By Counterforce Health Team in Sylvant (siltuximab) —

How to Get Sylvant (Siltuximab) Covered by UnitedHealthcare in New Jersey: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Sylvant Covered by UnitedHealthcare in New Jersey

Sylvant (siltuximab) requires mandatory prior authorization from UnitedHealthcare for multicentric Castleman disease. Your oncologist submits the PA request through the UnitedHealthcare Provider Portal with HIV-negative/HHV-8-negative test results, complete pathology report, and clinical documentation. If denied, you have 180 days to file an external appeal through New Jersey's Independent Health Care Appeals Program (IHCAP). First step today: Ask your oncologist's office to gather your HIV/HHV-8 test results and biopsy report—these are the most common missing pieces that cause delays.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization PA required for all Sylvant prescriptions UnitedHealthcare Provider Portal UHC NJ Prior Auth Guide
ICD-10 Code D47.Z2 (Castleman disease) Medical records, claims CMS POMS DI 23022.625
HCPCS J-Code J2860 (siltuximab, 10 mg per unit) Billing department NDC List J2860
NDC Numbers 73090-420-01 (100mg), 73090-421-01 (400mg) Pharmacy/billing Sylvant Ordering Guide
HIV/HHV-8 Status Must be negative (documented within 6 months) Lab results FDA Label
External Review 180 days from final denial IHCAP through Maximus NJ DOBI

Step-by-Step: Fastest Path to Approval

1. Confirm Diagnosis Documentation (Patient + Clinic)

Timeline: 1-2 days
Your oncologist needs these three critical pieces:

  • HIV-negative test (within 6 months)
  • HHV-8-negative test (within 6 months)
  • Complete lymph node biopsy report confirming multicentric Castleman disease
Tip: Call your lab directly to expedite results if tests are pending.

2. Calculate Dosing and Billing Units (Clinic)

Timeline: Same day
Sylvant is dosed at 11 mg/kg every 3 weeks. For billing:

  • Use HCPCS code J2860 (10 mg per unit)
  • Example: 70 kg patient = 770 mg dose = 77 billing units
  • Include appropriate NDC number based on vial size used

3. Submit Prior Authorization (Clinic)

Timeline: 1-5 business days for decision
Submit through:

Required attachments:

  • Medical necessity letter
  • Lab results (HIV/HHV-8 negative)
  • Complete pathology report
  • Recent CBC and comprehensive metabolic panel
  • Patient weight documentation

4. Request Peer-to-Peer if Denied (Clinic)

Timeline: Within 24 hours of denial
Your oncologist can request a direct discussion with a UnitedHealthcare medical director. This often resolves denials based on missing context or documentation.

5. File Internal Appeal if Needed (Patient or Clinic)

Timeline: 180 days from denial
UnitedHealthcare typically requires two levels of internal appeal before external review. Submit additional clinical documentation addressing the specific denial reason.

6. External Review Through IHCAP (Patient)

Timeline: 180 days from final internal denial
If internal appeals fail, file with New Jersey's Independent Health Care Appeals Program through Maximus Federal Services.

Coding That Helps Get Sylvant Approved

ICD-10 Diagnosis Code

D47.Z2 is the only U.S. ICD-10 code for Castleman disease, covering both unicentric and multicentric forms. This code is required for all claims and prior authorization requests.

HCPCS J-Code and Units Calculation

  • J2860: Injection, siltuximab, 10 mg per unit
  • Dosing: 11 mg/kg every 3 weeks
  • Units calculation: (Patient weight in kg × 11) ÷ 10 = billing units

Example calculations:

  • 60 kg patient: 660 mg ÷ 10 = 66 units
  • 80 kg patient: 880 mg ÷ 10 = 88 units
  • 100 kg patient: 1,100 mg ÷ 10 = 110 units

NDC Numbers and Vial Selection

  • 100 mg vial: NDC 73090-420-01
  • 400 mg vial: NDC 73090-421-01

Choose vial combinations that minimize waste while meeting the calculated dose.

Common Coding Pitfalls

  • Wrong ICD-10: Using D47.7 instead of D47.Z2
  • Unit errors: Forgetting to divide by 10 for J2860 billing
  • Missing NDC: Claims may be denied without proper NDC matching vial size
  • Weight conversion: Using pounds instead of kilograms in calculations

Common Denial Reasons & How to Fix Them

Denial Reason Fix Strategy Required Documentation
Missing HIV/HHV-8 status Submit current negative test results Lab reports dated within 6 months
Insufficient pathology Provide complete biopsy report Full histopathology confirming multicentric Castleman disease
"Not medically necessary" Submit detailed medical necessity letter Clinical notes, prior treatments, symptom progression
Step therapy not completed Request medical exception Document contraindications to alternatives like tocilizumab
Coding errors Verify ICD-10 and HCPCS codes Use D47.Z2 and J2860 with correct units

Appeals Playbook for New Jersey

Internal Appeals (UnitedHealthcare)

Level 1: Standard internal review

  • Deadline: 180 days from denial
  • Timeline: 30 days for decision (72 hours if urgent)
  • Submission: UnitedHealthcare Provider Portal or member services

Level 2: Second internal review

  • Deadline: 60 days from Level 1 denial
  • Timeline: 30 days for decision
  • Requirements: Additional clinical documentation

External Review (New Jersey IHCAP)

After completing internal appeals, New Jersey residents can file an external review through the Independent Health Care Appeals Program.

Key details:

  • Deadline: 180 days from final internal denial
  • Cost: Free to patients (insurers pay all fees)
  • Administrator: Maximus Federal Services
  • Timeline: 45 days for standard review, expedited available
  • Contact: 1-888-393-1062

Required for external review:

  • Completed internal appeals
  • Medical records supporting medical necessity
  • Denial letters from UnitedHealthcare
  • Physician statement explaining why treatment is needed
Note: New Jersey's external review has binding authority—if the independent medical reviewers approve coverage, UnitedHealthcare must comply.

Clinician Corner: Medical Necessity Documentation

Essential Elements for Medical Necessity Letter

  1. Confirmed diagnosis: Idiopathic multicentric Castleman disease with supporting pathology
  2. Exclusion criteria met: HIV-negative and HHV-8-negative status documented
  3. Clinical presentation: Systemic symptoms, laboratory abnormalities, imaging findings
  4. Treatment rationale: Why siltuximab is appropriate first-line therapy
  5. Monitoring plan: Regular lab work and clinical assessments

Supporting Evidence to Include

  • FDA approval: Siltuximab is the only FDA-approved treatment for HIV-negative, HHV-8-negative multicentric Castleman disease
  • Clinical guidelines: Reference international diagnostic criteria published in Blood (2017)
  • Patient-specific factors: Contraindications to alternative treatments if applicable
From our advocates: We've seen denials overturned when physicians include specific language from the FDA label and emphasize that siltuximab is the only approved therapy for this rare condition. Including the exact FDA indication language can be particularly effective in appeals.

Patient Scripts & Templates

Calling UnitedHealthcare Member Services

"Hi, I'm calling about prior authorization for Sylvant, also called siltuximab, for multicentric Castleman disease. My member ID is [ID number]. Can you tell me the status of my request and what additional information might be needed?"

Requesting Expedited Review

"My condition is urgent because multicentric Castleman disease can progress rapidly without treatment. I'd like to request an expedited prior authorization review. What's the process for that?"

Following Up on Appeals

"I submitted an internal appeal for Sylvant coverage on [date]. Can you provide an update on the status and expected timeline for a decision?"

Costs & Financial Assistance

Manufacturer Support

Janssen offers patient assistance programs for eligible patients. Contact Janssen CarePath at 1-844-553-2792 or visit janssencareconnect.com to check eligibility.

Copay Assistance

For commercially insured patients, copay cards may be available to reduce out-of-pocket costs. Medicare and Medicaid patients are typically not eligible for manufacturer copay programs.

Foundation Grants

Several patient assistance foundations provide grants for rare disease treatments:

  • Patient Access Network Foundation
  • Good Days (formerly Chronic Disease Fund)
  • HealthWell Foundation

FAQ

How long does UnitedHealthcare prior authorization take for Sylvant? Standard requests take 1-5 business days for complete submissions. Complex cases requiring medical director review may take up to 30 days, but expedited review (24-72 hours) is available for urgent cases.

What if Sylvant isn't on UnitedHealthcare's formulary? Sylvant may require a formulary exception or non-formulary drug approval. Your physician can request this as part of the prior authorization process, emphasizing that it's the only FDA-approved treatment for your condition.

Can I appeal if I live in New Jersey but have coverage through an employer plan? Self-funded employer plans follow federal ERISA rules rather than New Jersey state appeals processes. However, UnitedHealthcare's internal appeal process applies to all members regardless of plan type.

What happens if my appeal is denied? After completing UnitedHealthcare's internal appeals, New Jersey residents can file an external review through IHCAP. This independent review is binding on the insurance company.

Does step therapy apply to Sylvant? Given that siltuximab is the only FDA-approved treatment for multicentric Castleman disease, step therapy requirements may not apply. However, some plans may still require documentation that alternatives were considered or are contraindicated.

How do I get help with the appeals process in New Jersey? Contact the NJ Department of Banking and Insurance Consumer Hotline at 1-800-446-7467 or the IHCAP-specific line at 1-888-393-1062 for guidance on external reviews.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters and creates targeted, evidence-backed appeals that address each payer's specific requirements, helping get critical medications like Sylvant approved faster.

Whether you're navigating UnitedHealthcare's prior authorization process or preparing for an external review in New Jersey, having the right documentation and following proper procedures significantly improves your chances of approval. The key is persistence and ensuring all clinical evidence clearly demonstrates medical necessity for this FDA-approved treatment.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual circumstances and plan terms. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For official appeals procedures, contact UnitedHealthcare directly or the New Jersey Department of Banking and Insurance.

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