How to Get Tysabri (Natalizumab) Covered by UnitedHealthcare in Texas: Complete Appeals Guide with Forms and Templates
Quick Answer: Getting Tysabri Covered by UnitedHealthcare in Texas
UnitedHealthcare requires prior authorization for Tysabri (natalizumab) through OptumRx. You'll need TOUCH enrollment, JCV antibody results, recent MRI, and documentation of failed prior therapies. If denied, you have 180 days to appeal internally, then can request Texas external review through an Independent Review Organization (IRO). Start by having your neurologist submit the PA request with complete clinical documentation—this is your fastest path to approval.
Take action today: Contact your prescribing neurologist to initiate the prior authorization process through the UnitedHealthcare Provider Portal.
Table of Contents
- Coverage Requirements at a Glance
- Step-by-Step: Fastest Path to Approval
- Reading Your Denial Letter
- Common Denial Reasons & How to Fix Them
- Medical Necessity Letter Essentials
- UnitedHealthcare Appeals Process in Texas
- Texas External Review Rights
- Scripts and Templates
- Cost-Saving Programs
- Frequently Asked Questions
Coverage Requirements at a Glance
| Requirement | What It Means | Where to Find It | Source |
|---|---|---|---|
| Prior Authorization | Required for all Tysabri prescriptions | UnitedHealthcare Provider Portal | UHC PA Requirements |
| TOUCH Enrollment | Mandatory safety program for PML risk | TOUCH website via prescriber | FDA REMS Program |
| JCV Antibody Testing | Recent results required for PML risk assessment | Lab results from prescriber | UHC Medical Policy |
| Step Therapy | May require prior DMT failure documentation | Medical records | Texas Step Therapy Law |
| MRI Documentation | Recent brain MRI showing disease activity | Radiology reports | UHC Clinical Guidelines |
| Appeals Deadline | 180 days from denial date | Denial letter | Texas Insurance Code |
Step-by-Step: Fastest Path to Approval
1. Confirm TOUCH Enrollment (Patient & Provider)
Who does it: Your neurologist's office
Timeline: 1-2 business days
What's needed: Complete TOUCH registration forms
Submit via: TOUCH Prescribing Program portal
2. Gather Required Documentation
Who does it: Patient with clinic staff
Timeline: 3-5 business days
What's needed:
- Recent MRI reports (within 6 months)
- JCV antibody test results
- Complete DMT history with failure/intolerance reasons
- Current EDSS or functional assessment
3. Submit Prior Authorization Request
Who does it: Prescribing neurologist
Timeline: Same day via portal
Submit via: UnitedHealthcare Provider Portal or OptumRx phone (888-397-8129)
Expected response: 72 hours (standard) or 24 hours (expedited)
4. Request Step Therapy Exception (If Applicable)
Who does it: Prescriber
Timeline: Submit with PA or within 72 hours of step therapy denial
What's needed: Texas-specific exception form citing Texas Insurance Code §1369.0546
5. Schedule Peer-to-Peer Review (If Initially Denied)
Who does it: Prescriber
Timeline: Within 24 hours of denial
Submit via: UnitedHealthcare Provider Portal peer-to-peer scheduling
Duration: 5-10 minute call with UHC medical director
Reading Your Denial Letter
When UnitedHealthcare denies Tysabri coverage, your denial letter will include specific reason codes. Here's how to decode the most common ones:
"Prior authorization required" = No PA was submitted; have your doctor resubmit with complete documentation.
"Does not meet medical necessity criteria" = Clinical justification was insufficient; need stronger documentation of disease activity and prior treatment failures.
"Step therapy required" = Must try other DMTs first unless you qualify for an exception under Texas law.
"Not enrolled in TOUCH program" = Both patient and prescriber must complete TOUCH registration before approval.
Tip: Look for the appeals deadline prominently displayed in the denial letter—typically 180 days from the denial date in Texas.
Common Denial Reasons & How to Fix Them
| Denial Reason | How to Overturn | Required Documents |
|---|---|---|
| Missing TOUCH enrollment | Complete registration for patient and prescriber | TOUCH confirmation numbers |
| Inadequate MRI documentation | Submit recent brain MRI with radiologist interpretation | MRI reports showing lesions or activity |
| Step therapy not met | File Texas step therapy exception citing contraindications or prior failures | Texas Exception Form |
| Missing JCV antibody results | Provide recent JCV testing for PML risk stratification | Lab results within 6 months |
| Insufficient prior therapy documentation | Document specific DMTs tried, durations, and reasons for discontinuation | Detailed treatment history |
Medical Necessity Letter Essentials
Your neurologist's medical necessity letter should include these key components:
Patient Information & Diagnosis
- Full name, DOB, UnitedHealthcare member ID
- Specific MS diagnosis with ICD-10 code (G35)
- Date of diagnosis and current disease status
Clinical Justification
- Recent relapse history and MRI findings
- Current EDSS score and functional limitations
- Impact on daily activities and quality of life
Prior Treatment History
- Complete list of previous DMTs with dates
- Specific reasons for discontinuation (inefficacy, adverse events, contraindications)
- Documentation of inadequate response to alternatives
Safety Considerations
- JCV antibody status and PML risk assessment
- Confirmation of TOUCH program enrollment
- Ongoing monitoring plan
For healthcare providers: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned to each plan's specific requirements.
UnitedHealthcare Appeals Process in Texas
Internal Appeals (First Level)
Timeline: Must file within 180 days of denial
Response time: 30 days for pre-service, 60 days for post-service
How to file: UnitedHealthcare Provider Portal or member services
Required: Original denial letter, additional clinical documentation, appeal letter
Expedited Appeals
When available: Urgent medical situations where delay could jeopardize health
Timeline: 72 hours for decision
How to request: Mark "expedited" on appeal form and provide clinical justification
Second-Level Internal Appeal
Timeline: 60 days after first-level denial
Process: Reviewed by different medical director
Documentation: Include any new clinical evidence or peer-reviewed literature
Texas External Review Rights
If UnitedHealthcare denies your internal appeals, Texas law provides access to independent external review through the Texas Department of Insurance.
Eligibility Requirements
- Completed UnitedHealthcare's internal appeal process
- Denial based on medical necessity, appropriateness, or experimental status
- State-regulated plan (not ERISA, Medicare, or Medicaid)
How to Request External Review
- Complete TDI Form LHL009
- Submit to UnitedHealthcare (not directly to TDI)
- UnitedHealthcare forwards to TDI within 1 business day
- TDI assigns to Independent Review Organization (IRO)
Timeline
- Standard cases: 20 calendar days for IRO decision
- Life-threatening cases: 8 calendar days
- No cost to patient for external review
Contact Information
- TDI IRO Information: 1-866-554-4926
- Consumer Help Line: 1-800-252-3439
Note: The IRO's decision is binding on UnitedHealthcare for your specific claim.
Scripts and Templates
Patient Phone Script for UnitedHealthcare
"Hello, I'm calling about my Tysabri prior authorization request. My member ID is [ID number]. Can you please tell me the status and what additional documentation might be needed? I'd also like to confirm the appeals process if this is denied."
Medical Necessity Letter Template Opening
"I am writing to request prior authorization for Tysabri (natalizumab) for [Patient Name], a [age]-year-old patient with relapsing-remitting multiple sclerosis. This medication is medically necessary based on [specific clinical factors] and the patient's inadequate response to previous disease-modifying therapies including [list prior DMTs with dates and outcomes]."
Cost-Saving Programs
Manufacturer Support
- Biogen Above MS: Patient support program with copay assistance
- Eligibility: Commercially insured patients
- Potential savings: Up to $12,000 annually in copay assistance
- Apply: Through prescriber or Biogen patient programs
Foundation Assistance
- National MS Society: Financial assistance programs
- PAN Foundation: Medication copay assistance for MS patients
- HealthWell Foundation: Grants for eligible patients
Frequently Asked Questions
How long does UnitedHealthcare prior authorization take for Tysabri?
Standard review is 72 hours, expedited review is 24 hours once all required documentation is submitted through the provider portal.
What if Tysabri is non-formulary on my plan?
Request a formulary exception with your neurologist, providing clinical justification for why formulary alternatives are inappropriate or contraindicated.
Can I request an expedited appeal in Texas?
Yes, if delay in treatment could jeopardize your health. Mark your appeal as "expedited" and provide clinical documentation supporting urgency.
Does step therapy apply if I failed DMTs in another state?
Yes, prior treatment history from any state counts. Ensure your neurologist documents all previous therapies with specific reasons for discontinuation.
What happens if my external review is denied?
The IRO decision is final for that specific request, but you may be able to submit a new request with additional clinical evidence or if your medical condition changes.
How do I know if my plan is eligible for Texas external review?
State-regulated commercial plans are eligible. ERISA self-funded employer plans, Medicare, and Medicaid follow different federal appeal processes.
When navigating complex insurance denials, platforms like Counterforce Health can help patients and clinicians by analyzing denial letters and plan policies to create targeted appeals that address each insurer's specific requirements and evidence standards.
Sources & Further Reading
- UnitedHealthcare Prior Authorization Requirements
- Texas Step Therapy Exception Process
- Texas Department of Insurance IRO Process
- UnitedHealthcare Provider Portal
- Texas Department of Insurance Consumer Help
Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider about treatment decisions and contact UnitedHealthcare or the Texas Department of Insurance for the most current policy information and forms.
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