COVID-19 Prior Authorization Updates

UnitedHealthcare has implemented prior authorization and supply limits on the oral dosage form of ivermectin (human formulation). This is to help ensure ivermectin is only prescribed in appropriate doses for approved indications and guideline-recommended uses.

The prior authorization and supply limits are effective beginning as follows:

• Sept. 10, 2021 – Individual and Group Market health plans
• Sept. 15, 2021 – Medicare Advantage, Medicaid and Individual Exchange plans

Supply limits and coverage

Ivermectin tablets are approved by the FDA only for the medical treatment of specific parasitic infections in humans.¹ Coverage of ivermectin is dependent upon specific health plan certificates of coverage. Coverage for prescription claims of ivermectin for treatment outside of approved indications and guideline-recommended uses will be denied.

For approved indications and guideline-recommended uses, UnitedHealthcare criteria allows a limit of 20 ivermectin tablets prescribed within 90 days. Most approved indications for ivermectin are treated with 1 or 2 doses of oral (human) ivermectin and should be within the allowed quantity of 20 tablets within 90 days. 

Ivermectin is not covered for treatment of COVID-19 by any UnitedHealthcare plan. Taking large, or potentially unknown, doses of ivermectin can be dangerous. Ivermectin is generally safe to use when prescribed appropriately.

Prior authorization process

The process for prior authorization and prescriptions is as follows:

• The medical practitioner is responsible for consultation and any diagnostic tests to determine that a patient has a parasitic infection that fits within the guideline-recommended uses for ivermectin treatment.
  If clinically appropriate, the practitioner would issue a prescription for the medication.
• When the prescription is processed, the pharmacist should enter the diagnosis code supplied by the medical practitioner onto the prescription claim
  • If the diagnosis code is one of the approved uses for ivermectin, the prescription will
    process automatically.
  • If the diagnosis code falls outside of the approved uses, the claim will be rejected for prior authorization. When that happens, the medical practitioner (prescriber) is responsible for submitting a prior authorization request.
• Prior authorization requests may be requested by contacting OptumRx either online or by phone:
  • o   By phone: 1-800-711-4555
  • o   Online: professionals.optumrx.com/prior-authorization.html

¹ Parsippany, NJ: Edenbridge Pharmaceuticals, LLC. Ivermectin package insert. January 2014.

The temporary suspension of prior authorization requirements for in-patient admissions to in-network skilled nursing facilities (SNFs) ends on Jan. 31, 2021, except for select markets which are being communicated to directly. The temporary prior authorization suspensions apply to UnitedHealthcare Medicare Advantage, Medicaid and Individual and Group Market health plan members nationwide, where UnitedHealthcare has health plans available. The suspensions are effective Dec. 18, 2020 through Jan. 31, 2021.

State variations and regulations may apply during this time.  For Medicaid and other state-specific regulations, please refer to your state-specific website or your state’s UnitedHealthcare Community Plan website, if applicable.

Please note the following exceptions to the temporary provisions:

• The provisions and effective dates noted here replace similar temporary prior authorization provisions for SNF admissions, facility transfers and COVID-19-related oxygen requests currently posted on UHCprovider.com/covid19 or communicated previously, unless the similar prior authorization provisions extended to higher levels of care or have expiration dates after Jan. 31, 2021.
• Providers are not required to submit a new prior authorization when a member moves to a different yet similar site of care for the same service (e.g., hospital transfers or practice transfers).
• State regulatory requirements, including end dates for specific state prior authorization relief requirements, still apply. Providers should check their state pages for more information.
• For those areas where UnitedHealthcare will begin offering new Individual Exchange health plans beginning Jan. 1, 2021, the temporary provisions apply from Jan. 1, 2021 through Jan. 31, 2021.

After Jan. 31, 2021, we may retrospectively review select services rendered during this time period. Admission notification is still required during this time, in alignment with the current protocol to support you in arranging post-admission care or other support services, if needed. In most cases, notification of inpatient admission is provided to UnitedHealthcare by the hospital or facility through the UnitedHealthcare Provider Portal or an EDI 278N transmission that requires no intervention on the part of your staff.

Beginning Oct. 1, 2020, for all commercial and UnitedHealthcare Community Plan plans included in the genetic and molecular testing program, we are suspending prior authorization and notification requirements for the following three genetic and molecular CPT codes performed in an outpatient setting:

• 87480: Infectious agent detection by nucleic acid (DNA or RNA); candida species, direct probe technique
• 87660: Infectious agent detection by nucleic acid (DNA OR RNA); Trichomonas vaginalis, direct probe technique
• 87661: Infectious agent detection by nucleic acid (DNA OR RNA); Trichomonas vaginalis, amplified probe technique:

These codes were part of the expansion of the online prior authorization and notification program for genetic and molecular testing that took effect on July 1, 2020. We’re suspending the codes indefinitely to ease the administrative burden for care providers during the COVID-19 national public health emergency. Please note that we will be reviewing claims for these codes to ensure they are being billed appropriately.

You can learn more about the genetic and molecular testing program online or in the Genetic and Molecular Lab Test tool.

The following prior authorization provisions apply to all Individual and Group Market health plans, and Medicaid and Medicare Advantage plans.

• A 90-day extension, based on original authorization date, of open and approved prior authorizations with an end date or date of service between March 24, 2020 and May 31, 2020, for services at any care provider setting. For example, for a prior authorization with an original end date or date of service of April 30, 2020, the prior authorization would now extend through July 29, 2020.
  • Applies to existing prior authorizations for medical, behavioral health and dental services. This includes existing prior authorizations for many provider-administered drugs.
  • Authorizations issued on or after April 10, 2020 will not be subject to extension.
  • Applies to in-network and out-of-network existing prior authorizations.
  • Prior authorizations for inpatient procedures will extend 90 days from the expected admission date.
  • Providers should re-confirm member eligibility before providing services, when authorized dates of service are extended, to help ensure that accurate coverage and benefits are applied.
  • If a prior authorization approves the number of visits or services, then providers must obtain a new prior authorization for additional units, visits or services beyond what was approved in the original authorization.
    • For example, if the original authorization approved 10 sessions of physical therapy, any sessions beyond 10 would require a new authorization.
  • UnitedHealthcare will also follow related state mandates where applicable. However, when UnitedHealthcare provisions exceed those required by states, UnitedHealthcare provisions will apply.
    • For example, if a state has mandated an extension of prior authorizations by 60 days and UnitedHealthcare has extended prior authorizations by 90 days, we will apply the 90-day time frame to the extension.
  • Providers can check the status of authorizations by using either the Prior Authorization and Notification tool or by visiting the website listed on the back of the member's ID card.

We will not require prior authorizations for diagnostic radiology for COVID-19 testing and testing-related services (diagnostic imaging) during the national public health emergency period. We urge providers to submit notification for CPT^® codes 71250, 71260, 71270 for members with a COVID-19 diagnosis or suspected diagnosis, and who are enrolled in Medicaid and Individual and Group Market health plans. No notice is necessary for Medicare. Notification allows us to coordinate the care of our members who may have COVID-19 and better support them in their health care journey. For all other chest CTs, prior authorization continues to be required.

To help our members access the critical supplies they need and streamline operations for providers during the national public health emergency period, UnitedHealthcare is making changes to several durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) processes and provisions. The following provisions for prior authorization, reimbursement of recurring supplies and proof of delivery are effective for Medicare Advantage, Medicaid and Individual and Group Market health plan members, with dates of delivery from March 31, 2020, until May 31, 2020. Coverage and payment is subject to member's benefit plan and the provider's contracts. Normal prior authorization requirements will resume June 1, 2020.

Prior Authorization   

• For all COVID-19 discharges to home-based care requiring a respiratory assist device or a ventilator, the vendor can deliver on notification only to UnitedHealthcare for codes E0471, E0465, E0466 and E0467 for up to three months from time of delivery. Notification is requested and the claim must be submitted with the appropriate modifiers and diagnosis code (ICD-10). After the three-month period, a prior authorization will be required.
• For orders involving COVID-19-related oxygen requests, oxygen can be delivered without prior authorization and does not need to meet current clinical criteria.
• Where possible, we’re eliminating Face-To-Face evaluation requirements for the ordering provider for DMEPOS:
  • For prior authorizations for services that were completed before Oct. 1, 2019, a new prior authorization is required. Provider may complete a Face-To-Face assessment via telehealth.
  • For prior authorizations for services that were completed on Oct. 1, 2019, or later, UnitedHealthcare is extending prior authorizations through Sept. 30, 2020.          
  • For new DMEPOS prior authorizations, providers may complete a Face-To-Face assessment via telehealth.
• DMEPOS evaluation requirements remain in effect for complex rehab technology (CRT) and orthotics and prosthetics. However, vendors may use their own technology, if available, to minimize in-person contact.
• Prior authorization is not required for a DMEPOS repair when the claim uses the repair modifier.
• Consistent with existing policy, prior authorization is not required for breast pumps.

Reimbursement – Recurring Supplies

• The following changes to recurring supply processes will help maintain member supplies:
  • For initial orders, we’ll reimburse beyond 30 days to cover a 30- to 45-day supply depending on packaging.
  • For second orders, we’ll reimburse an additional 15-day supply to allow for overlap.
  • For remaining orders, vendors may manage frequency and duration to help members maintain sufficient product on hand, but it is not to exceed 45 days on hand. Supply limits still apply.

Proof of Delivery

A physical signature from the patient is not required, but the vendor must note the time and date of delivery and relationship to member, in addition to maintaining required documentation for follow-up requests. 

On May 11, 2020, the American Society for Reproductive Medicine issued guidance in support of the measured resumption of infertility treatments. Before resuming infertility treatments, providers should be flexible and prepared to recognize and address the status of their local COVID-19 transmission rate. Providers should review national, regional, state and municipal regulations that dictate what healthcare treatment is and is not permitted within their jurisdiction, based on their analysis of disease transmission and hospital capacity data.

Temporary Coverage Change for Embryo Cryopreservation

Previously, UnitedHealthcare announced a temporary policy change – effective for dates of service from March 17, 2020 through April 30, 2020 – to cover embryo cryopreservation in order to help members avoid mid-cycle disruption to infertility treatment accessed through their benefit plan. While this temporary coverage period has ended, here are the policy details to help ensure claims are submitted accurately and to help you understand the benefits payable from March 17, 2020 through April 30, 2020.

• The temporary change in coverage applied to infertility treatment care plans for members who started an in vitro fertilization (IVF) cycle and were ready for retrieval and embryo transfer, which was interrupted mid-cycle by the COVID-19 national emergency. It did not apply to previously scheduled cryopreservation services.
• UnitedHealthcare provided embryo cryopreservation coverage to fully insured members with infertility benefits, where plan benefits had not previously included embryo cryopreservation coverage.
  • Members with fully insured coverage may, in some instances, already have benefit coverage for embryo cryopreservation when the issued policy includes a state-mandated requirement for this coverage. In that instance, the member will receive the higher level of coverage: either the temporary change in coverage or the state-mandated requirement for coverage.
• For members in self-funded benefit plans with infertility benefits who do not have coverage for embryo cryopreservation and storage, coverage was provided if their plan sponsor opted in to offer this temporary change in coverage.
• UnitedHealthcare adjudicates benefits according to plan terms, including member cost share. The plan benefit will define the member cost share.

Claim Reconsiderations

If you receive a claim denial for embryo cryopreservation that meets the above criteria, you can submit a claim reconsideration using the reconsideration process outlined in the Provider Administrative Guide/Care Provider Manual, available at UHCprovider.com/guides.

Other infertility treatment care plan issues pertaining to adverse determinations affected by the COVID-19 pandemic may be addressed through a peer-to-peer review. To request a review, you can call us at 800-955-7615 or send a secure email to UHC_PeertoPeer_Scheduling@uhc.com.