By Counterforce Health Team in Tecentriq (atezolizumab) —

How to Get Tecentriq (atezolizumab) Covered by UnitedHealthcare in Virginia: Complete Coding, Appeals, and Authorization Guide

Answer Box: Getting Tecentriq Covered by UnitedHealthcare in Virginia

Tecentriq (atezolizumab) requires prior authorization from UnitedHealthcare and follows medical benefit billing using HCPCS code J9022. Your fastest path to approval: 1) Submit PA request with required PD-L1 testing results and proper ICD-10 codes (C34.x for lung cancer, C22.0 for liver cancer), 2) Use UnitedHealthcare Provider Portal for electronic submission, 3) If denied, file internal appeal within 180 days, then external review with Virginia's Bureau of Insurance within 120 days using Form 216-A.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 Mapping for Tecentriq Indications
  3. Product Coding: HCPCS, J-Codes, and NDCs
  4. Clean Authorization Request Anatomy
  5. Frequent Coding and Billing Pitfalls
  6. UnitedHealthcare Verification Steps
  7. Pre-Submission Audit Checklist
  8. Common Denial Reasons and Solutions
  9. Virginia Appeals Process
  10. Cost Assistance and Patient Support

Coding Basics: Medical vs. Pharmacy Benefit

Tecentriq (atezolizumab) is a provider-administered infusion therapy that's always billed under the medical benefit, not the pharmacy benefit. This means your oncology clinic or infusion center will submit claims using medical billing forms (CMS-1500 or UB-04) rather than pharmacy claims.

Key billing pathway:

  • Medical benefit: Uses HCPCS J-codes for the drug plus CPT codes for administration
  • Buy-and-bill model: Your provider purchases the medication and bills UnitedHealthcare after administration
  • Prior authorization required: Must be obtained before first infusion to avoid claim denials
Note: Unlike oral medications dispensed by specialty pharmacies, Tecentriq cannot be billed through UnitedHealthcare's pharmacy benefit or OptumRx. Always verify medical benefit coverage and obtain PA through the medical benefit pathway.

ICD-10 Mapping for Tecentriq Indications

Accurate diagnosis coding is critical for Tecentriq approval. UnitedHealthcare requires specific ICD-10 codes that match FDA-approved indications:

Primary Cancer Diagnoses

Cancer Type ICD-10 Codes Documentation Requirements
Non-Small Cell Lung Cancer C34.x (specify anatomical site) Histology confirmation, staging, PD-L1 testing results
Small Cell Lung Cancer C34.x (typically C34.90 if unspecified) Extensive vs. limited stage documentation
Hepatocellular Carcinoma C22.0 (liver cell carcinoma) Child-Pugh class, prior sorafenib trial
Melanoma C43.x (specify anatomical subsite) BRAF status, prior therapy history
Alveolar Soft Part Sarcoma C49.x (specify location) Rare tumor documentation, imaging

Metastatic Disease Codes

For stage IV disease, combine primary site codes with secondary site codes:

  • Brain metastases: C79.31
  • Liver metastases: C78.7
  • Bone metastases: C79.51
  • Lung metastases: C78.0
Documentation tip: Include specific anatomical sites (e.g., C34.10 for upper lobe, right bronchus) rather than unspecified codes when possible. This demonstrates thorough clinical assessment and reduces denial risk.

Product Coding: HCPCS, J-Codes, and NDCs

HCPCS J-Codes for Billing

Tecentriq (IV formulation):

  • J9022: Injection, atezolizumab, 10 mg
  • Bill in 10 mg increments based on actual dose administered

Tecentriq Hybryza (subcutaneous):

  • J9024: Injection, atezolizumab, 5 mg and hyaluronidase-tqjs
  • For subcutaneous administration in approved indications

NDC Numbers

Always include the correct NDC on claims:

  • Tecentriq IV: 50242-0917-01 (11-digit format)
  • Tecentriq Hybryza: 50242-0933-01 (11-digit format)

Dosing and Units Calculation

Common Tecentriq dosing regimens:

  • 840 mg every 2 weeks: Bill 84 units of J9022 (840 mg ÷ 10 mg = 84 units)
  • 1200 mg every 3 weeks: Bill 120 units of J9022
  • 1680 mg every 4 weeks: Bill 168 units of J9022

Required Modifiers

As of July 2023, use JZ modifier when no drug is discarded from single-use vials. Use JW modifier to report discarded amounts with appropriate documentation.

Clean Authorization Request Anatomy

A complete prior authorization request for Tecentriq should include:

Clinical Documentation Checklist

✅ Patient demographics and UnitedHealthcare member ID
✅ Primary diagnosis with specific ICD-10 code
✅ Staging information (TNM staging, performance status)
✅ PD-L1 testing results (when required by indication)
✅ Prior therapy history including dates, doses, and outcomes
✅ Treatment plan with proposed dosing schedule
✅ Site of care verification (approved infusion center)
✅ Prescriber information and NPI number

Required Lab Values and Biomarkers

For specific indications, include:

  • PD-L1 expression levels (≥1% for adjuvant NSCLC, ≥50% for some first-line cases)
  • Performance status (ECOG 0-1 typically required)
  • Organ function tests (liver, kidney, cardiac as appropriate)
  • Mutation testing (EGFR, ALK negative for certain NSCLC indications)

Frequent Coding and Billing Pitfalls

Common Mistakes That Cause Denials

Unit conversion errors: Always double-check dose calculations. Tecentriq J9022 represents 10 mg, not 1 mg.

Missing NDC numbers: Claims without proper NDC codes may be denied or processed incorrectly.

Wrong benefit type: Attempting to bill through pharmacy benefit instead of medical benefit.

Incomplete PD-L1 documentation: Failing to include actual test results and methodology.

Site of care issues: Billing from non-approved infusion locations.

Documentation Red Flags

  • Generic statements like "failed prior therapy" without specific drug names and dates
  • Missing contraindication screening for combination therapies
  • Outdated or incomplete staging information
  • PD-L1 results without specified testing methodology

UnitedHealthcare Verification Steps

Before submitting your authorization request:

1. Verify Current Coverage Policy

Check the most recent UnitedHealthcare Oncology Medication Clinical Coverage Policy for:

  • Covered indications
  • Required biomarker testing
  • Step therapy requirements
  • Site of care restrictions

2. Confirm Patient Eligibility

Use the UnitedHealthcare Provider Portal to verify:

  • Active coverage status
  • Medical benefit details
  • Prior authorization requirements
  • Deductible and copayment information

3. Check Formulary Status

Tecentriq may have different coverage tiers depending on the specific UnitedHealthcare plan. Verify current formulary placement and any preferred alternatives.

Pre-Submission Audit Checklist

Before submitting your Tecentriq prior authorization:

Clinical Requirements:

  • Correct ICD-10 diagnosis code with adequate specificity
  • FDA-approved indication or well-supported off-label use
  • Required biomarker testing completed and documented
  • Prior therapy trials documented with dates and outcomes
  • Performance status and organ function documented

Billing Requirements:

  • Correct HCPCS code (J9022 for IV, J9024 for subcutaneous)
  • Accurate NDC number included
  • Proper unit calculation based on prescribed dose
  • Appropriate modifiers applied (JZ/JW)
  • Site of care pre-approved for infusion services

Administrative Requirements:

  • Prior authorization submitted before first dose
  • All required forms completed and signed
  • Supporting documentation attached
  • Contact information current and accurate

Common Denial Reasons and Solutions

Denial Reason Solution Strategy Required Documentation
Missing PD-L1 testing Submit complete pathology report with PD-L1 percentage and testing methodology Lab report with specific assay used (22C3, SP263, etc.)
Step therapy not met Document prior therapy failures or contraindications Treatment records showing inadequate response or intolerance
Off-label indication Provide clinical rationale with supporting literature NCCN guidelines, peer-reviewed studies, FDA compendia
Site of care restriction Verify approved infusion location or request exception Facility accreditation, provider credentials
Bevacizumab contraindications Document thorough screening and absence of contraindications Cardiovascular assessment, bleeding risk evaluation

Virginia Appeals Process

If UnitedHealthcare denies your Tecentriq authorization, Virginia provides robust appeal rights:

Internal Appeals with UnitedHealthcare

Timeline: 180 days from denial notice
Levels: Typically 1-2 internal review levels
Expedited: Available for urgent medical situations (≤72 hours)
Submission: UnitedHealthcare Provider Portal, phone, or fax

External Review Through Virginia Bureau of Insurance

After exhausting internal appeals, you can request independent external review:

Deadline: 120 days from final internal denial
Forms: Form 216-A External Review Request
Timeline: 45 days for standard review, 72 hours for expedited
Contact: Virginia SCC Bureau of Insurance at 1-877-310-6560

Required documents:

  • Completed Form 216-A
  • Copy of insurance card
  • Final denial letter from UnitedHealthcare
  • Medical records and supporting documentation
  • Signed records release form
Virginia advantage: Virginia allows expedited external review for cancer treatment denials without requiring completion of all internal appeals first, recognizing the time-sensitive nature of cancer care.

Counterforce Health specializes in turning insurance denials into successful appeals by creating targeted, evidence-backed rebuttals that align with payer policies. Our platform analyzes denial letters, identifies specific coverage criteria, and drafts point-by-point appeals with the right clinical evidence and procedural requirements for UnitedHealthcare and Virginia's external review process.

From Our Advocates

In our experience helping patients navigate Tecentriq appeals, the most successful cases include comprehensive PD-L1 testing documentation and clear evidence of prior therapy failures. One key strategy is submitting additional peer-reviewed literature that directly addresses the payer's stated denial reason, particularly for combination therapies where multiple approval criteria must be met simultaneously.

Cost Assistance and Patient Support

Genentech Patient Support Programs

Genentech Access Solutions: Provides comprehensive support including:

  • Insurance verification and prior authorization assistance
  • Copay assistance programs for eligible patients
  • Patient assistance programs for uninsured/underinsured patients
  • Reimbursement support and appeals assistance

Contact: 1-888-249-4918 or visit Genentech Access Solutions

Additional Financial Resources

Virginia-specific programs:

  • Virginia Medicaid expansion may cover Tecentriq for eligible low-income adults
  • Virginia Cancer Care Fund provides financial assistance for cancer patients
  • Local cancer centers may offer patient assistance programs

National resources:

  • CancerCare Financial Assistance Program
  • Patient Access Network Foundation
  • HealthWell Foundation oncology grants

Verification and Next Steps

Getting Tecentriq covered by UnitedHealthcare in Virginia requires careful attention to coding accuracy, complete clinical documentation, and understanding of both payer policies and state appeal rights. The combination of proper medical billing practices with Virginia's patient-friendly external review process creates multiple pathways to coverage approval.

Your immediate next steps:

  1. Verify current UnitedHealthcare coverage policies for your patient's specific indication
  2. Gather all required clinical documentation including PD-L1 testing
  3. Submit prior authorization through the UnitedHealthcare Provider Portal
  4. If denied, utilize Counterforce Health's appeal assistance or Virginia's Bureau of Insurance external review process

Sources and Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Coverage decisions depend on individual circumstances, specific plan terms, and current policies. Always consult with healthcare providers and insurance representatives for personalized guidance. For official Virginia insurance regulations and appeal procedures, contact the Virginia State Corporation Commission Bureau of Insurance at 1-877-310-6560.

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