Rezdiffra Nash denied as not medically necessary by UnitedHealthcare?

UnitedHealthcare's specific coverage criteria for rezdiffra nash 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 Denies Rezdiffra for NASH as Not Medically Necessary — and Why You Can Appeal

UnitedHealthcare's medical necessity denials for Rezdiffra (resmetirom) typically occur because the clinical record submitted with the prior authorization request did not clearly establish that the patient meets each criterion in UHC's coverage policy — most commonly around the confirmed fibrosis stage, the absence of decompensated cirrhosis (per the prescribing label's approved population), or the failure to document the patient's metabolic comorbidities. These are documentation gaps, not clinical failures, and they are correctable on appeal.

Rezdiffra is the first and currently only FDA-approved pharmacologic treatment specifically for MASH with moderate-to-advanced liver fibrosis, supported by the applicable AASLD (American Association for the Study of Liver Diseases) guidelines. A thorough appeal anchored in objective fibrosis staging and a structured medical-necessity letter is highly likely to succeed.

## Federal Appeal Framework

• Internal appeal: File within 180 days of the denial. UHC must decide within 30 days (pre-service) or 60 days (post-service).
• Expedited review: Available if the standard timeline would seriously jeopardize the patient's health; response required within 72 hours.
• External review (ACA §2719): After a final internal denial, you have approximately four months to request an independent external review. An IRO reversal is binding on UHC.
• ERISA §503: For self-funded employer plans, request the complete administrative file and invoke full-and-fair review rights.

## Documentation to Gather

• Fibrosis staging: Liver biopsy pathology report (preferred) or validated non-invasive staging results (e.g., FIB-4 index, transient elastography/FibroScan) clearly indicating the fibrosis stage. Confirm this stage falls within Rezdiffra's FDA-approved indication as stated in the prescribing label.
• MASH diagnosis confirmation: Histologic or clinical confirmation of metabolic dysfunction-associated steatohepatitis, including documentation of the relevant metabolic risk factors.
• Absence of exclusion criteria: Chart documentation confirming the patient does not have characteristics that fall outside the approved indication; obtain this directly from the FDA prescribing label.
• Prior metabolic management: A timeline of lifestyle interventions, dietary modifications, and any prior pharmacologic management attempted for the underlying metabolic condition, with outcomes.
• Prescriber medical-necessity letter: A detailed letter from the hepatologist or gastroenterologist mapping each of UHC's coverage criteria to specific chart findings, citing the FDA label and applicable AASLD guidance.

## Criteria-Mapping Structure

Download UHC's current coverage policy for Rezdiffra from UHC's medical policy portal. Copy every listed criterion into a two-column table. In the right column, enter the exact chart finding — note date, author, and value — that satisfies each criterion. Flag any criterion for which the current documentation is incomplete and obtain supplemental documentation before submission. This explicit mapping is the single most persuasive element of a medical-necessity appeal.