CurrentUnitedHealthcarePolicy N/A

Prior Auth Injectable Chemo Faq

UnitedHealthcare requires prior authorization for outpatient injectable chemotherapy medications administered to patients being treated for cancer across commercial, Medicare Advantage, and Community Plan products; applies regardless of age and includes pediatric patients (<19) with coverage guidance. Secondary payer situations and non-cancer uses are treated differently.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Auth Injectable Chemo Faq

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit a prior authorization request through the UnitedHealthcare Provider Portal for outpatient injectable chemotherapy administered for cancer; authorization is required for payment and claims will be denied without it (unless UnitedHealthcare is secondary payer).

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes in this update.

1Active authorization per patient allowed

14mTrastuzumab authorization length

8mNon-trastuzumab adjuvant length

12mMetastatic regimen length

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UnitedHealthcare requires prior authorization for outpatient injectable chemotherapy administered to patients being treated for cancer. This requirement applies across UnitedHealthcare commercial, Medicare Advantage, Oxford and Community Plan products and applies regardless of age, including pediatric patients (<19).

The prior authorization program is intended to improve care and outcomes and lower total cost of care while reducing service denials for members undergoing cancer treatment. Prior authorization supports a streamlined approval process for NCCN-compliant regimens and treats secondary payer situations and outpatient injectable chemotherapy used for non-cancer diagnoses differently (those scenarios may be exempt from this requirement or require different benefit rules).

Active authorization per patient allowed1

Authorization length for trastuzumab regimens14 months

Authorization length for non-trastuzumab adjuvant regimens8 months

Authorization length for metastatic regimens12 months

Prior Authorization Criteria

Prior Authorization Requirement

Prior authorization is required when ALL of the following are met:

ALL of the following

Medication setting: Medication is an injectable chemotherapy medication administered in an outpatient setting
Diagnosis: Member is being treated for cancer (applies regardless of age)
Payer status: UnitedHealthcare is primary payer

Exceptions / Non-Applicability

Prior authorization requirement does NOT apply when ANY of the following are true:

ANY of the following

Non-cancer use: Medication is being used for a non-cancer diagnosis (requirement doesn't apply; some non-cancer uses may require authorization under other benefit rules)
Secondary payer: UnitedHealthcare is the secondary payer

Authorization Validity and Replacement Rules

Rules about active prior authorizations:

ALL of the following

Single active authorization: Only one active prior authorization for a chemotherapy regimen per patient is allowed at a time
Replacement when requesting new regimen: If a new chemotherapy regimen authorization is requested while an active authorization exists, provider will be asked to replace the active prior authorization with the new request
Expiration on new approval: If a new injectable chemotherapy medication is approved with a new authorization, previous authorizations expire as of the date of the new request

Authorization Periods

Prior authorization durations vary by regimen type:

ANY of the following

Trastuzumab-containing regimens: prior authorization period is 14 months14 months
Non-trastuzumab adjuvant regimens: prior authorization period is 8 months8 months
Metastatic regimens: prior authorization period is 12 months12 months
General validity: Most prior authorizations are valid for 365 days (length varies by request)

Clinical Information Required for Authorization

We request additional clinical information based on diagnosis/regimen — provide ALL applicable:

ALL of the following

Prior chemo for metastatic disease: Prior chemotherapy regimen if member is being treated for metastatic disease
Line of therapy if member has metastatic disease
Tumor histology and markers: Tumor histology and tumor markers for some tumor types (examples: KRAS, HER2, BRAF)
Other supporting information: Any other clinical information supporting the request (comorbidities, adverse reaction history, published literature for rare cancers, etc.)

Regimen Selection and Custom Regimens

When submitting regimen selections:

ALL of the following

Select entire NCCN regimen: Select the entire NCCN-recommended regimen during case entry (for example, authorize the full regimen even if initial cycles include fewer agents)
Request custom regimen if not listed: If the regimen is not listed, request a custom regimen
Unassigned J-code handling: New chemotherapy medications without assigned J-codes will be listed under unclassified codes J3490, J3590 or J9999
Each unassigned drug is listed under J3490, J3590 or J9999 as applicable

Changes to Regimen After Authorization

Impact of modifications to an authorized regimen:

ANY of the following

Dropping a medication: Dropping an authorized medication from the regimen does not terminate or affect the prior authorization
Adding a medication: Adding a new injectable chemotherapy medication requires submission of a new prior authorization request; may prompt peer-to-peer review
Adverse reaction substitution: If member experiences an adverse reaction to an authorized medication and clinician wants to change to a new injectable chemotherapy medication, a new prior authorization is required

Pediatric and Rare Cancer Review

Special review considerations:

ALL of the following

Pediatric protocols and coverage: Pediatric outpatient injectable chemotherapy requires prior authorization; chemotherapy agents are covered for those younger than age 19 based on national pediatric protocols
Rare adult cancers review: Rare adult cancers: oncologist reviews requests with current peer-reviewed literature; provide supporting published documentation when submitting

Provider Actions & Requirements

Prior Authorization

Obtain prior authorization for outpatient injectable chemotherapy

UnitedHealthcare requires prior authorization for outpatient injectable chemotherapy administered for cancer. Submit the prior authorization request through the UnitedHealthcare Provider Portal; claims for injectable chemotherapy will be denied without a prior authorization (unless UnitedHealthcare is the secondary payer).

Documentation Required

Provide clinical information with request

Provide all applicable clinical information with the prior authorization request, such as prior chemotherapy regimens for metastatic disease, line of therapy, tumor histology and tumor markers (e.g., KRAS, HER2, BRAF), comorbidities, adverse reaction history, and any supporting published literature for rare cancers or non‑NCCN regimens.

Billing Rule

Ensure date of service is within authorization window

Ensure the claim's date of service falls within the prior authorization approval date range. If the date of service is not within the authorization's date range, the claim will not be eligible for reimbursement.

Prior Authorization

Submit replacement authorization when changing regimen

If you request authorization for a new chemotherapy regimen while an active authorization exists for the patient, submit the new request as a replacement for the active prior authorization. Only one active chemotherapy authorization is allowed per patient; adding a medication requires a new prior authorization.

Prior Authorization

Submit new authorization early for continuation

To continue a current regimen, submit a new prior authorization request at least 2 weeks before the current authorization expires to avoid interruption of coverage.

Prior Authorization

Use portal or phone for predetermination

If the member's benefit plan does not require authorization, you may request a predetermination via the UnitedHealthcare Provider Portal. If the portal does not provide that option, call the Provider Services number on the member's ID card to request a predetermination.

Coding Guidance

Examples of J-code handling for unassigned drugsHCPCS

J3490	Unclassified drugs (used to list new chemotherapy medications without assigned J-code)
J3590	Unclassified drugs (used to list new chemotherapy medications without assigned J-code)
J9999	Unclassified drugs (used to list new chemotherapy medications without assigned J-code)

Claims review requires prior authorization for billed injectable chemotherapy HCPCSHCPCS

No codes listed

Background & Definitions

Prior authorization reviews follow UnitedHealthcare medical policies, which are based on National Comprehensive Cancer Network (NCCN) guidelines, including medication combinations, lines of therapy and treatment for disease progression. The prior authorization tool provides a streamlined approval process for NCCN‑compliant regimens.

When a requested regimen is not NCCN‑compliant, complex, or otherwise requires additional clinical consideration, an oncologist will review the request and any supporting clinical information or published literature provided by the clinician before a coverage decision is made.

Outpatient injectable chemotherapy: Injectable chemotherapy medications administered to patients in an outpatient setting for cancer treatment.

Frequently Asked Questions

Question	Answer
Does receipt of prior authorization guarantee payment?
No; prior authorization does not guarantee claim payment. Payment depends on member eligibility on date of service, reimbursement policies and provider participation agreement; some state laws may require payment.
Is prior authorization required if UnitedHealthcare is secondary payer?
No; prior authorization is not required when UnitedHealthcare is the secondary payer.
Do I need to put the case number on the claim form?
No; you do not need to list any case number on the claim form.
What if the regimen isn't listed or drug has no J-code?
Request a custom regimen; new drugs without assigned J-codes will be listed under J3490, J3590 or J9999; call the number on the member's ID card if medication isn't listed.
What clinical information may be required?
May include prior chemotherapy regimens, line of therapy, tumor histology and markers (KRAS, HER2, BRAF), comorbidities, adverse reaction history, or other supportive information.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Auth Injectable Chemo Faq

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Prior Auth Injectable Chemo Faq

Coverage Summary

Prior Authorization Criteria

Provider Actions & Requirements

Coding Guidance

Background & Definitions

Frequently Asked Questions