New Oncology Prior Authorization Requirements Announced for 2026

Apr 03, 2026

2 minutes

New Oncology Prior Authorization Requirements Announced for 2026

Effective October 1, 2026, new prior authorization requirements will be implemented for specific oncology-related procedure and medication codes across multiple health plans. The update applies broadly to commercial, Medicare, Medicaid, and individual exchange plans, aligning with recent procedure code changes issued by the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA).

Key Changes

Prior authorization will now be required for the following HCPCS codes when used in outpatient settings for cancer treatment:

G0562: Therapeutic radiology simulation-aided field setting; complex, including PET and CT imaging data acquisition for radiopharmaceutical-directed radiation therapy planning.
G0563: Stereotactic body radiation therapy (SBRT), including image guidance and real-time positron emission-based delivery adjustments, with a maximum of five fractions per treatment course.
J2860: Injection, siltuximab, 10 mg.

Plans and Coverage Impacted

The updated prior authorization requirements will affect a wide range of plans under UnitedHealthcare, including:

UnitedHealthcare Commercial Plans (nationwide)
UnitedHealthcare Medicare Advantage Plans (all states)
UnitedHealthcare Community Plan (Medicaid)
UnitedHealthcare Individual & Family ACA Marketplace Plans

UnitedHealthcare Community Plan

Arizona
Colorado
Florida
Hawaii
Kansas
Kentucky
Louisiana
Maryland
Mississippi
Nebraska
New Jersey
New Mexico
New York
Ohio
Pennsylvania
Rhode Island
Tennessee
Texas
Virginia
Washington
Wisconsin

UnitedHealthcare Individual Exchange plans

Alabama
Arizona
Colorado
Louisiana
Maryland
Michigan
Missouri
Mississippi
North Carolina
Nebraska
Florida
Georgia
Indiana
New Jersey
New Mexico
New York
Ohio
Oklahoma
South Carolina
Tennessee
Illinois
Iowa
Kansas
Texas
Virginia
Washington
Wisconsin
Wyoming

Support and Resources

For additional guidance or clarification, providers can:

Email: unitedoncology@uhc.com
Call: 888-397-8129
Visit the Oncology Prior Authorization and Notification page via UnitedHealthcare’s official resources

Services

Credentialing

Credentialing is the rigorous process of verifying a healthcare provider’s qualifications, including their education, training, licenses, and clinical experience. This service ensures that practitioners meet the high standards required by insurance networks and hospitals to provide care and receive reimbursement.

Billing & Collection

Billing and Collection service involves confirming a patient’s insurance coverage, active status, and specific benefits before their appointment. By identifying co-pays, deductibles, and required prior authorizations upfront, staff can prevent claim denials and help patients understand their financial responsibilities.

Eligibility Verification

Eligibility verification is the process of verifying a patient’s health insurance coverage and benefits to determine what services are covered and the level of coverage available. This process is essential for healthcare providers to ensure that they receive proper reimbursement for services rendered and that patients are not left with unexpected medical bills.

Revenue Cycle Management

RCM is the financial process that manages the entire lifecycle of a patient’s account, from the initial appointment scheduling to the final balance payment. It integrates eligibility, coding, billing, and collections into a single, cohesive workflow aimed at maximizing a practice's profitability.

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