New vascular embolization policy created to manage coverage criteria

Effective Dec. 1, 2026, we’ll implement a new vascular embolization policy and add prior authorization for CPT® code 37242 for plans that don’t currently require it. Additionally, as part of our efforts to help make health care simpler and more affordable for patients and providers, we are discontinuing site-of-service reviews for therapeutic vascular embolization procedures.

Currently, services within the scope of the new policy may be evaluated under multiple existing medical policies. Aligning the applicable clinical criteria under one policy will help support greater transparency and consistency in medical necessity review.

The new policy will outline the clinical criteria UnitedHealthcare will use to determine medical necessity when reviewing prior authorization requests for therapeutic vascular embolization procedures. The prior authorization requirement will apply to UnitedHealthcare commercial plans, UnitedHealthcare® Medicare Advantage Plans and most UnitedHealthcare Community Plans.

Coverage determinations will continue to be based on the member's benefit plan, applicable laws and the clinical criteria in the policy. As part of the review process, medical records may be requested to verify that the applicable clinical criteria have been met.

Site-of-service discontinuation

We’re discontinuing site-of-service reviews for therapeutic vascular embolization procedures, (CPT code 37242) as part of our efforts to help make health care simpler and more affordable for you and your patients.

We’ve previously shared that we’ll continue to require prior authorization for services that should be reviewed for clinical quality and safety as well as those with risks associated with procedures that can result in unnecessary hospitalizations at higher rates.

For plans where CPT code 37242 is currently reviewed only for site of service, the review will change to only medical necessity review of the service itself under the new policy. For applicable plans where CPT code 37242 doesn’t currently require prior authorization, it will be added. Medical necessity review will continue for other embolization codes within the policy’s scope.

Plans excluded from the new requirement

• UnitedHealthcare Nursing Home and UnitedHealthcare Assisted Living Plans
• Erickson Advantage
• Peoples Health Plans
• Preferred Care Network and Preferred Care Partners of Florida
• Rocky Mountain Medicare Advantage Plans
• UnitedHealthcare Community Plans in the following states: Idaho, Indiana, Kansas, Kentucky, Nebraska, New Jersey, New Mexico, North Carolina, Ohio, Pennsylvania and Tennessee. These states are subject to separate state-specific medical policy requirements and are currently pending state approval. Prior authorization requirements for vascular embolization procedures will be implemented upon approval and communicated to providers in advance.

Resources

• Transarterial radioembolization/selective internal radiation therapy for treating malignancies involving the liver policy and NCCN clinical practice guidelines in oncology 
• Prostate Surgeries and Interventions – Commercial and Individual Exchange Medical Policy
• Abnormal Uterine Bleeding and Uterine Fibroids