UnitedHealthcare Prior Auth requirements MA SCO

Services and situations requiring prior authorization

Prior authorization required services

Prior authorization is required for the listed services, procedures, and some diagnosis codes. Examples include behavioral health services, bone growth stimulators, BRCA testing, breast reconstruction, and many cardiovascular procedures.

Prior authorization required for the following services and procedures as listed below.

Examples

Behavioral health services require prior authorization through Optum Behavioral Health; call 800-632-2206.
Bone growth stimulators (CPT 20974, 20975, 20979) require prior authorization.
BRCA genetic testing (CPT 81163, 81164) requires prior authorization.
Breast reconstruction (non-mastectomy) procedures and related HCPCS (e.g., 19355, L8600) require prior authorization.
Cardiovascular procedures (examples: CPT 93653, 93656, 33285, HCPCS E0616 and multiple vascular CPT codes) require prior authorization; certain diagnosis codes also require prior authorization as noted.

Prior authorization requirements (excerpt)

Specific item groups and procedures require prior authorization as noted below.

Continuous glucose monitors require prior authorization (examples: HCPCS A4226, A4238, A4239, A9276, A9277, A9278, E0787).

Cosmetic procedures (examples: CPT 11950, 11951, 11952, 11954; 15820–15839; 15877–15879; etc.) require prior authorization.

Durable medical equipment (DME) items listed require prior authorization; some DME codes require prior authorization regardless of billed amount or for retail purchase (examples: E0466, E1230, E1239, E2510, E8000–E8002).

Enteral/In-home Nutrition

Enteral services and in‑home nutritional therapy require prior authorization.

Enteral services (examples: B4100, B4102, B4103, B4104) require prior authorization.

In-home nutritional therapy and gastrostomy-related codes (examples: B4149, B4150, B4152, B4153, B4155, B4158, B4159, B4160) require prior authorization.

Injectables and Inpatient Admissions

Prior authorization is required for listed injectable medications and for certain inpatient admissions.

Prior authorization is required for the injectable medications listed (examples: J2998, J9333, J1300, J1747, J2326, J2781, J3241, J1303).

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

Long-term Services Authorization

Long‑term services and supports require authorization through care planning.

Prior authorization for long‑term services and supports (home‑ and community‑based services) must be obtained through the member's case manager during the care planning assessment and determination of needs; for information call UnitedHealthcare Community Plan Senior Care Options at 888‑867‑5511.

Surgical Procedures

Certain surgical procedures require prior authorization as indicated.

Hysterectomy procedures (inpatient and some outpatient) require prior authorization (examples: CPT 58260, 58262, 58263, 58267, 58150, 58152, 58180, 58541–58544, 58550).

Joint replacement procedures and other listed surgical procedures require prior authorization (examples included in the surgical list).

Prior authorization criteria (partial)

Prior authorization or notification is required when specific thresholds or conditions apply.

Orthotics and prosthetics require prior authorization only when the retail purchase or cumulative rental cost exceeds $1,000 (examples: orthotics L3216, L3217, L3219, L3221; prosthetics L5301–L5987, L5856, L8629, etc.).

Code 38232 (stem cell harvest) requires prior authorization only for an oncology diagnosis (per note in unclassified/temporary codes).

Other conditional/threshold items

Private duty nursing requires prior authorization (examples: T1000, T1002, T1003).
Potentially unproven services and linked services require prior authorization (examples listed).

Submission and contact requirements

Submission channels and contact points for specific service groups requiring prior authorization:

Advanced outpatient imaging (certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology) — participating physicians must obtain prior authorization and provide notification prior to scheduling; submit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 866‑889‑8054.

Transplants and CAR T‑cell therapy services require prior authorization — contact the UnitedHealthcare Community and State Transplant Case Management team at 888‑936‑7246 for these services (examples listed include Abecma®, Breyanzi®, Carvykti™, Kymriah™, Tecartus™, Yescarta™).

Prior authorization and notification requirements

Coverage requires prior authorization or notification for certain procedures and devices; follow the specific instructions shown.

Vein procedures (removal and ablation of saphenous veins) require prior authorization (examples: CPT 37735, 37765, 37766, 37785, 37799).

Ventricular assist devices require prior authorization/notification — call the notification number on the member's health plan ID card and fax the form provided by the nurse to the Optum VAD Case Management team at 855‑282‑8929.

Temporary and unclassified codes (examples: C9098, J9999 and temporary CPT T‑codes/Q‑code mappings) may require prior authorization only for specified products or oncology diagnoses — check the listed guidance when submitting authorization requests.

CPT/HCPCS and ICD-10 codes referenced

Selected CPT/HCPCS codes requiring prior authorizationCPTCovered

20974	Bone growth stimulator (electronic stimulation or ultrasound)
20975	Bone growth stimulator
20979	Bone growth stimulator
81163	BRCA1/BRCA2 full sequence analysis
81164	BRCA1/BRCA2 duplication/deletion analysis

Breast reconstruction related codesCPT | HCPCSCovered

19316	Breast reconstruction (non-mastectomy)
19318	Breast reconstruction (non-mastectomy)
19325	Breast reconstruction (non-mastectomy)
19355	Breast reconstruction
L8600	Breast reconstruction prosthesis

Cardiovascular procedure codes (examples)CPT | HCPCSCovered

93653	Cardiac electrophysiology; insertion
93656	Cardiac ablation
33285	Insertion of leadless pacemaker
E0616	Cardiac assist device

Example ICD-10 diagnosis codes requiring prior authorization for vascular/cardiovascularICD-10Covered

I70.221	Atherosclerosis of native arteries of right leg with rest pain
I70.222	Atherosclerosis of native arteries of left leg with rest pain
I70.223	Atherosclerosis of native arteries of bilateral legs with rest pain

Selected ICD-10 osteomyelitis codesICD-10

M86.20	ICD-10 code referenced for prior authorization
M86.251	ICD-10 code referenced for prior authorization
M86.252	ICD-10 code referenced for prior authorization
M86.259	ICD-10 code referenced for prior authorization

Cochlear and inner ear device codesmixed

69714	Cochlear related CPT
69930	Cochlear related CPT
L8614	Cochlear HCPCS
L8619	Cochlear HCPCS
L8690	Inner ear device HCPCS
L8691	Inner ear device HCPCS
L8692	Inner ear device HCPCS

Sample HCPCS codes referencedHCPCS

E1036
E1161
E1232
K0108
K0455
K0730

Enteral, nutritional and experimental/linked service codesmixed

B4100	Enteral services
B4149	In-home nutritional therapy
64722	Experimental/investigational linked service example
95965

Injectable medication J-codes (examples)HCPCSCovered

J1300	Soliris
J1303	Ultomiris
J2998	Ryplazim
J9333	Rystiggo

Examples of CPT/HCPCS codes listedmixed

27120	Total hip replacement (example code present in list)
29870	Arthroscopy/endoscopy procedure (example code present in list)
A0140	Non-emergent air transport (example HCPCS present)

Transplant and temporary/unclassified codesmixed

38232	Stem cell harvest (note: code 38232 requires prior authorization only for an oncology diagnosis)
C9098	Temporary/unclassified code (requires prior authorization for temporary/unclassified codes)

Unclassified/temporary and Q-code mappingsmixed

C9098	Unclassified/temporary HCPCS - prior authorization noted for specific cases/products
J9999	Unclassified/temporary HCPCS - prior authorization noted for specific cases/products
0537T	Temporary CPT crosswalk
0538T	Temporary CPT crosswalk
0539T	Temporary CPT crosswalk
0540T	Temporary CPT crosswalk
Q2041	Q-code crosswalk
Q2042	Q-code crosswalk
Q2053	Q-code crosswalk
Q2054	Q-code crosswalk

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Vein procedures and VAD codesCPT | HCPCSCovered

37735	Removal/ablation of saphenous veins
37799	Unlisted procedure, vascular surgery
37765	Vein procedure CPT
37766	Vein procedure CPT
37785	Vein procedure CPT
33927	Ventricular assist device code
33928	Ventricular assist device code
33929	Ventricular assist device code
33975	Ventricular assist device code
33976	Ventricular assist device code

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Inpatient prior authorization

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

Applies toIn-network and out-of-network physicians, facilities and other health care professionals serving Massachusetts Senior Care Options members.

How to requestSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by phone or fax as listed in the provider submission instructions.

How providers submit prior authorization and important action items

Prior Authorization

Prior authorization required for transplants and CAR T‑cell therapy

For transplant and CAR T‑cell therapy services, prior authorization is required. Providers must contact the UnitedHealthcare Community & State Transplant Case Management team to request authorization and coordinate care management.

Includes CAR T‑cell therapies such as Abecma® (idecabtagene vicleucel), Breyanzi® (lisocabtagene maraleucel), Carvykti™ (ciltacabtagene autoleucel), Kymriah™ (tisagenlecleucel), Tecartus™ (brexucabtagene autoleucel) and Yescarta™ (axicabtagene ciloleucel).
Call UnitedHealthcare Community & State Transplant Case Management at 888-936-7246 to initiate prior authorization and notification.

Key definitions and terms

Prior authorization

DefinitionPrior authorization is the process by which providers must obtain approval from UnitedHealthcare before providing certain services or procedures (for example, advanced outpatient imaging).

Not requiredPrior authorization is not required for emergency or urgent care.

Submission channelsRequests can be submitted online via the Prior Authorization and Notification tool on UHCprovider.com, by phone, or by fax using the Prior Authorization Paper Fax Form.

Durable medical equipment (DME)

DefinitionDurable medical equipment (DME): items listed in the DME section that require prior authorization; some DME codes require authorization regardless of billed amount.

Prosthetics noteProsthetics are not considered DME; see the orthotics and prosthetics section for prosthetic-specific rules.

OpenPayer

Prior authorization requirements for Massachusetts Senior Care Options

Services and situations requiring prior authorization

CPT/HCPCS and ICD-10 codes referenced

How providers submit prior authorization and important action items

Key definitions and terms