Why UHC Denies Genetic / Genomic Testing
Test not considered medically necessary for this diagnosis
Does not meet hereditary cancer testing criteria
Results will not change treatment plan
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
Document how test results will directly change management
Meet NCCN testing criteria (family history, age, tumor type)
Reference specific actionable mutations being tested
Note FDA-approved companion diagnostics if applicable
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 Genetic/Familial High-Risk Assessment Guidelines
- CMS NCD for Next Generation Sequencing
Relevant CPT Codes
Specialty: Oncology / Medical Genetics
Want the full strategy?
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