By Counterforce Health Team in Synagis (palivizumab) —

Denied for Synagis (Palivizumab) by UnitedHealthcare in Ohio? Complete Appeals Guide (Templates & Timelines)

Answer Box: Getting Synagis Covered by UnitedHealthcare in Ohio

UnitedHealthcare requires prior authorization for Synagis (palivizumab) with strict eligibility criteria: premature infants ≤35 weeks gestation and <6 months old, or children <24 months with chronic lung disease/congenital heart disease. If denied, you have 180 days to appeal internally, then can request external review through Ohio Department of Insurance within 180 days of final denial. First step today: gather birth certificate, NICU discharge summary, and specialist notes, then submit a complete medical necessity letter addressing UnitedHealthcare's specific criteria. Call Ohio DOI at 1-800-686-1526 for appeal guidance.

Table of Contents

  1. Reading Your Denial Letter
  2. Common Fixable Causes
  3. First-Level Appeal Strategy
  4. Peer-to-Peer Review Process
  5. Second-Level & External Review in Ohio
  6. Appeal Letter Templates
  7. Tracking Your Case
  8. Boosting Your Win Rate
  9. If Your Appeal Fails
  10. FAQ

Reading Your Denial Letter

Your UnitedHealthcare denial letter contains critical information for your appeal. Look for these key elements:

Denial Reason Codes:

  • Medical necessity not established - Most common for Synagis
  • Prior authorization required - Submit PA request first
  • Step therapy required - Must try Beyfortus (nirsevimab) first
  • Outside coverage criteria - Patient doesn't meet high-risk requirements

Critical Deadlines:

  • Internal appeals: 180 days from denial date
  • Expedited appeals: Available for urgent cases (≤72 hours)
  • External review: 180 days from final internal denial
Tip: UnitedHealthcare processes Synagis through OptumRx. Check if your denial came from the medical or pharmacy benefit, as this affects your appeal pathway.

Common Fixable Causes

Many Synagis denials can be overturned by addressing these common issues:

Denial Reason Quick Fix Documentation Needed
Missing gestational age Submit birth certificate Hospital birth certificate showing ≤35 weeks
Insufficient risk documentation Get specialist letter Cardiology/pulmonology notes confirming ongoing risk
Wrong diagnosis codes Correct ICD-10 codes Updated prescription with proper diagnostic codes
Age eligibility unclear Clarify current age Documentation showing age at RSV season start
Beyfortus not tried first Document contraindication Letter explaining why Beyfortus inappropriate

Most Successful Fix: Complete documentation package submitted with initial PA request prevents 70% of denials.

First-Level Appeal Strategy

UnitedHealthcare's Synagis Coverage Criteria (2024)

Your appeal must demonstrate your child meets these specific requirements:

Eligible Conditions:

  • Premature birth: ≤35 weeks gestation AND <6 months old at RSV season start
  • Chronic lung disease: Bronchopulmonary dysplasia requiring oxygen/medications AND <24 months old
  • Congenital heart disease: Hemodynamically significant defect AND <24 months old

Required Documentation:

  1. Birth certificate with gestational age
  2. NICU discharge summary
  3. Current prescription with proper dosing
  4. Specialist consultation notes
  5. Evidence of ongoing medical need

Medical Necessity Letter Structure

Your letter should address these points in order:

  1. Patient identification and diagnosis
  2. Specific high-risk criteria met
  3. Prior therapy failures or contraindications
  4. Clinical rationale for Synagis vs. alternatives
  5. Dosing plan and monitoring
  6. Supporting medical literature
Note: UnitedHealthcare now requires documentation of why Beyfortus (nirsevimab) isn't appropriate before approving Synagis, given cost differences.

Peer-to-Peer Review Process

If your initial appeal is denied, request a peer-to-peer review within 14 days. This connects your doctor directly with UnitedHealthcare's medical director.

Scheduling Your P2P Call

For providers:

  • Call UnitedHealthcare provider services
  • Request P2P for case ID [your case number]
  • Must be completed within one business day of request
  • Reviewing physician must have pediatric expertise

P2P Talking Points Checklist

Before the call, prepare:

  • Patient's exact gestational age and current age
  • Specific high-risk criteria met
  • Documentation of Beyfortus contraindication/failure
  • Recent specialist evaluations
  • RSV season timeline in Ohio (typically October-March)

During the call, emphasize:

  • Alignment with AAP guidelines
  • Patient's specific risk factors
  • Cost-effectiveness of prevention vs. hospitalization
  • Timeline urgency for RSV season

Second-Level & External Review in Ohio

If UnitedHealthcare upholds their denial after internal appeals, Ohio residents can request external review through the Ohio Department of Insurance.

Ohio External Review Process

Eligibility Requirements:

  • Completed all internal appeals with UnitedHealthcare
  • Request within 180 days of final denial
  • Involves medical necessity or coverage determination

Review Types:

  • Standard review: 30 days
  • Expedited review: 72 hours (requires physician certification of urgency)

How to Request:

  1. Call Ohio DOI Consumer Hotline: 1-800-686-1526
  2. Submit written request with all documentation
  3. ODI assigns Independent Review Organization (IRO)
  4. IRO decision is binding on UnitedHealthcare
Ohio Advantage: Even if UnitedHealthcare claims your case isn't eligible for external review, Ohio DOI can independently determine eligibility and order review.

Required Documents for External Review

  • All UnitedHealthcare denial letters
  • Complete medical records
  • Physician letters of medical necessity
  • Insurance policy information
  • Birth certificate and specialist notes

Appeal Letter Templates

Template: First-Level Appeal Letter

[Date]

UnitedHealthcare Appeals Department
[Address from denial letter]

Re: Appeal for Synagis (Palivizumab) Denial
Member: [Patient Name], DOB: [Date]
Member ID: [ID Number]
Case/Reference Number: [If provided]

Dear Appeals Coordinator:

I am formally appealing the denial of Synagis (palivizumab) for [patient name], who meets UnitedHealthcare's established criteria for RSV prophylaxis in high-risk pediatric patients.

PATIENT QUALIFIES UNDER THESE CRITERIA:
[Check applicable box and provide details]
☐ Premature birth ≤35 weeks gestation, currently <6 months old
☐ Chronic lung disease (BPD) with ongoing treatment, <24 months old  
☐ Hemodynamically significant congenital heart disease, <24 months old

CLINICAL DOCUMENTATION ATTACHED:
- Birth certificate confirming [XX] weeks gestational age
- NICU discharge summary detailing [condition]
- Current Synagis prescription with dosing
- [Cardiology/Pulmonology] consultation confirming ongoing risk
- Documentation of Beyfortus contraindication: [reason]

MEDICAL NECESSITY JUSTIFICATION:
[Patient name] requires Synagis prophylaxis due to [specific risk factors]. The attached specialist evaluation confirms [ongoing medical condition requiring prophylaxis]. Per UnitedHealthcare's own policy and AAP guidelines, this patient meets criteria for coverage.

I request immediate reconsideration and approval of this medically necessary treatment. Please contact me at [phone] for any additional information needed.

Respectfully,
[Physician Name and Credentials]
[Practice Name]
[Contact Information]

Template: Peer-to-Peer Request Script

For clinic staff calling UnitedHealthcare:

"I'm calling to request a peer-to-peer review for a Synagis denial. Case ID [number]. Our patient is a [age] month old with [condition] who meets your coverage criteria. The denial appears to be based on [reason], but we have complete documentation. Can we schedule a P2P within 24 hours as required?"

Tracking Your Case

Appeal Timeline Tracker

Step Deadline Status Next Action
Submit first appeal 180 days from denial ☐ Complete Submit to UHC appeals
Request P2P if denied 14 days from denial ☐ Complete Call provider services
File external review 180 days from final denial ☐ Complete Contact Ohio DOI

When to Escalate to Ohio Regulators

Contact Ohio Department of Insurance if:

  • UnitedHealthcare misses appeal deadlines
  • You're told external review isn't available
  • Procedural violations occur during review

Ohio DOI Consumer Hotline: 1-800-686-1526

Boosting Your Win Rate

Evidence-Based Success Strategies

Most Effective Documentation:

  1. Specialist letters confirming ongoing high-risk status
  2. Gestational age verification via hospital records
  3. Beyfortus contraindication documentation
  4. AAP guideline citations supporting coverage

Common Win Scenarios:

  • Premature infants with documented chronic lung disease
  • Congenital heart disease with cardiology support
  • Clear contraindication to first-line Beyfortus
From Our Advocates: We've seen families succeed by getting their pediatric cardiologist to write a detailed letter explaining why their child's specific heart condition makes RSV prevention critical, even when the initial pediatrician's note was too general. The specialist's expertise often carries more weight with medical directors.

Guideline Citations to Include

  • FDA labeling for Synagis high-risk criteria
  • American Academy of Pediatrics RSV prevention guidelines
  • UnitedHealthcare's own policy language supporting coverage

If Your Appeal Fails

Alternative Coverage Options

Manufacturer Support:

  • Sobi Patient Support Program may offer copay assistance
  • Income-based patient assistance programs available

State Resources:

  • Ohio Medicaid may have different criteria
  • Children with Special Health Care Needs program

Clinical Alternatives:

  • Beyfortus (nirsevimab) if appropriate for patient
  • Enhanced monitoring during RSV season
  • Prophylactic measures and early intervention protocols
  • File complaint with Ohio Department of Insurance
  • Contact state insurance commissioner
  • Consider healthcare attorney consultation for complex cases

FAQ

How long does UnitedHealthcare prior authorization take in Ohio? Standard PA decisions within 72 hours for non-urgent requests, 24 hours for urgent cases. Appeals take 30 days for standard review.

What if Synagis is non-formulary on my plan? Request formulary exception with medical necessity documentation. Non-formulary doesn't mean non-covered if medically necessary.

Can I request expedited appeal for Synagis? Yes, if delay would seriously jeopardize health. Requires physician certification of urgency. Decision within 72 hours.

Does step therapy apply if we tried Beyfortus outside Ohio? Previous therapy trials from other states count. Include documentation of prior Beyfortus trial/failure.

What happens if I miss the appeal deadline? Contact Ohio DOI immediately. They may still accept late appeals in certain circumstances or help you understand options.

How much does Synagis cost without insurance? Approximately $1,820 per 50mg vial (2025 pricing). Typical course requires 3-5 doses depending on RSV season length.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals through evidence-based, targeted rebuttals. Our platform analyzes denial letters, identifies specific denial reasons, and drafts point-by-point appeals aligned with each payer's own policies, pulling the right clinical evidence and procedural requirements to maximize approval rates.

For more complex cases or when multiple appeals have failed, Counterforce Health can help identify the specific gaps in your documentation and craft appeals that address UnitedHealthcare's exact coverage criteria for Synagis.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal procedures may change. Always verify current requirements with UnitedHealthcare and Ohio Department of Insurance. Consult healthcare providers for medical decisions and consider legal counsel for complex insurance disputes.

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