Radiation therapy authorization requirements for Medicaid

Effective Oct. 7, 2021, prior authorization will be required for the following outpatient radiation therapies for UnitedHealthcare Community Plan Medicaid members.

  • Intensity modulated radiation
  • Stereotactic body radiation therapy
  • Fractionation for breast cancer, prostate cancer, lung cancer and bone metastasis
  • Image guided radiation therapy
  • Special and associated radiation therapy services
  • Implantable beta emitting microspheres (Y90)

Prior authorization will be required for UnitedHealthcare Community Plan members in:

  • California
  • Florida
  • Maryland
  • Mississippi
  • Ohio
  • Rhode Island
  • Washington
  • Wisconsin

Also starting Oct. 7, 2021, prior authorization requests for these noted outpatient radiation therapies and the existing prior authorization requirement for proton beam therapy (PBT) will be managed by Optum.

How to submit prior authorization

For proton beam therapy (PBT), if prior authorization for these services is already approved for administered treatment prior to Oct. 7, 2021, you do not need to submit a new prior authorization request for that approved treatment plan.

For intensity-modulated radiation therapy (IMRT), image-guided radiation therapy (IGRT), special services Y90/SIRT or SBRT, including SRS services started between Aug. 1–Oct. 6, 2021, you do not need to submit a prior authorization request. We’ll authorize the radiation therapy service(s) the member was receiving prior to Oct. 7, 2021, and the authorization will be effective for 90 days from the treatment start date. Any further radiation therapy services that extend after 90 days from the treatment start date prior authorization would be required prior to the start of services.

Please complete prior authorization requests on the UnitedHealthcare Provider Portal using your One Healthcare ID and the Prior Authorization and Notification tool. Once you’re in the tool, select Radiology, Cardiology, Oncology and Radiation Oncology Transactions  > Service Type of Radiation Oncology > Product Type of Medicaid > member state.

Coverage determination guidelines

On Oct. 1, 2021, medical policies for all radiation therapy services will be available at UnitedHealthcare Community Plan Medical & Drug Policies and Coverage Determination Guidelines.

Prior to Oct. 1, 2021, the new medical policies (Radiation Therapy: Fractionation, Image-Guidance and Special Services and Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery) can be accessed from the UnitedHealthcare Community Plan Medical Policy Update Bulletin: July 2021.

Training

Training dates, times and registration options will be available in September on the UnitedHealthcare Provider Portal.

Questions?

Email unitedoncology@uhc.com

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