Daa Pangenotypic Mavyret denied as not medically necessary by UnitedHealthcare?

UnitedHealthcare's specific coverage criteria for daa pangenotypic mavyret are defined in its own published medical/coverage policy and the FDA-approved prescribing label. A successful appeal documents that your medical records satisfy each criterion those sources list — confirmed diagnosis, any required prior treatments (with dates and outcomes), and clinical severity. If the exact criteria weren't included with your denial, request them in writing; your appeal then maps each requirement to the matching fact in your chart.

## Why UnitedHealthcare Denies Mavyret on Medical-Necessity Grounds

UnitedHealthcare's (UHC) medical-necessity reviews for hepatitis C direct-acting antivirals like Mavyret (glecaprevir/pibrentasvir) evaluate whether the submitted clinical record satisfies each criterion in UHC's current HCV DAA coverage determination policy. Denials commonly occur when genotype confirmation is missing from the PA submission, when liver disease severity is not explicitly documented, when prior-treatment history is absent or ambiguous, or when the prescriber's letter does not address the specific criteria UHC applies.

The denial does not mean your prescriber's clinical judgment is wrong — it means UHC's reviewer could not confirm every required criterion from the documentation provided.

## Why This Denial Is Appealable

HCV is a curable, progressive disease. Mavyret is FDA-approved for the indication at issue. A medical-necessity denial that does not account for documented clinical evidence is subject to reversal at both the internal and external review levels, particularly when a complete, criterion-matched record is submitted.

## Federal Appeal Framework

• ACA §2719 / ERISA §503: Non-grandfathered plans must provide full-and-fair internal review followed by independent external review.
• Timeline: Internal appeal must generally be filed within 180 days of the denial notice. External review must generally be requested within 4 months of an internal denial.
• Expedited option: If delay would seriously jeopardize your health, expedited review is available; decisions typically required within 72 hours.

## The Appeal Process

1. Request UHC's complete clinical rationale for the denial, including the specific criteria not met. 2. Obtain UHC's current coverage determination policy for HCV DAAs — available on UHC's provider portal. 3. Have your prescriber write a medical-necessity letter that addresses each criterion in UHC's policy by name, citing the exact chart finding that satisfies it. 4. Request a peer-to-peer review between your prescriber and UHC's medical director; this is your prescriber's right and often resolves medical-necessity denials without a formal written appeal. 5. Submit the internal appeal with the complete clinical package. 6. If denied, escalate to independent external review.

## Documentation to Gather

• HCV diagnosis and genotype: Current lab results confirming active infection and the specific genotype.
• Liver disease severity: Fibrosis or cirrhosis staging from biopsy, elastography, or validated scoring, as recorded in the chart.
• Prior-treatment history: Dates, regimens, response, and reasons for discontinuation of any prior HCV therapy — or explicit documentation of treatment-naive status.
• Comorbidities affecting regimen selection: Chart documentation of renal function, HIV co-infection, concurrent medications, or other factors that informed the prescriber's choice of Mavyret, per the FDA prescribing label.
• Prescriber medical-necessity letter: Addresses UHC's published criteria point by point, with specific chart citations.

## Criteria-Mapping Structure

Create a two-column table. Left column: copy each requirement from UHC's published HCV DAA coverage policy and from the FDA-approved Mavyret prescribing label. Right column: cite the exact chart fact, date, and source document satisfying each requirement. Submit this table as the core of your appeal — it demonstrates a complete, evidence-based response to every basis for the denial.