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Prior authorization requirements for Massachusetts Senior Care Options

Lists prior authorization requirements and submission methods for participating UnitedHealthcare Community Plan of Massachusetts Senior Care Options providers for inpatient and outpatient services; includes behavioral health contact and examples of codes that require or do not require prior authorization.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Massachusetts Senior Care Options

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJuly 1, 2025

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7/1/2025Policy effective date

1 numberPrior authorization phone contact

1 faxPrior authorization fax contact

800-632-2206Optum Behavioral Health contact

$1,000

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

YesInpatient admissions require PA

Coverage and Authorization Criteria

Coverage criteria examples

Items that require prior authorization (examples) and items for which prior authorization is not required (examples of diagnosis codes).

Covered when ALL of the following apply:

Examples that require prior authorization

Behavioral health services require prior authorization via Optum Behavioral Health (call 800-632-2206).
Bone growth stimulators (electronic stimulation or ultrasound) require prior authorization (CPT 20974, 20975, 20979).
BRCA genetic testing requires prior authorization (CPT 81163, 81164).
Breast reconstruction (non-mastectomy) procedures require prior authorization (CPT 19316, 19318, 19325, 19355).

Examples that do NOT require prior authorization

Certain diagnosis codes such as 37230 and 37231 are listed as not requiring prior authorization.

Prior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all procedures and services.

Operational note

Authorization requirements (partial)

Coverage-related authorization requirements shown in this excerpt:

Cochlear implants and other specified inner-ear implantable devices require prior authorization (e.g., CPT 69714, 69930 and HCPCS L8614, L8619, L8690–L8692).

Continuous glucose monitors and related supplies require prior authorization (e.g., HCPCS A4226, A4238, A4239).

Durable medical equipment (DME) requires prior authorization; some DME items require authorization regardless of billed amount; others require authorization only if retail purchase or cumulative rental exceeds $1,000 (examples: E0466, E1230, E1239, E2510 and multiple K-codes).

Enteral services and in-home nutritional therapy require prior authorization (examples: B4100, B4102–B4104, B4149, B4150 and related codes).

Prior authorization coverage criteria (section-level)

Services and codes requiring prior authorization as listed below.

Services and code groups requiring prior authorization

Enteral services and in-home nutritional therapy (B41xx series and related B41/B4149–B4161 codes) require prior authorization.
Experimental or investigational procedures and linked services require prior authorization (examples: CPT 64722, 64744, 66180, 95965, 95966).
Femoroacetabular impingement (FAI) procedures require prior authorization (examples: CPT 29914–29916).
Gender dysphoria treatment/surgeries require prior authorization when the specified diagnosis codes/procedures apply (diagnosis examples include F64.0–F64.2).
Joint replacement procedures (total hip and knee and related joint replacement codes) require prior authorization.

Prior authorization criteria (partial list)

Prior authorization is required for the following categories and conditions as noted.

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

Advanced outpatient imaging procedures (certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology) require prior authorization for participating physicians; scheduling and portal instructions are provided (UHCprovider.com).

Orthotics and prosthetics: prior authorization is required only for listed orthotics/prosthetic codes when the retail purchase or cumulative rental cost is more than $1,000.

Transplant and CAR T-cell therapy services (listed products) require notification/prior authorization; contact UnitedHealthcare Community and State Transplant Case Management at 888-936-7246 or use the notification number on the member ID card.

Prior authorization criteria and contact instructions

Prior authorization requirements and special conditions for listed services and codes:

Transplant and CAR T-cell therapy: prior authorization/notification required for listed products; call UnitedHealthcare Community and State Transplant Case Management at 888-936-7246 or the notification number on the member ID card.

Temporary/unclassified codes C9098 and J9999: prior authorization is required only when used for Carvykti™ (ciltacabtagene autoleucel).

Code 38232: prior authorization is required only when the code is used for an oncology diagnosis.

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

Ventricular assist devices: prior authorization is required; follow instructions to call the notification number on the back of the member's health plan ID card and fax the form to the Optum VAD Case Management team at 855-282-8929.

Codes and Billing Examples

Breast reconstruction (non-mastectomy) CPT codes requiring prior authorizationCPT

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

Bone growth stimulator CPT codes requiring prior authorizationCPT

20974	Bone growth stimulator
20975	Bone growth stimulator
20979	Bone growth stimulator

BRCA testing CPT codes requiring prior authorizationCPT

81163	BRCA genetic testing
81164	BRCA genetic testing

Cardiovascular/endovascular CPT codes referencedCPT

37220	Endovascular procedures
37221	Endovascular procedures
37224	Endovascular procedures
37225	Endovascular procedures
37226	Endovascular procedures
37227	Endovascular procedures
37228	Endovascular procedures
37229	Endovascular procedures
37230	Endovascular procedures
37231	Endovascular procedures

ICD-10 codes (osteomyelitis and related series)ICD-10

M86.172	ICD-10 code listed in cardiovascular/general information section
M86.179	ICD-10 code listed
M86.18	ICD-10 code listed

Continuous glucose monitor HCPCS codesHCPCS

A4226	Continuous glucose monitor supply
A4238	Continuous glucose monitor supply
A4239	Continuous glucose monitor supply

Examples of DME/orthotics/prosthetics codesHCPCS

E0466	DME code (example)
K0831	DME/prosthetic related code
K0859	DME code

Selected injectable medication J-codesHCPCSCovered

J0791	Adakveo
J0739	Apretude
J1414	Beqvez
J3247	Cosentyx IV
J0584	Crysvita
J1551	Cutaquig
J1413	Elevidys
J3380	Entyvio
J1305	Evkeeza
J0223	Givlaari

1–10 of 22

1/3

Diagnosis codes referenced for gender dysphoria treatmentICD-10

F64.0	Gender dysphoria
F64.1	Gender dysphoria
F64.2	Gender dysphoria
F64.8	Other gender identity disorders
F64.9	Gender identity disorder, unspecified
Z87.890	Personal history of other specified conditions

Joint, total hip and knee replacement procedure codes (examples)CPTCovered

27130	Total hip replacement (example listed)
27447	Total knee replacement (example listed)

Non-emergent air transport HCPCS examplesHCPCSCovered

A0140	Non-emergent air transport
A0435	Ambulance ground mileage or similar non-emergent transport

Orthotics and prosthetics HCPCS examplesHCPCSCovered

L3216	Orthotics example
L5301	Prosthetics example

Listed CPT/HCPCS codes in this sectionmixed

63685
61885
64568
61850
61863
61864
61867
61868
61886
64590

1–10 of 95

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inv-19: DME retail purchase/cumulative rental authorization threshold

DME retail purchase/cumulative rental authorization threshold$1,000

Applies toDurable medical equipment and orthotics/prosthetics when purchased at retail or rented cumulatively

Authorization conditionPrior authorization required only if retail purchase or cumulative rental cost exceeds $1,000

inv-20: Prior authorization threshold for orthotics/prosthetics

How to Submit Requests and Operational Requirements

Prior Authorization

How to submit prior authorization requests

This list contains prior authorization requirements for participating UnitedHealthcare Community Plan of Massachusetts Senior Care Options health care professionals providing inpatient and outpatient services. Please submit your request in one of the following ways: Online: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) — sign in with your One Healthcare ID. Phone: 888-867-5511. Fax: 888-840-6450 (use the Prior Authorization Paper Fax Form). 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.

Online: Prior Authorization and Notification tool on UHCprovider.com (One Healthcare ID required)
Phone: 888-867-5511
Fax: 888-840-6450 (Prior Authorization Paper Fax Form)

Note

Behavioral health prior authorization contact

Behavioral health services are managed through the designated behavioral health network. For prior authorization for behavioral health services, contact Optum Behavioral Health.

Terms and Thresholds

inv-42: Prior authorization — definition / label

DefinitionPrior authorization: formal approval that must be obtained before certain procedures, services or supplies are provided to participating UnitedHealthcare Community Plan of Massachusetts Senior Care Options members

Submission methodsRequests may be submitted online via the Prior Authorization and Notification tool on UHCprovider.com, by phone (888-867-5511), or by 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

inv-43: Behavioral health prior authorization — obtained through Optum Behavioral Health

Behavioral health prior authorization contactBehavioral health prior authorization must be obtained through Optum Behavioral Health at 800-632-2206

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Massachusetts Senior Care Options

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJuly 1, 2025

Next Review DateN/A

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

SourceLink

On This Page

Injectable medications require prior authorization; certain unclassified/temporary codes require notification/prior authorization only for specific products; submit injectable and unclassified/temporary code requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com).

Inpatient admissions (acute inpatient, acute inpatient rehabilitation, LTAC and skilled nursing) require prior authorization.

Orthotics/prosthetics prior authorization thresholdRetail purchase or cumulative rental cost > $1,000

ScopeApplies to orthotics codes listed in the policy when retail purchase or cumulative rental exceeds $1,000

Action requiredObtain prior authorization only when threshold exceeded

inv-21: 38232 oncology prior auth condition

Condition for CPT 38232 prior authorizationPrior authorization is required only when CPT code 38232 is used for an oncology diagnosis

ScopeApplies specifically to code 38232 as listed in the policy code section

ImplicationIf 38232 is billed for non-oncology indications, prior authorization is not required per this policy note

Optum Behavioral Health: 800-632-2206

Prior Authorization

Examples of services requiring prior authorization

Certain procedures and services listed in this policy require prior authorization. Examples include bone growth stimulators and related procedure codes.

Bone growth stimulators (electronic stimulation or ultrasound to heal fractures) — CPT/HCPCS: 20974, 20975, 20979

Prior Authorization

Prior Authorization Required — Non-emergent Air Transport

Non-emergent air transport requires prior authorization. Obtain authorization before arranging non-emergent air transport.

Non-emergent air transport HCPCS: A0140, A0430, A0431, A0435

Prior Authorization

Prior authorization required — selected devices

Prior authorization is required for selected devices, including cochlear implants and continuous glucose monitors.

Cochlear and related devices: CPT/HCPCS 69714, 69930; HCPCS L8614, L8619, L8690, L8691, L8692
Continuous Glucose Monitor HCPCS: A4226, A4238

Prior Authorization

DME prior authorization rules

Durable medical equipment (DME) rules: certain DME items require prior authorization regardless of billed amount; other orthotics/prosthetics may require prior authorization only when retail purchase or cumulative rental cost exceeds $1,000.

Examples of DME requiring prior authorization regardless of billed amount: E0466, E1230, E1239, E2510
Prior authorization required only when retail purchase or cumulative rental cost > $1,000 for specified orthotics/prosthetics (see policy for full code list)

Prior Authorization

Enteral and in-home nutritional therapy — Prior Authorization

Enteral services and in-home nutritional therapy require prior authorization. This includes enteral formula and supplies and in-home nutrition services.

Enteral services HCPCS: B4100, B4102, B4103, B4104
In-home nutritional therapy HCPCS: B4149, B4150

Note

Prior authorization submission instruction

Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

UHCprovider.com → sign in with One Healthcare ID → Prior Authorization and Notification tab

Prior Authorization

Inpatient prior authorization requirement

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

Prior authorization required for acute inpatient, AIR, LTAC and skilled nursing admissions — contact 888-867-5511 or use portal

Prior Authorization

Injectable medications and biologics prior authorization

Injectable medications and biologics require prior authorization or notification. Submit requests through the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal. Some unclassified/temporary codes require authorization only for specific products—see policy list for exceptions.

Submit injectable medication prior authorization requests via UHCprovider.com Prior Authorization and Notification tool
Covered/limited examples include J3032, J3401, J9332, J9334, J3399, J1748 and others; see policy for full list and exceptions

Prior Authorization

Sleep apnea surgical procedures — Prior Authorization Required

Prior authorization is required for sleep apnea surgical procedures including maxillomandibular advancement and oral-pharyngeal tissue reduction procedures used to treat obstructive sleep apnea.

Sleep apnea procedures and surgeries requiring prior authorization — examples of CPT codes: 21685, 42299, 41512, 41599, 42145, 30430, 30462

Prior Authorization

Spinal surgery and neurostimulator prior authorization

Spinal surgery and neurostimulator implantation require prior authorization. This includes a broad list of spinal procedure codes and neurostimulator implantation and related device codes.

Spinal surgery — examples of CPT codes requiring prior authorization: 22100–22102, 22110, 22112, 22114, 22206–22214, 22220, 22222, 22224, 22532, 22533, 22548, 22551, 22554, 22556, 22558, 22590, 22595, 22600, 22610, 22612, 22630, 22633, 22800–22812, 22818, 22819, 22830, 22849–22856, 22861, 22867, 22869, 22899, 63001–63056, 63064, 63075–63090, 63101, 63102, 63170–63173, 63185, 63190, 63191, 63197, 63200
Neurostimulators — device and implantation codes requiring prior authorization: E0747, E0748, E0749, E0760; procedure CPT examples: 63650, 63655, 63685, 61885, 64568, 61850, 61863, 61864, 61867, 61868, 61886, 64590

Applies to behavioral health services billed with relevant CPT/HCPCS codes as noted in the policy

Provider instructionCall the designated Optum Behavioral Health number to request prior authorization for behavioral health services

inv-44: Cochlear implant — definition as described

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

Prior authorizationPrior authorization is required for cochlear and other inner ear devices (codes listed, e.g., 69714, 69930, L8614, L8619, L8690-L8692)

Examples of codesExamples include CPT 69714, 69930 and HCPCS L8614, L8619, L8690, L8691, L8692

inv-45: In-home nutritional therapy / Enteral services — definition

DefinitionIn-home nutritional therapy / Enteral services: nutrition delivered in the home either enterally or through other means (enteral services)

Prior authorizationEnteral services and in-home nutritional therapy codes (e.g., B4100–B4104, B4149, B4150) require prior authorization

Examples of codesB4100, B4102, B4103, B4104, B4149, B4150

inv-46: Inpatient categories requiring prior authorization

Inpatient categories requiring prior authorizationAcute inpatient; Acute inpatient rehabilitation (AIR); Long-term acute care (LTAC); Skilled nursing

Policy noteInpatient admissions in these categories require prior authorization per policy

SubmissionSubmit requests via the Prior Authorization and Notification tool on UHCprovider.com or by phone/fax as provided

inv-47: Notification required only for listed products when using specified unclassified/temporary codes

Notification for unclassified/temporary codesNotification/prior authorization is required only for the listed products when using specified unclassified or temporary codes (examples and products listed in policy)

ExamplesPolicy lists specific unclassified/temporary codes and links them to named products (e.g., Amvuttra, Eylea HD, Nulibry, Ocrevus Zunovo, Pavblu, Saphnelo, Tzield, Yimmugo)

Submission instructionFor these codes, submit prior authorization requests online via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool

inv-48: Prior authorization threshold — orthotics/prosthetics retail purchase or cumulative rental cost > $1,000

Orthotics/prosthetics prior authorization thresholdPrior authorization is required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $1,000

Applies toOrthotics codes listed in the policy (examples include L3216, L5301) and associated HCPCS codes

ActionObtain prior authorization when retail purchase or cumulative rental exceeds $1,000

inv-49: Advanced outpatient imaging — definition (CT, MRI, MRA, PET, nuclear medicine, nuclear cardiology)

DefinitionAdvanced outpatient imaging: certain CT, MRI, MRA and PET scans, and nuclear medicine and nuclear cardiology procedures

Prior authorizationPrior authorization is required for participating physicians requesting these advanced outpatient imaging procedures

Scheduling guidanceProviders are instructed to use UHCprovider.com for scheduling and the Prior Authorization and Notification tool

inv-50: Ventricular assist devices — definition

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

Prior authorization/processPrior authorization is required; call the notification number on the back of the member's health plan ID card and fax the nurse-provided form to the Optum VAD Case Management team at 855-282-8929

Examples of codesPolicy lists VAD-related CPT/HCPCS codes such as 33927–33983 (as applicable)

inv-51: Vein procedures (saphenous) — definition

DefinitionVein procedures (saphenous): removal and ablation of the main trunks and named branches of the saphenous veins for treating venous disease

Prior authorizationPrior authorization is required for these vein procedures (examples include CPT codes 37735, 37765, 37766, 37785)

ScopeIncludes removal and ablation procedures of saphenous vein trunks and named branches as listed in the policy