By Counterforce Health Team in Tecentriq (atezolizumab) —

Denied Tecentriq (atezolizumab) by UnitedHealthcare in Illinois? Complete Appeal Guide (2025 Forms & Timelines)

Answer Box: Getting Tecentriq (atezolizumab) Covered by UnitedHealthcare in Illinois

Fastest path to approval: Submit prior authorization through UnitedHealthcare's provider portal with oncologist specialty, PD-L1 test results (≥50% tumor cells or ≥10% immune cells for NSCLC), and NCCN guideline support. If denied, request peer-to-peer review within 180 days—85% success rate with strong clinical documentation. Illinois residents have 4 months for external review through the Illinois Department of Insurance if internal appeals fail.

Start today: Call UnitedHealthcare at 866-889-8054 to check PA status or file at UHCprovider.com.

Table of Contents

Understanding Your Denial Letter

When UnitedHealthcare denies Tecentriq (atezolizumab), the denial letter contains critical information that determines your next steps. Look for these key elements:

Denial Reason Codes:

  • Medical necessity not established - Missing clinical documentation or biomarker testing
  • Step therapy required - Need to try other treatments first (rare for Tecentriq)
  • Non-formulary - Drug not on your plan's covered list
  • Quantity limits exceeded - Dosing frequency or amount restrictions
  • Site of care restrictions - Must be administered in specific settings

Critical Deadlines:

  • Internal appeal: 180 days from denial date
  • External review: 4 months from final internal denial (Illinois-specific)
  • Expedited appeals: Available for urgent oncology cases
Tip: Document everything. Keep copies of denial letters, EOBs, and all correspondence. Illinois law requires insurers to provide specific denial reasons and appeal instructions.

UnitedHealthcare PA Requirements for Tecentriq

UnitedHealthcare requires prior authorization for Tecentriq through OptumRx, with specific clinical criteria that must be met:

Coverage Requirements Table

Requirement Details Documentation Needed
Prescriber Oncologist or hematologist-oncologist Board certification verification
PD-L1 Testing ≥50% tumor cells OR ≥10% immune cells (NSCLC) FDA-approved test results
Biomarker Status EGFR/ALK negative (NSCLC) Molecular testing report
Prior Therapy Document failures/contraindications Treatment history, adverse events
Diagnosis Specific FDA-approved indications Pathology report, staging

Medical Necessity Criteria by Indication

Metastatic NSCLC (First-line):

  • PD-L1 expression ≥50% tumor cells OR ≥10% tumor-infiltrating immune cells
  • No EGFR exon 19 deletion or exon 21 L858R mutations
  • No ALK rearrangements
  • ECOG performance status 0-2

Hepatocellular Carcinoma:

  • Unresectable or metastatic disease
  • Prior sorafenib failure or contraindication
  • Child-Pugh Class A or B
  • Combination with bevacizumab required

Urothelial Carcinoma:

  • Cisplatin-ineligible patients
  • PD-L1 ≥5% on tumor-infiltrating immune cells
  • Locally advanced or metastatic disease
Note: Submit renewals 6+ weeks before current authorization expires. UnitedHealthcare typically approves for 6-12 months initially.

Step-by-Step Appeal Process

Level 1: Internal Appeal (Standard Process)

1. Gather Required Documents (Day 1-3)

  • Complete denial letter with reason codes
  • Insurance card and policy information
  • Prescriber's medical necessity letter
  • Clinical notes from last 3 months
  • Lab results and imaging reports
  • Prior therapy documentation

2. Submit Internal Appeal (Day 4-7)

  • Online: UnitedHealthcare provider portal
  • Phone: 866-889-8054 (providers) or number on insurance card
  • Mail: Address specified in denial letter
  • Timeline: 15 business days for standard review, 72 hours for expedited

3. Medical Necessity Letter Components Your oncologist's letter should include:

  • Patient demographics and diagnosis with ICD-10 codes
  • Disease staging and progression status
  • PD-L1 and biomarker test results with dates
  • Prior treatment history and outcomes
  • Contraindications to alternative therapies
  • NCCN guideline references supporting Tecentriq use
  • Proposed dosing schedule and monitoring plan

Level 2: Expedited Review for Urgent Cases

Illinois residents can request expedited appeals when delays would seriously jeopardize health:

  • Timeline: 24-72 hours for decision
  • Eligibility: Active cancer treatment, disease progression
  • Required: Physician certification of urgency
  • Submit: Same methods as standard appeal with "EXPEDITED" notation

Peer-to-Peer Review Strategy

Peer-to-peer reviews have an 85% success rate for oncology appeals when properly prepared. Here's how to maximize your chances:

Scheduling the Call

  • Request immediately after denial via provider portal
  • Available Monday-Friday, typically 8 AM-5 PM
  • UnitedHealthcare medical director will call your oncologist
  • Prepare 15-20 minutes for discussion

Preparation Checklist for Your Oncologist

Clinical Evidence to Have Ready:

  • Recent imaging showing disease status
  • RECIST criteria measurements
  • Tumor markers and trends
  • ECOG performance status
  • Safety labs (CBC, CMP, LFTs)
  • Prior therapy timeline with specific outcomes

Talking Points Script: "This patient has [specific diagnosis] with PD-L1 expression of [%]. They've progressed on [prior therapies] with documented [specific adverse events/failures]. NCCN guidelines recommend Tecentriq as [line of therapy] for this indication. The patient has excellent performance status and no contraindications to treatment."

Common Objections and Responses

UHC Objection Clinical Response
"Try pembrolizumab first" "Patient had hypersensitivity reaction to pembrolizumab"
"PD-L1 testing insufficient" "FDA-approved test shows [specific %] with pathologist confirmation"
"Performance status unclear" "ECOG 0-1 documented in recent visit note dated [date]"
"Disease progression not documented" "RECIST 1.1 shows [%] increase in target lesions on [date]"

Illinois External Review Rights

If UnitedHealthcare denies your internal appeals, Illinois law guarantees an independent external review through the Illinois Health Carrier External Review Act.

Eligibility and Timeline

  • When: After exhausting UnitedHealthcare's internal appeal process
  • Deadline: 4 months from final internal denial notice
  • Cost: Free to consumers
  • Decision timeline: 45 days (standard), 72 hours (expedited)

How to File External Review

Step 1: Download Forms

Step 2: Submit Request

  • Mail: Illinois Department of Insurance, External Review Program
  • Include: Completed form, copy of final denial, medical records
  • Timeline: IDOI forwards to UnitedHealthcare within 1 business day

Step 3: Independent Review

  • IDOI assigns Independent Review Organization (IRO)
  • Board-certified oncologist reviews case
  • Decision binding on UnitedHealthcare if approved
Critical: Illinois has a shorter external review window than many states. Don't wait—file within 4 months of your final denial.

Appeal Templates & Scripts

Patient Phone Script for UnitedHealthcare

"Hello, I'm calling about a prior authorization denial for Tecentriq. My member ID is [number]. I received a denial letter dated [date] with reference number [number]. I'd like to understand the specific medical necessity criteria and file an internal appeal. Can you connect me with someone who can help with oncology medication appeals?"

Medical Necessity Letter Template

Your oncologist can adapt this framework:

"[Patient Name] is a [age]-year-old with [specific diagnosis, stage]. Recent imaging on [date] shows [disease status]. PD-L1 testing via [FDA-approved test] demonstrates [specific percentage] expression.

Prior treatments include [list with dates and outcomes]. [Specific therapy] was discontinued due to [documented adverse event/progression]. NCCN guidelines version [number] recommend atezolizumab as [line] therapy for this indication.

The patient has ECOG performance status [0-2] and no contraindications to anti-PD-L1 therapy. Proposed treatment is atezolizumab 1200mg IV every 3 weeks with standard monitoring including CBC, CMP, and imaging every 8-12 weeks.

Request approval for 6-month duration with renewal based on response and tolerability."

Counterforce Health helps patients and providers streamline this process by automatically generating evidence-backed appeals that align with payer-specific requirements, turning denials into targeted rebuttals with the right clinical documentation.

Cost Assistance Options

While working through appeals, explore these cost assistance programs:

Manufacturer Support

  • Genentech Patient Foundation: Income-based free drug program
  • Copay assistance: Up to $25,000 annually for eligible patients
  • Eligibility: Commercial insurance, income limits apply
  • Apply: Genentech Access Solutions

Illinois State Resources

  • Illinois Comprehensive Health Insurance Plan: High-risk pool coverage
  • Medicaid: Expanded coverage for adults up to 138% federal poverty level
  • SHIP Program: Medicare counseling at 800-548-9034

When to Escalate

Illinois Department of Insurance Complaint Process

If UnitedHealthcare fails to follow proper procedures or timelines:

Contact Information:

What to Include:

  • Detailed timeline of denials and appeals
  • Copies of all correspondence
  • Documentation of missed deadlines
  • Specific violations of Illinois insurance law

Illinois Attorney General Health Care Bureau

  • Hotline: 877-305-5145
  • Purpose: Informal intervention with insurers
  • Best for: Pattern of inappropriate denials

When traditional appeals aren't working, Counterforce Health can help identify the specific denial basis and craft targeted rebuttals using payer-specific workflows and evidence requirements.

FAQ

How long does UnitedHealthcare PA take in Illinois? Standard prior authorization decisions are made within 15 business days. Expedited reviews for urgent oncology cases are completed within 72 hours.

What if Tecentriq is non-formulary on my plan? Non-formulary drugs can still be covered through medical exception processes. Your oncologist must demonstrate medical necessity and why formulary alternatives are inappropriate.

Can I request an expedited appeal? Yes, if delays would jeopardize your health. Your oncologist must provide written certification of urgency. Expedited appeals are decided within 24-72 hours.

Does step therapy apply if I've failed treatments outside Illinois? Out-of-state treatment failures should be accepted if properly documented. Include medical records showing specific adverse events or disease progression.

What happens if external review approves but UnitedHealthcare still denies? External review decisions are binding under Illinois law. If UnitedHealthcare doesn't comply, file a complaint with the Illinois Department of Insurance immediately.

How much does Tecentriq cost without insurance? List price is approximately $8,113 per 840mg vial and $11,589 per 1200mg vial. Monthly costs can exceed $15,000 depending on dosing schedule.

Can I appeal while continuing current treatment? Yes, file appeals immediately while maintaining current therapy if possible. Don't delay treatment waiting for appeal outcomes.

What if my oncologist leaves the practice during appeals? New oncologists can continue appeals with proper medical record transfer. Notify UnitedHealthcare of prescriber changes to avoid delays.

Sources & Further Reading

Disclaimer: 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 coverage decisions. Appeal timelines and requirements may change—verify current information with official sources.

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