By Counterforce Health Team in Signifor / Signifor LAR (pasireotide) —

How to Get Signifor LAR (Pasireotide) Covered by UnitedHealthcare in Ohio: Complete Prior Authorization and Appeal Guide

Quick Answer: Getting Signifor LAR Approved in Ohio

UnitedHealthcare requires prior authorization for Signifor LAR (pasireotide) with specific criteria: confirmed endogenous Cushing's disease and documentation that pituitary surgery wasn't curative or isn't an option. No step therapy required. If denied, you have 180 days for internal appeals, then external review through Ohio's Department of Insurance. Start by gathering your surgical history, biochemical tests (24-hour urinary free cortisol), and endocrinologist's notes. Submit through OptumRx specialty pharmacy portal immediately.

First step today: Call UnitedHealthcare member services at the number on your card to confirm your specific plan's PA requirements and get the OptumRx specialty pharmacy contact information.

Table of Contents

  1. Understanding Your Denial Letter
  2. UnitedHealthcare's Signifor LAR Coverage Requirements
  3. Fixing Common Issues Before Appeals
  4. First-Level Appeal Strategy
  5. Peer-to-Peer Review Process
  6. Ohio External Review Process
  7. Appeal Templates and Scripts
  8. Tracking Your Case
  9. Cost Assistance Options
  10. When to Escalate to Regulators

Understanding Your Denial Letter

When UnitedHealthcare denies Signifor LAR coverage, your denial letter will specify the reason and include crucial deadlines. Common denial codes include:

Most Frequent Denial Reasons:

  • Missing biochemical documentation (24-hour urinary free cortisol results)
  • Inadequate surgical history documentation
  • Non-specialist prescriber (requires board-certified endocrinologist)
  • Incomplete prior authorization submission to OptumRx
Tip: Look for the "Member Rights" section in your denial letter—it outlines your appeal timeline and submission options specific to your plan type.

Your denial letter must include:

  • Specific reason for denial
  • Internal appeal deadline (typically 180 days for commercial plans)
  • Required forms or submission process
  • Contact information for appeals

UnitedHealthcare's Signifor LAR Coverage Requirements

Coverage at a Glance

Requirement What It Means Documentation Needed Source
Prior Authorization Required through OptumRx Complete PA form with clinical data UHC PA Notification
Diagnosis Endogenous Cushing's disease only ICD-10 codes, clinical notes UHC PA Notification
Surgical Status Surgery not curative OR not a candidate Operative notes, specialist assessment UHC PA Notification
Prescriber Board-certified endocrinologist preferred Medical license verification Clinical best practice
Quantity Limits 1 vial per 28 days (LAR formulation) Dosing schedule documentation OptumRx Guidelines

Biochemical Documentation Requirements

For Cushing's disease coverage, you'll need:

  • Two elevated 24-hour urinary free cortisol (UFC) tests above laboratory reference range
  • Late-night salivary cortisol results (if UFC unavailable)
  • ACTH levels to confirm ACTH-dependent disease
  • Clinical symptoms documented in medical records
Note: Use liquid chromatography-mass spectrometry for UFC testing when possible—it's the gold standard insurers prefer.

Fixing Common Issues Before Appeals

Before filing a formal appeal, check these fixable problems:

Missing Documentation Checklist

  • Complete OptumRx prior authorization form
  • Board-certified endocrinologist's prescription and clinical notes
  • Two abnormal UFC or late-night salivary cortisol results
  • Surgical consultation notes or operative reports
  • ICD-10 diagnosis codes for Cushing's disease
  • Current insurance card and member ID verification

Coding and Submission Issues

  • Wrong pharmacy: Signifor LAR must go through OptumRx specialty pharmacy, not retail
  • Incomplete forms: Missing signature, date, or clinical justification
  • Timing issues: PA submitted after prescription fill attempt

Contact OptumRx directly at the number provided in your member materials to verify submission status before appealing.

First-Level Appeal Strategy

Step-by-Step Internal Appeal Process

  1. Submit within deadline (180 days for most commercial plans)
  2. Use multiple submission methods: Online portal, fax, and certified mail
  3. Include comprehensive medical necessity letter
  4. Attach all supporting documentation
  5. Request expedited review if medically urgent

Medical Necessity Letter Components

Your appeal letter should address:

Clinical Rationale Section:

  • Confirmed diagnosis of endogenous Cushing's disease
  • Specific biochemical evidence (UFC levels, timing)
  • Physical examination findings consistent with Cushing's
  • Impact on quality of life and functional status

Surgical History Documentation:

  • Previous pituitary surgery details and outcomes
  • Reason surgery wasn't curative (residual disease, recurrence)
  • OR medical contraindications to surgery
  • Specialist consultation recommendations

Treatment Justification:

  • Why Signifor LAR is medically necessary
  • Expected clinical benefits
  • Monitoring plan for glucose and gallbladder function
  • Dosing rationale (10-40 mg every 4 weeks)

Peer-to-Peer Review Process

Scheduling Your Review

UnitedHealthcare offers peer-to-peer reviews where your endocrinologist speaks directly with their medical director. This often resolves denials faster than formal appeals.

Key Requirements:

  • Must be requested within 24 hours of denial notification
  • Only the prescribing physician can participate
  • Schedule through UnitedHealthcare Provider Portal
  • Prepare clinical talking points in advance

Peer-to-Peer Success Strategies

Before the Call:

  • Review UnitedHealthcare's specific Signifor policy criteria
  • Prepare patient timeline with key clinical milestones
  • Have lab results and imaging readily available
  • Practice concise clinical summary (2-3 minutes)

During the Call:

  • Lead with diagnosis and biochemical confirmation
  • Emphasize surgical history/contraindications
  • Address any step therapy concerns proactively
  • Offer to provide additional documentation immediately

Ohio External Review Process

If UnitedHealthcare upholds their denial after internal appeals, Ohio residents can request an independent external review.

External Review Timeline

Review Type Decision Deadline How to Request
Standard 30 days Written request to health plan
Expedited (urgent) 72 hours Phone/electronic with written follow-up

Filing Requirements

Deadline: Within 180 days of final internal denial Eligibility: Denials based on medical necessity, experimental/investigational determinations Cost: No fee for external review in Ohio

Required Documentation:

  • Copy of final denial letter from UnitedHealthcare
  • All medical records supporting your case
  • Physician statement of medical necessity
  • Completed external review request form

Submit to: Your health plan first (they forward to Ohio Department of Insurance)

Ohio Department of Insurance Contact

For questions about external review:

Appeal Templates and Scripts

Patient Phone Script for UnitedHealthcare

"Hi, I'm calling about a prior authorization denial for Signifor LAR. My member ID is [ID number]. I'd like to understand the specific reason for denial and start the appeal process. Can you please connect me with someone who can help with specialty drug appeals and provide the correct forms?"

Medical Necessity Letter Template

[Date]
[UnitedHealthcare Appeals Department Address]

RE: Appeal for Prior Authorization Denial
Member: [Name, DOB, Member ID]
Medication: Signifor LAR (pasireotide)
Denial Date: [Date]

Dear Medical Director,

I am writing to appeal the denial of coverage for Signifor LAR for my patient with confirmed endogenous Cushing's disease. This medication is medically necessary based on the following clinical evidence:

DIAGNOSIS AND BIOCHEMICAL CONFIRMATION:
- Confirmed endogenous Cushing's disease diagnosed [date]
- Elevated 24-hour urinary free cortisol: [values and dates]
- Clinical presentation consistent with Cushing's syndrome
- ACTH-dependent disease confirmed

SURGICAL HISTORY:
- [Previous surgery details] OR [Contraindications to surgery]
- [Outcome/reason surgery not curative]

MEDICAL NECESSITY:
- Patient meets UnitedHealthcare policy criteria for Signifor LAR
- Expected to improve biochemical control and quality of life
- Appropriate monitoring plan in place

I respectfully request reconsideration of this denial. Please contact me at [phone] with any questions.

Sincerely,
[Physician name and credentials]

Tracking Your Case

Appeal Status Monitoring

UnitedHealthcare Tracking Methods:

  • Provider portal case status updates
  • Phone follow-up every 7-10 days
  • Written confirmation of receipt
  • Documentation of all communications

Create an Appeal Log:

  • Date of each submission/call
  • Person spoken with (name, title)
  • Reference numbers assigned
  • Next steps or deadlines given
  • Documents requested or provided

Cost Assistance Options

While pursuing coverage, explore these cost-reduction programs:

Manufacturer Support

Recordati Rare Diseases offers patient assistance programs (verify current availability and eligibility at their official website or through your specialty pharmacy).

Specialty Pharmacy Services

OptumRx provides:

  • Insurance verification and prior authorization support
  • Copay assistance program coordination
  • Injection training for LAR formulation
  • Ongoing clinical monitoring

State and Federal Programs

  • Ohio Medicaid may cover Signifor LAR with appropriate documentation
  • Medicare Part D coverage varies by plan formulary
  • Clinical trial opportunities through ClinicalTrials.gov

When to Escalate to Regulators

Filing a Complaint with Ohio Regulators

Contact the Ohio Department of Insurance if:

  • UnitedHealthcare doesn't respond within required timeframes
  • You believe the denial violates state insurance laws
  • The external review process is improperly denied

Ohio Department of Insurance Complaint Process:

Federal Options

For self-funded employer plans (ERISA), contact:

  • U.S. Department of Labor Employee Benefits Security Administration
  • Phone: 866-444-3272

Counterforce Health helps patients and clinicians navigate complex prior authorization and appeals processes for specialty medications. Our platform analyzes denial letters, identifies specific policy requirements, and generates targeted appeals with the right clinical evidence and regulatory citations. By turning insurance denials into evidence-backed rebuttals, we help patients get faster access to needed treatments while reducing the administrative burden on healthcare providers.

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take for Signifor LAR in Ohio? Standard prior authorization decisions are typically made within 72 hours for urgent cases, or up to 15 business days for non-urgent requests through OptumRx.

What if Signifor LAR is non-formulary on my plan? Non-formulary status doesn't prevent coverage—it typically means higher copays and stricter prior authorization requirements. Focus your appeal on medical necessity and policy criteria compliance.

Can I request an expedited appeal if my condition is worsening? Yes, if delay in treatment could seriously jeopardize your health, request expedited review. Both internal appeals and Ohio external review offer expedited timelines (typically 72 hours).

Does step therapy apply to Signifor LAR in Ohio? UnitedHealthcare's current policy does not require step therapy for Signifor LAR in Cushing's disease. Approval is based on diagnosis confirmation and surgical history, not prior medication failures.

What happens if I disagree with the external review decision? External review decisions are binding on your insurance plan, but you retain the right to pursue other legal remedies or file regulatory complaints if you believe the process was flawed.

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 guidance specific to your situation. For official Ohio insurance regulations and complaint processes, visit insurance.ohio.gov.

Sources & Further Reading

For additional support with complex appeals and prior authorization challenges, visit Counterforce Health for resources and assistance.

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