Expansion of colonoscopy screening site of service coverage review, effective Jan. 1, 2021

Beginning Jan. 1, 2021, UnitedHealthcare will expand notifications, prior authorization requirements and site of service medical necessity reviews for screening colonoscopy procedures to include 2 additional screening colonoscopy procedures/HCPCS codes G0105 and G0121. Additionally, UnitedHealthcare will implement a new Utilization Review Guideline and Oxford Clinical Policy to include site of service medical necessity reviews for the following screening colonoscopy procedures in HCPCS/CPT® codes: 45378, 45380, 45381, 45384, 45385, G0105 and G0121.

Screening colonoscopies are a covered benefit. UnitedHealthcare commercial benefit plans cover colonoscopy screenings without member cost-sharing for adults age 50-75 in accordance with U.S. Preventive Services Task Force recommendations and the Affordable Care Act.  

This change applies to UnitedHealthcare fully insured individual and group benefit plans, including Oxford, Neighborhood Health Partnership and UnitedHealthcare of the River Valley. This will also apply to UnitedHealthcare ASO SOS Buy-up customers. 

UnitedHealthcare will only require notification/prior authorization and conduct site of service medical necessity review if these procedures will be performed in an outpatient hospital setting. A screening colonoscopy done in an outpatient hospital setting:

  • May be twice as expensive on average compared to ambulatory surgery centers (ASC).
  • May cost an average of $4,295 at an outpatient hospital setting and at an ambulatory surgery center may cost an average of $1,945.

The change will go into effect on Jan. 1, 2021, for most fully insured plans and ASO SOS Buy-up plans with the following exceptions:

  • The change is effective for Iowa and Illinois on Feb. 1, 2021.
  • Alaska, Kentucky, Massachusetts, Rhode Island, Texas, Utah and Wisconsin are excluded at this time.
  • UnitedHealthcare West and Sierra plans are out-of-scope.

If a hospital outpatient department is not covered, members will be informed that their plan covers a colonoscopy at a non-hospital location, such as an ambulatory surgical center. Members will be encouraged to talk to their provider to find a covered location where the member can have the procedure done or to discuss other treatment options. The member or provider may contact UnitedHealthcare by calling the number on their ID card for assistance providing notification or requesting authorization for a screening colonoscopy and for locating an ASC for a screening colonoscopy procedure. 

For questions, please contact your broker or UnitedHealthcare representative.