By Counterforce Health Team in Entresto (sacubitril/valsartan) —

Do You Qualify for Entresto Coverage by UnitedHealthcare in Michigan? Complete Decision Tree & Appeals Guide

Answer Box: Your Fast Track to Entresto Coverage in Michigan

Most likely to qualify: Heart failure patients with LVEF ≤40%, NYHA Class II-IV symptoms, prior ACE inhibitor/ARB trial (or documented intolerance), and cardiology involvement. First step today: Gather your recent echocardiogram report and medication history, then have your cardiologist submit UnitedHealthcare's Entresto PA form via their provider portal. If denied: Request a peer-to-peer review within 24 hours, then file internal appeals within 180 days. Michigan advantage: After internal appeals, you get binding external review through Michigan DIFS within 127 days.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible" - Your Action Plan
  4. If "Possibly Eligible" - Tests to Request
  5. If "Not Yet" - Alternative Paths
  6. If Denied - Michigan Appeals Playbook
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & Quick Fixes
  9. FAQ: Michigan-Specific Questions
  10. Resources & Next Steps

How to Use This Decision Tree

This guide helps you determine if you qualify for Entresto (sacubitril/valsartan) coverage through UnitedHealthcare in Michigan, then provides the exact steps to get approved or appeal a denial.

Start here: Answer the eligibility questions below, then jump to your matching section. Each path includes specific forms, timelines, and contact information for Michigan residents.

Note: This covers commercial UnitedHealthcare plans using OptumRx. Medicare Advantage and Medicaid plans may have different criteria.

Eligibility Triage: Do You Qualify?

Work through these questions with your cardiologist to determine your approval likelihood:

✅ Likely Eligible if ALL apply:

  • Heart failure diagnosis with ICD-10 codes (I50.x)
  • Recent echocardiogram showing LVEF ≤40% OR structural heart disease (left atrial enlargement, LV hypertrophy)
  • NYHA Class II-IV symptoms documented in chart
  • Prescribed by cardiologist or clear cardiology consultation
  • Prior ACE inhibitor or ARB trial documented, OR clear contraindication/intolerance
  • No current ACE inhibitor/ARB use (must be discontinued)
  • No history of angioedema with ACE inhibitors or ARBs

⚠️ Possibly Eligible if MOST apply:

  • Heart failure diagnosis but missing recent LVEF documentation
  • LVEF 41-49% (mildly reduced) with some structural disease
  • Primary care provider prescribing (cardiology consult may be required)
  • Limited ACE inhibitor/ARB trial history documented
  • Mild contraindications to standard therapy

❌ Not Yet Eligible if ANY apply:

  • No documented heart failure diagnosis
  • LVEF >50% with no structural heart disease
  • Currently taking ACE inhibitor or ARB
  • History of ACE inhibitor/ARB-induced angioedema
  • No prior guideline-directed therapy attempted without clear contraindication

If "Likely Eligible" - Your Action Plan

You have strong approval odds. Here's your fastest path:

Step 1: Gather Required Documentation

Patient checklist:

  • ✅ UnitedHealthcare insurance card and member ID
  • ✅ Recent echocardiogram report (within 6-12 months) showing LVEF
  • ✅ Complete medication list including ACE inhibitor/ARB history
  • ✅ Documentation of any drug allergies or intolerances

Clinician checklist:

  • ✅ Heart failure diagnosis with ICD-10 codes
  • ✅ NYHA functional class documentation
  • ✅ Prior therapy trials and outcomes
  • ✅ Current medication reconciliation
  • ✅ Cardiology consultation note (if not cardiologist-prescribed)

Step 2: Submit Prior Authorization

Method: UnitedHealthcare Provider Portal (preferred) or fax Form: UnitedHealthcare Entresto PA/Medical Necessity form Timeline: Decision typically within 72 hours for complete submissions

Step 3: Ensure ACE Inhibitor/ARB Transition

  • Stop ACE inhibitor at least 36 hours before Entresto start
  • Stop ARB and start Entresto at next scheduled dose (no washout needed)
  • Document transition plan in prior authorization
Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals for medications like Entresto. Their platform ingests denial letters and plan policies to draft point-by-point rebuttals aligned to each payer's specific rules, helping patients and clinicians navigate complex prior authorization requirements.

If "Possibly Eligible" - Tests to Request

You may qualify with additional documentation:

Missing LVEF Documentation

Request: Updated echocardiogram with quantitative LVEF measurement Timeline: Schedule within 2-4 weeks What to track: Specific LVEF percentage, left atrial size, wall thickness measurements

Cardiology Requirement

Request: Cardiology consultation if prescribed by primary care Timeline: Expedite if possible (2-3 weeks) What to document: Specialist agreement with Entresto therapy, optimization of other HF medications

Prior Therapy Documentation

Gather: Pharmacy records showing ACE inhibitor/ARB trials Document: Specific drugs, doses, duration, reasons for discontinuation Alternative: Chart notes documenting contraindications to standard therapy

If "Not Yet" - Alternative Paths

Don't give up. Consider these approaches:

Exception Request Pathway

If you don't meet standard criteria, work with your cardiologist to request a medical necessity exception documenting:

  • Unique clinical circumstances
  • Why standard therapy is inappropriate
  • Expected benefits of Entresto in your specific case

Alternative Coverage Options

Step therapy completion: Trial and document failure of required first-line therapies Manufacturer support: Novartis patient assistance programs Foundation grants: Research heart failure-specific assistance programs

If Denied - Michigan Appeals Playbook

Michigan offers strong patient protections with binding external review:

Level 1: Peer-to-Peer Review

Timeline: Request within 24 hours of denial Process: Your cardiologist discusses case directly with UnitedHealthcare medical director Preparation: Have echocardiogram, medication history, and clinical notes ready Success rate: Approximately 86% of well-documented appeals succeed

Level 2: Internal Appeals

Timeline: File within 180 days of denial Decision: 30 days (standard) or 72 hours (expedited) Method: UnitedHealthcare Provider Portal or written appeal Required: Denial letter, clinical documentation, medical necessity letter

Level 3: Michigan DIFS External Review

Timeline: File within 127 days of final internal denial Decision: 60 days (standard) or 72 hours (expedited) Method: Online DIFS External Review Form or Form FIS 0018 Cost: Free to patients Binding: UnitedHealthcare must comply with favorable decisions

For expedited external review: Physician must document that delay would "seriously jeopardize life or health or ability to regain maximum function"

Coverage Requirements at a Glance

Requirement What UnitedHealthcare Needs Where to Find It Source
Prior Authorization Yes, required for all Entresto Denial letter or formulary UHC PA Requirements
Heart Failure Diagnosis ICD-10 codes I50.x documented Problem list, chart notes UHC Entresto Policy
LVEF Documentation ≤40% or structural heart disease Recent echocardiogram report UHC Entresto Policy
NYHA Class II-IV symptoms documented Clinical notes UHC Entresto Policy
Prescriber Requirement Cardiologist or cardiology consult Provider credentials, consult note UHC Entresto Policy
Prior Therapy ACE inhibitor/ARB trial or contraindication Medication history, allergy list UHC Entresto Policy

Common Denial Reasons & Quick Fixes

Denial Reason Quick Fix Documents Needed
"No HF diagnosis documented" Submit problem list with ICD-10 codes Chart notes with I50.x codes
"LVEF not documented" Provide recent echocardiogram Full echo report with LVEF percentage
"No cardiology involvement" Obtain cardiology consultation Specialist note or co-signature
"Concurrent ACE inhibitor use" Document medication stop date Updated medication list, stop orders
"No prior ACE/ARB trial" Provide medication history Pharmacy records, clinical notes
"Missing NYHA class" Document functional symptoms Office visit notes with symptom assessment
From our advocates: We've seen many Michigan patients successfully overturn initial Entresto denials by ensuring their cardiologist clearly documents the 36-hour ACE inhibitor washout period and provides specific LVEF measurements from recent imaging. Having these details ready for the peer-to-peer call often resolves the denial immediately.

FAQ: Michigan-Specific Questions

How long does UnitedHealthcare prior authorization take in Michigan? Standard decisions within 72 hours of complete submission. Expedited reviews for urgent cases completed within 24-48 hours.

What if Entresto isn't on my UnitedHealthcare formulary? Request a formulary exception through the same prior authorization process. Include medical necessity documentation and alternative medication failures.

Can I request expedited appeals in Michigan? Yes, both UnitedHealthcare internal appeals and Michigan DIFS external reviews offer expedited timelines (72 hours) when delay poses serious health risks.

Does Michigan's external review cost anything? No, Michigan DIFS external review is free for patients. The decision is binding on UnitedHealthcare if favorable.

What if I have a Medicare Advantage plan through UnitedHealthcare? Medicare Advantage plans may have different criteria. Contact UnitedHealthcare Medicare & Retirement directly for specific requirements.

How do I prove ACE inhibitor intolerance for step therapy exceptions? Document specific adverse effects (cough, angioedema, hyperkalemia) with dates, severity, and clinical notes. Pharmacy records showing short trial durations also help.

Can my primary care doctor prescribe Entresto? UnitedHealthcare typically requires cardiologist prescribing or clear cardiology consultation. Primary care providers should coordinate with cardiology for approval.

What's the success rate for Entresto appeals in Michigan? Well-documented appeals with complete clinical information succeed approximately 86% of the time, particularly when cardiology involvement and prior therapy trials are clearly documented.

Resources & Next Steps

Official Forms & Contacts

Patient Support Resources

Clinical Guidelines

Need personalized help? Counterforce Health transforms insurance denials into evidence-backed appeals by analyzing your specific denial letter and plan policy to craft targeted rebuttals. Their platform helps patients and clinicians navigate complex prior authorization requirements with payer-specific workflows and deadline tracking.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult your healthcare provider for medical decisions and verify current policy requirements with UnitedHealthcare and Michigan DIFS, as coverage criteria and timelines may change.

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