June 01, 2022

Medicare and D-SNP: Prior authorization and site of service expansion

This article is an update to a previously published article that appeared in November of 2021.

Starting May 1, 2022, for UnitedHealthcare® Medicare Advantage plans, we’re expanding our prior authorization requirements and site of service medical necessity reviews for certain surgical procedures.

We’ll now require prior authorization and conduct site of service medical necessity reviews for 50 additional surgical procedure/CPT® codes for services planned to be performed in an outpatient hospital setting.

Excluded states

  • Health care professionals in the following states are excluded from these updates: Alaska, Arkansas, Hawaii, Kentucky, Massachusetts, Utah and Wisconsin
  • Effective Aug. 1, 2022, Arkansas will no longer be excluded
    • Alaska, Hawaii, Kentucky, Massachusetts, Utah and Wisconsin will continue to be excluded

Utilization review guidelines
You can access the revised UnitedHealthcare Outpatient Surgical Procedures – Site of Service Utilization Review Guideline (URG) by visiting our Medical & Drug Policies and Coverage Determination Guidelines page.

Questions?
See our frequently asked questions.

CPT® is a registered trademark of the American Medical Association.

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