Why UHC Denies Cardiac Catheterization
Non-invasive testing not completed first
Stress test results do not meet threshold for catheterization
Stable angina without high-risk features
Know UnitedHealthcare's Criteria
UHC uses InterQual criteria and their own Clinical UM Guidelines (CG series). Medical directors are typically accessible for P2P within 5 business days.
Key policies to know:
- Requires eviCore for MSK and advanced imaging prior auth
- Clinical UM Guidelines (CG series) are publicly available online
- Prior auth through Optum/UHG portal
- Known for strict step therapy requirements on biologics
UHC's Specific Approach to Cardiac Catheterization
Applicable Policy
UHC Clinical UM Guideline CG-CARD-15 (Cardiac Catheterization)
How UHC Typically Denies This
UHC requires a positive non-invasive stress test with specific high-risk findings or acute coronary syndrome presentation. Stable angina without high-risk stress test findings is commonly denied.
Your Strategy for This Payer
Lead with the stress test results and quantify the ischemic burden. UHC responds to ACC/AHA Appropriate Use Criteria -- if your case maps to an 'appropriate' rating, cite the specific AUC scenario number.
Key Phrase to Use on the Call
"This patient has [specific stress test findings] representing [quantified ischemic burden], which maps to ACC/AHA Appropriate Use Criteria scenario [number] rated as 'Appropriate' for diagnostic catheterization."
Building Your Medical Necessity Argument
Reference positive stress test with specific findings
Document unstable symptoms or acute coronary syndrome presentation
Note high-risk features on non-invasive testing
Cite Duke Treadmill Score or imaging results supporting catheterization
P2P Call Tips for UHC
Reference UHC's own Clinical UM Guideline number (e.g., CG-SURG-71)
UHC medical directors respond well to InterQual criteria language
Be specific about which InterQual subset applies
Have the CG policy number ready -- shows you've done your homework
Guidelines to Reference
- ACC/AHA Guidelines for Coronary Revascularization
- ACCF Appropriate Use Criteria for Coronary Cath
Relevant CPT Codes
Specialty: Cardiology
Want the full strategy?
The P2P Playbook covers payer-specific approaches for Cardiac Catheterization denied by UHC -- plus 15 denial objections with word-for-word responses, what reviewers are actually thinking, and the 60-second prep framework. Written by a medical director who reviewed cases for major payers.
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