How to appeal a UnitedHealthcare hepatitis c cures denial

The framework that applies to your appeal

Federal law gives you the right to a full and fair internal appeal, then an external review by an independent third party.

UnitedHealthcare-specific note: UHC's parent UnitedHealth Group owns Optum (PBM Optum Rx) and Surest. Surest plans have different cost-sharing rules. State complaints flow to state insurance department + DOL/EBSA for self-funded.

What UnitedHealthcare's policy requires for hepatitis c cures

Cited policy: OptumRx Hepatitis C Direct-Acting Antivirals Prior Authorization

Confirmed chronic HCV (RNA+); genotype; fibrosis assessment; prescriber attestation; 8-wk Mavyret approved in TN non-cirrhotic per FDA label.

How UnitedHealthcare denies hepatitis c cures — and how to counter it

Where UnitedHealthcare pushes back: 1) Step therapy through Harvoni/Zepatier before Mavyret/Epclusa; 2) Specialist (GI/hepatology/ID) prescriber required; 3) Insufficient fibrosis (F0-F1).

Counter-arguments that hold up: AASLD/IDSA lists Mavyret + Epclusa as PREFERRED first-line pangenotypic — older GT-specific regimens are no longer first-line. Step therapy through off-guidance regimens is medically inappropriate. AASLD verbatim: 'Clinicians with experience treating HCV — including primary care providers, advanced practice providers, and specialists — can effectively manage uncomplicated HCV.' AASLD: treatment recommended for ALL regardless of fibrosis stage.

What UnitedHealthcare typically denies for hepatitis c cures

Across UnitedHealthcare's commercial and Medicare books, denials cluster around a small number of patterns. For hepatitis c cures, expect:

• GLP-1 weight-loss exclusion
• Out-of-network reduction citing UCR
• Step therapy on biologics
• Prior auth denied for advanced imaging
• Quantity limits on specialty drugs

Treatments most often denied in this category

These are the hepatitis c cures treatments most often flagged for prior auth, step therapy, or medical necessity review:

• Mavyret 8wk
• Mavyret 12-16wk
• Epclusa 12wk
• Epclusa+RBV
• Vosevi
• Harvoni

How to submit the appeal to UnitedHealthcare

1. Read the denial letter — note the exact denial reason code and the appeal deadline (180 days from the date on the letter).
2. Gather supporting documentation: physician letter of medical necessity, relevant clinical notes, peer-reviewed citations supporting the treatment for your indication, and the policy or coverage document UnitedHealthcare cited in the denial.
3. File the appeal through UnitedHealthcare's portal (members: https://www.myuhc.com ; providers: https://www.uhcprovider.com). Standard decision returns within 30 days; expedited urgent appeals return within 72 hours.
4. If denied again, request external review by an independent reviewer within 4 months of the final internal denial. In MN, the state insurance department coordinates external review for fully-insured plans; ERISA self-funded plans use a federal external review through DOL/EBSA.

Clinician or prior-auth team handling this on the practice side? See UnitedHealthcare's prior-authorization criteria by drug: UnitedHealthcare PA criteria on ApprovalHelp.