prior Authorization

Cosmetic, reconstructive and gender dysphoria prior authorization

Prior authorization is required for listed cosmetic/reconstructive procedures and for gender dysphoria treatment; the policy enumerates multiple CPT codes (examples include 29914–29916 and CPTs in the 14000–158xx and 157xx series).

Gender dysphoria and related surgical codes include 29914, 29915, 29916 and multiple 14xxx/15xxx CPTs
Cosmetic/reconstructive examples listed in chunks 14 and 15

Prior Authorization

Hearing aids and home health care prior authorization

Hearing aids, related devices and replacements may require prior authorization; replacements billed with certain modifiers require prior authorization. Home health care services billed in outpatient/home settings also require prior authorization for the listed codes.

Hearing device examples: V5050, V5100, V5171, V5247, V5253, V5257, V5261
Home health codes requiring prior authorization in outpatient/home settings: 99503, G0155 and related G01xx codes

Prior Authorization

Prior authorization required for listed outpatient/home codes

Prior authorization is required for the CPT/HCPCS codes listed for outpatient and home settings; submit authorization before providing services in outpatient settings including the member's home.

Examples of outpatient/home codes requiring prior authorization: 99503, G0155, G0151, G0156, G0152, G0157, G0153

Prior Authorization

Additional outpatient/home code mentions

Additional codes flagged as requiring prior authorization or notification in outpatient/home settings include G0493, G0494, G0495 and G0496; these explicitly include the note 'including member's home.'

Codes noted with 'including member's home': G0493, G0494, G0495, G0496, G0300

Prior Authorization

Hysterectomy prior authorization

Prior authorization is required for the hysterectomy CPTs listed in the policy for inpatient and outpatient procedures; examples include 58150, 58152, 58260, 58262, 58541 and 58542.

Hysterectomy codes include: 58150, 58152, 58260, 58262, 58541, 58542

Prior Authorization

Injectable medications — facility settings prior authorization

Prior authorization is required for injectable medications when administered in facility settings including acute inpatient, acute inpatient rehabilitation (AIR), long-term acute care (LTAC) and skilled nursing facilities (SNF).

Prior Authorization

Joint replacement prior authorization

Total hip and knee replacement procedures require prior authorization; the policy lists numerous CPTs for total hip and knee replacement that must be authorized prior to care.

Examples of listed joint replacement CPTs: 27120, 27122, 27125, 27412, 27447, 29866, J7330

Prior Authorization

Orthognathic surgery prior authorization

Orthognathic (maxillofacial/jaw) surgery and procedures for functional impairment require prior authorization; listed CPTs include 21120, 21121, 21122, 21123 and associated HCPCS codes (A0140, A0430, A0431, A0435, A0436).

Orthognathic CPT examples: 21120, 21121, 21122, 21123
Associated HCPCS: A0140, A0430, A0431, A0435, A0436

Prior Authorization

Joint replacement and LTSS prior authorization

Total hip and knee replacement procedures require prior authorization and Long-Term Services and Supports (LTSS) prior authorization must be obtained through the member's case manager during care planning; contact the One Care Member Engagement Center at 866-633-4454 for LTSS prior authorization assistance.

One Care Member Engagement Center phone for LTSS: 866-633-4454

Prior Authorization

Orthognathic surgery prior authorization (repeat)

Orthognathic surgery prior authorization is required for the listed CPTs and associated HCPCS codes; see the policy's orthognathic sections for the enumerated codes and HCPCS device codes.

See policy for full list of CPTs (21120–21255 range) and HCPCS A01xx/A04xx codes associated with orthognathic procedures

Prior Authorization

Orthotics prior authorization (retail purchase only)

Orthotics listed in the policy require prior authorization only when billed as a retail purchase; example orthotics HCPCS codes include L3216, L3222, L3217, L3219 and L3221.

Orthotics retail-purchase codes: L3216, L3222, L3217, L3219, L3221

Prior Authorization

Medications and unclassified code prior authorization/notification

Certain high-cost, unclassified or temporary drug codes and some J-codes require notification or prior authorization; examples include Zolgensma (J3399) and unclassified/temporary codes such as C9086 and C9399 where notification/PA is required for specific products.

Example high-cost drug J-code: J3399 (Zolgensma)
Unclassified/temporary codes requiring notification/PA for specified products: C9086, C9399

Prior Authorization

Prosthetics, DME, and private duty nursing prior authorization

Numerous prosthetic L-codes and DME items require prior authorization or are subject to the cumulative rental cost threshold; example L-codes listed include L6895 and L6900. Private duty nursing (T1002, T1003) also requires prior authorization.

Prosthetic L-code examples: L6895, L6900
Private duty nursing codes: T1002, T1003
Cumulative rental cost > $1,000 may trigger prior authorization

Prior Authorization

Radiology prior authorization / notification

Participating physicians ordering advanced outpatient imaging (CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology) must provide notification or obtain prior authorization prior to scheduling; submit requests via the UnitedHealthcare Provider Portal or call 866-889-8054.

Radiology prior authorization phone: 866-889-8054
Submit requests using the Prior Authorization and Notification tool on UHCprovider.com

Prior Authorization

Rhinoplasty prior authorization

Prior authorization is required for rhinoplasty procedures for nasal functional impairment; listed CPTs include 30400, 30410, 30420 and 30430.

Rhinoplasty CPTs: 30400, 30410, 30420, 30430

Prior Authorization

Sleep apnea and spinal surgery prior authorization

Maxillomandibular advancement and other sleep apnea surgeries and multiple spinal surgery CPTs require prior authorization; examples include 21685, 42299, 41512, 22100–22102 and additional spinal CPTs listed in the policy.

Sleep apnea CPTs: 21685, 42299, 41512, 41599, 42145
Spinal surgery examples: 22100, 22101, 22102, 22110, 22112, 22114

Prior Authorization

Prior authorization required for listed surgical procedures

Prior authorization is required for the listed surgical procedures in the policy (including rhinoplasty, maxillomandibular advancement and multiple spinal procedures); obtain authorization before scheduling these surgeries.

Prior Authorization

Transplant and CAR T-cell authorization / notification

Transplant and CAR T‑cell therapy services require you to call UnitedHealthcare Community & State Transplant Case Management at 888-936-7246 or the notification number on the member's health plan ID card to obtain authorization or provide notification.

Transplant Case Management phone: 888-936-7246
Includes named CAR-T products listed in the policy

Prior Authorization

Ventricular assist device prior authorization process

Ventricular assist devices require prior authorization/notification: call the notification number on the back of the member's health plan ID card and then fax the form provided by the nurse to the Optum VAD Case per the instructions in the policy.

Follow the policy instruction: call the notification number on the member's ID card, then fax nurse-provided form to Optum VAD Case
Example VAD CPTs listed: 33927, 33928, 33929, 33975–33983

Prior Authorization

Vein procedure prior authorization

Vein procedures for removal or ablation of the saphenous veins require prior authorization; example CPTs include 37735, 37765, 37766 and 37785.

Vein procedure CPT examples: 37735, 37765, 37766, 37785

Authorization requirementPrior authorization is required for bone growth stimulators.

inv-48: Prior authorization

DefinitionPrior authorization: a required approval process for specified services, devices, procedures and codes before they are provided.

ScopeApplies to many service categories including DME, enteral services, implants, injectables, and specified surgical procedures.

ExclusionsEmergency and urgent care do not require prior authorization per policy guidance.

inv-49: Prosthetics vs DME

ClarificationProsthetics are not considered durable medical equipment (DME); see the orthotics and prosthetics section for authorization rules.

PA trigger for prostheticsPrior authorization for prosthetic codes may be required when retail purchase or cumulative rental cost exceeds $1,000.

Related codesProsthetic-related L-codes and HCPCS are listed separately from DME codes in the policy.

inv-51: LTSS / Home- and Community-Based Services prior authorization

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

Contact for assistanceFor additional information, contact the One Care Member Engagement Center at 866-633-4454.

Applies toApplies to long-term services and supports tied to Home- and Community-Based Services care planning.

inv-52: One Care Member Engagement Center (phone contact for case manager prior authorization)

Service nameOne Care Member Engagement Center (phone contact for case manager prior authorization).

Phone number866-633-4454 (contact for LTSS prior authorization and One Care inquiries).

RoleFacilitates case manager coordination for LTSS prior authorization during care planning.

inv-53: UHCprovider prior authorization portal

Tool namePrior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com).

How to accessSign in to UHCprovider.com and select the Prior Authorization and Notification tab on your dashboard to submit requests.

Alternate contactRadiology prior authorization phone: 866-889-8054 (for advanced outpatient imaging procedures).

inv-54: UnitedHealthcare Community and State Transplant Case Management

ProgramUnitedHealthcare Community & State Transplant Case Management: team that manages transplant and CAR T-cell therapy authorization/notification.

Phone numberCall 888-936-7246 (Transplant Case Management) or the notification number on the member's ID card for specific authorization instructions.

ScopeApplies to transplant procedures and named CAR T-cell products listed in the policy.

inv-55: Optum VAD Case (Ventricular Assist Device case management)

ProgramOptum VAD Case: case management process for ventricular assist devices.

Authorization stepsCall 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.

ApplicabilityRequired for ventricular assist device services and related CPT/HCPCS codes listed in the policy.