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Prior Authorization for Radiation Therapy Services

This information applies only to members with the coverage listed below in the HealthPlan Effective Dates section.

To submit and manage your prior authorizations, please sign in to the UnitedHealthcare Provider Portal.

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Program requirements

Prior authorization requirements include the following radiation therapy modalities and services:

Radiation Treatment Delivery

  • 77402 - Radiation treatment delivery; Level 1 (eg, single-electron field, multiple-electron fields, or 2D photons), including imaging guidance, when performed
  • 77407 - Radiation treatment delivery; Level 2, single-isocenter (eg, 3D or IMRT), photons, including imaging guidance, when performed
  • 77412 - Radiation treatment delivery; Level 3, multiple isocenters with photon therapy (eg, 2D, 3D, or IMRT) or a single-isocenter photon therapy (eg, 3D or IMRT) with active motion management, or total skin electrons, or mixed-electron/photon field(s), including imaging guidance, when performed

Proton Beam (PBT)

  • 77520 - Proton treatment delivery; simple, without compensation
  • 77522 - Proton treatment delivery; simple, with compensation
  • 77523 - Proton treatment delivery; intermediate
  • 77525 - Proton treatment delivery; complex

Stereotactic body radiation therapy (SBRT), including stereotactic radiosurgery (SRS)

  • 77371 - Radiation treatment delivery, SRS, multi-source cobalt-60-based complete course of treatment of cranial lesion(s) consisting of one session
  • 77372 - Radiation treatment delivery, SRS, linear accelerator based, complete course of treatment of cranial lesion(s) consisting of one session
  •  77373 - SBRT, treatment delivery, per fraction to one or more lesions, including image guidance, entire course not to exceed five fractions
  • G0339 - Image-guided robotic linear accelerator-based SRS, complete course of therapy in one session or first session of fractionated treatment
  • G0340 - Image guided robotic linear accelerator based SRS, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions; maximum five sessions per course of treatment

Image-guided radiation therapy (IGRT)

  • 77387 - Guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction tracking, when performed

Special and associated services

  • 77331 - Special dosimetry (eg, TLD, microdosimetry) (specify), only when prescribed by the treating physician
  • 77370 - Special medical radiation physics consultation
  • 77399 - Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services
  • 77470 - Special Treatment Procedure (eg. Total body radiation, hemibody radiation, per oral endocavity or intraoperative cone irradiation

Selective internal radiation therapy (SIRT), Yttrium 90 (Y90) and implantable beta-emitting microspheres for treatment of malignant tumors

  • S2095 - Transcatheter occlusion or embolization for tumor destruction, percutaneous, any method, using yttrium-90 microspheres
  • 79445 - Radiopharmaceutical therapy, by intra-arterial particulate administration

Fractionation using Radiation Treatment Delivery and Proton beam therapy (PBT) for prostate, breast, lung and bone metastasis cancers

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Prior authorization for radiation therapy services is required for members with the following coverage:

UnitedHealthcare Commercial Plans

  • All Savers – Effective April 1, 2021
  • Neighborhood Health Partners – Effective April 1, 2021
  • Surest – Effective July 1, 2024
  • UHOne – Effective April 1, 2021
  • UnitedHealthcare commercial plans, excluding Indemnity/Options PPO – Effective April 1, 2021
  • UnitedHealthcare Insurance Company of the River Valley – Effective April 1, 2021
  • UnitedHealthcare of the Mid-Atlantic, Inc. – Effective April 1, 2021
  • UnitedHealthcare Oxford Health Plan – Effective November 7, 2021
  • UnitedHealthcare Plan of the River Valley, Inc. – Effective April 1, 2021
  • UnitedHealthcare Value and Balance Exchange Plans – Effective April 1, 2022

UnitedHealthcare Community Plans

  • UnitedHealthcare Community Plan in Colorado – Effective January 1, 2025
  • UnitedHealthcare Community Plan in Florida – Effective October 7, 2021
  • UnitedHealthcare Community Plan of Kentucky – Effective June 1, 2023
  • UnitedHealthcare Community Plan of Louisiana – Effective June 1, 2023
  • UnitedHealthcare Community Plan in Maryland – Effective October 7, 2021
  • UnitedHealthcare Community Plan in New Jersey – Effective July 1, 2022
  • UnitedHealthcare Community Plan in New Mexico – Effective July 1, 2024
  • UnitedHealthcare Community Plan of New York – Effective November 1, 2024
  • UnitedHealthcare Community Plan in Ohio – Effective October 7, 2021
  • UnitedHealthcare Community Plan in Rhode Island – Effective October 7, 2021
  • UnitedHealthcare Community Plan of Virginia – Effective February 1, 2023
  • UnitedHealthcare Community Plan in Washington – Effective October 7, 2021
  • UnitedHealthcare Community Plan in Wisconsin – Effective October 7, 2021

UnitedHealthcare Medicare & Retirement Plan

  • Preferred Care Network - Effective January 1, 2024
  • Preferred Care Partners - Effective January 1, 2024
  • UnitedHealthcare Community Plan (Dual Special Needs Plan) – Effective June 7, 2022
  • UnitedHealthcare Medicare Advantage - Effective June 7, 2022
  • UnitedHealthcare West Medicare Advantage - Effective June 7, 2022

We're working with Optum, our affiliate, to support you in managing the prior authorization process. Optum offers solutions to help improve the care provider experience for transactions, such as submitting prior authorization requests. Here's how to submit your request:

  • From any page on UHCprovider.com, select Sign In at the top-right corner
  • Enter your One Healthcare ID
  • From the left-hand tabs, select Prior Authorizations & Notifications. Then, click “Create a new request.” 
  • Select the appropriate prior authorization type from the dropdown.
  • Enter the required information and click Continue.

Or call 888-397-8129 from 8 a.m. – 5 p.m. local time, Monday -Friday. For medical policies and criteria, visit UHCprovider.com/policies.

You can print radiation oncology clinical worksheets after signing into the UHCprovider.com/Prior Authorization and Notification tool. 

Select “Radiology, Cardiology, Oncology and Radiation Oncology Transactions”

Select the service type of “Radiation Oncology” and any of the product types

You will then be redirected to the MBMNow website.

You can print radiation oncology clinical worksheets by navigating to the “Contact Us” tab from the MBMNow homepage.

Open the “User Guide” to view and access worksheets by primary diagnosis/cancer type

Select “Link to Worksheets”

The worksheets are sorted in alphabetical order by primary diagnosis/cancer type. Scroll to the desired section and print the appropriate page(s) as needed.

 

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