CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Massachusetts Senior Care Options

Lists prior authorization requirements and routing for UnitedHealthcare Community Plan of Massachusetts Senior Care Options providers, including behavioral health routing through Optum and contact methods for submitting requests.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Massachusetts Senior Care Options

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApril 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Provider Portal Prior Authorization and Notification tool, by phone at 888-867-5511, or by fax at 888-840-6450.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1effective date listed

888-867-5511phone for prior auth

800-632-2206Optum BH phone

$1,000DME purchase/rental threshold

multiple itemsexplicitly requiring prior auth

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Services and Conditions Requiring Prior Authorization

Services requiring prior authorization (examples)

Selected services and examples that require prior authorization:

Bone growth stimulator (electronic stimulation or ultrasound) — prior authorization required

CPT: 20974, 20975, 20979

BRCA genetic testing — prior authorization required

CPT: 81163, 81164

Breast reconstruction (non‑mastectomy) — prior authorization required

CPT: 19316, 19318, 19325, 19355

Exceptions / No prior authorization required (examples)

Examples of diagnosis codes for which prior authorization is NOT required (partial list):

Selected diagnosis codes listed as not requiring prior authorization for specified procedures

Examples include: E08.52, E09.52, E10.52, E11.52, E13.52 and vascular codes I70.221–I70.223 (partial list)

Partial prior authorization and coverage notes (excerpt)

Prior authorization requirements and thresholds for selected devices and equipment as listed in this excerpt.

Cochlear implants and related CPT/HCPCS codes require prior authorization

Examples: CPT 69714, 69930; HCPCS L8614, L8619, L8690‑L8692

Continuous Glucose Monitor (CGM) devices and listed HCPCS/CPT codes require prior authorization

Examples: A4226, A4238, A4239, A9276‑A9278, E0787, E2102

Durable medical equipment (DME)

Some DME items require prior authorization regardless of billed amount
Other DME/prosthetic/orthotic items require prior authorization only if retail purchase or cumulative rental cost exceeds $1,000
See threshold: retail purchase or cumulative rental > $1,000

Prior authorization criteria sets

Prior authorization is required for the following service categories and codes as listed in the document.

Enteral and in‑home nutritional therapy — prior authorization required for listed B4xxx codes

Examples: B4104, B4149, B4150, B4152‑B4161

Experimental or investigational procedures (and linked services) — prior authorization required

Examples: CPT 64722, 64744, 66180, 95965‑95966, 0200T, 0201T

Injectable medications — prior authorization required for many J‑codes and some unclassified/temporary codes with product‑specific rules

Examples: J0791, J9334, J1748 and many others listed

Inpatient admissions — prior authorization required for acute inpatient, acute inpatient rehabilitation (AIR), long‑term acute care (LTAC) and skilled nursing facilities (SNF)

Prior authorization/notification requirements

Sections list services needing prior authorization or notification and relevant contacts or routing instructions.

Inpatient admissions — prior authorization required for acute inpatient, AIR, LTAC and SNF

Joint, total hip and knee replacement procedures — prior authorization required

Multiple CPT examples listed (e.g., 27120, 27486 and many others)

Orthotics and prosthetics — prior authorization required only when retail purchase or cumulative rental cost > $1,000

See L‑codes list for specific items

Advanced outpatient imaging (CT/MRI/MRA/PET and certain nuclear medicine/nuclear cardiology) — notification/prior authorization required; ordering clinician responsible for notification before scheduling

See provider portal for radiology prior authorization details

Prior authorization criteria

Prior authorization requirements and how to obtain authorization for listed services

Transplant and CAR T‑cell therapy services — prior authorization/notification required

Call UnitedHealthcare Community and State Transplant Case Management at 888‑936‑7246 or the notification number on the member's ID card; applies to listed CAR‑T products

Carvykti and specific unclassified/temporary codes — prior authorization required only for Carvykti when billed with C9098 or J9999; code 38232 requires prior authorization only for oncology diagnoses

Vein removal and ablation procedures (branches of the saphenous veins) — prior authorization required

Examples: CPT 37735, 37765, 37766, 37785

Ventricular assist devices (VAD) — prior authorization required and special routing for notifications

Call the notification number on the member's ID card, then fax the nurse‑provided form to Optum VAD Case Management at 855‑282‑8929; examples: CPT 33927, 33928, 33929, 33975, 33976, 33979, 33981, 33982

Relevant CPT, HCPCS and ICD-10 Codes

Examples of CPT/HCPCS codes that require prior authorizationCPTCovered

20974	Bone growth stimulator - electronic stimulation or ultrasound
20975	Bone growth stimulator
20979	Bone growth stimulator
81163	BRCA genetic testing
81164	BRCA genetic testing

Examples of codes noted as not requiring prior authorization (diagnosis-specific)CPTNot Covered

37230	Endovascular procedure code listed as not requiring prior authorization for certain diagnosis codes
37231	Endovascular procedure code listed as not requiring prior authorization for certain diagnosis codes

ICD-10 entries (osteomyelitis and related)ICD-10

M86.172	ICD-10 code listed for prior authorization mapping
M86.179	ICD-10 code listed for prior authorization mapping
M86.18	ICD-10 code listed for prior authorization mapping
M86.19	ICD-10 code listed for prior authorization mapping

CGM and cochlear device codesmixed

A4226	CGM supply/device HCPCS
A4238	CGM supply/device HCPCS
L8614	Cochlear implant HCPCS
69714	Cochlear procedure CPT

DME/prosthetics HCPCS codes (extensive list in excerpt)HCPCS

E0466	DME HCPCS examples
E1230	DME HCPCS examples
K0835	Prosthetic/orthotic HCPCS examples
K0891	DME/prosthetic HCPCS examples

Examples of codes requiring prior authorizationHCPCSCovered

J0791	Adakveo (example listed injectable)
J9334	Zolgensma (listed injectable)
B4100	Enteral services code

Example drug and HCPCS codes mentionedHCPCS

J1748	Zymfentra (HCPCS listed)
J7330	Joint replacement related HCPCS code listed

Sample joint replacement CPT codesCPT

27120	Total hip replacement (example CPT)
27486	Knee replacement (example CPT)

Miscellaneous service codes requiring authorizationmixed

A0140	Non-emergent air transport
E0747	Implantable stimulator code example
L3216	Orthotics/prosthetics examples

Neurostimulator / stimulator CPT examplesCPT

64555	Neurostimulator implantation (CPT)
63650	Spinal neurostimulation lead placement (CPT)

Ventricular assist device codesCPTCovered

33927-33982

CPT codes associated with ventricular assist device procedures (examples listed)

Transplant-related codesCPTCovered

38232

Stem cell/human cellular therapy code — prior auth required only for oncology diagnosis

Unclassified/temporary code notes (related to transplant/CAR-T)mixedCovered

C9098	Unclassified/temporary code - prior authorization notes (Carvykti specific)
J9999	Unclassified/temporary code - prior authorization notes (Carvykti specific)

CAR-T product examples referencedmixed

(listed products)

Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta, Zynteglo (product names listed in transplant/CAR-T section)

Vein procedure codesCPTCovered

37735, 37765, 37766, 37785

Vein removal and ablation of branches of the saphenous veins

DME prior authorization purchase/rental threshold

ThresholdPrior authorization required only for a retail purchase or cumulative rental cost of more than $1,000.

Applies toDurable medical equipment and related prosthetic/orthotic items listed in the DME/prosthetics sections.

How enforcedAuthorization requirement applies when the retail purchase price or cumulative rental exceeds the $1,000 threshold as noted in the DME entries.

Related codes (examples)K0859, E0170, E0194, E0203 (see DME/prosthetics entries in the document).

How to Submit Requests and Operational Requirements

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests online via the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal (One Healthcare ID). You may also call 888-867-5511 or fax using the Prior Authorization Paper Fax Form to 888-840-6450. Out-of-network providers must request prior authorization for all procedures and services.

Prior Authorization

Behavioral health prior authorization routing

Behavioral health services prior authorization must be requested through Optum Behavioral Health by calling 800-632-2206.

Denial Risk

Exceptions to prior authorization

Key Terms and Definitions

Prior authorization (definition)

DefinitionPrior authorization is the requirement to obtain approval from UnitedHealthcare before certain procedures or services are provided, except for emergency or urgent care.

When not requiredNot required for emergency or urgent care situations.

Who must complyParticipating and out-of-network physicians, facilities and other health care professionals must request prior authorization for applicable services.

Behavioral health prior authorization routing

RoutingBehavioral health services prior authorization must be requested through Optum Behavioral Health.

PhoneCall Optum Behavioral Health at 800-632-2206 for prior authorization requests.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Massachusetts Senior Care Options

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApril 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Provider Portal Prior Authorization and Notification tool, by phone at 888-867-5511, or by fax at 888-840-6450.

SourceLink

On This Page

Transplant and CAR T‑cell therapy services — prior authorization/notification required

Contact UnitedHealthcare Community and State Transplant Case Management at 888‑936‑7246 or the notification number on the member's ID card

Spinal surgery — prior authorization required

Numerous CPT codes listed in the spinal surgery section

Retail purchase or cumulative rental cost threshold

ThresholdPrior authorization required for orthotics/prosthetics with retail purchase or cumulative rental cost greater than $1,000.

Applies toOrthotics and prosthetics codes listed in the Orthotics/Prosthetics sections (L-codes and other specified HCPCS codes).

Example codesL3216, L3222, L5301, L5987 (examples shown in orthotics/prosthetics sections).

NotesSome prosthetic/orthotic items may have authorization required regardless of billed amount; check specific code entries for exceptions.

Prior authorization is not required for emergency or urgent care.

Prior Authorization

Cochlear devices - prior authorization

Cochlear implants and related inner-ear medical devices require prior authorization for the listed CPT/HCPCS codes (e.g., 69714, 69930, L8614, L8619, L8690, L8691, L8692).

Prior Authorization

Continuous Glucose Monitor - prior authorization

Continuous glucose monitor (CGM) devices require prior authorization for the listed HCPCS/CPT codes (e.g., A4226, A4238, A4239, A9276, A9277, A9278, E0787, E2102).

Prior Authorization

Durable Medical Equipment - prior authorization rules

Durable medical equipment (DME) requires prior authorization; some DME items require prior authorization regardless of billed amount while others require prior authorization only when retail purchase or cumulative rental cost exceeds $1,000.

Examples of DME codes listed include E0466, E1230, K0859 and many others.
Prior authorization is required regardless of billed amount for certain listed DME entries; other DME entries require prior authorization only when retail purchase or cumulative rental > $1,000.

Prior Authorization

Enteral and in-home nutritional therapy prior authorization

Enteral services and in-home nutritional therapy require prior authorization for the listed B4xxx codes (for example B4104, B4149, B4150, B4152, B4153, B4155, B4158, B4159, B4160, B4161) including gastrostomy tube–related codes.

Prior Authorization

Experimental/investigational procedures

Procedures identified as experimental or investigational (and linked services) require prior authorization for the listed CPT/HCPCS codes (examples include 64722, 64744, 66180, 95965, 95966, 0200T, 0201T).

Prior Authorization

Gender dysphoria treatment prior authorization

Gender dysphoria treatments and the many associated surgical codes require prior authorization when billed with the referenced diagnosis codes (e.g., F64.x and others).

Examples of listed diagnosis codes include F64.0, F64.1, F64.2, F64.8, F64.9 and Z87.890.
Examples of listed procedure codes span numerous CPT codes cited in the document.

Prior Authorization

Hearing aids prior authorization

Hearing aids and related device replacements require prior authorization for the listed V-codes and when replacements are billed with the specified modifiers (e.g., radionavigation aids).

Examples of device codes include V5030, V5040, V5050, V5060 and many others listed in the hearing aids section.
Prior authorization is required for replacements when billed with modifier radionavigation aids.

Prior Authorization

Home health care prior authorization

Home health care requires prior authorization only in outpatient settings, including services provided in the member’s home, for the listed CPT/HCPCS codes (for example 99503, G0151–G0159, G0299, G0300, G0493–G0496, S9122–S9131, S9474).

Prior Authorization

Inpatient admissions prior authorization

Inpatient admissions require prior authorization for acute inpatient, acute inpatient rehabilitation (AIR), long-term acute care (LTAC) and skilled nursing facility (SNF) placements.

Prior Authorization

Joint replacement prior authorization

Joint replacement procedures, including total hip and knee replacements and related CPT codes (examples listed throughout the joint replacement section), require prior authorization.

Sample CPT examples in the document include 27120, 27122, 27125, 27130, 27412, 27445, 27446, 27447, and others.

Prior Authorization

Injectable medications prior authorization

Many injectable medications require prior authorization; the document lists numerous J‑codes and specific products (e.g., J0791, J9334, J1748) and notes special notification/prior authorization rules for certain unclassified or temporary codes.

Unclassified/temporary codes (e.g., C9086, C9151, J3490, J3590) have notification/prior authorization rules that apply only to specified products listed in the injectable medications sections.

Prior Authorization

How to submit prior authorization requests (provider portal)

Submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-889-8054 for radiology/prior authorization inquiries as directed in the radiology/portal guidance.

Prior Authorization

LTSS prior authorization via case manager

Long-term services and supports (LTSS) for home- and community-based services require prior authorization through the member’s case manager during care planning assessment and determination of needs.

For additional information, call UnitedHealthcare Community Plan Senior Care Options at 888-867-5511.

Prior Authorization

Transplant/CAR T-cell prior authorization/notification

For transplant and CAR T‑cell therapy services (including listed products), contact the UnitedHealthcare Community and State Transplant Case Management team at 888-936-7246 or call the notification number on the back of the member’s health plan ID card.

Note

Radiology notification responsibility

Health care professionals ordering an advanced outpatient imaging procedure are responsible for providing notification prior to scheduling; see Radiology prior authorization details on the provider portal.

Radiology prior authorization and notification details (and specific CPT codes) are available on the provider portal; call 866-889-8054 for assistance.

Prior Authorization

Transplant and CAR T-cell therapy prior authorization notification

For transplant and CAR T‑cell therapy services (including named products), call the UnitedHealthcare Community and State Transplant Case Management team at 888-936-7246 or the notification number on the member’s health plan ID card before scheduling.

Prior Authorization

Special prior authorization notes for codes 38232, C9098, J9999

Code 38232 requires prior authorization only when submitted with an oncology diagnosis. Temporary/unclassified codes C9098 and J9999 require prior authorization only for Carvykti™.

Prior Authorization

Ventricular assist device prior authorization process

For ventricular assist devices (VADs), 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 Management team at 855-282-8929; prior authorization is required for the listed VAD procedure codes (e.g., 33927, 33928, 33929, 33975, 33976, 33979, 33981, 33982).

Prior Authorization

Vein procedures prior authorization

Vein removal and ablation procedures for branches of the saphenous veins (codes 37735, 37765, 37766, 37785) require prior authorization.

ScopeApplies to behavioral health CPT/HCPCS services requiring prior authorization per the document.

Cochlear implant

DefinitionCochlear implant: a medical device within the inner ear with an external portion that helps persons with profound sensorineural deafness achieve conversational speech.

AuthorizationCochlear implants and related CPT/HCPCS codes require prior authorization as noted in the cochlear device entries.

Example codes69714, 69930, L8614, L8619, L8690-L8692 (codes listed for cochlear devices).

Continuous Glucose Monitor

DefinitionContinuous Glucose Monitor (CGM): device and supply entries listed with associated HCPCS/CPT codes in the document.

AuthorizationPrior authorization is required for CGM devices and listed HCPCS/CPT codes (e.g., A4226, A4238, A4239, A9276-A9278, E0787, E2102).

Example codesA4226, A4238, A4239, A9276, A9277, A9278, E0787, E2102.

Experimental or investigational (and/or linked services)

DefinitionExperimental or investigational (and/or linked services): procedures or services identified as experimental/investigational in the document.

AuthorizationPrior authorization is required for procedures designated as experimental or investigational (examples and CPT codes are listed).

Example codes64722, 64744, 66180, 95965, 95966, 0200T, 0201T (codes shown in the experimental/investigational section).

Home health care (authorization scope)

ScopeHome health care prior authorization is required only in outpatient settings, including the member's home.

Example codes99503, G0151–G0159, G0299, G0300, G0493–G0496, S9122–S9124 (home health care codes listed).

When applicableApplies when services are provided in outpatient/home settings; inpatient/homebound rules differ and should be confirmed separately.

Advanced outpatient imaging

DefinitionAdvanced outpatient imaging includes certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures that require notification or prior authorization.

Provider responsibilityHealth care professionals ordering advanced outpatient imaging are responsible for providing notification prior to scheduling the procedure.

How to obtainSee Radiology prior authorization details on the provider portal or follow the document's notification instructions.

Ventricular assist device

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

Authorization processCall 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 codes33927, 33928, 33929, 33975, 33976, 33979, 33981, 33982 (VAD-related CPT codes listed).

Branches of the saphenous veins

DefinitionBranches of the saphenous veins: veins referenced in removal and ablation procedures for treating venous disease and varicose veins of the extremities.

AuthorizationVein removal and ablation procedures for branches of the saphenous veins require prior authorization (codes include 37735, 37765, 37766, 37785).

ContextThese entries are listed alongside VAD entries and other vascular procedures in the document's vascular/vein procedure sections.