Tag: #radiotherapy

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

UHC Commercial Plans: some radiotherapies do not require prior auth

Posted on by KR2Medical Billing

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 #unitedhealthcare, Training, Updates

UHC Community Health, Medicaid (Multiple States): Radiation therapy Prior Auth requirement

Posted on by KR2Medical Billing

This policy will affect DOS (dates of services) on 10/07/2021 and thereafter, and will apply to UnitedHealthcare Community Plan members in the following states:

  • California
  • Florida
  • Maryland
  • Mississippi
  • Ohio
  • Rhode Island
  • Washington
  • Wisconsin

The prior authorization requirement will apply to the following outpatient radiation therapies, for UnitedHealthcare Community Plan Medicaid members, in the above mentioned states:

  • Intensity modulated radiation
  • Stereotactic body radiation therapy
  • Fractionation for breast cancer, prostate cancer, lung cancer and bone metastasis
  • Image guided radiation therapy
  • Special and associated radiation therapy services
  • Implantable beta emitting microspheres (Y90)

Authorization requirement for proton beam therapy (PBT):

If prior authorization for these services is already approved for administered treatment prior to Oct. 7, 2021, you do not need to submit a new prior authorization request for that approved treatment plan.

Authorization requirement for intensity-modulated radiation therapy (IMRT), image-guided radiation therapy (IGRT), special services Y90/SIRT or SBRT, including SRS:

Services started between Aug. 1–Oct. 6, 2021, you do not need to submit a prior authorization request. UHC Community Health will authorize the radiation therapy service(s) the member was receiving prior to Oct. 7, 2021, 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.

Completing Authorization requests:

Please complete prior authorization requests 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  > Service Type of Radiation Oncology > Product Type of Medicaid > member state.

Where to find the Prior Authorization Criteria:

Prior to Oct. 1, 2021, the new medical policies (Radiation Therapy: Fractionation, Image-Guidance and Special Services and Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery) can be accessed from the UnitedHealthcare Community Plan Medical Policy Update Bulletin: July 2021.

On Oct. 1, 2021, medical policies for all radiation therapy services will be available at UnitedHealthcare Community Plan Medical & Drug Policies and Coverage Determination Guidelines.

Direct Link to the medical policy for Radiation Therapy: Fractionation, Image-Guidance, and Special Services, please click here.

Direct Link to the medical policy for Proton Beam Radiation Therapy, please click here.

Direct Link to the medical policy for Intensity-Modulated Radiation Therapy, please click here.

Questions:

Email unitedoncology@uhc.com

Posted in Insurance, Training, Updates

Anthem Medi-Cal: Radiotherapies and radioimmunotherapies will require prior authorization 04/01/2021

Posted on by KR2Medical Billing

PA requirements will be added to the following codes:

  • A9543 Injection, Yttrium Y-90 ibritumomab tiuxetan (Zevalin)
  • A9590 Injection, Iodine I-131, iobenguane, 1 mCi (Azedra)
  • A9513 Injection, Lutetium Lu 177, dotatate, therapeutic, 1 millicurie (Lutathera)
  • A9606 Injection, Radium ra-223 dichloride, therapeutic, per microcurie (Xofigo)

Effective 04/01/2021 the above codes will require an auth.

Providers have 2 ways to order a PA:

Federal and state law, as well as state contract language, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage.