Posted in #unitedhealthcare, Prior Authorization Insurance Carrier Updates, Training, Updates

UHC Commercial Plans: some radiotherapies do not require prior auth

This policy change applies to UHC Commercial Plans:

  • UnitedHealthcare Plan of the River Valley, Inc.
  • UnitedHealthcare Insurance Company of the River Valley
  • UnitedHealthcare of the Mid-Atlantic, Inc.
  • MAHP Life and Health Insurance Company
  • Neighborhood Health Partners
  • UHOne
  • All Savers (fractionation prior authorization requirement for All Savers will be delayed)
  • Rhode Island and Oxford Health Plan members will be excluded

If you are a provider seeing any of the patients with the above mentioned plans and refer them for some outpatient radiotherapies, then this change applies to you.

There are 8 Radiotherapy codes, when performed in outpatient setting will no longer require a prior authorization.

These codes are:

  • 37243-Vascular embolization or occlusion, for tumors, organ ischemia, or infarction
  • 61796-Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion
  • 61797-Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion
  • 61798-Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 complex cranial lesion
  • 61799-Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); each additional cranial lesion, complex
  • 61800-Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)
  • 63620-Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion
  • 63621-Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional spinal lesion (List separately in addition to code for primary procedure)

If you would like to read the full coverage of determination, please click here.

If you are a provider that is ordering other types of outpatient radiotherapy, please ubmit an online prior authorization request, sign in to Link to access the Prior Authorization and Notification tool. Select the “Radiology, Cardiology, Oncology and Radiation Therapy” box. After selecting “commercial” as the product type, you’ll be directed to another website to process the authorization requests.

Find this type of content useful? Follow my blog for more prior authorization updates, medical billing and coding guideline updates, and medical/reimbursement policy updates.

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Posted in #Medicareadvantage, #unitedhealthcare, Training, Updates

UHC Commercial and Exchange Plans: update to Radiology Prior Auth List

As of December 1,2021 the following codes will be added to the radiology prior authorization list. These codes will require an authorization for DOS 12/01/2021 and thereafter.

The prior authorization for these codes WILL NOT APPLY TO The following situations: if the advanced imaging is done in-

  • Emergency room
  • Urgent care center
  • Observation unit
  • Inpatient stay

In case you missed it:

In June 2021, UHC also added more Radiology and Cardiology codes on the Prior Authorization List. These codes apply to UnitedHealthCare Community Plan, Medicare Advantage, commercial and exchange Plans

For complete details on the radiology protocol, refer to the current UnitedHealthcare Administrative Guide

Find this type of information useful? Follow my blog for more insurance payer updates, medical coding and medical billing guideline changes, reimbursement and medical policy updates.


Posted in Cinga Insurance, Training, Updates

Cigna: RAMICADE Reimbursement Policy Change

Are you a provider that administers RAMICADE for Cigna patients? Then this blog post is for you!

As of July 2021 Cigna removed RAMICADE from its preferred medications list. This change will apply to Cigna Commercial Plans.

This change will Apply to Individual and Family Plans on January 1,2022 and thereafter.  

What providers should do?

IF you are a provider that currently accepts CIGNA Commercial plan patients in your office, CIGNA encourages you to work with your Cigna Patients to switch to either AVSOLA or INFLECTRA.

Do I need a new authorization starting 07/01/2021?

No. Providers are allowed to administer either AVSOLA or INFLECTRA without any further action: provided that the patient meets medical necessity and there is no change in dosing, frequency or site of services.

What is the Authorization time frame for AVSOLA and INFLECTRA?

July 1, 2021 to May 1, 2022.

How can a provider obtain a copy of the authorization?

Please call 1800-882-4462 Cigna Coverage Review Department, to request a letter of authorization.

What if I RAMICADE is medically necessary for my patients?

If provider believes that a non-preferred medication is medically necessary for the patient, provider can contact Cigna Coverage Review Department and request a medical necessity review. Provider can also request medical review through CovermyMeds or Surescripts.

Who can I contact for additional information?

Please contact Accredo: 1866-759-1557 or CuraScript SD 1877-599-7748 or any other participating specialty pharmacy.

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