Why UHC Denies Inpatient Rehabilitation Facility (IRF)
Patient does not require 3 hours/day therapy intensity
Skilled nursing facility is appropriate alternative
Medical complexity does not warrant IRF level
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 ability to participate in 3+ hours/day of therapy
List qualifying diagnoses under the 60% rule
Note medical complexity requiring physician supervision
Explain why SNF level is insufficient for this patient
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
- CMS IRF Coverage Requirements (60% Rule)
- InterQual Criteria for Rehabilitation Facility Admission
Relevant CPT Codes
Specialty: Physical Medicine & Rehabilitation
Want the full strategy?
The P2P Playbook covers payer-specific approaches for Inpatient Rehabilitation Facility (IRF) 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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