Rezdiffra Nash denied for missing prior authorization 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 Requires Prior Authorization for Rezdiffra for NASH — and How to Navigate It

Rezdiffra (resmetirom) is a specialty hepatology medication that UnitedHealthcare places on a tier requiring prior authorization (PA). A prior-auth-required denial does not mean UHC has concluded the drug is inappropriate — it means the clinical documentation package needed to unlock coverage was not submitted, or was submitted with gaps that prevented approval. This is the most procedurally correctable type of denial.

Understanding exactly which criteria UHC requires — and assembling documentation that addresses every one of them before resubmitting — is the key to converting a PA denial into an approval, often without needing to escalate to a formal internal appeal.

## Federal Appeal Framework

• Resubmission vs. appeal: If the denial was a PA denial for missing documentation, resubmitting with a complete package is often faster than a formal appeal. Confirm with UHC whether a resubmission or an appeal is the correct pathway.
• Internal appeal: If the complete package is denied, file a formal appeal within 180 days. UHC must respond within 30 days (pre-service).
• Expedited review: If the standard timeline would seriously jeopardize the patient's health (e.g., rapidly advancing fibrosis), request expedited processing — UHC must respond within 72 hours.
• External review (ACA §2719): After a final internal denial, you have approximately four months to request independent external review. An IRO reversal is binding.
• ERISA §503: For self-funded employer plans, request the complete administrative file and invoke full-and-fair review rights.

## Documentation to Gather

• UHC's PA criteria: Download UHC's current prior authorization criteria for Rezdiffra from the UHC provider portal or request them by phone. Read every criterion before assembling documents.
• Confirmed MASH diagnosis and fibrosis stage: Liver biopsy pathology report (preferred) or validated non-invasive fibrosis staging (FIB-4, elastography) confirming the fibrosis stage falls within Rezdiffra's FDA-approved indication per the prescribing label.
• Metabolic comorbidity documentation: Chart documentation of the metabolic risk factors associated with MASH (documented per the prescribing label's patient population description).
• Prior treatment history: A timeline of lifestyle interventions and any prior pharmacologic management, with dates and clinical outcomes.
• Prescriber medical-necessity letter: A structured letter from the hepatologist or gastroenterologist that addresses each PA criterion by name, cites the applicable AASLD guidance, and references the FDA-approved prescribing label.

## Criteria-Mapping Structure

List every criterion from UHC's PA requirements for Rezdiffra in a table. For each criterion, identify the specific document and chart entry that satisfies it. Submit the table as a cover sheet to the PA package so the reviewer can confirm compliance at a glance. A well-mapped PA submission is approved at a significantly higher rate than a narrative-only letter — and, if denied, the same table becomes the backbone of a formal appeal.