Why UHC Denies PET/CT Scan
Staging not appropriate for tumor type
Follow-up scan too soon after treatment
Diagnosis does not meet NCD criteria
Know UnitedHealthcare's Criteria
UHC uses InterQual criteria and their own Clinical UM Guidelines (CG series). Medical directors are typically accessible for P2P within 5 business days.
Key policies to know:
- Requires eviCore for MSK and advanced imaging prior auth
- Clinical UM Guidelines (CG series) are publicly available online
- Prior auth through Optum/UHG portal
- Known for strict step therapy requirements on biologics
UHC's Specific Approach to PET/CT Scan
Applicable Policy
UHC Clinical UM Guideline CG-RAD-40 (PET/CT Imaging)
How UHC Typically Denies This
UHC strictly follows CMS NCD criteria for PET scans. They deny when the specific cancer type or clinical scenario isn't covered under the NCD, or when the scan is for surveillance rather than initial staging or treatment response.
Your Strategy for This Payer
Map your indication to the specific CMS NCD code. UHC won't approve beyond what the NCD covers. If it's an NCD-covered indication, make that clear up front.
Key Phrase to Use on the Call
"This PET/CT is indicated for [initial staging/treatment response/suspected recurrence] of [cancer type], which is a covered indication under CMS NCD 220.6.17 and UHC CG-RAD-40."
Building Your Medical Necessity Argument
Reference the specific NCD indication being met
Document how PET results will change management
Note prior imaging results that are insufficient
Cite NCCN guideline recommendation for PET at this stage
P2P Call Tips for UHC
Reference UHC's own Clinical UM Guideline number (e.g., CG-SURG-71)
UHC medical directors respond well to InterQual criteria language
Be specific about which InterQual subset applies
Have the CG policy number ready -- shows you've done your homework
Guidelines to Reference
- CMS National Coverage Determination for FDG PET
- NCCN Guidelines by cancer type
Relevant CPT Codes
Specialty: Oncology / Pulmonology
Want the full strategy?
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