By Counterforce Health Team in Xywav (Ca/Mg/K/Na oxybates) —

Getting Xywav (Ca/Mg/K/Na Oxybates) Covered by UnitedHealthcare in Virginia: Complete ICD-10, NDC, and Appeal Guide

Quick Answer: UnitedHealthcare requires prior authorization for Xywav (Ca/Mg/K/Na oxybates) in Virginia. You need REMS enrollment, documented step therapy failures, and specific ICD-10 codes (G47.41 for narcolepsy with cataplexy, G47.11 for idiopathic hypersomnia). Submit via OptumRx with sleep studies and failed alternative documentation. If denied, Virginia's external review through the State Corporation Commission can overturn decisions within 45 days. Start by confirming REMS enrollment and gathering sleep study records.

Table of Contents

Coding Basics: Medical vs. Pharmacy Benefit

Xywav is processed through UnitedHealthcare's pharmacy benefit (not medical benefit) because it's an oral solution dispensed directly to patients. This means your claim flows through OptumRx, UnitedHealthcare's pharmacy benefit manager, rather than through medical claims processing.

Key implications:

  • Prior authorization requests go to OptumRx (Fax: 1-866-434-5523)
  • Claims use NDC numbers rather than HCPCS J-codes
  • Specialty pharmacy dispensing only (REMS requirement)
  • Different appeals pathways than medical benefit denials

ICD-10 Mapping for Xywav Coverage

Accurate ICD-10-CM coding is essential for UnitedHealthcare approval. Use these specific codes based on your diagnosis:

Condition ICD-10-CM Code Documentation Requirements
Narcolepsy with cataplexy G47.41 Sleep studies (PSG/MSLT), cataplexy episodes documented
Narcolepsy without cataplexy G47.419 Sleep studies showing REM sleep abnormalities
Narcolepsy, unspecified G47.429 When cataplexy status unclear
Idiopathic hypersomnia G47.11 Exclusion of other causes, excessive daytime sleepiness >3 months

Documentation that supports coding:

  • Polysomnography (PSG) results showing sleep architecture abnormalities
  • Multiple Sleep Latency Test (MSLT) with mean sleep latency ≤8 minutes
  • Clinical notes describing cataplexy episodes (sudden muscle weakness triggered by emotions)
  • Epworth Sleepiness Scale scores
  • Exclusion of insufficient sleep, medication effects, or other medical causes
Note: UnitedHealthcare requires that diagnosis codes match FDA-approved indications. Off-label use typically requires additional medical necessity documentation.

Product Coding: NDC, HCPCS, and Billing Units

NDC Information

Primary NDC: 68727-150-01 (180 mL bottle) 11-digit format for billing: 68727-0150-01

Billing Unit Conversion

Xywav contains 0.5 grams per 1 mL. For billing calculations:

  • Patient prescribed 6 grams nightly = 12 mL per night
  • Patient prescribed 9 grams nightly = 18 mL per night
  • Always bill in milliliters (mL), not grams

HCPCS Considerations

Currently, Xywav doesn't have a permanent J-code. For payers requiring HCPCS codes:

  • Use the NDC number as primary identifier
  • Include miscellaneous code if required by specific payer crosswalk
  • Always verify current requirements with OptumRx
Tip: Jazz Pharmaceuticals provides billing support through their JazzCares program for coding questions.

Clean Prior Authorization Request

A complete OptumRx prior authorization for Xywav includes:

Required Documentation Checklist

  • Completed OptumRx prior authorization form
  • REMS enrollment confirmation (patient and prescriber)
  • Sleep study reports (PSG and MSLT)
  • ICD-10 diagnosis codes with supporting clinical notes
  • Step therapy documentation (failed alternatives)
  • Prescriber credentials (sleep medicine specialist or neurologist)
  • Current medication list (confirm no sedative hypnotics)

Step Therapy Requirements

Document failed trials with:

  1. First-line stimulants: modafinil, armodafinil, methylphenidate, or amphetamines
  2. For Xywav specifically: trial of Xyrem (if not contraindicated due to sodium restrictions)

For each failed medication, include:

  • Dates of treatment
  • Dosage and duration
  • Reason for discontinuation (inefficacy, intolerance, contraindications)
  • Clinical response assessment

REMS Program Requirements

Both patient and prescriber must be enrolled in the Xywav/Xyrem REMS program before any prescription can be dispensed. This enrollment must be documented in your PA submission.

Frequent Coding Pitfalls

Common Errors That Cause Denials

Unit Conversion Mistakes

  • Billing in grams instead of mL
  • Incorrect dose calculations (remember: 0.5g per 1mL)
  • Mismatched quantities between prescription and billing

ICD-10 Code Issues

  • Using unspecified codes when specific ones are available
  • Mismatching principal diagnosis with medical necessity
  • Missing supporting documentation for diagnosis codes

REMS Documentation Gaps

  • Submitting PA before REMS enrollment complete
  • Missing prescriber certification
  • Incorrect specialty pharmacy routing

Step Therapy Documentation

  • Insufficient detail about failed alternatives
  • Missing dates or dosages of prior treatments
  • Lack of clinical rationale for treatment failures
From our advocates: We've seen PA approvals increase significantly when providers include a detailed timeline of all sleep medications tried, with specific dates and clinical responses. One neurologist's practice improved their approval rate from 60% to 95% by creating a standardized template that included Epworth Sleepiness Scale scores before and after each failed medication trial.

Verification with UnitedHealthcare Resources

Pre-Submission Verification

  1. Check formulary status: Confirm Xywav's tier and coverage requirements on the current UnitedHealthcare formulary
  2. Verify PA form: Use the most current OptumRx prior authorization form
  3. Confirm REMS status: Verify both patient and prescriber enrollment before submission
  4. Review plan-specific requirements: Some UnitedHealthcare plans may have additional criteria

UnitedHealthcare Provider Resources

  • Provider Portal: Submit PAs and check status online
  • OptumRx Phone: 1-800-711-4555 for PA status inquiries
  • PA Fax Line: 1-866-434-5523 for form submission

Appeals Process in Virginia

If UnitedHealthcare denies your Xywav prior authorization, Virginia provides strong appeal protections through the State Corporation Commission (SCC) Bureau of Insurance.

Internal Appeals (First Step)

  • Timeline: Must file within timeframe specified in denial letter (typically 180 days)
  • Method: UnitedHealthcare member portal, phone, or written appeal
  • Required: Additional clinical documentation addressing denial reasons

External Review (Virginia SCC)

If internal appeals fail, Virginia's external review process offers independent oversight:

Timeline: 120 days from final denial to file external review request Forms: Complete Form 216-A (standard) or Form 216-C (expedited) Decision timeframe: 45 days for standard review, 72 hours for expedited Success rate: External reviews overturn approximately 30-40% of denials with proper documentation

Submission methods:

  • Fax: (804) 371-9915
  • Email: [email protected]
  • Mail: State Corporation Commission, Bureau of Insurance – External Review, P.O. Box 1157, Richmond, VA 23218

Required Documents for External Review

  • Final adverse determination letter from UnitedHealthcare
  • Completed Form 216-A or 216-C
  • Copy of insurance card
  • Any additional medical documentation not included in internal appeal
  • Medical records release authorization
Note: For urgent cases where delay could cause serious harm, expedited external review requires physician certification using Form 216-C.

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with UnitedHealthcare's specific requirements, pulling the right citations and clinical evidence for medications like Xywav. For Virginia patients facing complex denials, this systematic approach can significantly improve appeal success rates.

Quick Audit Checklist

Before submitting your Xywav prior authorization to OptumRx:

Documentation Review

  • ICD-10 code matches diagnosis and is most specific available
  • NDC 68727-0150-01 correctly formatted for billing
  • Dose conversion accurate (grams to mL)
  • Sleep study reports included (PSG and MSLT)
  • REMS enrollment confirmed for patient and prescriber

Step Therapy Compliance

  • All required alternatives documented as tried/failed
  • Specific dates, dosages, and outcomes recorded
  • Clinical rationale for each treatment failure explained
  • Contraindications to alternatives noted if applicable

Submission Requirements

  • Current OptumRx PA form used
  • Prescriber credentials verified (sleep specialist/neurologist)
  • No concurrent sedative hypnotic medications
  • Specialty pharmacy identified and REMS-certified

FAQ

How long does UnitedHealthcare prior authorization take for Xywav in Virginia? Standard PA decisions are typically made within 72 hours to 14 days. Expedited reviews for urgent cases can be processed within 24-72 hours.

What if Xywav is non-formulary on my UnitedHealthcare plan? Non-formulary drugs can still be covered through medical necessity exceptions. Submit a comprehensive PA with detailed clinical justification and evidence of failed formulary alternatives.

Can I request an expedited appeal if my Xywav is denied? Yes, if your physician certifies that delay could seriously jeopardize your health. Use Virginia Form 216-C for expedited external review, decided within 72 hours.

Does step therapy apply if I've tried alternatives outside Virginia? Yes, step therapy documentation from any location is valid. Include complete records of all prior treatments regardless of where they occurred.

What's the difference between Xyrem and Xywav for UnitedHealthcare coverage? Both require similar PA processes, but Xywav may be preferred for patients with sodium restrictions. Document medical necessity for Xywav over Xyrem if applicable.

How much does Xywav cost with UnitedHealthcare coverage? Costs vary by plan tier and deductible status. Jazz Pharmaceuticals offers copay assistance programs that may reduce out-of-pocket expenses.

What happens if my external review is denied in Virginia? The external review decision is final and binding. However, you retain rights to pursue legal action if you believe there were violations of insurance law or contract terms.

Can family members help with my appeal process? Yes, but they need written authorization to act on your behalf. Virginia provides Authorized Representative forms for this purpose.

For complex cases or multiple denials, Counterforce Health can help analyze your specific situation and develop targeted appeal strategies based on UnitedHealthcare's policies and Virginia's regulatory requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and clinical circumstances. Always consult with your healthcare provider and insurance plan for specific coverage determinations. For assistance with Virginia insurance regulations, contact the State Corporation Commission Bureau of Insurance at 1-877-310-6560.

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