Daa Pangenotypic Mavyret denied for missing prior authorization 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 Requires Prior Authorization for Mavyret

Prior authorization (PA) for Mavyret (glecaprevir/pibrentasvir) is standard practice across most commercial insurers. UnitedHealthcare's medical and pharmacy policies require the prescriber to demonstrate, before the drug is dispensed, that the patient meets the plan's coverage criteria — typically based on hepatitis C diagnosis confirmation, genotype, treatment history, and liver disease staging. A PA denial usually means either that the initial request was incomplete or that UHC's criteria-matching process flagged a documentation gap rather than a genuine clinical disagreement.

## Why This Denial Is Appealable

Most PA denials for Mavyret are reversed on appeal when the medical record is presented completely. The denial is driven by what UHC received, not necessarily by what is in your chart. Gaps in submitted documentation are curable.

## Federal Appeal Framework

• Internal appeal (ERISA §503 / ACA §2719): File within the deadline on your denial letter. For employer-sponsored plans, ERISA §503 guarantees a full-and-fair review. For ACA-compliant plans, §2719 adds independent external review rights.
• Expedited appeal: If your treating physician certifies that a standard timeline would seriously jeopardize your health, you are entitled to an expedited internal and, if needed, expedited external review — often within 72 hours.
• External review window: Approximately four months from the final internal denial date under federal standards; check your state's rule, as some states shorten this window.

## Concrete Appeal Steps

1. Request UHC's full PA criteria document (the specific clinical coverage policy) in writing — UHC is required to provide it. 2. Map every criterion in that policy to the corresponding entry in your medical record before writing the appeal. 3. Have your gastroenterologist or hepatologist write a medical-necessity letter that addresses each criterion point by point. 4. Submit the internal appeal with the medical record excerpts, the prescriber letter, and any applicable specialist notes. 5. If denied internally, file for external independent review immediately.

## Documentation to Gather

• Diagnosis: hepatitis C diagnosis documentation (lab reports confirming active infection, genotype result)
• Treatment history: prior HCV treatment records with start/end dates and documented outcomes, or documentation that this is a treatment-naive case
• Liver disease staging: fibroscan, biopsy, or equivalent study showing current fibrosis or cirrhosis status
• Prescriber medical-necessity letter: addresses UHC's published PA criteria for Mavyret one by one
• Current medications list: to address any comedication or comorbidity requirements in the policy

## Criteria-Mapping Structure

Obtain UHC's current coverage/PA policy for Mavyret (available on UHC's provider portal or by written request). Create a two-column table: left column lists each stated requirement verbatim; right column cites the specific chart document, page, and date that satisfies it. This structure forces the internal reviewer to engage with the evidence rather than issuing a blanket denial.