Comprehensive Radiation Therapy Management ......2021/04/01 · © 2021 United HealthCare Services, Inc. All Rights Reserved. Introducing the Comprehensive Radiation Therapy Management

© 2021 United HealthCare Services, Inc. All Rights Reserved.

Comprehensive Radiation Therapy ManagementTraining for authorization request submissions


Agenda

2

1 Overview

2 Why prior authorization is important

3 Prior authorization requirements

4 Online request process

5 Demonstration of online request process

6 Additional information

7 Questions?


• We regularly evaluate our medical policies, clinical programs and health benefits, based on the latest scientific evidence to help ensure our member benefit coverage is medically appropriate

• Effective for dates of service beginning on April 1, 2021, we’ll require prior authorization for certain radiation therapy services — these requirements apply to most UnitedHealthcare commercial plans

• We’re making this change as part of our commitment to working with members and care providers to help support improved population health outcomes, positive care experiences and affordable products

• An important part of this commitment includes coordinating coverage guidelines and policies for radiation therapy services

New prior authorization requirements for radiation therapy services

Overview

3


Introducing the Comprehensive Radiation Therapy

Management program

Overview (cont.)

4

• Beginning April 1, 2021, prior authorization for many of our commercial members will be managed by the Comprehensive Radiation Therapy Management program, a capability within Medical Benefit Management’s (MBM) Specialty Medical Guidance program

• This program offer is provided as a part of Optum, an affiliate company of UnitedHealthcare, and provides expanded prior authorization for Radiation Therapy modalities

• The Comprehensive Radiation Therapy Management program is an evidence-based prior authorization and utilization management


This requirement includes the following radiation therapy modalities and services:

• 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 (e.g., dosimetry and special physics consults, which are reflected in the codes in the appendix of this presentation and the Network Bulletin)

• Fractionation using IMRT, PBT and Standard 2D/3D radiation therapy for prostate, breast, lung and bone metastasis cancers

• Selective internal radiation therapy (SIRT), Yttrium 90 (Y90) and implantable beta-emitting microspheres for treatment of malignant tumors

Please use the new process when requesting prior authorization

for certain radiation therapy services.

Included modalities and services

5


Why prior authorization is important

6

• We require coverage reviews for

these therapies, because it’s

important to us to provide our

members with coverage for care

that’s medically appropriate, as we

work toward the Quadruple Aim of

improving health care services,

health outcomes, overall cost of

care and care provider engagement

• Prior authorization helps us make

sure members are getting the

appropriate care


We’re working with Optum, our affiliate, to support you in managing the prior authorization process.

Optum offers solutions to help improve the care provider experience for transactions, such as submitting prior authorization requests.

Here’s how it works

Input clinical data

The system will prompt you to provide clinical information

during the intake process

Access the system

Access the Prior Authorization and Notification tool on Link at

UHCprovider.com/paan. Click on oncology, enter required

information and you will be directed to the MBMNow system.

Rapid decision

If the clinical criteria are met, you will receive an “approved” decision

at or near the time of submission

If needed, peer-to-peer review

To help ensure we have all the information we need to provide an

accurate coverage determination, we may contact you

1

2

3

4

How do I submit a prior authorization request?

7


Demonstration of online request process

Enter a new prior authorization request in the MBMNow system

Look up an existing authorization in the MBMNow system

Add a new authorization request for members who have an existing authorization

This demonstration will show you how to:

Create new Find existing Add to existing

8


Additional information

9

• If you have any questions about the new prior authorization requirement, please visit uhc.com/contact-us/for-providers and select your state

• You can also email [email protected] or call us at 888-397-8129

• For system issues, please call the UnitedHealthcare Connectivity Help Desk at 866-842-3278 (option 1), Monday–Friday, 7 a.m.–9 p.m. CT

Where can I find more information?

http://www.uhc.com/contact-us/for-providers

mailto:[email protected]

Questions?

Appendix


Plans in scope

12

Prior authorization for certain outpatient radiation therapies will be required for the following health plans:

• UnitedHealthcare commercial plans, excluding Indemnity/Options PPO

• UnitedHealthcare Plan of the River Valley, Inc.

• UnitedHealthcare Insurance Company of the River Valley

• UnitedHealthcare of the Mid-Atlantic, Inc.

• Neighborhood Health Partners

• UnitedHealthOne

• All Savers (fractionation prior authorization requirement for All Savers will be delayed)

The following health plans are excluded:

• Health plans in the state of Rhode Island

- The launch for fully insured members in the state of Rhode Island will be delayed until further notice, due to Rhode Island Governor Raimondo’s Executive Order 20-29 and the Office of the Health Insurance Commissioner’s (OHIC) issues Health Insurance Bulletin 2020-03, in response to the COVID-19 pandemic

• UnitedHealthcare Oxford commercial health plan


Codes requiring prior authorization

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Code Description77014 CT GUIDANCE RADIATION THERAPY FLDS PLACEMENT77387 STEREOSCOPIC X-RAY GUID LOCALIZ TRG VOL DEL RTG6001 Ultrasonic guidance for placement of radiation therapy fieldsG6002 Stereoscopic X-ray guidance for localization of target volume for the delivery of radiation therapy

G6017Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy

(e.g., 3D positional tracking, gating, 3D surface tracking), each fraction of treatment

77331 Special Dosimetry77370 Special Physics Consult77399 Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services77470 Special Treatment Procedure77401 RADIATION TX DELIVERY SUPERFICIAL&/ORTHO VOLTA

77402 RADIATION TREATMENT DELIVERY 1 MEV+ SIMPLE77407 RADIATION TX DELIVERY 1 MEV => INTERMEDIATE

77412RADIATION TREATMENT DELIVERY, 2 SEPARATE TREATMENT AREAS, 3 OR MORE PORTS ON A

SINGLE TREATMENT AREA, USE OF MULTIPLE BLOCKS; 20 MEV OR GREATER

G6003 RAD TX DEL 2 TX AREA PORT/PL OPP PORTS:TO 5 MEVG6004 RAD TX DEL 1 TX AREA PORT/PL OPP PORTS: 6-10 MEVG6005 RAD TX DEL 1 TX AREA PORT/PL OPP PORTS: 11-19 MEG6006 RAD TX DEL 1 TX AREA PORT/PL OPP PORTS: 20 ME/>G6007 RT DEL 2 SEP AR 3/> PT 1 TX AR MX BLKS:TO 5 MEVG6008 RT DEL 2 SEP AR 3/> PT 1 TX AR MX BLKS:6-10 MEVG6009 RT DEL 2 SEP AR 3/> PT 1 TX AR MX BLKS:11-19 MEV

G6010RADIATION TREATMENT DELIVERY, 2 SEPARATE TREATMENT AREAS, 3 OR MORE PORTS ON A

SINGLE TREATMENT AREA, USE OF MULTIPLE BLOCKS: 20 MEV OR GREATERG6011 RAD TX DEL 3/> SEP TX AR CSTM BLOCKING; TO 5 MEVG6012 RAD TX DEL 3/> SEP TX AR CSTM BLOCKING; 6-10 MEVG6013 RAD TX DEL 3/> SEP TX AR CSTM BLOCKING;11-19 MEVG6014 RAD TX DEL 3/> SEP TX AR CSTM BLOCKING;20 MEV/>

61796STEREOTACTIC RADIOSURGERY (PARTICLE BEAM, GAMMA RAY OR LINEAR ACCELERATOR); 1

SIMPLE CRANIAL LESION


Codes requiring prior authorization(cont.)

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Code Description

61797Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); each additional cranial lesion,

simple (list separately in addition to code for primary procedure)

61798Application of stereotactic headframe for stereotactic radiosurgery (list separately in addition to code for

primary procedure)

61799Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); each additional cranial lesion,

complex (list separately in addition to code for primary procedure)

61800Application 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

63621Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); each additional spinal lesion (list

separately in addition to code for primary procedure)77371 Radiation delivery stereotactic cranial cobalt 77372 Radiation delivery stereotactic cranial linear77373 Stereotactic body radiation delivery

G0339Image-guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in

1 session or first session of fractionated treatment

G0340Image-guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes

and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum

5 sessions per course of treatment

S2095Transcatheter occlusion or embolization for tumor destruction, percutaneous, any method, using

yttrium-90 microspheres


Codes requiring prior authorization(cont.)

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Code Description

79445 Radiopharmaceutical therapy, intra-arterial particulate admin

37243

Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural

road-mapping and imaging guidance necessary to complete the intervention; for tumors, organ ischemia

or infarction77385 INTENSITY-MODULATED RADIATION TX DLVR SIMPLE

77386 INTENSITY-MODULATED RADIATION TX DLVR COMPLEX

G6015Intensity-modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally

modulated beams, binary, dynamic MLC, per treatment session

G6016Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high

resolution (milled or cast) compensator, convergent beam modulated fields, per treatment session77520 Proton treatment delivery; simple, without compensation 77522 Proton treatment delivery; simple, with compensation 77523 Proton treatment delivery; intermediate 77525 Proton treatment delivery; complex


Frequently asked questions

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• Frequently asked questions document can be found here.

https://www.uhcprovider.com/content/dam/provider/docs/public/prior-auth/oncology/radiation-therapy-management-commercial-faq.pdf


UnitedHealthcare medical policies

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• The UnitedHealthcare medical policies pertaining to radiation oncology can be found at the following links:

- Fractionation, Image-Guidance and Special Services

-Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery

- Intensity-Modulated Radiation Therapy

-Proton Beam Radiation Therapy

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/index/commercial/radiation-therapy-fractionation-image-special-services-04012021.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/index/commercial/stereotactic-body-radiation-therapy-radiosurgery-04012021.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/intensity-modulated-radiation-therapy.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/proton-beam-radiation-therapy.pdf

Thank you

Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Health plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California, UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of the Mid-Atlantic, Inc., MAMSI Life and Health Insurance Company, UnitedHealthcare of New York, Inc., UnitedHealthcare Insurance Company of New York, UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Pennsylvania, Inc., UnitedHealthcare of Texas, Inc., UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc., UnitedHealthcare of Washington, Inc., Optimum Choice, Inc., Oxford Health Insurance, Inc., Oxford Health Plans (NJ), Inc., Oxford Health Plans (CT), Inc., All Savers Insurance Company or other affiliates. Administrative services provided by OptumHealth Care Solutions, LLC, OptumRx, Oxford Health Plans LLC, United HealthCare Services, Inc. or other affiliates. Behavioral health products provided by U.S. Behavioral Health Plan, California (USBHPC) or its affiliates.PCA-1-21-02034-VC-WEB_06022021© 2021 United HealthCare Services, Inc. All Rights Reserved.© 2021 Optum, Inc. All Rights Reserved.

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Comprehensive Radiation Therapy Management ......2021/04/01 · © 2021 United HealthCare Services, Inc. All Rights Reserved. Introducing the Comprehensive Radiation Therapy Management