Why UHC Denies Chemotherapy / Infusion Therapy
Regimen not first-line per NCCN guidelines
Off-label use without compendia support
Continuation after disease progression not justified
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
Building Your Medical Necessity Argument
Cite specific NCCN guideline category and recommendation level
Document prior treatment lines and responses
Reference tumor molecular markers guiding treatment selection
If off-label, cite peer-reviewed evidence or compendia listing
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
- NCCN Clinical Practice Guidelines by cancer type
- CMS Anticancer Chemotherapy NCD
Relevant CPT Codes
Specialty: Oncology
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