How to appeal a UnitedHealthcare liver (non-hcv) — nash/mash, pbc, aih, wilson 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 liver (non-hcv) — nash/mash, pbc, aih, wilson

Cited policy: OptumRx Prior Authorization — Rezdiffra (Resmetirom) for NASH/MASH

F2-F3 fibrosis (biopsy or NIT — FibroScan + FIB-4). Excludes F4 cirrhosis. Cardiometabolic risk factor. Hepatologist Rx.

How UnitedHealthcare denies liver (non-hcv) — nash/mash, pbc, aih, wilson — and how to counter it

Where UnitedHealthcare pushes back: 1) F2/F3 staging documentation request; 2) Lifestyle intervention not documented; 3) F4 cirrhosis flagged.

Counter-arguments that hold up: Submit FibroScan VCTE (kPa) + FIB-4 combination. Document lifestyle intervention >=6 months with weight loss. Distinguish F3 from F4: imaging without portal HTN signs, platelet >150K, FibroScan <15 kPa, no varices on EGD. MAESTRO-NASH NEJM 2024 + AASLD 2023 + 2024 addendum.

What UnitedHealthcare typically denies for liver (non-hcv) — nash/mash, pbc, aih, wilson

Across UnitedHealthcare's commercial and Medicare books, denials cluster around a small number of patterns. For liver (non-hcv) — nash/mash, pbc, aih, wilson, 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 liver (non-hcv) — nash/mash, pbc, aih, wilson treatments most often flagged for prior auth, step therapy, or medical necessity review:

• Rezdiffra (NASH)
• Ocaliva
• Iqirvo
• Livdelzi
• UDCA
• Xifaxan + lactulose

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.