Commercial Intensity Modulated Radiation Therapy Program

Prior Authorization for Intensity Modulated Radiation Therapy (IMRT) services is required for members of the following Commercial health plans:

• UnitedHealthcare
• UnitedHealthcare West
• UnitedHealthcare of the Mid-Atlantic
• UnitedHealthcare Plan of the River Valley
• Neighborhood Health Partnership

While you can begin the prior authorization process by fax, phone or online, we recommend that you use the fax method for the quickest turnaround time.

Using the appropriate IMRT cover sheet and IMRT FAX form can provide us the clinical information that we need to process the authorization.

Fax

• Complete the appropriate IMRT fax cover sheet for the member's health plan. Cover sheets are in the “IMRT Clinical Cover Sheet” section of this page.
• If IMRT will be used to treat a specific primary tumor as listed on the form, fax it to the number on the form.
• If the diagnosis code is not listed on the form, have the radiation oncologist complete the appropriate IMRT disease-specific form. Forms are available in the “IMRT Clinical Forms” section on this page. If there is not a disease-specific form, use the Other Cancer Types or Non-Cancerous Conditions form.
• Fax the appropriate IMRT fax cover sheet and the IMRT disease-specific form to the number on the fax cover sheet.

Phone

You can start the prior authorization process by calling the number on the back of the member’s ID card to provide demographic information and open the case.

Online 

Go to the Prior Authorization and Notification Tool on Link. 

• Have the clinician fill out the IMRT disease-specific forms.
• Make sure the Prior Authorization Request Form is complete.
• Use the Disease-Specific Form when the IMRT is for a primary cancer or local recurrence.
• Use the Bone Metastases or Brain Metastases Form if the IMRT is for bone or brain metastases.
• Use the Other Cancer Types Form if there is not a specific form for your patient's medical condition.

You may request an urgent review for an Intensity Modulated Radiation Therapy (IMRT) if the member's clinical symptoms as listed by the radiation oncologist require emergent treatment within 48 hours.

To view complete IMRT Medical Policy, visit the Commerical Medical & Drug Policies and Coverage Determination Guidelines section.

If you are requesting IMRT for a UnitedHealthcare member* as part of a clinical trial, please submit your request to the Oncology Clinical Trial Review team one of the following ways:

• Phone: 866-936-6002
• Email: cancer_resource_services@optum.com
• Fax: 800-731-2515

We review all requests specific to both the clinical trial and the member's coverage document, which may cover the costs of routine care, but not the investigational item, device or service. We’ll notify you of the review outcome in writing.

*For members of Neighborhood Health Partnership and UnitedHealthcare Plan of the River Valley, please call the member service number on the back of the member's ID card to request coverage for IMRT clinical trials.

• MAMSI MD IPA and Optimum Choice Inc. (Mid-Atlantic Plans) IMRT Fax Cover Sheet
• Neighborhood Health Partnership IMRT Fax Coversheet
• UnitedHealthcare IMRT Fax Cover Sheet
• UnitedHealthcare West CA, WA and OR IMRT Fax Cover Sheet
• UnitedHealthcare West OK and TX IMRT Fax Cover Sheet
• UnitedHealthcare of River Valley IMRT Fax Cover Sheet

• Bladder Cancer IMRT Request Form
• Bone Metastases Cancer IMRT Request Form
• Brain Metastases Cancer IMRT Request Form
• Breast Cancer IMRT Request Form
• Cervical Cancer IMRT Request Form
• CNS Lymphoma Cancer IMRT Request Form
• CNS Neoplasm Cancer IMRT Request Form
• Colorectal Cancer IMRT Request Form
• Gastric Cancer IMRT Request Form
• Head and Neck Cancer IMRT Request Form
• Lung Cancer IMRT Request Form
• Non-Cancerous Conditions IMRT Request Form
• Other Cancer Types IMRT Request Form
• Soft Tissue Sarcoma Cancer IMRT Request Form
• Uterine Cancer IMRT Request Form