Why UHC Denies Colonoscopy
Screening interval not met
Prior authorization not obtained
Age does not meet screening criteria
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
Distinguish diagnostic from screening indication
Document symptoms warranting diagnostic colonoscopy
Reference family history or personal risk factors
Note positive screening test (FIT, Cologuard) requiring follow-up
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
- USPSTF Colorectal Cancer Screening Recommendations
- AGA Guidelines for Colonoscopy Surveillance
- NCCN High-Risk Screening Guidelines
Relevant CPT Codes
Specialty: Gastroenterology
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