Prior authorization requirement changes for radiation therapies

Affects UnitedHealthcare Community Plan members in New York

Effective Nov. 1, 2024, we will require prior authorization for the following outpatient radiation therapies for UnitedHealthcare Community Plan members in New York:

• 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 Nov. 1, 2024, 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 Nov. 1, 2024, 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 Sept. 1, 2024, and Oct. 31, 2024, you do not need to submit a prior authorization request. We’ll authorize the radiation therapy service(s) the member was receiving prior to Nov.1, 2024, 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.

You can submit a prior authorization request through the UnitedHealthcare Provider Portal:

• From any page on UHCprovider.com, select Sign In at the top-right corner
• Enter your One Healthcare ID
• New users who don’t have a One Healthcare ID: Visit UHCprovider.com/access to get started
• From the left-hand tabs, select Prior Authorizations & Notifications

Once you’re on the Prior Authorization and Notifications page, click “Create a new request” and follow these steps:

• Select ‘Radiology oncology’ from the Select Prior Authorization Type for Submission dropdown menu
• Select ‘Medicaid’ from the Select Plan Type dropdown menu
• Select Continue to open the online submission tool

The online tool will open on Oct. 25, 2024, for prior authorization requests with a start date of Nov. 1, 2024.

Coverage determination guidelines

On Nov. 1, 2024, 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.

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