By Counterforce Health Team in Brensocatib (BRINSUPRI) —

Denied for Brensocatib (BRINSUPRI) by UnitedHealthcare in Georgia? How to Appeal (Templates & Timelines)

Answer Box: UnitedHealthcare requires prior authorization for Brensocatib (BRINSUPRI) with likely step therapy requirements. If denied, you have 180 days to appeal internally, then 60 days for Georgia's external review. Start by gathering your denial letter, medical records, and a letter of medical necessity from your doctor. Submit appeals through UnitedHealthcare's provider portal or mail to their appeals department. Georgia's external review through the Department of Insurance is free and binding on UnitedHealthcare.

Table of Contents

Understanding Your Denial

Brensocatib (BRINSUPRI) is the first FDA-approved treatment specifically for non-cystic fibrosis bronchiectasis in adults and adolescents 12 years and older. At approximately $88,000 per year, UnitedHealthcare treats it as a specialty medication requiring prior authorization and often step therapy.

When you receive a denial, look for these key details on your Explanation of Benefits (EOB):

  • Denial code (e.g., "Prior authorization required," "Step therapy not met")
  • Date of denial (starts your appeal clock)
  • Benefit type (pharmacy vs. medical benefit)
  • Appeal instructions and deadlines

Most Brensocatib denials fall under pharmacy benefit management through OptumRx, UnitedHealthcare's pharmacy benefit manager.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before coverage UnitedHealthcare Provider Portal UHC Policy
Step Therapy Try macrolides first OptumRx clinical criteria OptumRx Guidelines
Age Requirement ≥12 years old FDA label FDA Approval
Diagnosis Confirmed NCF bronchiectasis Medical records + imaging Clinical documentation
Appeals Deadline 180 days from denial Denial letter UHC Appeals Process
External Review 60 days after final denial Georgia DOI Georgia DOI

Step-by-Step: Fastest Path to Approval

  1. Gather Documentation (Patient/Clinic)
    • Insurance card and policy details
    • Complete medical records showing NCF bronchiectasis diagnosis
    • Prior treatment history (especially macrolide trials)
    • Recent imaging (HRCT or chest CT)
    • Timeline: Immediate
  2. Submit Prior Authorization (Clinic)
  3. Prepare for Step Therapy (Clinic)
    • Document macrolide trial failures or contraindications
    • Include airway clearance technique attempts
    • Timeline: Concurrent with PA submission
  4. Request Peer-to-Peer Review (Clinic)
    • If initially denied, schedule within 1 business day
    • Prepare clinical talking points
    • Timeline: 24-48 hours after denial
  5. File Internal Appeal (Patient/Clinic)
    • Submit within 180 days of denial
    • Include letter of medical necessity
    • Timeline: 30 days for standard review
  6. External Review if Needed (Patient)
    • File with Georgia DOI within 60 days of final denial
    • Free process, binding decision
    • Timeline: 30 business days (72 hours if urgent)

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
Prior authorization not obtained Submit PA with complete clinical documentation via provider portal
Step therapy not met Document macrolide failures, contraindications, or intolerance with specific dates and outcomes
Not medically necessary Provide letter of medical necessity citing FDA approval and clinical trials (ASPEN, WILLOW)
Age restriction Confirm patient is ≥12 years old with documentation
Experimental/investigational Reference FDA approval as first approved treatment
Quantity limits exceeded Justify dosing (10mg or 25mg daily) per FDA labeling

Appeals Playbook for UnitedHealthcare in Georgia

Internal Appeals

  • Level 1: Reconsideration request
  • Level 2: Formal appeal
  • Deadline: 180 days from denial date
  • Submit via: Provider portal or mail
  • Timeline: 30 days for standard, 72 hours for urgent

External Review (Georgia)

  • When: After exhausting internal appeals
  • Deadline: 60 days from final denial
  • Cost: Free to consumer
  • Submit to: Georgia Department of Insurance
  • Timeline: 30 business days (72 hours urgent)
  • Decision: Binding on UnitedHealthcare
Note: Georgia's 60-day external review deadline is stricter than some states. Don't wait—file promptly after receiving your final internal appeal denial.

Clinician Corner: Medical Necessity Letter

A strong letter of medical necessity should include:

Patient Information

  • Demographics and policy details
  • Confirmed NCF bronchiectasis diagnosis with ICD-10 code
  • Imaging results (HRCT showing bronchiectasis)

Clinical Justification

  • Exacerbation history and frequency
  • Prior treatment failures (document specific macrolides tried, duration, outcomes)
  • Contraindications to standard therapies
  • Functional impairment and quality of life impact

Evidence Base

  • Reference FDA approval for NCF bronchiectasis
  • Cite ASPEN trial data showing reduced exacerbations
  • Include relevant clinical guidelines
  • Specify proposed dosing (10mg or 25mg daily)

Monitoring Plan

  • Regular follow-up schedule
  • Pulmonary function monitoring
  • Safety assessments per FDA labeling

Appeal Letter Templates

Patient Appeal Letter Template

[Date]
[Patient Name]
[Address]
[Policy Number]

UnitedHealthcare Appeals Department
[Address from denial letter]

Re: Appeal for Coverage of Brensocatib (BRINSUPRI)
Policy Number: [Number]
Denial Date: [Date]

Dear Appeals Review Team,

I am writing to formally appeal the denial of coverage for Brensocatib (BRINSUPRI), denied on [date] with reason code [code]. This medication is medically necessary for my non-cystic fibrosis bronchiectasis as documented by my physician.

Key Points:
• FDA-approved first-line treatment for my specific condition
• Previous macrolide therapy failed [include specific details]
• No contraindications to Brensocatib
• Meets all age and diagnostic criteria

Please find attached:
• Letter of medical necessity from Dr. [Name]
• Medical records documenting diagnosis and prior treatments
• Relevant clinical studies supporting use

I request expedited review given the progressive nature of my condition. Please contact me at [phone] with any questions.

Sincerely,
[Signature]
[Printed Name]

Provider Peer-to-Peer Script

"This is Dr. [Name] calling regarding [Patient Name], policy [number]. We're requesting coverage for Brensocatib for confirmed non-cystic fibrosis bronchiectasis. The patient has failed macrolide therapy with [specific drug] over [timeframe] with [specific outcomes]. Brensocatib is the only FDA-approved treatment for this condition, and the patient meets all criteria per the ASPEN trial inclusion parameters. Are there specific additional requirements for approval?"

When Appeals Fail: External Review in Georgia

If UnitedHealthcare upholds their denial after internal appeals, Georgia residents have powerful protection through external review.

Georgia's External Review Process:

  1. Eligibility: Must exhaust internal appeals first
  2. Timeline: 60 days from final denial letter
  3. Cost: Free to consumers
  4. Process: Independent medical review
  5. Decision: Legally binding on UnitedHealthcare

To File:

  • Complete Georgia DOI external review form
  • Include all denial letters and medical records
  • Submit via Georgia DOI portal
  • Call 1-800-656-2298 for assistance
From our advocates: "We've seen Georgia external reviews succeed when internal appeals failed, especially for rare disease medications like Brensocatib. The key is comprehensive documentation showing medical necessity and prior treatment failures. Independent reviewers often have more flexibility than internal utilization management."

Costs & Patient Assistance

With a list price around $88,000 annually, patient assistance is crucial:

Manufacturer Support

  • Insmed patient assistance programs (verify current offerings at manufacturer website)
  • Copay assistance for commercially insured patients

Foundation Grants

  • Patient Advocate Foundation
  • National Organization for Rare Disorders (NORD)
  • Disease-specific foundations

State Resources

  • Georgia's limited Medicaid expansion may cover some patients
  • Pharmaceutical assistance programs through the state

Counterforce Health helps patients navigate these complex approval processes by turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and creates customized appeals aligned to each payer's specific requirements.

FAQ

How long does UnitedHealthcare prior authorization take in Georgia? Standard PA decisions are typically made within 14 days. Urgent requests may be processed within 72 hours if clinical urgency is documented.

What if Brensocatib is not on my formulary? Request a formulary exception with your appeal. Emphasize it's the only FDA-approved treatment for your condition with no therapeutic alternatives.

Can I request an expedited appeal? Yes, if delay could seriously jeopardize your health or if you're currently hospitalized. Mark all submissions as "URGENT" and provide supporting clinical documentation.

Does step therapy apply if I failed macrolides outside Georgia? Yes, document all prior treatments regardless of where they occurred. UnitedHealthcare should accept properly documented treatment histories from any licensed provider.

What happens if external review denies coverage? External review decisions are final in the administrative process. Further options may include legal action, but this is rare and should involve legal counsel.

How do I track my appeal status? Use the UnitedHealthcare member portal or call the number on your insurance card. Keep detailed records of all communications and reference numbers.

When navigating these complex approval processes, consider partnering with Counterforce Health, which specializes in converting insurance denials into successful appeals through targeted, evidence-based strategies tailored to each payer's specific requirements.

Sources & Further Reading

This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for specific guidance. Appeal processes and requirements may change—verify current procedures with official sources before proceeding.

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