By Counterforce Health Team in Cabometyx (cabozantinib) —

How to Get Cabometyx (Cabozantinib) Covered by UnitedHealthcare in Washington: Complete PA Guide with ICD-10 Codes and Appeals

Answer Box: Getting Cabometyx Covered by UnitedHealthcare in Washington

UnitedHealthcare requires prior authorization (PA) for Cabometyx (cabozantinib tablets) through OptumRx for all FDA-approved cancer indications in Washington. Submit PA with confirmed diagnosis (ICD-10: C64 for RCC, C22.0 for HCC), prior therapy documentation, and RECIST imaging showing progression. If denied, pursue internal appeals within 60 days, then external review through Washington's Independent Review Organization (IRO) system within 180 days.

First step today: Have your oncologist submit PA via UHC Provider Portal with complete documentation or call 866-889-8054 for expedited review.

Table of Contents

Coding Basics: Medical vs. Pharmacy Benefit

Cabometyx (cabozantinib tablets) is typically covered under the pharmacy benefit rather than medical benefit, which affects both coding and prior authorization pathways.

Pharmacy Benefit Path (Primary)

  • NDC codes are used for billing
  • Prior authorization through OptumRx
  • Copay/coinsurance applies based on specialty tier
  • 30-day supply limits common

Medical Benefit Path (Rare for Tablets)

  • Only applies to injectable cabozantinib (different formulation)
  • Uses HCPCS J-code J9179 for injection
  • Requires administration codes and modifier documentation
Important: Cabometyx tablets and cabozantinib capsules are not interchangeable. UnitedHealthcare frequently denies requests that don't specify the correct formulation.

ICD-10 Mapping for Cabometyx Coverage

Accurate ICD-10 coding is critical for Cabometyx prior authorization approval. Here are the primary codes by indication:

Primary Cancer Codes

Cancer Type ICD-10 Code Documentation Requirements
Renal Cell Carcinoma C64.1 (right kidney)
C64.2 (left kidney)
C64.9 (unspecified)		 Pathology report with histology, staging (TNM), imaging showing progression
Hepatocellular Carcinoma C22.0 (liver cell carcinoma) Liver biopsy/imaging confirming HCC, staging, alpha-fetoprotein levels
Differentiated Thyroid Cancer C73 (malignant neoplasm of thyroid) Thyroid biopsy confirming papillary/follicular subtype, staging

Metastatic Disease Codes

  • Secondary kidney involvement: C79.01 (right), C79.02 (left)
  • Secondary liver: C78.7
  • Always sequence primary malignancy first

Documentation Words That Support Coding

Your medical records should include specific language that supports the ICD-10 code assignment:

  • For RCC: "Clear cell renal cell carcinoma," "papillary RCC," laterality (right/left kidney)
  • For HCC: "Hepatocellular carcinoma," "liver cell carcinoma" (not just "liver cancer")
  • Staging information: TNM staging, AJCC stage, performance status (ECOG)

Product Coding: NDCs and HCPCS

NDC Codes for Cabometyx Tablets

Strength NDC Code Package Size Notes
20 mg 57962-0304-30 30-count bottle Lower dose for toxicity management
40 mg 57962-0305-30 30-count bottle Dose reduction option
60 mg 57962-0306-30 30-count bottle Standard HCC/RCC dosing

HCPCS Alternatives

  • J8999: Oral chemotherapeutic, NOS (not otherwise specified) - sometimes used when NDCs aren't accepted
  • J9179: Injectable cabozantinib, 1 mg - only for injection formulation

Units and Quantity Calculations

  • Standard dosing: 60 mg daily = 30 tablets per month
  • Always verify exact NDC with your pharmacy to avoid substitution denials

Clean Prior Authorization Request

A successful Cabometyx PA request includes these essential elements:

Required Clinical Information

  1. Patient Demographics: Full name, DOB, member ID, provider NPI
  2. Diagnosis: Primary ICD-10 code with laterality/specificity
  3. Clinical History: Prior therapies tried, dates, outcomes, reasons for discontinuation
  4. Current Status: ECOG performance status, recent imaging with RECIST measurements
  5. Prescription Details: Exact NDC, strength, quantity, directions

Supporting Documentation Checklist

  • Pathology report confirming cancer type and histology
  • Staging information (TNM, AJCC)
  • Recent imaging showing progression (CT, MRI with RECIST 1.1 measurements)
  • Prior therapy summary with dates and outcomes
  • Laboratory values (CBC, comprehensive metabolic panel, liver function)
  • NCCN guideline citations supporting use
Clinician Corner: Your medical necessity letter should address why Cabometyx is appropriate for this specific patient, including contraindications to alternatives and expected treatment goals. Reference FDA labeling and NCCN guidelines Category 1 or 2A recommendations when available.

Common Coding Pitfalls

Frequent Denial Triggers

  1. Wrong Formulation: Requesting capsules instead of tablets
  2. Missing Laterality: Using C64.9 when C64.1 or C64.2 is appropriate
  3. Incorrect Line of Therapy: Not documenting prior treatments for subsequent-line indications
  4. Insufficient Imaging: Missing RECIST measurements or progression documentation

How to Avoid These Issues

  • Always specify "Cabometyx tablets" in prescriptions
  • Include specific kidney laterality when known from imaging/pathology
  • Document complete treatment history with dates and outcomes
  • Ensure imaging reports include measurable disease per RECIST criteria

Verification with UnitedHealthcare

Before submitting your PA request, verify these details:

Member Portal Checks

  1. Formulary Status: Confirm Cabometyx is on formulary (typically Tier 4-5 specialty)
  2. PA Requirements: Review current OptumRx PA criteria
  3. Copay Information: Understand patient's financial responsibility

Provider Portal Resources

  • Access PA forms and submission guidelines
  • Check real-time PA status
  • Review denial reasons and appeal options

Contact Information for Verification

  • UnitedHealthcare Provider Services: 866-889-8054
  • OptumRx Prior Authorization: Available through provider portal
  • Member Services: Number on back of insurance card

Appeals Process in Washington

Washington State provides robust appeal rights for UnitedHealthcare denials, including external review through Independent Review Organizations (IROs).

Internal Appeals (Required First Step)

Level Timeline Process
Stage 1 File within 60 days of denial Submit via member portal, written request, or phone
Stage 2 File within 60 days of Stage 1 denial Include additional clinical evidence
Expedited 72 hours for urgent cases Request if delay risks health

External Review Process

After exhausting internal appeals, Washington residents can request external review through the state's IRO system:

  • Timeline to file: Up to 180 days from final internal denial
  • Standard review: Decision within 30-45 days
  • Expedited review: 72 hours for urgent oncology cases
  • Cost: Free to enrollees
  • Contact: Washington State Office of the Insurance Commissioner at 1-800-562-6900

Required Documents for Appeals

  • Original denial letter with reason codes
  • Complete medical records supporting medical necessity
  • Peer-reviewed literature supporting off-label use (if applicable)
  • Provider attestation of medical necessity
From our advocates: We've seen oncology drug appeals succeed about 40-60% of the time when they include comprehensive prior therapy documentation and clear evidence of disease progression. The key is addressing the specific denial reason with targeted clinical evidence, not just resubmitting the same information.

Quick Audit Checklist

Before submitting your Cabometyx PA or appeal, review this checklist:

Pre-Submission Review

  • Correct drug name specified (Cabometyx tablets, not capsules)
  • Accurate NDC code for prescribed strength
  • Complete ICD-10 code with laterality when applicable
  • Prior therapy history with specific dates and outcomes
  • Recent imaging with progression documentation
  • Performance status assessment (ECOG)
  • All required attachments included
  • Provider signature and NPI number
  • Patient consent for information sharing

Quality Check

  • Medical necessity clearly articulated
  • NCCN or FDA references included
  • Contraindications to alternatives addressed
  • Dosing rationale provided
  • Monitoring plan outlined

Cost Assistance and Support Programs

While pursuing coverage approval, patients may benefit from financial assistance:

Manufacturer Support

  • Exelixis Patient Support Program: Provides copay assistance and free drug programs for eligible patients
  • Eligibility: Typically for patients with commercial insurance and income qualifications

Foundation Grants

  • Patient Access Network (PAN) Foundation: Provides copay assistance for cancer medications
  • CancerCare: Offers financial assistance and case management

State Programs

  • Washington Apple Health (Medicaid): May cover Cabometyx with prior authorization
  • Washington Prescription Drug Program: Additional state assistance options

FAQ

How long does UnitedHealthcare PA take for Cabometyx in Washington? Standard PA decisions take 72 hours for routine requests, 24-48 hours for expedited reviews when clinical urgency is documented.

What if Cabometyx is non-formulary on my UnitedHealthcare plan? Submit a formulary exception request with your PA, including medical necessity documentation and evidence that formulary alternatives are inappropriate.

Can I request an expedited appeal if my cancer is progressing? Yes, Washington allows expedited appeals for urgent medical situations. Document that delay would jeopardize your health and request 72-hour review.

Does step therapy apply if I've tried other treatments outside Washington? Prior therapy from other states counts toward step therapy requirements. Include complete documentation of treatments, dates, and outcomes.

What happens if UnitedHealthcare misses appeal deadlines? If UnitedHealthcare exceeds internal appeal timelines without good cause, you can proceed directly to external review through Washington's IRO system.

How much does external review cost in Washington? External review through Washington's IRO system is free to enrollees. UnitedHealthcare pays the IRO fees.

When Treatment Coverage Gets Complex

Navigating cancer treatment approvals can feel overwhelming, especially when dealing with prior authorizations and appeals. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to identify the specific denial basis—whether it's PA criteria, step therapy, or "not medically necessary"—then drafts point-by-point rebuttals aligned to the plan's own rules.

For medications like Cabometyx, Counterforce Health pulls the right clinical evidence, including FDA labeling, peer-reviewed studies, and specialty guidelines, weaving them into appeals with required clinical facts like diagnosis codes, prior treatment history, and dosing rationale. This systematic approach helps create cleaner submissions that reduce back-and-forth with insurers and improve approval rates.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and is not medical advice. Always consult with your healthcare provider about treatment decisions and insurance coverage options. Coverage policies may vary by plan and change over time. Verify current requirements with UnitedHealthcare and Washington state regulators.

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