CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Massachusetts Senior Care Options

Lists prior authorization requirements and submission methods for UnitedHealthcare Community Plan of Massachusetts Senior Care Options participating providers for inpatient and outpatient services.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Massachusetts Senior Care Options

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 1, 2025

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Feb 1, 2025effective date

888-867-5511prior authorization phone

Optum 800-632-2206behavioral health contact

$1,000purchase threshold

Requires PAadvanced imaging

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Services and Codes Requiring Prior Authorization

Prior authorization requirements

Prior authorization is required for many specified services and codes. Submit requests via the UnitedHealthcare Provider Portal (Prior Authorization and Notification tab), phone, or fax. Behavioral health services route through the designated behavioral health network.

Prior authorization is required except for emergency or urgent care; out-of-network providers must request prior authorization for all procedures and services.

How to submit

Online: use the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal (UHCprovider.com).
Phone: 888-867-5511.
Fax: 888-840-6450 using the Prior Authorization Paper Fax Form.

Behavioral health prior authorization: call Optum Behavioral Health at 800-632-2206 for behavioral health services routed through the designated behavioral health network.

Prior authorization coverage criteria (listed items)

The following services and device categories are explicitly indicated in the list as requiring prior authorization.

Cochlear and other auditory implants require prior authorization (examples: CPT 69714, 69930; HCPCS L8614, L8619, L8690, L8691, L8692).

Continuous Glucose Monitor (CGM) systems and related supplies require prior authorization (examples: A4226, A4238, A4239, A9276, A9277, A9278, E0787, E2102, E2103).

Bone growth stimulators and BRCA genetic testing are listed as requiring prior authorization (examples: CPT 20974, 20975, 20979; 81163, 81164).

Various DME and prosthetic device HCPCS codes are listed as requiring prior authorization; for many codes prior authorization is required regardless of billed amount (see durable equipment lists).

Prior authorization required — durable medical equipment and HCPCS codes

Prior authorization is required regardless of billed amount for the listed durable medical equipment and HCPCS codes below.

Prior authorization required regardless of billed amount for listed E-series codes: E1235, E1236, E1237, E1238, E1250, E1285, E1290, E1300, E1399, E2298.

Prior authorization required regardless of billed amount for listed K- and other HCPCS codes: K0108, K0455, K0730, K0734, K0808, K0836, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0854, K0855, K0856, K0857, K0858, K0860, K0861, K0862, K0863, K0864.

Nutrition-related services

Enteral and nutrition-related services require prior authorization.

Prior authorization required for enteral services (examples: HCPCS B4100, B4102, B4103, B4104).

Prior authorization required for in-home nutritional therapy and gastrostomy tube services and supplies (examples: B4149, B4150, B4152, B4153, B4155, B4158, B4159, B4160, B4161).

Injectable medication prior authorization

Injectable medications listed in the document require prior authorization; notification/prior authorization rules apply for unclassified and temporary codes.

Prior authorization is required for the listed injectable medications (examples: J0791, J0739, J1414, J3247, J0584, J1551, J1413, J3380, J1305, J0223, J0129, J0224, J1576, J1304, J1301, J0896, J2998, J9333, J1300, J1747, J2326, J2781, J3241, J1628, J1303).

For unclassified and temporary codes (examples: C9086, C9149, C9151, C9157, C9172, C9399, J3490, J3590), notification/prior authorization is required only for specified products; providers should submit requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool.

Inpatient authorization

Inpatient admissions require prior authorization.

Prior authorization is required for acute inpatient admissions.

Prior authorization is required for acute inpatient rehabilitation (AIR) admissions.

Prior authorization is required for long-term acute care (LTAC) admissions.

Prior authorization is required for skilled nursing facility (SNF) admissions.

Prior authorization requirements (enumerated categories)

Prior authorization or prior notification is required for multiple categories and specific services; use the UnitedHealthcare Prior Authorization and Notification tool or the listed phone numbers as directed.

Injectable medications and certain unclassified/temporary drug codes require prior authorization/notification as specified; submit via the Provider Portal for many products.

Inpatient admissions (acute, AIR, LTAC, SNF) require prior authorization.

Advanced outpatient imaging (certain CT, MRI, MRA, PET and selected nuclear medicine procedures) requires notification/prior authorization; the ordering provider is responsible for notification prior to scheduling.

Transplants and CAR T-cell therapies require prior authorization/notification; contact the UnitedHealthcare Community and State Transplant Case Management team at 888-936-7246 or the notification number on the member's ID card.

Durable medical equipment, orthotics and prosthetics, and certain potentially unproven services require prior authorization when retail purchase or cumulative rental cost exceeds $1,000; specific HCPCS codes are listed.

Procedure prior authorization requirements

The following vein procedures require prior authorization.

Vein procedures for removal and ablation of the main trunks and named branches of the saphenous veins (examples: CPT 37735, 37765, 37766, 37785) require prior authorization.

VAD prior authorization process

Ventricular assist device (VAD) services require prior authorization and a specific notification/fax process.

Ventricular assist devices require prior authorization (examples: CPT 33927, 33928, 33929, 33975, 33976, 33979, 33981, 33982, 33983).

Process: call 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.

Transplant/CAR-T authorization notes

Transplant and CAR-T services require prior authorization/notification and have code-specific notes and exceptions.

Transplants and CAR T-cell therapies require prior authorization/notification; providers should call UnitedHealthcare Community and State Transplant Case Management at 888-936-7246 or the notification number on the member's ID card.

Exceptions

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

For listed CAR-T products (examples provided) contact transplant case management as noted before scheduling or obtaining services.

Codes and Diagnosis Groups

Selected CPT/HCPCS codes requiring prior authorizationCPTCovered

20974	Bone growth stimulator
20975	Bone growth stimulator
20979	Bone growth stimulator
81163	BRCA testing
81164	BRCA testing

Breast reconstruction codesCPTCovered

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

Selected ICD-10 diagnosis codes requiring prior authorizationICD-10Covered

I70.221	Example cardiovascular/vascular diagnosis code (listed among many)
I70.222	Example cardiovascular/vascular diagnosis code
I70.223	Example cardiovascular/vascular diagnosis code
E11.52	Example diagnosis code (listed)

M86.x ICD-10 groupICD-10

M86.20	Osteomyelitis, unspecified site
M86.251	Chronic osteomyelitis, right shoulder
M86.252	Chronic osteomyelitis, left shoulder
M86.259	Chronic osteomyelitis, unspecified shoulder
M86.261	Chronic osteomyelitis, right upper arm
M86.262	Chronic osteomyelitis, left upper arm
M86.269	Chronic osteomyelitis, unspecified upper arm

Assorted ICD-10 diagnosesICD-10

I96	Gangrene, not elsewhere classified
L03.115	Cellulitis of right toe
L03.116	Cellulitis of left toe
Q27.30	Pulmonary artery anomaly, unspecified

Implant and CGM codesmixedCovered

69714	Insertion of cochlear implant; with cochlear implant
69930	Removal of cochlear implant
L8614	Cochlear implant
L8619	Prosthetic implant, auditory
A4226	Continuous glucose monitor transmitter
A4238	CGM supplies
A4239	CGM supplies
A9276	Sensor; invasive (e.g., subcutaneous), for glucose monitoring
E0787	CGM system

Enteral servicesHCPCSCovered

B4100	Enteral services
B4102	Enteral services
B4103	Enteral services
B4104	Enteral services

Home health care (outpatient/home)CPT|HCPCSCovered

G0151	Home health care
G0152	Home health care
G0153	Home health care

Joint replacement proceduresCPTCovered

27120	Total hip replacement
27445	Knee replacement related

Joint replacement / orthopedic procedures (examples from list)CPT

27120	Total hip arthroplasty
27122	Hip replacement
27447	Knee replacement
27486	Arthroscopy procedures
29866	Arthroscopy shoulder

Orthotics / prosthetics examplesHCPCS

L3216	Orthotic code (example)
L5301	Prosthetic code (example)

Non-emergent air transportHCPCS

A0140	Non-emergent air transport (basic life support)
A0430	Air ambulance transport, basic life support, fixed wing

Referenced CPT/HCPCS codesmixed

64590	Referenced in transplant/CAR-T section
32850	Cardiothoracic/related procedure (listed)
38232	Stem cell harvest (requires PA only for oncology diagnosis)
J3392	Drug HCPCS code referenced
J3393	Drug HCPCS code referenced
C9098	Temporary/unclassified code (PA only for Carvykti™)
J9999	Unclassified drug code (PA only for Carvykti™)
Q2041	HCPCS Q-code referenced
Q2042	HCPCS Q-code referenced
Q2053	HCPCS Q-code referenced

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Retail purchase / cumulative rental cost threshold — $1,000

Threshold amount$1,000

Applies toRetail purchase or cumulative rental cost of certain prosthetics, prosthetic-related services and other potentially unproven items

EffectPrior authorization is required when retail purchase or cumulative rental cost exceeds $1,000

Reference noteSome listed DME/prosthetic codes still require prior authorization regardless of billed amount; threshold applies only to specified items

How Providers Submit Requests and Required Notifications

Prior Authorization

How to submit prior authorization requests

Submit prior authorization and notification requests using the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com → Sign In → Prior Authorization and Notification tab), by phone at 888-867-5511, or by fax 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.

Prior Authorization

Behavioral health prior authorization

Behavioral health services are managed through Optum Behavioral Health. For prior authorization for behavioral health services, call Optum Behavioral Health at 800-632-2206.

Prior Authorization

Examples of services requiring prior authorization

Examples of services that require prior authorization include (but are not limited to) bone growth stimulators (CPT/HCPCS 20974, 20975, 20979), BRCA genetic testing (81163, 81164), certain reconstructive and cardiovascular procedures, and many of the items and services listed in this section. Always verify codes and requirements prior to scheduling.

Key Definitions and Thresholds

Definition of prior authorization

DefinitionPrior authorization is the requirement to obtain approval before services are rendered

ExceptionPrior authorization is not required for emergency or urgent care

Out-of-network ruleOut-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services

Behavioral health network

Designated networkOptum Behavioral Health

How to requestFor prior authorization, call Optum Behavioral Health at 800-632-2206

Scope

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Massachusetts Senior Care Options

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 1, 2025

Next Review DateN/A

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

SourceLink

On This Page

Non-emergent air transport requires prior authorization (examples: A0140, A0430, A0431, A0435).

Neurostimulator and related device implantation procedures require prior authorization (examples: CPT/HCPCS and neurostimulator codes listed).

Joint replacement and related orthopedic surgical procedures require prior authorization; multiple CPT codes are enumerated in the list.

retail_purchase_or_cumulative_rental_threshold — $1,000

Threshold amount$1,000

Label (internal)retail_purchase_or_cumulative_rental_threshold

ScopeApplies to potentially unproven services, private duty nursing, prosthetics and selected procedures when retail purchase or cumulative rental cost > $1,000

Action requiredPrior authorization required when threshold exceeded; providers should submit requests via the Provider Portal

Bone growth stimulators: 20974, 20975, 20979
BRCA testing: 81163, 81164

Prior Authorization

Cochlear and auditory implants prior authorization

Cochlear and other auditory implants require prior authorization. Examples of applicable codes include 69714, 69930, L8614, L8619, L8690–L8692.

Cochlear/auditory implant codes: 69714, 69930, L8614, L8619, L8690, L8691, L8692

Prior Authorization

Continuous Glucose Monitor prior authorization

Continuous glucose monitors (CGMs) require prior authorization. Applicable HCPCS/CPT codes include A4226, A4238, A4239, A9276–A9278, E0787, E2102–E2103 — confirm code-specific requirements when submitting a request.

CGM codes: A4226, A4238, A4239, A9276, A9277, A9278, E0787, E2102, E2103

Prior Authorization

Prior authorization for nutritional and gastrostomy services

Durable medical equipment (DME), enteral nutrition, gastrostomy-related services, and in‑home nutritional therapy require prior authorization as noted below. Enteral supplies and gastrostomy device codes (for example B4100–B4161) and in‑home nutritional therapy codes (B4149–B4153) require prior authorization regardless of billed amount.

Enteral service and gastrostomy codes: B4100, B4102–B4161
In‑home nutritional therapy: B4149, B4150, B4152, B4153

Prior Authorization

Prior authorization for hearing aids and devices

Hearing aids and related device services require prior authorization for replacements when billed with specified modifiers or radionavigation aids. Common hearing device HCPCS include V5030–V5263 and V5298; verify modifier use and replacement rules when submitting requests.

Hearing device codes: V5030, V5040, V5050, V5060, V5070, V5080, V5100, V5130, V5140, V5150, V5171, V5172, V5181, V5190, V5211–V5215, V5221, V5230, V5243–V5247, V5249, V5251–V5263, V5298

Prior Authorization

Prior authorization for home health care (outpatient/home settings)

Home health care delivered in outpatient settings, including care provided in the member's home, requires prior authorization. Examples of applicable CPT/HCPCS codes include 99503 and G0151–G0159, G0299–G0300, G0493–G0496, and ancillary S‑codes (S9122–S9131, S9474, etc.).

Home health codes: 99503, G0151–G0159, G0299, G0300, G0493–G0496, S9122–S9131, S9474

Prior Authorization

Prior authorization for joint replacement procedures

Joint replacement procedures (including total hip and knee replacements) require prior authorization. Representative CPT codes include the hip and knee arthroplasty series (for example 27120, 27122, 27125, 27130, 27132–27138 and 27412, 27445–27446, 27447 series). Confirm the precise codes for the planned procedure when requesting authorization.

Joint replacement example codes: 27120, 27122, 27125, 27130, 27132–27138, 27412, 27445, 27446

Prior Authorization

Transplant and CAR‑T prior authorization contact

For transplant and CAR‑T cell therapy services (including Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta, Zynteglo and others) contact the UnitedHealthcare Community and State Transplant Case Management team at 888-936-7246, or use the notification phone number on the back of the member's ID card. The transplant/CAR‑T team will provide case management and instructions for submission and forms.

Transplant/CAR‑T contact: 888-936-7246
Also use the notification number on the member's health plan ID card

Behavioral health services are authorized through the designated behavioral health network rather than through the general UHC prior authorization line

Cochlear implant definition

Device descriptionA medical device within the inner ear with an external portion that helps persons with profound sensorineural deafness achieve conversational speech

Relevant codes69714, 69930, L8614, L8619, L8690, L8691, L8692

Authorization requirementCochlear and other auditory implants require prior authorization

Prior authorization threshold

TriggerRetail purchase or cumulative rental cost exceeding $1,000

Applies toCertain prosthetics, private duty nursing, potentially unproven services and selected items as listed

ExceptionSome DME and HCPCS codes still require prior authorization regardless of billed amount

Provider Portal prior authorization and notification tool

Submission channel (online)UnitedHealthcare Provider Portal — Prior Authorization and Notification tab

Phone888-867-5511 (general prior authorization line)

Fax888-840-6450 (Prior Authorization Paper Fax Form)

Inpatient admissions

Inpatient settingsAcute inpatient, acute inpatient rehabilitation (AIR), long-term acute care (LTAC) and skilled nursing facilities (SNF)

RequirementPrior authorization is required for admissions to the listed inpatient settings

Submission adviceSubmit prior authorization requests via the Provider Portal or contact numbers provided in the document

Advanced outpatient imaging

Procedures coveredCertain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures (advanced outpatient imaging)

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

How to notify/authorizeUse the Prior Authorization and Notification tool on the UHC Provider Portal or call 866-889-8054

Services/items with retail purchase or cumulative rental cost > $1,000

Threshold triggerRetail purchase or cumulative rental cost greater than $1,000

Applies toPotentially unproven services, prosthetics, private duty nursing and select prosthetic/orthotic codes listed

Action requiredPrior authorization required when threshold exceeded; specific HCPCS codes listed in the policy

Ventricular assist device (VAD) definition

DefinitionA ventricular assist device (VAD) is a mechanical pump that takes over the function of the damaged ventricle and restores normal blood flow

Authorization requirementVADs require prior authorization

How to obtain authorizationCall the notification number on the back of the member's health plan ID card and fax the nurse-provided form to Optum VAD Case Management at 855-282-8929

CAR-T cell therapy definition

DefinitionCAR-T cell therapy refers to specified autologous cellular immunotherapies (examples listed: Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta, Zynteglo)

Notification requirementTransplant and CAR-T services require prior authorization/notification

ContactCall the UnitedHealthcare Community and State Transplant Case Management team at 888-936-7246 or use the notification number on the member's ID card