CurrentUnitedHealthcarePolicy CS060KY.10

Transarterial Radioembolization Ky Cs

Kentucky-only UnitedHealthcare medical policy governing coverage of TARE/SIRT using yttrium-90 microspheres for malignant liver cancers in individuals 19 years and older; references InterQual CP for specific medical necessity criteria. Policy states coverage for select indications and noncoverage for other indications.

Policy Summary

PayerUnitedHealthcare

PolicyTransarterial Radioembolization Ky Cs

Policy CodePolicy CS060KY.10

Change TypeMaterial updates to age threshold, InterQual reference, indications

Effective DateMay 1, 2026

Next Review Date

Key ActionProviders must document medical necessity in the patient record and apply InterQual CP: Procedures, Ablative or Transarterial Therapy, Liver when requesting coverage for individuals 19 and older.

SourceLink

POLICY UPDATE CHANGES

Policy applies to individuals 19 years of age and older; TARE/SIRT is covered without further review for individuals younger than 19.

Replaced instruction referencing InterQual for age ≥ 18 with referencing InterQual for medical necessity clinical coverage criteria (age-independent within adult population).

Specified medically necessary indications including unresectable HCC limited to the liver, HCC as bridge to transplant, unresectable neuroendocrine metastases after failed systemic therapy, unresectable colorectal liver metastases refractory to/relapsed after chemotherapy with limited extra-hepatic disease, and unresectable intrahepatic cholangiocarcinoma.

Stated TARE/SIRT is unproven and not medically necessary for all other indications due to insufficient evidence of efficacy.

Removed definitions for ECOG scale, Limited Extra-Hepatic Disease, Refractory, and Transarterial Radioembolization (TARE).

Removed Supporting Information, Clinical Evidence and References sections.

5Covered Indications (listed)

1States covered

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Coverage Summary

Kentucky-only UnitedHealthcare medical policy CS060KY.10 governing Transarterial Radioembolization (TARE)/Selective Internal Radiation Therapy (SIRT) with yttrium-90 microspheres for malignant cancers of the liver. Effective date: May 1, 2026; last review/effective: May 1, 2026.

Policy applies to individuals 19 years of age and older (individuals younger than 19 are covered without further review). InterQual CP: Procedures, Ablative or Transarterial Therapy, Liver is referenced as the primary medical necessity clinical coverage criteria. Covered indications include: unresectable primary hepatocellular carcinoma (HCC) limited to the liver; HCC as a bridge to liver transplantation; unresectable neuroendocrine liver metastases after failed systemic therapy; unresectable colorectal liver metastases refractory to or relapsed after systemic chemotherapy with limited extra‑hepatic disease; and unresectable intrahepatic cholangiocarcinoma. The policy states that TARE/SIRT is unproven and not medically necessary for all other indications due to insufficient evidence of efficacy.

Key facts

Adult age threshold for review19+

States coveredKentucky (1)

Covered indications (count)5

Primary medical necessity referenceInterQual CP: Procedures, Ablative or Transarterial Therapy, Liver

Medical-Necessity Criteria

Coding

Relevant CPT/HCPCS/Other Procedure Codes (reference list)mixed

37243	Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction.
75894	Transcatheter therapy, embolization, any method, radiological supervision and interpretation.
79445	Radiopharmaceutical therapy, by intra-arterial particulate administration.
S2095	Transcatheter occlusion or embolization for tumor destruction, percutaneous, any method, using yttrium-90 microspheres.

Provider Actions

Documentation Required

Medical record documentation required

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services. Include relevant medical history, a physical examination, and results of pertinent diagnostic tests or procedures. Documentation should be legible, maintained in the patient's record, and available upon request.

Relevant medical history
Physical examination
Pertinent diagnostic test results or procedure reports

Prior Authorization

Refer to InterQual for medical necessity determination

Coverage determinations for individuals 19 years of age and older require application of InterQual CP: Procedures, Ablative or Transarterial Therapy, Liver for the specific clinical criteria. Providers should follow the InterQual criteria when requesting coverage for TARE/SIRT in this population.

Background

This policy applies only to the state of Kentucky and addresses TARE/SIRT using yttrium-90 microspheres (TheraSphere and SIR-Spheres). Both commercial products have FDA approvals with indication-specific approvals: SIR-Spheres for unresectable metastatic colorectal liver tumors (with adjuvant IHAC of floxuridine) and TheraSphere for certain unresectable hepatocellular carcinoma indications; use of these products is also regulated by the United States Nuclear Regulatory Commission (U.S. NRC). InterQual criteria are used as the primary medical necessity standard referenced in the policy.

Definition - InterQual CP: Procedures, Ablative or Transarterial Therapy, Liver: Proprietary clinical criteria set used by UnitedHealthcare for primary medical/surgical coverage decisions for liver ablative or transarterial therapies; providers are directed to refer to these InterQual criteria for detailed medical necessity clinical coverage requirements.

Revision History

2026-05-01material change - addedLatest

Policy applies to individuals 19 years of age and older; TARE/SIRT is covered without further review for individuals younger than 19.

2026-05-01material change - revisedLatest

Replaced instruction referencing InterQual for age ≥ 18 with referencing InterQual for medical necessity clinical coverage criteria (age-independent within adult population).