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:

• Mid-Atlantic Health Plan, UnitedHealthcare MD-IPA Plan, Optimum Choice
• Neighborhood Health Partnership
• UnitedHealthcare
• UnitedHealthcare Plan of the River Valley
• UnitedHealthcare West

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

Using the appropriate IMRT Clinical Cover Sheet and IMRT Treatment Request Form can provide us the clinical information that we need to process the authorization.

Fax

• Complete the appropriate IMRT Clinical 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, follow the instructions on the form to submit your request.
• 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 Treatment Request Form” section on this page. 
  • If there isn't a disease-specific form, then use the "Other Cancer Types or Non-Cancerous Conditions Form".
• Submit the IMRT Clinical Cover Sheet and the IMRT Treatment Request Form by following the instructions on the applicable clinical 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

• 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 Commercial 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 in 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.

• Mid-Atlantic Plans IMRT Cover Sheet (Mid-Atlantic Medical Services, MD-Individual Practice Association and Optimum Choice)
• Neighborhood Health Partnership IMRT Cover Sheet
• UnitedHealthcare IMRT Cover Sheet
• UnitedHealthcare West IMRT Cover Sheet (California, Oregon and Washington)
  
• UnitedHealthcare West IMRT Cover Sheet (Oklahoma and Texas)
• UnitedHealthcare of River Valley IMRT 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