UnitedHealthcare (UHC) has replaced and added procedure codes on its notification and prior authorization (PA) lists.
More such changes will take effect April 1.
The changes are a result of the American Medical Association’s update of Current Procedural Terminology (CPT) codes for 2019, updates of the Healthcare Common Procedure Coding System (HCPCS) by the Centers for Medicare & Medicaid Services, and U.S. Food and Drug Administration (FDA) approvals of new drugs.
The following replaced and deleted codes now affect these categories of procedures for prior authorization under all UHC plans:
Radiology (breast imaging):
- CPT codes 77046 and 77048 replace deleted code 77058.
- CPT codes 77047 and 77049 replace deleted 77059
- CPT code 81163 replaces deleted 81211.
- CPT codes 81165 and 81166 replace deleted 81214.
- Chemotherapy: HCPCS codes J9311 and J9312 replace deleted J9310.
- Injectable medications: HCPCS codes J0567, J3398, J7318, J0517, J1301, and J717 replace C9014, C9032, C9465, C9466, C9493, and Q9995.
Also deleted from the lists is transplants CAR-T cell therapy: HCPCS Q2040.
Effective April 1:
- Stimulators (new): CPT code 64590 will require prior authorization for UHC Medicare Advantage, Connected TX, Community Dual Special Needs, and Community-Medicare plans.
- Orthotics/prosthetics: 56 HCPCS codes will have additional PA criteria for UHC Community Plan of Texas (StarPlus Plan). For a list of the codes, see January 2019 UHC Network Bulletin, page 11.
- For all UHC Community plans except Connected TX and Community Dual Special Needs plans, prior authorization will be required for 12 orthotics/prosthetics codes and 12 durable medical equipment codes. See the above link for a list of codes.
- Genetic and molecular testing performed in an outpatient setting: UHC will require PA for 58 additional codes for commercial plan and Community Plan patients (excluding Medicare Advantage). For details, see January 2019 UHC Network Bulletin, pages 20-23.
- Medical injectable drugs: Applicable HCPCS C-codes will be added to the PA requirement lists and medical benefit drug policies for commercial health plans. For injectable medications, you need to use all HCPCS and CPT codes related to a drug requiring prior authorization, even unclassified codes or temporary C-codes.
UnitedHealthcare recommends always requesting preservice coverage reviews for medications on its Review at Launch Commercial and Community Plan medication lists. These are lists of drugs newly approved by FDA for which some patients may not be eligible right away.
Information about prior authorization and up-to-date lists are available at UHCProvider.com/priorauth.
Sourcing Requirement for Synojoynt
The FDA recently approved Synojoynt for the treatment of osteoarthritis of the knee in patients who have failed conservative noninvasive treatments such as physical therapy and simple pain medicines. Effective April 1 for its commercial plans, UHC will require you to get Synojoynt from a designated specialty pharmacy.
Source: UHC Network Bulletin, January 2019
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