UHC now requiring G0416 for prostate biopsies across all products

January 11, 2021

FYI: This post originally ran in October 2020 when UHC first announced this move. We have bumped it to the top of our blog as a reminder the policy change is now in effect.

After making the move to align prostate biopsies with G0416 for Medicare Advantage plans earlier this year, UnitedHealthcare has announced the policy will be put into effect for its commercial products beginning Jan. 1, 2020.

This means that any prostate needle biopsies coded 88305 will be denied, bringing UHC in line with Medicare and Cigna, who instituted an identical policy effective Aug. 18.

MORE: View the UHC bulletin announcing the policy change (PDF)

In August, several clients informed us UHC was issuing refund requests to recover 88305 payments for prostate biopsies performed on Medicare Advantage members throughout the past six months, despite the payer not previously issuing any communication about this change.

When questioned, UHC responded that their policy for prostate biopsies to be billed with G0416 has been in effect since January 2015. While this change is in line with Medicare policy, UHC had continued to pay prostate biopsies billed with 88305 until this recent communication.

These moves follow a host of aggressive policy changes UHC has instituted during the Public Health Emergency, including moves to limit out-of-network lab services and the implementation of its controversial Lab Test Registry, which is now set to launch Jan. 1 as well.

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