Radiation Therapy Prior Authorization Requirements by Payer

Radiation therapy prior authorization requirements in 2026 are written around a code set that did not exist a year ago, and each payer rewrote its program on its own schedule. UnitedHealthcare retired authorization on the deleted codes and attached it to 77402, 77407, 77412 and 77387-26 from January 1. eviCore issued two editions of its clinical guidelines and two of its coding manual for Cigna in the first ten weeks of the year. Aetna’s standing clinical policy bulletins still refer medical necessity to eviCore, while a new bundled authorization starts with Medicaid members. Humana published a superficial radiation policy and little else. In addition, Medicare Advantage plans now owe a decision in 7 calendar days.

This page lists what each payer publishes and what to put in the request. Our earlier post covers the federal deadlines, WISeR and the code remap in more depth.

Many authorization teams are learning four changed programs at once this year, so this page puts them side by side.

Payer by payer

Payer	What is published for 2026	What it means for the request
UnitedHealthcare (Medicare Advantage, Community Plan, commercial, Individual Exchange)	Notice of December 23, 2025: prior authorization ends for the deleted IMRT, IGRT and 2D/3D codes (77385, 77386, G6015, G6016, 77014, G6001, G6002, G6017, 77401, G6003 to G6014) and from January 1, 2026 is required for 77402, 77407, 77412 and 77387-26 for oncologic and hematologic diagnoses. Approvals issued before January 1 for courses under way are converted; no new request. Commercial policy 2026T0613L (effective March 1, 2026) sets fraction limits and coding rules.	Request the level you will bill: 77412 only with multiple isocenters, active motion management, total skin electrons or mixed fields documented. Request 77387-26 alongside. The commercial program also covers SRS and SBRT (77371 to 77373, G0339, G0340), proton (77520 to 77525), 77331, 77370, 77399, 77470 and Y90.
Cigna (eviCore by Evernorth)	Radiation Oncology Guidelines V1.0.2026 effective January 1, 2026 and V2.0.2026 effective February 25, 2026 (Cigna editions published November 18, 2025 and January 20, 2026). Radiation Oncology Coding Manual V1.0.2026 effective January 1 and V1.1.2026 effective February 27, 2026.	The guidelines set IMRT versus 3D and fraction counts by site; the coding manual sets units. Whole breast IMRT, for example, requires overlap with a prior field or a 3D plan that exceeds organ-at-risk tolerances. 77373 is allowed up to a maximum of 5 fractions for all sites as a complete episode.
Aetna (eviCore for Medicare Advantage, insured HMO and insured PPO)	Clinical Policy Bulletin 0590 (IMRT) and its siblings remain the coverage documents and state “for medical necessity criteria, see eviCore Healthcare Radiation Therapy Clinical Guidelines.” eviCore’s Aetna code list effective January 1, 2026 includes 77402, 77407, 77412, 77387, 77373, 79101 and A9607. Aetna announced September 17, 2026 that bundled oncology prior authorizations now cover all cancer types for eligible Medicaid members in eight states through the Eviti portal, with a full roll-out across Aetna businesses planned for 2027.	eviCore clinical worksheets by cancer type. Authorization effective dates are set 14 calendar days before the earlier of treatment start or case initiation to cover simulation and planning. Urgent requests are processed within 48 to 72 hours of complete clinical information.
Humana	Superficial Radiation Treatment policy HUM-2632-000 (Medicaid edition effective March 9, 2026): 77436 to 77439 covered for superficial nonmelanoma skin cancer when surgery is contraindicated or refused; image-guided superficial radiation therapy is not covered.	No 2026 Humana IMRT, SBRT or fractionation policy was found for this post; confirm requirements per plan through Humana’s preauthorization list.

UnitedHealthcare in detail

Submissions go through the Provider Portal under Prior Authorizations and Notifications; the commercial program’s phone line is 888-397-8129.

Policy 2026T0613L, effective March 1, 2026, holds the fraction limits: breast up to 21 fractions including a boost (33 with regional nodes, postmastectomy treatment, prior thoracic radiation or a connective tissue disorder), APBI up to 5 fractions with IMRT or 10 with 3D, localized prostate up to 28 (45 with pelvic nodes, post-prostatectomy treatment, inflammatory bowel disease or prior pelvic radiation), bone metastases up to 10, locally advanced lung up to 35. Image guidance is medically necessary with IMRT, proton therapy, re-irradiation or abutting fields, fiducials, and listed 3D situations such as five-fraction whole-breast treatment and left breast DIBH. The hypofractionation post tabulates these against regimens.

The Medicare Advantage policy “Radiation and Oncologic Procedures” (effective September 1, 2026) notes there is no NCD for IGRT, special services or Level 1 to 3 delivery and refers each to the commercial policy, while IMRT and proton follow local coverage determinations where they exist.

Cigna and eviCore in detail

eviCore’s coding manual sets the unit rules a Cigna claim must follow once the course is approved: one unit of 77402, 77407 or 77412 per date of service, with a second unit for twice-daily treatment reported with modifier 76 or 77 on a separate line; one unit of 77387-26 per date of service, and the modifier is mandatory; one unit of 77427 per five fractions with no extra unit for one or two leftover fractions; 77431 only when the whole course is one or two fractions; 77435 once per SBRT course; 77336 once per five fractions. It also states that adaptive planning has no CPT code.

Most of the restrictions are in the clinical guideline. LUGPA, reviewing the January 1 edition, called it the most restrictive utilization policy it had seen, citing IMRT to 3D downgrades and limits on IGRT, SBRT, hypofractionation and re-irradiation. The V2.0.2026 edition keeps the structure: by site, a list of fraction counts that are medically necessary, followed by what is not.

Aetna in detail

Aetna’s clinical policy bulletins have not been rewritten for the code set; CPB 0590 still describes IMRT as medically necessary where critical structures cannot be adequately protected with 3D conformal therapy and defers criteria to eviCore. The operational document is eviCore’s Aetna FAQ: eviCore has managed Aetna radiation oncology authorization since July 1, 2019 for Medicare Advantage, insured HMO and insured PPO members; requests are preferred through the eviCore portal with clinical worksheets, and cases marked urgent that do not meet urgent criteria are reassigned as routine.

The bundled authorization is new. Aetna’s September 17, 2026 release says a single request can combine medical oncology, radiation oncology and related high-tech imaging for eligible Medicaid members in Oklahoma, Illinois, Maryland, New Jersey, Virginia, Florida, Kentucky and West Virginia, effective September 1, with Medicare and commercial members expected in the first half of 2027.

Blue Cross Blue Shield of Michigan: OncoHealth from September 1

For dates of service from September 1, 2026, Blue Cross Blue Shield of Michigan and Blue Care Network send radiation oncology authorization, proton therapy included, to OncoHealth through its Oncology Value Management program. Before that date eviCore reviewed these requests for most members. The change covers most fully insured and self-funded commercial members, individual coverage, and all Medicare Plus Blue and BCN Advantage members. MESSA members have no requirements under the program, some self-funded groups opted out, and Carelon keeps radiation oncology for UAW Retiree Medical Benefits Trust members.

The code list includes 77402, 77407, 77412, 77387, 77427, the planning and physics codes and brachytherapy. Requests go to OncoHealth’s OneUM portal or by phone at 1-888-916-2616. A course that started under an eviCore approval before September 1 and continues past it is worth checking with OncoHealth before the next authorization period runs out.

The Medicare Advantage deadlines

Under CMS-0057-F, Medicare Advantage organizations and Medicaid and CHIP programs and plans must decide expedited requests within 72 hours and standard requests within 7 calendar days from January 1, 2026, and must give a specific reason for every denial. Exchange plan issuers are exempt from the timeframes, and the first public metrics were due March 31, 2026. A UnitedHealthcare or Aetna Medicare Advantage request for a 77407 course therefore has a federal deadline; a commercial request for the same course does not.

What a complete submission contains

Diagnosis with stage and histology, treatment intent (curative, adjuvant, palliative), and prior radiation to the region.
Technique and the delivery code requested: 77402, 77407 or 77412, with the Level 3 criterion named and the method described (gating, tracking, 4D CBCT; number of isocenters; mixed fields; total skin electrons).
Total dose and number of fractions, matched to the payer’s published limit for the site, and twice-daily treatment stated if planned.
Image guidance rationale tied to the payer’s criteria (IMRT, re-irradiation, fiducials, DIBH), with 77387-26 requested.
Planning codes (77295 or 77301), simulation, devices and physics, since eviCore authorizes units for those too.
Treatment start date, which sets the eviCore effective window and the UHC conversion rule.
An urgent designation only when the clinical definition is met.

What to do now

Build a payer matrix of the four programs, submission channel, policy edition and effective date, and review it quarterly; eviCore changed editions twice before March.
Track the 72-hour and 7-day deadlines on every Medicare Advantage, Medicaid and CHIP request and escalate on day 8 with the CMS-0057-F citation.
Request the level you will bill, and the fraction count you will deliver. A course approved as 77407 for 20 fractions that bills 77412 for 22 will be denied for both the level and the fraction count.
Confirm converted approvals show the new codes on the UnitedHealthcare portal before the first claim.
Reconcile delivered fractions against the plan. Iridium Suite’s CodePath audits scheduling, delivery, coding and billing against the treatment plan, so a fraction count or delivery level that differs from what was requested can be found before the claim; see CodePath.
Watch Aetna’s 2027 bundle roll-out and ask the plan representative whether a bundled approval carries fraction and level detail or defers to eviCore.

Radiation therapy prior authorization requirements by payer in 2026: UnitedHealthcare, Cigna and eviCore, Aetna and Humana rules, and what to submit