By Counterforce Health Team in Kymriah (tisagenlecleucel) —

Getting Kymriah (Tisagenlecleucel) Approved by UnitedHealthcare in Michigan: Complete Forms, Appeals, and Contact Guide

Answer Box: Your Fastest Path to Kymriah Approval

Kymriah (tisagenlecleucel) requires prior authorization from UnitedHealthcare as a medical benefit (not pharmacy) through OptumHealth Transplant Solutions. Treatment must occur at a certified Michigan center like University of Michigan, Karmanos Cancer Institute, Henry Ford, or Spectrum Health. Start today: 1) Confirm your plan covers transplant services, 2) Choose an in-network certified center, 3) Have the center submit PA via UHC Provider Portal with complete treatment history and CD19+ pathology. Standard review takes 5-15 business days; expedited available if medically urgent.

Table of Contents

  1. Verify Your Plan and Find the Right Forms
  2. Required Forms and Documentation
  3. Submission Portals and Online Access
  4. Fax Numbers and Mailing Addresses
  5. Michigan Certified Kymriah Centers
  6. Support Phone Lines and Contacts
  7. Michigan Appeals and External Review
  8. When to Update Your Resources

1. Verify Your Plan and Find the Right Policy

Before starting your Kymriah request, you need to understand how UnitedHealthcare handles CAR-T therapy coverage.

Coverage Channel Verification

Kymriah is NOT covered as a traditional pharmacy benefit. Instead, UnitedHealthcare processes it as a medical benefit under transplant services, managed by OptumHealth Transplant Solutions rather than OptumRx.

Call the member services number on your ID card and ask:

  • "Does my plan include transplant/cellular therapy benefits?"
  • "Which entity manages CAR-T therapy: UnitedHealthcare directly or OptumHealth Transplant Solutions?"
  • "What Michigan centers are in-network for Kymriah?"

Policy Documents to Request

UnitedHealthcare's oncology medication policies explicitly exclude CAR-T therapies, directing coverage decisions to the "Chimeric Antigen Receptor T-Cell (CAR T) Therapy" Clinical Guideline under transplant benefits.

Request these documents from UHC:

  • OptumHealth Transplant Solutions CAR-T Clinical Guideline
  • Your plan's transplant services benefit language
  • Prior authorization forms specific to transplant/cellular therapy

2. Required Forms and Documentation

Primary Prior Authorization Form

Submit your Kymriah request through the UnitedHealthcare Provider Portal as a medical service, not a drug request. The system will generate the appropriate CAR-T prior authorization form based on your plan type.

Alternative submission: Some plans accept the OptumRx specialty coordination line (888-397-8129) for CAR-T cases, though these are still routed to the transplant team.

Essential Documentation Checklist

Document Type Specific Requirements Why It's Needed
Pathology Report CD19+ confirmation, specific lymphoma/ALL subtype Proves FDA-approved indication
Treatment History All prior therapies with dates, responses, failures Shows standard-of-care attempts
Recent Imaging PET/CT within 30 days, bone marrow if applicable Documents current disease status
Organ Function Labs Cardiac, hepatic, renal, pulmonary function Safety assessment for CAR-T
ICD-10 Codes C91.00 (ALL), C83.30-series (DLBCL) Billing and coverage determination
Center Certification FACT accreditation documentation UHC requirement for all CAR-T

Medical Necessity Letter Template

Your oncologist should include these elements:

  1. Patient diagnosis with exact ICD-10 code
  2. Prior treatment timeline showing failure/intolerance of standard regimens
  3. Current disease status and urgency of treatment need
  4. Why Kymriah is appropriate (FDA indication, NCCN guidelines)
  5. Treatment center qualifications and safety monitoring plan

3. Submission Portals and Online Access

UnitedHealthcare Provider Portal

Primary submission route: UHCprovider.com

Navigation path:

  1. Sign in to Provider Portal
  2. Go to "Prior Authorization and Notification"
  3. Search by member's plan and "tisagenlecleucel" or applicable HCPCS code
  4. Complete online PA request as medical service
  5. Upload all supporting documentation

Required portal access: Your Kymriah treatment center must have an active UHC provider portal account. Individual physicians cannot submit CAR-T requests—they must go through the certified treatment facility.

Member Portal Limitations

UnitedHealthcare members cannot submit Kymriah prior authorizations through their member portal. This must be done by the certified treatment center on your behalf.

Member portal use: Check benefit coverage, track PA status once submitted, and access denial letters for appeals.

4. Fax Numbers and Mailing Addresses

Plan-Specific Contact Information

Critical note: UnitedHealthcare uses different fax numbers and addresses based on your specific plan type (Commercial, Medicare Advantage, Medicaid). Always use the contact information from your denial letter or PA form rather than generic numbers.

General guidance from UHC's 2024 materials:

Cover Sheet Best Practices

When faxing CAR-T requests:

  • Mark as "URGENT" if clinically appropriate
  • Include member ID, provider NPI, and PA reference number
  • List total page count including attachments
  • Request fax confirmation and keep records

5. Michigan Certified Kymriah Centers

Current Authorized Facilities

According to the official Kymriah Treatment Center Locator, these Michigan centers can administer Kymriah:

Center Location Patient Population Network Status
University of Michigan Medical Center Ann Arbor Adult and Pediatric Verify with UHC
Barbara Ann Karmanos Cancer Institute Detroit Adult Verify with UHC
Henry Ford Health System Detroit Adult Verify with UHC
Spectrum Health Grand Rapids Adult Verify with UHC
Helen DeVos Children's Hospital Grand Rapids Pediatric Verify with UHC

Network Verification Steps

Before choosing a center:

  1. Call UHC member services to confirm in-network status
  2. Ask about any "center of excellence" requirements
  3. Verify the center treats your specific indication (pediatric vs. adult)
  4. Confirm FACT certification for immune effector cell therapy

6. Support Phone Lines and Contacts

UnitedHealthcare Member Services

Primary contact: Number on your insurance ID card Ask about: Plan benefits, network status, PA requirements, appeal deadlines

OptumHealth Transplant Solutions

Specialty line: 888-397-8129 (for CAR-T coordination) Use for: Complex cases, center-of-excellence questions, case management

Provider Support

UHC Provider Services: Available through provider portal Peer-to-peer requests: Usually available within 24-48 hours after denial

What to Ask When You Call

For member services:

  • "What are my transplant/cellular therapy benefits?"
  • "Is [specific center] in-network for Kymriah?"
  • "What's the status of PA request [reference number]?"

For providers requesting peer-to-peer:

  • "I need to schedule a peer-to-peer review for a Kymriah denial"
  • "What medical director handles CAR-T cases?"
  • "Can we expedite this review due to clinical urgency?"

7. Michigan Appeals and External Review

UnitedHealthcare Internal Appeals

Timeline: Up to 180 days from denial to file internal appeal Process: Two-step system (reconsideration, then formal appeal) Decision timeframe: 30 days standard, 72 hours for urgent cases

Submit appeals using:

  • Contact information from your specific denial letter
  • UHC provider portal (for providers)
  • Plan-specific member portal

Michigan External Review Process

After UHC's final denial, Michigan residents can request external review through the Department of Insurance and Financial Services (DIFS).

Key Michigan details:

DIFS Contact Information:

  • Phone: 877-999-6442 (consumer assistance)
  • Hours: 8 AM - 5 PM, Monday-Friday

Required Documents for Appeals

Internal appeal to UHC:

  • Copy of denial letter
  • Updated medical necessity letter
  • Any new clinical evidence
  • Treatment timeline showing urgency

External review with DIFS:

  • UHC's final adverse determination letter
  • Your narrative explaining disagreement
  • All supporting medical records
  • Physician letter for expedited review (if applicable)

8. When to Update Your Resources

Quarterly Checks

UnitedHealthcare updates PA requirements and forms regularly. Check these every 3 months:

Annual Policy Updates

UnitedHealthcare typically updates major policies effective January 1st. Key 2026 changes:

When Your Plan Changes

If you switch UHC plans or move to a different state:

  • Verify continued transplant benefit coverage
  • Confirm your chosen center remains in-network
  • Check if existing PAs transfer or need resubmission

Common Denial Reasons & How to Fix Them

Denial Reason Solution Documentation Needed
Missing CD19 positivity Submit complete pathology report Flow cytometry showing CD19+ disease
Not at certified center Transfer care or request single-case agreement FACT certification proof
Insufficient prior therapy Document all previous treatments Complete treatment timeline with outcomes
Missing conditioning plan Include bridging therapy protocol Center's treatment plan and safety monitoring

Frequently Asked Questions

How long does UnitedHealthcare PA take for Kymriah in Michigan? Standard review: 5-15 business days. Expedited review available within 72 hours if clinical urgency is documented.

What if Kymriah isn't covered by my specific UHC plan? Check if your plan includes transplant/cellular therapy benefits. Some plans exclude these services entirely.

Can I get expedited review for Kymriah? Yes, if your physician documents that delay would seriously jeopardize your health. Both UHC and Michigan DIFS offer expedited reviews.

Does step therapy apply to Kymriah? Generally no, since Kymriah is indicated for relapsed/refractory disease after standard therapies have failed.

What if my preferred center isn't in-network? Request a single-case agreement (SCA) with UHC, especially if no in-network Michigan center treats your specific indication.

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals for complex therapies like Kymriah. Our platform analyzes denial letters, identifies the specific coverage gaps, and generates evidence-backed appeals that address each payer's unique requirements. For CAR-T therapies, we help ensure all clinical documentation, treatment center certifications, and medical necessity arguments align with UnitedHealthcare's transplant benefit criteria.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance processes and is not medical advice. Coverage decisions depend on your specific plan terms and clinical circumstances. Always consult with your healthcare team and insurance plan directly for guidance on your individual situation. For additional help with Michigan insurance appeals, contact DIFS at 877-999-6442.

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