By Counterforce Health Team in Cabometyx (cabozantinib) —

How to Get Cabometyx (cabozantinib) Covered by UnitedHealthcare in California: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Cabometyx Covered by UnitedHealthcare in California

Cabometyx (cabozantinib) requires prior authorization from UnitedHealthcare/OptumRx for all FDA-approved indications. Your fastest path to approval: (1) Ensure your oncologist submits a complete PA request with diagnosis, staging, and prior therapy documentation via the UnitedHealthcare provider portal, (2) If denied, file an internal appeal within 180 days with additional clinical evidence, (3) If still denied, request California's Independent Medical Review (IMR) through DMHC—which has a 68% success rate for specialty drug appeals. Start today by calling UnitedHealthcare at 1-800-711-4555 to confirm your plan's specific requirements.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 Mapping for Cabometyx
  3. Product Coding: HCPCS, NDC, and Units
  4. Clean Prior Authorization Request
  5. Common Coding Pitfalls
  6. UnitedHealthcare Verification
  7. Appeals Process in California
  8. Quick Audit Checklist
  9. FAQ

Coding Basics: Medical vs. Pharmacy Benefit

Cabometyx is covered under the pharmacy benefit, not the medical benefit, because it's an oral medication dispensed as tablets for home administration. This affects how claims are submitted and which prior authorization pathways apply.

Coverage Path Overview

Benefit Type When It Applies Coding Requirements Prior Auth Process
Pharmacy Benefit Standard (oral tablets) NDC numbers, J8999 if needed OptumRx PA forms
Medical Benefit Rare (inpatient only) J8999 + NDC modifier UHC medical PA

Key Point: Nearly all Cabometyx prescriptions go through OptumRx (UnitedHealthcare's pharmacy benefit manager), which requires prior authorization for all cancer indications.

ICD-10 Mapping for Cabometyx

Accurate diagnosis coding is critical for Cabometyx approval. Here are the primary ICD-10 codes for FDA-approved indications:

Primary Diagnosis Codes

Cancer Type ICD-10 Code Documentation Requirements
Renal Cell Carcinoma C64.9 (unspecified kidney) Pathology report, staging, imaging
C64.1 (right kidney) Site-specific when known
C64.2 (left kidney) Site-specific when known
Hepatocellular Carcinoma C22.0 (liver, primary) Must show prior sorafenib failure
Thyroid Cancer C73 (thyroid gland) RAI-refractory status required

Supporting History Codes

  • Z85.528 - Personal history of malignant neoplasm of kidney
  • Z08 - Encounter for follow-up examination after treatment (use first)
  • Z51.11 - Encounter for antineoplastic chemotherapy
Documentation Tip: Include specific staging (e.g., "metastatic RCC" or "advanced HCC") in clinical notes to support medical necessity.

Product Coding: HCPCS, NDC, and Units

HCPCS J-Code

Cabometyx uses J8999 ("Prescription drug, oral, chemotherapeutic, NOS") since no specific J-code exists for cabozantinib tablets.

NDC Numbers (Current FDA Labeling)

  • 20 mg tablets: 42388-023-26
  • 40 mg tablets: 42388-023-36
  • 60 mg tablets: 42388-023-37
  • 15 mg tablets: 42388-023-46

Billing Units

Bill by total milligrams dispensed. For example:

  • 30-day supply of 60 mg daily = 1,800 mg total
  • Use NDC 42388-023-37 with quantity "30" (tablets)
Important: Do not confuse Cabometyx tablets with cabozantinib capsules (different NDCs and not interchangeable).

Clean Prior Authorization Request

A complete PA request should include these elements:

Required Clinical Information

  1. Patient demographics and UnitedHealthcare member ID
  2. Primary diagnosis with ICD-10 code and staging
  3. Prior therapy history with dates, responses, and reasons for discontinuation
  4. Current clinical status with recent imaging/lab results
  5. Prescriber information and DEA number
  6. Dosing regimen (typically 60 mg daily for monotherapy)

Supporting Documentation

  • Pathology reports confirming diagnosis
  • Imaging studies showing disease progression
  • Office notes documenting prior treatment failures
  • Lab values (liver function, renal function)
  • Treatment plan and monitoring schedule
Clinician Corner: UnitedHealthcare often requires specific documentation of sorafenib failure for hepatocellular carcinoma cases. Include dates of treatment, best response achieved, and reason for discontinuation.

Common Coding Pitfalls

Frequent Mistakes to Avoid

Problem Impact Solution
Using capsule NDCs instead of tablet NDCs Automatic denial Verify NDC matches Cabometyx tablets
Missing staging information "Insufficient documentation" denial Include TNM staging or equivalent
Incomplete prior therapy history Step therapy denial Document all previous treatments with dates
Wrong formulation in notes Clinical mismatch Specify "Cabometyx tablets" not "cabozantinib"

Unit Conversion Errors

  • Correct: 60 mg daily × 30 days = 1,800 mg total
  • Incorrect: Billing 60 units instead of milligrams
  • Fix: Always verify total milligrams match the NDC strength and quantity

UnitedHealthcare Verification

Before Submitting Your Request

  1. Check formulary status on the OptumRx website or member portal
  2. Verify PA requirements for your specific plan type
  3. Confirm provider is in-network for oncology services
  4. Review step therapy requirements (may vary by indication)

Provider Resources

  • Prior authorization forms: Available through UnitedHealthcare provider portal
  • Clinical criteria: Published in OptumRx medical policies
  • Status checking: Real-time updates via provider portal
  • Help line: 1-800-711-4555 for provider services

Appeals Process in California

California offers robust appeal rights through both internal insurance appeals and the state's Independent Medical Review (IMR) system.

Internal Appeal Process

Step Timeline Requirements Where to Submit
Initial Reconsideration Within 180 days of denial Denial letter + additional clinical evidence UnitedHealthcare provider portal
Formal Internal Appeal Within 60 days if reconsideration denied Complete medical records + peer-reviewed literature UnitedHealthcare appeals department

California Independent Medical Review (IMR)

If UnitedHealthcare denies your internal appeal, California's IMR process offers a 68% success rate for specialty drug appeals.

How to File an IMR:

  1. Eligibility: Must complete internal appeal first
  2. Timeline: Within 6 months of final denial
  3. Cost: Free to patients
  4. Process: Independent physicians review your case
  5. Decision: Binding on UnitedHealthcare

Contact Information:

  • DMHC Help Center: 888-466-2219
  • Online application: healthhelp.ca.gov
  • Required documents: All denial letters, medical records, supporting literature
From Our Advocates: We've seen multiple Cabometyx denials overturned through California's IMR process when patients included comprehensive staging information, documented treatment failures, and current imaging showing disease progression. The key is thorough clinical documentation that directly addresses the denial reasons.

When to Request Expedited Review

Request expedited processing if:

  • Disease progression could occur during standard review
  • Delay could jeopardize health outcomes
  • Patient is currently hospitalized
  • Oncologist certifies urgency

Quick Audit Checklist

Before submitting your Cabometyx prior authorization:

Clinical Documentation:

  • Primary diagnosis with correct ICD-10 code
  • Cancer staging clearly documented
  • Prior therapy history with dates and outcomes
  • Recent imaging/lab results included
  • Treatment plan and monitoring schedule

Coding Accuracy:

  • Correct Cabometyx tablet NDCs (not capsules)
  • Accurate dosing and quantity calculations
  • J8999 code if billing medical benefit
  • Supporting diagnosis codes included

Administrative Details:

  • Patient demographics and member ID verified
  • Prescriber information complete
  • In-network provider confirmed
  • Submission method verified (portal vs. fax)

California-Specific:

  • Plan type confirmed (DMHC vs. CDI regulated)
  • Appeal rights information provided to patient
  • IMR timeline explained if initial denial occurs

Financial Assistance Options

Counterforce Health helps patients navigate the complex prior authorization and appeals process by creating evidence-backed appeals that address specific denial reasons. The platform analyzes denial letters and creates targeted rebuttals using the insurer's own coverage policies.

Additional Cost Support:

  • Exelixis Patient Assistance: Income-based free drug program
  • Copay assistance: Up to $25,000/year for eligible patients
  • Foundation grants: CancerCare, Patient Advocate Foundation
  • California state programs: Verify eligibility through Covered California

FAQ

How long does UnitedHealthcare prior authorization take for Cabometyx? Standard PA decisions are made within 72 hours for urgent requests and 15 days for non-urgent requests. OptumRx has recently streamlined their process to improve approval times.

What if Cabometyx is non-formulary on my plan? Non-formulary medications can still be covered through the exceptions process. Your oncologist needs to demonstrate medical necessity and that formulary alternatives are inappropriate.

Can I request an expedited appeal in California? Yes, both UnitedHealthcare internal appeals and California IMR offer expedited review for urgent medical situations. Your oncologist must certify that delay could harm your health.

Does step therapy apply if I've tried treatments outside California? Yes, prior treatments from any state count toward step therapy requirements. Ensure your oncologist documents all previous therapies with dates and outcomes.

What happens if UnitedHealthcare approves Cabometyx but limits the quantity? Quantity limits can be appealed using the same process. Include dosing rationale and treatment guidelines that support the prescribed quantity.

How do I know if my plan is regulated by DMHC or CDI? Most UnitedHealthcare HMO and PPO plans in California are DMHC-regulated. Check your member ID card or call member services to confirm which regulator oversees your plan.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and change frequently. Always verify current requirements with UnitedHealthcare and consult with your healthcare provider about treatment decisions. For personalized assistance with appeals and prior authorizations, consider consulting with organizations like Counterforce Health that specialize in insurance coverage advocacy.

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