Gastroenterology Endoscopy Prior Authorization and Notification

As of June 1, 2023, prior authorizations for gastroenterology endoscopy services are required for UnitedHealthcare commercial plan members. Please note screening colonoscopy procedures are not included in this new medical necessity review requirement. 

Affected states

• All states, except Rhode Island and Kentucky
• Iowa effective: Aug. 1, 2023
• U.S. territories (U.S. Virgin Islands, Guam and Puerto Rico) are excluded

Affected plans

This requirement pertains to patients with UnitedHealthcare commercial plans, including:

• UnitedHealthcare Plan of the River Valley
• Neighborhood Health Partnership
• UnitedHealthcare Level Funded
• Oxford Health Plans

Additional information 

Currently, some gastroenterology endoscopy procedures may require prior authorization and site of service medical necessity review if the procedure is planned in an outpatient hospital. Beginning June 1, 2023, we’ll require prior authorization for these procedures regardless of the outpatient location in which you plan to perform the procedure.

Screening colonoscopy procedures only require prior authorization for site of service medical necessity review if the service is planned at an outpatient hospital.

Specific gastroenterology programs

All commercial plans

• Screening Colonoscopy Procedures — Site of Service — Commercial Medical Policy
• Outpatient Surgical Procedures — Site of Service — Commercial Utilization Review Guideline
• Gastrointestinal Colonoscopy Procedure Guidelines — Commercial
• Gastrointestinal Endoscopy Procedure Guidelines — Commercial
• Capsule Endoscopy Procedure Guidelines — Commercial

Oxford plans

• Screening Colonoscopy Procedures — Site of Service — Oxford Clinical Policy
• Outpatient Surgical Procedures — Site of Service — Oxford Clinical Policy
• Oxford — Gastroenterology and Capsule Endoscopy Guidelines

FAQ and CPT code list crosswalk table

• Prior Authorization for Gastroenterology Services FAQ
• Prior Authorization CPT Code List and Crosswalk Table

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