Prior authorization requirement changes for radiation therapies
Affects UnitedHealthcare Community Plan members in Kentucky
Effective May 1, 2023, we will require prior authorization for the following outpatient radiation therapies for UnitedHealthcare Community Plan members in Kentucky:
- Intensity-modulated radiation therapy (IMRT)
- Proton beam therapy (PBT)
- Stereotactic body radiation therapy (SBRT), including stereotactic radiosurgery (SRS)
- Image-guided radiation therapy (IGRT)
- Special and associated services (Special Plan & Services – Special Services – SPS) - (e.g., dosimetry and special physics consults)
- Hypofractionation (aka fractionation) using IMRT, PBT and standard 2D/3D radiation therapy for prostate, breast, lung and bone metastatic cancers
- Selective internal radiation therapy (SIRT), Yttrium 90 (Y90) and implantable beta-emitting microspheres for treatment of malignant tumors
Prior authorization management change
As part of the new prior authorization requirement, we are also changing the way we manage requests.
Starting May 1, 2023, Optum®, a UnitedHealthcare affiliate, will manage prior authorization requests for the above-noted outpatient radiation therapies and existing prior authorization requirement for PBT. This change should not impact your process for submitting prior authorization requests.
How to submit prior authorization
For PBT, if prior authorization for these services is already approved for administered treatment prior to May 1, 2023, you do not need to submit a new prior authorization request for that approved treatment plan.
For IMRT, standard radiation therapy 2D/3D, IGRT, special services, Y90/SIRT or SBRT, including SRS services started between March 1, 2023, and April 30, 2023, you do not need to submit a prior authorization request. We’ll authorize the radiation therapy service(s) the member was receiving prior to May 1, 2023, and the authorization will be effective for 90 days from the treatment start date. For any further radiation therapy services that extend after 90 days from the treatment start date, we’ll require prior authorization before the start of services.
Submit your prior authorization request by signing into 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
- Select member state
The online tool will open on April 25, 2023, for prior authorization requests with a start date of May 1, 2023.
Coverage determination guidelines
On May 1, 2023, medical policies for all radiation therapy services will be available at UnitedHealthcare Community Plan Medical & Drug Policies and Coverage Determination Guidelines.
Training
A Radiation Therapy Prior Authorization – Self Paced Provider Training resource is available to help your staff streamline the prior authorization request submissions process.
Questions?
For answers to specific questions, email unitedoncology@uhc.com.
