CurrentUnitedHealthcarePolicy N/A

Prior Authorization and Notification Requirements — UnitedHealthcare Community Plan of Massachusetts Senior Care Options

Governs prior authorization and notification procedures for participating providers delivering inpatient and outpatient services to UnitedHealthcare Community Plan of Massachusetts Senior Care Options members; includes submission methods and lists services/CPT/HCPCS/ICD-10 codes that require prior authorization.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization and Notification Requirements — UnitedHealthcare Community Plan of Massachusetts Senior Care Options

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3ways to submit prior authorization requests

Optum BHphone for behavioral health authorizations

888-840-6450fax number for prior authorization

888-867-5511phone number for prior authorization

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.

Prior authorization required

explicit PA requirement stated

Coverage and Authorization Criteria

General prior authorization stance

Prior authorization is required for certain non-emergent services and listed codes. 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 is required for specified services and codes listed in this policy.

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.

PA by category

Prior authorization requirements organized by service category (examples and representative codes shown):

Cochlear implants and inner ear devices: prior authorization is indicated for listed device codes (e.g., L8619, L8690, L8691, L8692).

Continuous glucose monitors (CGM): prior authorization is required for listed CGM codes (e.g., A4226, A4238, A4239, A9276, A9277, A9278, E0787, E2102).

Durable medical equipment (DME): many DME items require prior authorization; some DME require prior authorization regardless of billed amount (numerous E/K series HCPCS codes listed).

Enteral / in‑home nutritional therapy (including gastrostomy tube related codes): prior authorization is required for listed enteral therapy codes (e.g., B4100–B4161).

Experimental / investigational procedures (and linked services): prior authorization is required for listed codes (examples include 64722, 64744, 66180, 95965, 95966, 0200T, 0201T).

Gender dysphoria treatment: prior authorization is required for the listed procedures and associated diagnosis codes (ICD‑10 F64.1, F64.2, F64.8, F64.9 and multiple CPT codes shown).

Prior authorization criteria (excerpt)

Authorization/notification requirement summary for selected services and code groups:

Gender dysphoria treatment: prior authorization is required for the services and codes listed in this section (see ICD‑10 F64.1–F64.9 and related CPT codes).

Hearing aids and device replacements: prior authorization is required for certain hearing aid/device replacement codes as listed (e.g., V5030, V5040, V5060, etc.).

Home health (outpatient): prior authorization is required only for the outpatient home health codes listed; these services are identified as occurring in the member’s home.

Injectable medications and unclassified/temporary codes: prior authorization or notification is required for many injectable medications and certain unclassified/temporary codes; submission via the Prior Authorization and Notification tool or the specified contact is required.

Advanced outpatient imaging (selected CT, MRI, MRA, PET, nuclear medicine/nuclear cardiology): prior authorization is required; obtain authorization via the Provider Portal or call the imaging authorization number provided.

Temporary/unclassified and oncology exceptions

Special-case rules apply to temporary/unclassified codes and certain oncology/CAR T‑cell therapy situations:

Code 38232: prior authorization is required only when billed for an oncology diagnosis.

Temporary/unclassified codes C9098 and J9999: prior authorization is required only in specified circumstances (for example, when used for the CARVYKTI™ therapy as noted).

Rhinoplasty

Rhinoplasty procedure group prior authorization rules:

Rhinoplasty (functional): prior authorization is required when performed for treatment of nasal functional impairment and septal deviation. Representative CPT codes include 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465.

CPT / HCPCS / ICD-10 Code Lists

Sample CPT/HCPCS codes notedCPTCovered

20974	Bone growth stimulator / electronic stimulation (listed as requiring prior authorization)
20975	Bone growth stimulator / electronic stimulation (listed)
20979	Bone growth stimulator / ultrasound (listed)
81163	BRCA genetic testing (listed as requiring prior authorization)
81164	BRCA genetic testing (listed)
19316	Breast reconstruction (non-mastectomy) (listed)
19318	Breast reconstruction (non-mastectomy) (listed)
19325	Breast reconstruction (non-mastectomy) (listed)
19355	Breast reconstruction (non-mastectomy) (listed)

Sample CPT/HCPCS codes noted (continued)CPTCovered

No codes listed

Sample ICD-10 / other diagnosis codes notedICD-10Covered

E11.52	Diagnosis code listed as requiring prior authorization (example)
I70.449	Diagnosis/vascular code listed

ICD-10 codes (osteomyelitis series)ICD-10

M86.559
M86.561
M86.562
M86.571
M86.572
M86.579
M86.58
M86.59
M86.60

ICD-10 codes (gender dysphoria)ICD-10

F64.1	Gender identity disorder of adolescence and adulthood
F64.2
F64.8
F64.9

Gender dysphoria / gender identity diagnosis codesICD-10

F64.1	Gender identity disorder of adolescence/adulthood
F64.2	Gender identity disorder of childhood
F64.8	Other gender identity disorders
F64.9	Gender identity disorder, unspecified

Examples of device/orthotic/prosthetic codesHCPCS

V5030	Hearing aid, monaural, body worn
L3216	Custom foot orthosis, polypropylene, per foot
L5301	Prosthesis, breast, external

Rhinoplasty codesCPTCovered

30400	Rhinoplasty CPT code (listed as requiring prior authorization for functional impairment)
30435	Rhinoplasty CPT code
30465	Rhinoplasty CPT code

Spinal and VAD-related codes (examples)CPTCovered

22532	Spinal surgery CPT code (listed among codes requiring prior authorization)
22850	Spinal surgery/implant code
33927	Ventricular assist device-related CPT code

Temporary/unclassified codesHCPCSCovered

Q2053	Temporary/HCPCS code referenced for specific prior authorization rules
C9098	Unclassified code requiring prior authorization in limited cases
J9999	Unclassified code requiring prior authorization in limited cases

Orthotic/Prosthetic PA cost threshold

Orthotic/Prosthetic PA cost thresholdPrior authorization is required for orthotics and prosthetics when retail purchase or cumulative rental cost exceeds $1,000.

Threshold amount$1,000

Applies toOrthotics and prosthetics listed with retail purchase or cumulative rental cost over the threshold

Supporting codes examplesL3216, L3217, L3219, L3221, L5301, L5987

Submission Instructions and Provider Requirements

Prior Authorization

Submission Methods and General Prior Authorization Rule

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). You may also fax requests using the Prior Authorization Paper Fax Form to 888-840-6450 or call 888-867-5511. Prior authorization is not required for emergency or urgent care. Out-of-network providers must request prior authorization for all procedures and services.

Online: Prior Authorization and Notification tool on UHCprovider.com (sign in with One Healthcare ID)
Fax: Prior Authorization Paper Fax Form to 888-840-6450
Phone: 888-867-5511
Prior authorization not required for emergency or urgent care
Out-of-network providers must request prior authorization for all procedures/services

Prior Authorization

Behavioral Health Prior Authorization

Behavioral health services are managed through a designated behavioral health network. For authorization of behavioral health services please call Optum Behavioral Health.

Definitions and Terms

Prior authorization — definition

DefinitionPrior authorization is the process by which providers must request approval from UnitedHealthcare before delivering certain non-emergent services; not required for emergency or urgent care.

When not requiredEmergency or urgent care are exempt from prior authorization requirements.

Submission requirement for out-of-networkOut-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services.

Submission methods (summary)Online Portal, Fax, Phone (see submission instructions for details).

Cochlear implant / inner ear medical device

Definition (truncated)

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization and Notification Requirements — UnitedHealthcare Community Plan of Massachusetts Senior Care Options

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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

Optum Behavioral Health: 800-632-2206

Prior Authorization

Sample Codes Requiring Prior Authorization

The policy lists many sample CPT/HCPCS/ICD-10 codes that require prior authorization. The list below is a representative sample — always check the Provider Portal for the complete, up-to-date code list and submission instructions.

Examples: 20974, 20975, 20979 (bone growth stimulators)
BRCA testing: 81163, 81164
Breast reconstruction: 19316, 19318, 19325, 19355
Cardiology examples: 93653, 93656, 33285

Prior Authorization

Cochlear Implants / Inner Ear Devices

Cochlear implants and other inner-ear implantable devices require prior authorization. This includes the surgical and device HCPCS/CPT codes and the device supply codes.

Cochlear/inner ear: 69714, 69930, L8614, L8619, L8690, L8691, L8692
Prior authorization required for implantable inner ear devices and associated services

Prior Authorization

Continuous Glucose Monitors (CGM)

Continuous glucose monitors (CGMs) and related supplies require prior authorization. Submit requests via the Provider Portal or call the number shown on the portal instructions.

CGM supply/device HCPCS: A4226, A4238, A4239, A9276, A9277, A9278, E0787, E2102
Prior authorization required for CGM devices and supplies

Prior Authorization

Cosmetic / Reconstructive Procedures

Cosmetic and reconstructive procedures require prior authorization when listed. Cosmetic procedures intended to change or improve appearance without treating a medical condition typically require prior authorization and may be denied if considered cosmetic.

Sample cosmetic CPT/HCPCS: 11950-11954, 15820-15839, 15877-15879, 17999
Reconstructive/functional codes that may require authorization: 19300, 21172, 21175, 21179, 21180-21270

Prior Authorization

Durable Medical Equipment (DME)

Durable medical equipment (DME) and many DME HCPCS codes require prior authorization. Some DME/prosthetic/orthotic items require prior authorization regardless of billed amount; others require prior authorization only when retail purchase or cumulative rental exceeds $1,000.

Examples of DME/prosthetic/orthotic HCPCS that commonly require authorization: E0466, E1230, E1239, E2510, K0831, K0835, K0837, K0838, K0857, K0859, K0877, K0884, K0890, K0891, K0898, K0899
Some orthotics/prosthetics: L3216, L3217, L3219, L3221, L5301, L5987, L5856, L8629, L5968, L5981
Prior authorization required regardless of billed amount for specified DME codes; retail purchase/cumulative rental threshold applies to others

Prior Authorization

Enteral / In-Home Nutritional Therapy

Enteral and in-home nutritional therapy require prior authorization. This includes enteral formula supplies, gastrostomy-related supplies and equipment used for home nutritional therapy.

Enteral/in-home nutrition HCPCS: B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153
Gastrostomy-related HCPCS: B4155, B4158, B4159, B4160, B4161
Prior authorization required for in-home nutritional therapy (enteral and related gastrostomy services)

Prior Authorization

Injectable Medications and Unclassified Codes

Many injectable medications (including specialty, high-cost, and certain J-codes) require prior authorization or notification. Prior authorization is required for inpatient acute admissions, acute inpatient rehabilitation, LTAC and SNF settings as indicated.

Examples of injectable drugs requiring authorization: J2998 (Ryplazim), J9333 (Rystiggo), J1300 (Soliris), J1747 (Spevigo), J2326/J2781 (Spinraza), J3241 (Tepezza), J1303 (Ultomiris)
Prior authorization required for acute inpatient, AIR, LTAC and SNF admissions when applicable
Submit injectable drug prior auth via Provider Portal Prior Authorization and Notification tool or call 888-397-8129

Prior Authorization

Temporary / Unclassified Code Prior Authorization Notes

Temporary and unclassified codes have special prior authorization rules. For specific temporary/unclassified codes prior authorization may be required only for particular drugs or indications.

Temporary/unclassified codes: C9086, C9149, C9151, C9157, C9161, C9399, C9098, J9999, J3490, J3590
Prior authorization/notification is required for certain products billed with unclassified/temporary codes (examples: Amvuttra, Eylea HD, Nulibry, Saphnelo, Tzield)
Code 38232 requires prior authorization only when billed for an oncology diagnosis
For C9098 and J9999, prior authorization is required only for Carvykti

Prior Authorization

Vein Procedures Prior Authorization

Vein procedures for removal and ablation of the main trunks and named branches of the saphenous veins (for treatment of venous disease and varicose veins) require prior authorization. Confirm authorization for the specific CPT codes prior to scheduling.

Vein procedure CPTs that require prior authorization: 37735, 37799, 37765, 37766, 37785
Prior authorization required for removal and ablation of saphenous vein trunks and named branches

Note

General Provider Action Reminder

For any of the items listed in this section, always verify the current authorization requirements and submit requests via the Provider Portal Prior Authorization and Notification tool. If you need assistance, contact the numbers listed on the Provider Portal or the member's ID card for specialty notifications.

Provider Portal: Prior Authorization and Notification tool (UHCprovider.com)
Assistance numbers: 888-867-5511 (general), 888-397-8129 (prior auth for certain drugs), numbers shown on member ID for specialty notifications

A medical device within the inner ear with an external portion that helps persons with profound sensorineural deafness (text truncated in source).

Examples of related codes69714, 69930, L8614

Authorization notePrior authorization is indicated for cochlear and other inner ear medical devices.

Prior authorization required — summary

General statementSeveral entries explicitly state that prior authorization is required for the listed codes or services (e.g., cochlear devices, continuous glucose monitors, DME, enteral therapy).

Examples of categories requiring PACochlear/inner ear devices; Continuous glucose monitors (CGM); Durable medical equipment (DME); Enteral/in-home nutritional therapy; Experimental/investigational procedures; Gender dysphoria treatment.

Examples of codesA4226, E0466, B4100, 64722, F64.1

Inpatient admissions — definition

DefinitionInpatient admissions include acute inpatient; acute inpatient rehabilitation (AIR); long-term acute care (LTAC); and skilled nursing facilities (SNF).

Authorization requirementPrior authorization is required for these inpatient admission types.

ContextListed under 'Inpatient admissions' in the injectable medications / procedures section.

Advanced outpatient imaging — definition

DefinitionAdvanced outpatient imaging refers to certain CT, MRI, MRA and PET scans, and select nuclear medicine and nuclear cardiology procedures that require prior authorization.

Provider responsibilityHealth care professionals ordering these procedures must obtain prior authorization via the UnitedHealthcare Provider Portal or call the imaging PA phone number.

Contact optionCall 866-889-8054 or submit via the Prior Authorization and Notification tool on UHCprovider.com.

Prior Authorization and Notification tool (UHCprovider Portal)

Tool namePrior Authorization and Notification tool (UnitedHealthcare Provider Portal)

Portal accessGo to UHCprovider.com, sign in with One Healthcare ID, then select the Prior Authorization and Notification tab on your dashboard.

Alternate submission methodsFax (888-840-6450) using Prior Authorization Paper Fax Form; Phone (888-867-5511).

VAD case management contact / fax process

Team nameOptum VAD Case Management team

Contact 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 Management team.

Fax number855-282-8929

Applies toVentricular assist device (VAD) services and related CPT/HCPCS codes (e.g., 33927, 33928, 33929).