Prolia denied for missing prior authorization by UnitedHealthcare?

UnitedHealthcare's specific coverage criteria for prolia 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 Prolia

UHC routinely requires prior authorization (PA) for Prolia (denosumab) because it is a specialty injectable with specific clinical criteria attached. A "prior-auth-required" denial typically means either (a) no PA was obtained before the prescription was dispensed or administered, or (b) a PA request was submitted but did not include sufficient documentation to satisfy UHC's medical-necessity criteria. The denial is not a judgment that Prolia is wrong for your patient — it is a procedural gate that can be opened with the right documentation.

## Your Federal Appeal Rights

Under ACA §2719 and ERISA §503, you have a right to both internal and independent external review:

• Urgent/concurrent care: If you are currently receiving Prolia injections, you may qualify for a concurrent care continuation — UHC generally cannot terminate ongoing treatment without advance notice and an appeal opportunity.
• Expedited review: Request this in writing if a standard timeline would seriously jeopardize bone health or fracture risk management.
• External review window: Approximately four months after the final internal denial; the denial letter must provide the exact deadline.

## The Appeal Process

1. Obtain UHC's current published Prolia coverage policy (available at uhcprovider.com) — this lists every criterion the PA reviewer will apply. 2. Have your prescriber document each criterion in a structured medical-necessity letter, citing specific chart dates and clinical findings (no need for you to state numbers here — the prescriber's chart should do that). 3. Resubmit the PA, or file a formal written internal appeal, within the deadline shown on the denial letter. 4. If the internal appeal fails, request external review immediately — an independent review organization will re-examine the clinical evidence without deference to UHC's initial decision.

## Documentation to Gather

• Diagnosis confirmation: Current chart notes with a diagnosis that matches an FDA-approved Prolia indication.
• Prior-treatment history: Dates, agents used, and documented outcomes for any bone-loss therapies tried before Prolia was prescribed — UHC's policy may require a step-therapy sequence.
• Clinical severity: DXA scan reports, fracture history, and any specialist assessment of fracture risk documented in the chart.
• Prescriber medical-necessity letter: Explicitly addresses each criterion in UHC's coverage policy with chart-sourced evidence.
• FDA prescribing label: Confirms the indication is approved and the proposed use falls within labeled parameters.

## Criteria-Mapping Structure

Print UHC's coverage policy. For each numbered criterion, write the corresponding chart fact beside it. Submit this as an exhibit so the reviewer can check each box without hunting through narrative. Any criterion the reviewer cannot check is the one to address in the appeal letter — acknowledge it, provide the missing evidence, or argue why the policy language does not require it.