Effective May 1, 2020, we’re introducing a required notification/prior authorization process for Percutaneous Patent Foramen Ovale (PFO) Closure for UnitedHealthcare commercial members. In Iowa, this change will be effective Aug. 1, 2020.
You’ll need to complete the notification/prior authorization process when requesting a PFO Closure for new and existing UnitedHealthcare commercial members for the following CPT® procedure code:
If a notification/prior authorization isn’t completed before performing the procedure, the claim will be denied. Members can’t be billed for services denied due to lack of prior authorization.
Why We’re Making This Change
We’re making this change as part of an ongoing effort to improve health care quality and affordability for members while managing the appropriate use of certain services. Based on available clinical evidence, percutaneous PFO closure, for the prevention of recurrent ischemic stroke, will be covered for certain clinical indications.
How to Request Notification/Prior Authorization
You can complete the notification/prior authorization process:
After we receive your request and the required clinical records, we’ll review the request and contact both the requesting care provider and member by mail and phone with our coverage decision within 15 calendar days from the date of submission or sooner based on regulations. If coverage is denied, details on how to appeal will be provided in the letter.
For more information about this notification/prior authorization requirement, please review these frequently asked questions. If you have questions, please call Provider Services at the number on the back of the member’s ID card.