By Counterforce Health Team in Arikayce (amikacin liposome inhalation) —

How to Get Arikayce Covered by UnitedHealthcare in Michigan: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Arikayce Covered by UnitedHealthcare in Michigan

Eligibility: Arikayce requires prior authorization through OptumRx for refractory MAC lung disease after ≥6 months of failed combination therapy. Fastest approval path: Submit complete PA request with documented treatment failure, culture results, and specialist oversight. First step today: Contact your pulmonologist or infectious disease specialist to gather 12-month treatment records and recent susceptibility testing. If denied, you have 180 days to appeal internally, then 127 days to file external review with Michigan DIFS.

Table of Contents

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required through OptumRx UnitedHealthcare Provider Portal UHC PA Requirements
Treatment Duration ≥6 months failed combination therapy Medical records, prescription history OptumRx Criteria
Specialist Oversight ID specialist or pulmonologist required Prescriber credentials UHC Medical Necessity Form
Combination Therapy Must use with background regimen Current prescription records FDA Labeling
Initial Authorization 6 months PA approval letter OptumRx Guidelines
Appeals Deadline 180 days internal, 127 days external Denial letter date Michigan DIFS

Step-by-Step: Fastest Path to Approval

1. Confirm Diagnosis and Treatment History

Who: Your pulmonologist or infectious disease specialist
Document needed: Complete MAC diagnosis with culture results
Timeline: 1-2 days to gather records
Source: ATS/IDSA Guidelines

2. Document Treatment Failure

Who: Healthcare team
Document needed: 12-month prescription history showing ≥6 months of combination therapy
Timeline: 2-3 days for pharmacy records
Source: UHC PA Requirements

3. Obtain Recent Susceptibility Testing

Who: Laboratory/physician
Document needed: Amikacin MIC <64 mcg/mL within 6 months
Timeline: 3-5 days if new testing needed
Source: FDA Prescribing Information

4. Submit Prior Authorization

Who: Prescriber or office staff
How to submit: UnitedHealthcare Provider Portal or call OptumRx at 1-800-711-4555
Timeline: 7-14 days for standard review
Source: UHC Provider Portal

5. Monitor Status and Respond to Requests

Who: Patient and healthcare team
Action: Check portal daily, respond to information requests within 24-48 hours
Timeline: Ongoing during review period

6. If Denied, File Internal Appeal

Who: Patient or authorized representative
Document needed: Denial letter, additional clinical evidence
Timeline: File within 180 days, decision in 15-30 days
Source: Michigan Insurance Appeals

7. If Still Denied, File External Review

Who: Patient
Document needed: DIFS Form FIS 0018, final denial letter
Timeline: File within 127 days, decision in 60 days (72 hours if expedited)
Source: Michigan DIFS External Review

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documents
Insufficient treatment duration Provide detailed prescription history Pharmacy records showing ≥6 months of therapy
Missing susceptibility data Submit recent lab results Amikacin MIC testing within 6 months
Non-specialist prescriber Transfer care or obtain consultation ID specialist or pulmonologist oversight
Incomplete background regimen Document current combination therapy Active prescriptions for macrolide, ethambutol, rifamycin
Lack of medical necessity Strengthen clinical documentation Culture results, symptom progression, functional impact

Medical Necessity Letter Essentials

When your physician writes the medical necessity letter, ensure it includes:

Diagnosis Confirmation

  • ICD-10 code A31.0 (Pulmonary mycobacterial infection)
  • Clinical symptoms and radiographic findings
  • Microbiologic confirmation with ≥2 positive cultures

Treatment History

  • Specific dates of combination therapy (≥6 months)
  • Medications used: macrolide + ethambutol + rifamycin
  • Documentation of treatment failure or intolerance

Clinical Rationale

  • FDA approval for refractory MAC lung disease
  • Reference to ATS/IDSA guidelines supporting use
  • Patient-specific factors requiring Arikayce

Monitoring Plan

  • Baseline and periodic audiometry
  • Safety monitoring protocols
  • Expected treatment duration
From Our Advocates: We've seen the strongest approvals when physicians include specific culture dates, exact medication dosages with start/stop dates, and a clear statement about why standard therapy failed. One successful letter documented three separate 6-month treatment attempts over 18 months, making the refractory nature undeniable.

Appeals Playbook for Michigan

Internal Appeals with UnitedHealthcare

Level 1 Appeal

  • Deadline: 180 days from denial date
  • How to file: Online portal, phone, or mail
  • Timeline: 15-30 days for decision
  • Required: Copy of denial letter, additional clinical documentation

Level 2 Appeal

  • Trigger: Automatic if Level 1 denied
  • Timeline: 15-30 days for decision
  • Review: Different clinical reviewers than initial determination

External Review through Michigan DIFS

Eligibility: Must exhaust internal appeals first

  • Deadline: 127 days from final adverse determination
  • How to file: Complete DIFS Form FIS 0018
  • Timeline: 60 days standard, 72 hours expedited
  • Contact: 877-999-6442 for assistance

Expedited Review

  • When to use: Medical urgency or serious jeopardy to health
  • Deadline: 10 days from adverse determination
  • Requirement: Physician letter substantiating urgency

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and payer policies to draft point-by-point rebuttals that align with each plan's specific requirements, helping patients get medications like Arikayce approved faster.

Patient Success Story

Sarah, a 58-year-old teacher from Grand Rapids, was diagnosed with MAC lung disease in 2022. After 8 months of standard combination therapy with azithromycin, ethambutol, and rifampin, her cultures remained positive and symptoms worsened.

Initial Denial: UnitedHealthcare denied Arikayce citing "insufficient treatment duration" despite 8 months of therapy.

Appeal Strategy: Her pulmonologist gathered detailed pharmacy records showing exact prescription dates and submitted culture results demonstrating persistent MAC despite adherence to therapy.

Peer-to-Peer Review: The physician requested a peer-to-peer review with UnitedHealthcare's medical director, emphasizing the FDA-approved indication for refractory MAC.

Resolution: UnitedHealthcare approved Arikayce for 6 months after the peer-to-peer discussion clarified the treatment failure criteria.

Key Lessons: Detailed documentation of treatment timeline and direct physician communication with the medical director were crucial for overturning the initial denial.

Costs & Financial Assistance

Arikayce Pricing

  • Cash price: Approximately $1,500-$1,600 per 590mg vial
  • Monthly cost: $45,000-$48,000 without insurance

Financial Assistance Options

  • Insmed Patient Assistance Program: Income-based assistance for eligible patients
  • Arikayce Copay Program: May reduce out-of-pocket costs for insured patients
  • HealthWell Foundation: Grants for respiratory conditions (verify current availability)
  • Patient Access Network (PAN) Foundation: Copay assistance programs

For more information on financial assistance, visit the Arikayce HCP website or contact Insmed patient support at 1-844-4-INSMED.

Frequently Asked Questions

Q: How long does UnitedHealthcare prior authorization take in Michigan? A: Standard review takes 7-14 days. Urgent cases may qualify for expedited review within 72 hours if medically necessary.

Q: What if Arikayce is non-formulary on my plan? A: Non-formulary drugs can still be covered through prior authorization with medical necessity documentation. The appeals process remains the same.

Q: Can I request an expedited appeal? A: Yes, if your condition would be seriously jeopardized by delay. Your physician must provide a letter supporting medical urgency.

Q: Does step therapy apply if I've already failed treatments? A: Document all previous therapies with dates and outcomes. UnitedHealthcare should recognize prior treatment failures as meeting step therapy requirements.

Q: What happens if my internal appeal is denied? A: You have 127 days to file an external review with Michigan DIFS. The Independent Review Organization will provide an impartial medical review.

Q: How often do external appeals succeed in Michigan? A: Approximately 81.7% of appealed prior authorization denials are partially or fully overturned, according to recent Medicare Advantage data.

Q: Can I continue current treatment while appealing? A: Continue your current MAC regimen as prescribed. Don't stop treatment while waiting for Arikayce approval.

Q: Who can help me with the appeals process? A: Your physician, patient advocates, or services like Counterforce Health can assist with appeal preparation and submission.

What to Gather Before You Start

Essential Documents

  • Insurance card with member ID
  • Complete MAC diagnosis records
  • Culture results (≥2 positive samples)
  • 12-month prescription history
  • Recent susceptibility testing (amikacin MIC)
  • Current medication list
  • Specialist consultation notes
  • Any previous denial letters

Contact Information

  • Prescriber name and NPI number
  • Pharmacy contact information
  • UnitedHealthcare member services number
  • Michigan DIFS contact: 877-999-6442

Timeline Tracking

  • Date of MAC diagnosis
  • Start dates of each treatment attempt
  • Date of treatment failure determination
  • Prior authorization submission date
  • Appeal deadlines (if applicable)

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 plan for specific guidance regarding your coverage and treatment options. Insurance policies and procedures may change; verify current requirements with your insurer and state regulators.

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