March 01, 2022

New radiation therapy prior authorization requirements

Effective June 7, 2022, prior authorization will be required and managed by Optum for the following outpatient radiation therapies:

  • Proton beam therapy (PBT)
  • Fractionation for intensity-modulated radiation therapy (IMRT), PBT and standard 2D/3D radiation therapy for prostate, breast, lung, and bone metastasis cancers
  • Image-guided radiation therapy (IGRT)
  • Special and associated radiation therapy services
  • Selective internal radiation therapy (SIRT), Yttrium 90 (Y90) and implantable beta-emitting microspheres for treatment of malignant tumors

Impacted health plans: This applies to UnitedHealthcare® Medicare Advantage, UnitedHealthcare West Medicare Advantage and UnitedHealthcare Community Plan (Dual Special Needs Plan) health plans.

Also starting June 7, 2022, the management of the existing prior authorization requirement for IMRT and stereotactic body radiation therapy (SBRT) including stereotactic radiosurgery (SRS) will be transitioned to Optum.

For members currently receiving radiation therapy the following applies:

For IMRT and SBRT, if prior authorization for these services is already approved for administered treatment prior to>June 7, 2022, you do not need to submit a new prior authorization request for that approved treatment plan.

For PBT, standard radiation therapy (2D/3D), IGRT, special and associated services or Y90/SIRT services started between March 1, 2022 and June 6, 2022, you do not need to submit a prior authorization request. We’ll authorize the radiation therapy service(s) the member was receiving prior to June 7, 2022, 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.

How to submit prior authorization:
Submit your prior authorization request 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
  • Select Service Type of Radiation Oncology
  • ·Select product type of Medicare 

The online tool will open on June 1, 2022 for prior authorization requests with a start date of June 7, 2022.

Coverage determination guidelines
On June 7, 2022, the updated Medicare Advantage Coverage Summary titled Radiologic Therapeutic Procedures will be available at UnitedHealthcare Medicare Advantage Coverage Summaries.

Training dates, times and registration options will be available in May of 2022 on the UnitedHealthcare Provider Portal.

Additional information is available in Medicare Advantage Therapeutic Radiation Prior Authorization Authorization Program FAQ or Email