How to appeal a UnitedHealthcare thyroid eye disease (ted) — tepezza (teprotumumab) and igf-1r therapy 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 thyroid eye disease (ted) — tepezza (teprotumumab) and igf-1r therapy

Cited policy: UHC Pharmacy / Medical Benefit Drug Policy: Teprotumumab (Tepezza)

Diagnosis of TED with EUGOGO moderate-to-severe activity; commonly requires CAS ≥3 (often ≥4 in stricter PA), Hertel proptosis ≥3 mm above normal, prior or contraindicated IV methylprednisolone trial; euthyroid status; baseline audiogram and glucose monitoring per FDA label.

How UnitedHealthcare denies thyroid eye disease (ted) — tepezza (teprotumumab) and igf-1r therapy — and how to counter it

Where UnitedHealthcare pushes back: 1) CAS criterion not met (<3 or <4); 2) Disease classified as chronic-stable / >16 mo from onset; 3) Prior IV steroid trial not documented; 4) Hearing baseline not on file.

Counter-arguments that hold up: Cite Kahaly Lancet Diabetes Endocrinol 2021 pooled efficacy across CAS strata including CAS 1-2. For chronic-stable disease cite Ugradar Ophthalmology 2022 — meaningful proptosis reduction in disease >16 mo; FDA label is not restricted to active phase. Submit EUGOGO methylpred log with cumulative dose and CAS / proptosis response, or document contraindication (active hepatitis, uncontrolled DM). Submit baseline audiogram and glucose / A1c. Cite OPTIC (Douglas NEJM 2020) primary endpoint.

What UnitedHealthcare typically denies for thyroid eye disease (ted) — tepezza (teprotumumab) and igf-1r therapy

Across UnitedHealthcare's commercial and Medicare books, denials cluster around a small number of patterns. For thyroid eye disease (ted) — tepezza (teprotumumab) and igf-1r therapy, 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 thyroid eye disease (ted) — tepezza (teprotumumab) and igf-1r therapy treatments most often flagged for prior auth, step therapy, or medical necessity review:

• Tepezza standard course
• Tepezza re-treatment
• Tepezza chronic-stable
• IV methylprednisolone
• Oral prednisone
• Orbital radiotherapy

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.