By Counterforce Health Team in Oxervate (cenegermin) —

How to Get Oxervate (Cenegermin) Covered by UnitedHealthcare in New York: Complete Prior Authorization and Appeals Guide

Answer Box: Get Oxervate Covered by UnitedHealthcare in New York

UnitedHealthcare requires prior authorization for Oxervate (cenegermin) with specific criteria: confirmed Stage 2 or 3 neurotrophic keratitis diagnosis and documented failure of at least one OTC artificial tear product. Submit PA through the OptumRx portal or fax to 1-844-403-1027. If denied, New York residents have strong appeal rights including 180-day internal appeal deadlines and external review through the Department of Financial Services. Start today: Gather your ophthalmology records documenting NK staging and artificial tear trial failure, then contact your prescriber to initiate the PA request.

Table of Contents

  1. Why New York State Rules Matter
  2. UnitedHealthcare Prior Authorization Requirements
  3. New York Turnaround Standards
  4. Step Therapy Protections in New York
  5. Appeals Process: Internal and External Review
  6. Practical Scripts and Documentation
  7. Coverage Limits and ERISA Considerations
  8. Quick Reference: Contacts and Forms
  9. FAQ

Why New York State Rules Matter

New York has some of the strongest patient protection laws in the nation, and they directly impact how UnitedHealthcare must handle Oxervate denials. With over 95% of New Yorkers having health insurance and UnitedHealthcare holding about 26% market share, understanding your state-specific rights is crucial.

Key New York Advantages

  • Extended appeal deadlines: 180 days to file internal appeals (up from 60 days in many states)
  • Robust external review: Independent medical experts through the Department of Financial Services
  • Step therapy override protections: Five specific criteria that must grant exceptions
  • Expedited review rights: 72-hour standard, 24-hour for urgent drug appeals

New York's laws apply to fully insured plans but may not cover self-funded employer plans under ERISA. However, many self-funded plans voluntarily follow state timelines.

UnitedHealthcare Prior Authorization Requirements

UnitedHealthcare covers Oxervate under OptumRx prior authorization when strict medical necessity criteria are met. The UnitedHealthcare Oxervate policy requires:

Coverage Criteria Table

Requirement What It Means Documentation Needed
Diagnosis Stage 2 or 3 neurotrophic keratitis Chart note explicitly stating staging
Prior therapy Failed at least one OTC artificial tear Product name, duration, outcome
Prescriber Ophthalmologist or consultation Specialist involvement documented
Staging evidence Objective findings consistent with NK Slit-lamp exam, corneal sensitivity testing

Required Clinical Documentation

Your ophthalmologist should include:

  • ICD-10 codes: H16.231-H16.233 for affected eye(s)
  • Corneal sensitivity testing results (Cochet-Bonnet or equivalent)
  • Artificial tear trial details: specific product, frequency (typically 6x/day), duration (usually 4+ weeks), and lack of epithelial closure
  • Underlying etiology if known (herpetic disease, diabetes, trigeminal nerve damage)

New York Turnaround Standards

Standard Prior Authorization Timeline

  • UnitedHealthcare/OptumRx: Typically 3-5 business days for standard PA
  • Expedited/urgent: 72 hours when delay would seriously jeopardize health

New York-Specific Protections

Under recent state reforms, insurers face penalties up to $10,000 per day for missing urgent appeal deadlines. For Oxervate, document urgency if there's:

  • Active corneal melting or impending perforation
  • Rapid progression of epithelial defect
  • Risk of permanent vision loss without immediate treatment
Tip: For vision-threatening cases, explicitly request expedited review and have your ophthalmologist document that delay would "seriously jeopardize the patient's ability to regain maximum function."

Step Therapy Protections in New York

New York Insurance Law § 4903 provides five specific grounds for step therapy overrides. For Oxervate, the most relevant are:

Override Criteria That Apply to Oxervate

  1. Expected ineffectiveness based on clinical characteristics
  2. Prior failure of required drug (artificial tears)
  3. Patient stability on current therapy (for re-authorization)
  4. Adherence barriers or functional impact

Required Documentation for Override

Your request must include "supporting rationale and documentation" to trigger the 72-hour decision deadline. Include:

  • Explicit statutory reference: "Step Therapy Protocol Override Request under NY Insurance Law § 4903(c-1)"
  • Clinical facts supporting the override criterion
  • Provider statement that switching is not in the patient's best interest

Timeline Protections

  • 72 hours for standard step therapy override decisions
  • 24 hours for urgent cases
  • Deemed approved if UnitedHealthcare misses deadlines

Appeals Process: Internal and External Review

Internal Appeals with UnitedHealthcare

Deadline: 180 days from denial date (New York extended timeline)

How to file:

  • OptumRx member portal
  • Written appeal to address on denial letter
  • Fax: 1-844-403-1027 (verify current number)

Required documents:

  • Completed appeal form
  • Medical necessity letter from ophthalmologist
  • Clinical records supporting NK staging
  • Documentation of artificial tear failure

External Review Through New York DFS

If UnitedHealthcare upholds the denial, you can request external review by independent medical experts.

Eligibility: Denials based on medical necessity, experimental/investigational status, or out-of-network requirements

Deadline: 4 months from final adverse determination

Process:

  1. Complete New York State External Appeal Application
  2. Submit online at DFS External Appeal Portal
  3. Include physician attestation form and consent to release records

Decision timeline: 30 days standard, 72 hours expedited (24 hours for non-formulary drugs)

Note: External appeal decisions are binding on UnitedHealthcare and have historically favored patients in similar rare disease cases.

Practical Scripts and Documentation

Phone Script for UnitedHealthcare

"I'm calling about a prior authorization denial for Oxervate for neurotrophic keratitis. My patient meets your published criteria with documented Stage 2 NK and artificial tear failure. I need to understand the specific clinical reason for denial and request a peer-to-peer review with an ophthalmologist."

Medical Necessity Letter Template Points

Your ophthalmologist should address:

  1. Diagnosis confirmation: "The patient has Stage 2 neurotrophic keratitis affecting the [right/left] eye with documented corneal sensitivity reduction to [measurement] and persistent epithelial defect measuring [size]."
  2. Prior therapy failure: "Conservative treatment with [specific OTC tear product] at 6 times daily for [duration] failed to achieve epithelial closure, with documented persistence of the corneal defect."
  3. Risk without treatment: "Without Oxervate therapy, the patient faces significant risk of corneal perforation and permanent vision loss in this [only/better] seeing eye."
  4. Guideline support: Reference FDA labeling and relevant ophthalmology society guidelines supporting Oxervate use in Stage 2/3 NK.

Coverage Limits and ERISA Considerations

Fully Insured vs. Self-Funded Plans

  • Fully insured UnitedHealthcare plans: Subject to all New York state protections
  • Self-funded employer plans: May not be required to follow state appeal timelines but often do voluntarily
  • Check your plan type: Look for "insured by UnitedHealthcare" vs. "administered by UnitedHealthcare"

Coverage Duration

UnitedHealthcare typically approves one 8-week course initially. Re-authorization may be considered but requires:

  • Documentation of clinical response to initial course
  • Evidence of recurrent or persistent disease
  • Ophthalmologist attestation of continued medical necessity

Quick Reference: Contacts and Forms

Key Contacts

  • OptumRx Prior Authorization: 1-800-711-4555
  • New York DFS External Appeals: 1-800-400-8882
  • Community Health Advocates (free help): 888-614-5400

Essential Forms

State Resources

From our advocates: We've seen multiple UnitedHealthcare Oxervate denials overturned when providers included detailed corneal sensitivity measurements and specific artificial tear trial documentation. The key is meeting their exact criteria with objective evidence rather than general statements about treatment failure.

When dealing with insurance coverage challenges, Counterforce Health helps patients, clinicians, and specialty pharmacies turn denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to craft point-by-point rebuttals using the right clinical evidence and procedural requirements for each payer.

FAQ

How long does UnitedHealthcare prior authorization take for Oxervate in New York? Standard PA typically takes 3-5 business days. Expedited review for urgent cases must be completed within 72 hours under New York law.

What if Oxervate is non-formulary on my UnitedHealthcare plan? Non-formulary status doesn't prevent coverage if medical necessity criteria are met. You may need a formulary exception, which follows similar PA processes.

Can I request an expedited appeal if my Oxervate is denied? Yes, if your ophthalmologist certifies that delay would seriously jeopardize your health or ability to regain maximum function. Expedited external appeals get 24-hour decisions for drug denials.

Does step therapy apply if I've already failed artificial tears outside New York? Prior therapy failure from any location should count toward UnitedHealthcare's step therapy requirements. Document the specific products tried and outcomes.

What happens if UnitedHealthcare misses appeal deadlines in New York? Under New York law, missed deadlines result in deemed approval of your request. Document the timeline and request written confirmation.

How much does Oxervate cost without insurance coverage? An 8-week course commonly costs in the low six figures. Contact Dompé's patient assistance program for potential support options.

Can Community Health Advocates help with UnitedHealthcare denials? Yes, CHA provides free assistance to all New Yorkers regardless of insurer and has historically achieved strong success rates in denial-related cases.

What's the success rate for external appeals in New York? While specific Oxervate data isn't published, New York external appeals have historically high overturn rates, and UnitedHealthcare of New York showed a 99.72% reversal rate in recent grievance data.

Getting Oxervate covered requires persistence and proper documentation, but New York's strong patient protections provide multiple pathways to challenge denials. Counterforce Health can help navigate complex appeals processes and ensure your case includes all necessary clinical evidence and procedural 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 medical circumstances. Always consult with your healthcare provider and insurance plan for specific guidance. For official information about New York insurance regulations, visit the Department of Financial Services website.

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