IgA Tarpeyo denied for missing prior authorization by UnitedHealthcare?

UnitedHealthcare's specific coverage criteria for iga tarpeyo 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 UHC Requires Prior Authorization for Tarpeyo — and What to Do When It's Denied

UnitedHealthcare requires prior authorization (PA) for Tarpeyo (budesonide delayed-release capsules for IgA nephropathy) as a specialty medication with defined coverage criteria. A PA denial — as distinct from a PA requirement — means that a reviewer examined the submitted clinical information and concluded it did not satisfy one or more criteria in UHC's coverage policy. The most common failure points are: insufficient documentation of disease severity, a missing prior-treatment history, or a prescriber attestation that doesn't directly address each criterion.

Understanding which specific criterion was unmet is essential before you appeal. Under federal rules, UHC must tell you which criteria were applied and how your submission fell short.

## Your Federal Appeal Rights

• ACA §2719 / ERISA §503: A PA denial is an adverse benefit determination subject to the full internal-appeal and external-review framework. You do not need to wait for a claim denial — a PA denial triggers appeal rights immediately.
• Right to criteria: Request UHC's clinical coverage criteria for Tarpeyo in writing. These must be provided under ERISA and ACA disclosure rules.
• Timeline: File your internal appeal within 180 days of the adverse PA determination. External review is available for approximately four months after exhausting internal remedies. If your nephrologist certifies that a standard appeal timeline poses a serious risk of harm to your kidney function, request expedited review — a decision within 72 hours.
• Peer-to-peer option: Before filing a formal appeal, ask your nephrologist to request a peer-to-peer call with the UHC medical reviewer. Many PA denials are reversed at this stage without a formal appeal.

## Documentation to Gather Before You Appeal

1. Complete diagnosis workup — biopsy or pathology report confirming primary IgA nephropathy; all nephrology visit notes documenting the clinical course. 2. Disease-severity evidence — laboratory results showing kidney-function markers and proteinuria over time; chart notes documenting the clinical trajectory. 3. Supportive care documentation — records demonstrating that background supportive therapies have been optimized, with dates and documented outcomes. 4. Prior-treatment history — a complete, dated list of all relevant prior treatments with outcomes and reasons for change. 5. Prescriber PA letter — your nephrologist should write a letter that addresses each of UHC's stated PA criteria by number, citing specific chart findings for each. Generic letters that do not map to criteria are frequently rejected. 6. FDA prescribing label — confirm that the prescribed use matches the approved indication; attach as an exhibit.

## Criteria-Mapping Structure

Obtain UHC's PA coverage policy and list each criterion in a numbered table. In the adjacent column, write the specific chart fact or document that satisfies that criterion. Your nephrologist's letter should mirror this table structure. A reviewer should be able to tick off each criterion without searching for the evidence.