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New policy and prior auth requirement for select embolization procedures
Act
by Nov 30, 2026
Effective date
Dec 1, 2026
Identified
Sep 2, 2026
Summary
Effective December 1, 2026, UnitedHealthcare is implementing a new unified vascular embolization policy and adding prior authorization requirements for CPT 37242 on commercial, Medicare Advantage, and most Community Plans. Site-of-service reviews for therapeutic vascular embolization (CPT 37242) are being discontinued, with reviews shifting to medical necessity only. This consolidates multiple existing policies into one for greater consistency.
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What to do
by Nov 30, 2026 · 6 steps
01Billing team must update all systems to require prior authorization for CPT 37242 for UnitedHealthcare commercial, Medicare Advantage, and applicable Community Plans.
02Remove any site-of-service review logic for CPT 37242 from billing workflows and replace with medical necessity review protocols.
03Update encounter templates and provider documentation requirements to support medical necessity justification.
04Identify all claims submitted for CPT 37242 under old site-of-service-only review processes and establish new submission procedures.
05Verify which UnitedHealthcare Community Plans in excluded states (ID, IN, KS, KY, NE, NJ, NM, NC, OH, PA, TN) are NOT affected pending state approval.
06Claims submitted without required prior authorization for CPT 37242 will be denied effective December 1, 2026.
Codes mentioned
37242
Original notice
New policy and prior auth requirement for select embolization procedures
uhcprovider.com · Always check the source before changing claims.
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