CurrentUnitedHealthcarePolicy CSIND0030.13

Oncology Medication Clinical Coverage (for Indiana Only)

Parameters for coverage of injectable oncology medications and therapeutic radiopharmaceuticals under the medical benefit for UnitedHealthcare members in Indiana, based on NCCN Drugs & Biologics Compendium recommendations. Affects providers requesting coverage for listed injectable oncology drugs and related therapies.

Policy Summary

PayerUnitedHealthcare

PolicyOncology Medication Clinical Coverage (for Indiana Only)

Policy CodePolicy CSIND0030.13

Change TypeRoutine reviewno content changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization demonstrating the indication is listed in the NCCN Drugs & Biologics Compendium with Category 1, 2A, or 2B for the specific cancer.

SourceLink

POLICY UPDATE CHANGES

Routine review; no content changes.

Categories 1/2A/2Brecognized as proven indications

Category 3considered unproven and not medically necessary

Indianastate applicability

Yesincludes radiopharmaceuticals

Coverage Criteria and Indications

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Diagnosis-specific coverage criteria

Covered when ALL of the following are met:

NCCN-based indication: The drug or biologic is listed in the NCCN Drugs and Biologics Compendium with a Category of Evidence and Consensus of 1, 2A, or 2B for the specific cancer indication.Category 1, 2A, or 2B

NCCN Drugs and Biologics Compendium referenced in policy

Pediatric coverage: All chemotherapy agents will be covered for individuals under the age of 19 years for oncology indications.<19 years

Pediatric patients often treated on national pediatric protocols

This policy does not provide coverage criteria for Chimeric Antigen Receptor (CAR)-T cell or Tumor-Infiltrating Lymphocyte (TIL) cell products. CAR‑T therapies may be eligible for coverage under the member's Transplantation Services benefit and are adjudicated according to OptumHealth Transplant Solutions clinical guidelines for CAR‑T and TIL therapies; coverage decisions also depend on the member's contractual benefit provisions.

Indications assigned NCCN Category 3 are considered unproven and not medically necessary for coverage purposes. Category 3 reflects major disagreement among guideline panel members about interpretation or generalizability of the evidence and therefore does not meet the policy's evidence threshold for medical benefit coverage.

Covered Codes and Examples

Covered injectable oncology medications (examples)mixedCovered

denosumab (Prolia & Xgeva)	listed example injectable oncology medications
erythropoiesis-stimulating agents	listed example injectable oncology medications
gonadotropin releasing hormone analogs	listed example injectable oncology medications
leucovorin, levoleucovorin	listed example injectable oncology medications
rituximab	listed example injectable oncology medications
somatostatin analogs	listed example injectable oncology medications
white blood cell colony stimulating factors	listed example injectable oncology medications

Therapeutic radiopharmaceutical examplesmixedCovered

Azedra (iobenguane I 131)	therapeutic radiopharmaceutical example
Lutathera (lutetium Lu 177 dotatate)	therapeutic radiopharmaceutical example
Xofigo (radium-223)	therapeutic radiopharmaceutical example

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization required per NCCN-based criteria. Coverage is contingent on meeting diagnosis-specific criteria aligned to the NCCN Drugs & Biologics Compendium. Providers should obtain prior authorization when required by the members plan before initiating therapy.

Coverage follows NCCN Categories of Evidence and Consensus: Categories 1, 2A, 2B = proven; Category 3 = unproven and not medically necessary
Prior authorization requirements are subject to the member's federal, state, and contractual benefit terms
UnitedHealthcare may use third-party tools (e.g., InterQual) to assist in coverage determinations

Denial Risk

NCCN Category 3 = Not Medically Necessary

NCCN Category 3 triggers noncoverage. Indications categorized as NCCN Category 3 (unproven) are considered not medically necessary and may be denied. Confirm the NCCN Compendium category for the requested indication and include supporting documentation if an exception is being requested.

If the requested use is listed as NCCN Category 3, coverage is not supported under this policy
Providers may submit clinical rationale and supporting evidence for exceptional review per contractual processes

Documentation Required

Benefit and Documentation Requirements

Benefit and documentation considerations. Use this policy in conjunction with the members federal, state, and contractual benefit terms; in case of conflict, those benefit terms govern. Document the diagnosis, NCCN Compendium category, prior treatments, and rationale for therapy in the medical record and prior authorization submission.

Verify member coverage (federal/state/contractual) prior to authorization and treatment
Include documentation of diagnosis, NCCN category, prior therapies, dosing, and treatment intent with prior authorization request
Pediatric: UnitedHealthcare will cover chemotherapy agents for individuals under age 19 for oncology indications per policy note

Step Therapy

Step therapy not specified in this policy. The policy does not define a required step-therapy sequence; clinical judgment and applicable benefit or third-party tools (e.g., InterQual) may inform the order of treatments. Follow any plan-specific step-therapy or utilization management requirements if present.

No explicit step-therapy sequences are mandated by this policy
If the members plan includes step-therapy rules, those take precedence and must be followed
Consider prior treatments and clinical guidelines when recommending therapy order

Background and Scope

UnitedHealthcare uses the NCCN Drugs & Biologics Compendium to define which injectable oncology medications and therapeutic radiopharmaceuticals are appropriate for specific cancer indications. The Compendium lists drugs and biologics with an associated Category of Evidence and Consensus; this policy recognizes NCCN Categories 1, 2A, and 2B as proven indications for coverage and treats Category 3 as unproven and not medically necessary. Therapeutic radiopharmaceuticals are included in the scope of the policy and are defined as radioactive agents that selectively accumulate in tumors (examples include Azedra (iobenguane I-131), Lutathera (lutetium Lu-177 dotatate), and Xofigo (radium-223)).

NCCN Category Definitions

Category 1 — Recommendation based on high-level evidence with uniform consensus.

DefinitionRecommendation based on high-level evidence (e.g., high-powered randomized clinical trials or meta-analyses) with uniform consensus that the recommendation is indicated.

Evidence levelHigh-level (randomized trials, meta-analyses)

ConsensusUniform (near unanimous positive support; some neutral positions possible)

Category 2A — Recommendation based on lower-level evidence with uniform consensus.

DefinitionRecommendation based on lower-level evidence but with uniform consensus that the recommendation is appropriate.

Evidence levelLower-level (phase II, cohort studies, case series, expert experience)

Clinical noteMay be superseded as higher-level evidence becomes available; consensus driven by collective clinical experience.

Category 2B — Recommendation based on lower-level evidence with nonuniform consensus.

DefinitionRecommendation based on lower-level evidence with nonuniform consensus; more than one approach may be appropriate.

ConsensusNonuniform — institutions may adopt different management approaches due to inconclusive evidence.

InterpretationSignals that multiple reasonable approaches exist and users should consider institutional practices and clinical judgment.

Category 3 — Recommendation with major disagreement; considered unproven and not medically necessary.

DefinitionRecommendation with major disagreement among panel members; considered unproven and not medically necessary for coverage purposes.

ImplicationAlerts users to significant interpretation issues in the data and refers them to source manuscripts for controversy details.

Example contextMajor disagreements can arise when interventions lack direct randomized comparisons or when generalizability of trial data is disputed.