UHC Genetic and Molecular Lab Testing Prior Authorization Requirement

April 2019 ~

Effective July 1, UnitedHealthcare (UHC) will expand the existing prior authorization/notification for genetic and molecular testing performed in an outpatient setting to UnitedHealthcare Plan of the River Valley, Inc., UnitedHealthcare Insurance Company of the River Valley, MAMSI Life and Health Insurance Company, Optimum Choice, Inc., MD Individual Practice Association, Inc. and UnitedHealthcare self-insured plans.

According to the notice, providers are instructed to use the Genetic and Molecular Test tool on Link to submit the notification/ prior authorization request. Next, providers will be asked to fill in the member’s information and choose the test and the lab to perform the test. Ordering providers will need to submit requests for tests that require authorization. Labs may submit their own notification requests for tests that only require notification.

The following will require notification/prior authorization:

• Tier 1 Molecular Pathology Procedures
• Tier 2 Molecular Pathology Procedures
• Genomic Sequencing Procedures
• Multianalyte Assays with Algorithmic Analyses that include Molecular Pathology Testing
• The following CPT codes:
• 0001U,
• 0012U – 0014U,
• 0016U – 0019U,
• 0022U – 0023U,
• 0026U – 0034U,
• 0036U – 0037U,
• 0040U,
• 0045U – 0050U,
• 0055U – 0057U,
• 0060U,
• 0069U – 0076U,
• 0078U,
• 0081U,
• 0004M,
• 0006M – 0007M,
• 0009M,
• 0011M – 0013M,
• 81105 – 81111,
• 81120 – 81121,
• 81161 – 81210,
• 81215 – 81420,
• 81425 – 81479,
• 81507,
• 81518 – 81521,
• 81545,
• 81595 – 81599,
• S3870

UHC notes that BRCA prior authorization requirements will not change with this expansion.

CPT^® is a registered trademark of the American Medical Association.

Source(s): UnitedHealthcare Network Bulletin April 2019;