By Counterforce Health Team in Uplizna (inebilizumab) —

How to Get Uplizna (inebilizumab) Covered by UnitedHealthcare in Georgia: Coding, Appeals, and Prior Authorization Guide

Quick Answer: Getting Uplizna Covered by UnitedHealthcare in Georgia

UnitedHealthcare requires prior authorization for Uplizna (inebilizumab) in Georgia with step therapy requirements. For NMOSD patients, document AQP4-IgG positivity and rituximab failure. For IgG4-RD patients, show glucocorticoid inadequacy. Use ICD-10 code G36.0 (NMOSD) or D89.84 (IgG4-RD), HCPCS J1823, and submit via provider portal. First step: Gather specialist consultation notes, lab results, and prior therapy documentation. Internal appeals must be filed within 180 days; external review through Georgia Department of Insurance within 60 days of final denial.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 Mapping and Documentation
  3. Product Coding: HCPCS, J-Code, and NDC
  4. Clean Request Anatomy
  5. Frequent Coding Pitfalls
  6. UnitedHealthcare Verification Steps
  7. Appeals Process in Georgia
  8. Quick Audit Checklist

Coding Basics: Medical vs. Pharmacy Benefit

Uplizna (inebilizumab) is covered under UnitedHealthcare's medical benefit, not pharmacy benefit, since it's administered as an IV infusion. This means claims go through medical claims processing with different prior authorization pathways than oral medications.

Key Differences:

  • Medical benefit: Requires J-code billing, administered by healthcare providers
  • Pharmacy benefit: Uses NDC numbers, dispensed by pharmacies
  • Prior authorization: Medical benefit drugs use UnitedHealthcare's provider portal, not OptumRx
Note: Some UnitedHealthcare plans may route specialty infusions through OptumRx for prior authorization while maintaining medical benefit coverage. Verify with your specific plan.

ICD-10 Mapping and Documentation

Proper diagnosis coding is critical for Uplizna approval. UnitedHealthcare's policy explicitly requires specific diagnoses with supporting documentation.

Primary ICD-10 Codes

For NMOSD (Neuromyelitis Optica Spectrum Disorder):

  • G36.0 - Neuromyelitis optica [Devic]
  • Required documentation: AQP4-IgG antibody positivity via cell-based assay

For IgG4-Related Disease:

  • D89.84 - IgG4-related disease
  • Required documentation: ACR/EULAR classification criteria (score ≥20)

Supporting Documentation Requirements

NMOSD Documentation Must Include:

  • Specialist neurologist consultation
  • Positive AQP4-IgG serology with assay method specified
  • MRI evidence of characteristic lesions (LETM, optic neuritis)
  • Exclusion of multiple sclerosis and other mimics
  • EDSS score ≤8 for Uplizna eligibility

IgG4-RD Documentation Must Include:

  • Rheumatologist or immunologist consultation
  • Clinical evidence of organ involvement
  • Serologic, radiologic, and pathologic findings
  • Number of disease flares in past year
  • Response to prior glucocorticoid therapy

Source: UnitedHealthcare Uplizna Policy

Product Coding: HCPCS, J-Code, and NDC

HCPCS J-Code

J1823 - Injection, inebilizumab-cdon, 1 mg

  • Billing units: 1 unit = 1 mg
  • Standard dose: 300 mg = 300 units
  • Effective: Permanent J-code since January 1, 2021

NDC Information

  • Primary NDC: 72677-0551-01 (100 mg/10 mL single-dose vial)
  • Packaging: Supplied as cartons of 3×100 mg vials
  • Format requirement: Use 11-digit NDC format on claims

Administration Coding

  • CPT 96365 - Intravenous infusion, initial, up to 1 hour
  • Place of service: 11 (office), 49 (infusion center), or appropriate setting

Units Calculation Example

For a 300 mg infusion:

  • J1823 × 300 units (300 mg ÷ 1 mg per unit)
  • CPT 96365 × 1 unit (administration)
  • NDC 72677-0551-01 with quantity 3 (three 100 mg vials)

Source: Uplizna Billing and Coding Guide

Clean Request Anatomy

Sample Prior Authorization Request Structure

Patient Information:

  • UnitedHealthcare member ID
  • Date of birth and demographics
  • Prescribing specialist information

Clinical Documentation:

  • Primary diagnosis with ICD-10 code
  • Supporting lab results (AQP4-IgG or IgG4 levels)
  • Prior therapy history with dates and outcomes
  • Specialist consultation notes

Coding Information:

  • HCPCS J1823 for drug
  • CPT 96365 for administration
  • NDC 72677-0551-01 for product identification
  • Requested quantity and frequency

Medical Necessity Statement:

  • Why Uplizna is appropriate for this patient
  • Why alternatives are inadequate or contraindicated
  • Treatment goals and monitoring plan

Frequent Coding Pitfalls

Common Errors to Avoid

  1. Wrong J-Code Usage
    • Error: Using J3490 (unclassified injection)
    • Fix: Always use permanent J-code J1823
  2. Unit Conversion Mistakes
    • Error: Billing 3 units for 300 mg dose (thinking vials)
    • Fix: Bill 300 units (1 unit = 1 mg)
  3. NDC Format Issues
    • Error: Using 10-digit NDC format
    • Fix: Convert to 11-digit format with proper leading zeros
  4. Missing Documentation
    • Error: Submitting PA without specialist consultation
    • Fix: Include neurologist notes for NMOSD, rheumatologist for IgG4-RD
  5. Diagnosis Code Mismatch
    • Error: Using G35 (multiple sclerosis) instead of G36.0
    • Fix: Ensure ICD-10 matches confirmed diagnosis

UnitedHealthcare Verification Steps

Pre-Submission Checklist

Step 1: Verify Coverage

  • Check patient's UnitedHealthcare plan type
  • Confirm medical benefit coverage for J1823
  • Review current formulary status

Step 2: Prior Authorization Requirements

  • Access UnitedHealthcare provider portal
  • Download current Uplizna policy document
  • Review step therapy requirements

Step 3: Documentation Review

  • Specialist consultation within past 6 months
  • Required lab results and imaging
  • Prior therapy documentation with dates

Step 4: Coding Verification

  • Cross-check J1823 with current HCPCS database
  • Verify NDC with manufacturer information
  • Confirm administration CPT codes

Source: UnitedHealthcare Provider Resources

Appeals Process in Georgia

Internal Appeal Timeline

Filing Deadline: 180 days from denial date Decision Timeline: 30 calendar days (72 hours if urgent) How to File: UnitedHealthcare provider portal or written request

External Review Process

After exhausting internal appeals, Georgia law provides external review through the Georgia Department of Insurance.

Key Details:

  • Filing deadline: 60 days from final internal denial
  • Decision timeline: 30-45 days standard, 72 hours urgent
  • Cost: Free to patients
  • Binding: Decision is binding on UnitedHealthcare

Contact Information:

  • Georgia Department of Insurance: 1-800-656-2298
  • Consumer Services Division for appeals assistance

Required Appeal Documentation

  1. Original denial letter
  2. All clinical records supporting medical necessity
  3. Specialist letter addressing denial reasons
  4. Evidence of step therapy completion or contraindication
  5. Current treatment plan and monitoring schedule
From our advocates: We've seen successful Uplizna appeals in Georgia when providers directly address UnitedHealthcare's specific denial reasons with updated clinical evidence. One effective approach combines peer-reviewed literature supporting off-label use with detailed documentation of treatment failures, particularly when rituximab caused serious adverse effects requiring discontinuation.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to create point-by-point rebuttals that address payers' specific criteria, significantly improving approval rates for complex specialty medications like Uplizna.

Quick Audit Checklist

Pre-Submission Review

Patient Eligibility:

  • UnitedHealthcare member with active coverage
  • Medical benefit includes specialty drug coverage
  • Patient meets age requirements (adult)

Clinical Documentation:

  • Confirmed diagnosis: NMOSD (AQP4-IgG+) or IgG4-RD
  • Specialist consultation (neurologist/rheumatologist)
  • Required lab results with dates
  • Prior therapy documentation with outcomes

Coding Accuracy:

  • ICD-10: G36.0 (NMOSD) or D89.84 (IgG4-RD)
  • HCPCS: J1823 with correct units (mg)
  • NDC: 72677-0551-01 in 11-digit format
  • CPT: 96365 for administration

Step Therapy Compliance:

  • NMOSD: Documented rituximab failure/contraindication
  • IgG4-RD: Documented glucocorticoid inadequacy
  • Medical necessity letter addresses alternatives

Safety Requirements:

  • Hepatitis B screening completed
  • Vaccination history reviewed
  • Infection risk assessment documented

Coverage at a Glance

Requirement Details Documentation Needed Source
Prior Authorization Required for all plans Complete PA form via provider portal UHC Policy
Step Therapy NMOSD: Rituximab failure; IgG4-RD: Steroid inadequacy Prior therapy records with dates/outcomes UHC Policy
Specialist Requirement Neurologist (NMOSD) or Rheumatologist (IgG4-RD) Consultation notes within 6 months UHC Policy
Diagnosis Confirmation AQP4-IgG+ or ACR/EULAR criteria Lab results and clinical assessment UHC Policy
Appeal Deadline 180 days internal, 60 days external Denial letter and supporting evidence GA Department of Insurance

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take in Georgia? Standard decisions are made within 30 calendar days. Urgent requests are processed within 72 hours if delay could jeopardize the patient's health.

What if Uplizna is non-formulary on my plan? Uplizna may still be covered under medical benefit even if not on pharmacy formulary. Submit prior authorization with medical necessity documentation.

Can I request an expedited appeal in Georgia? Yes, if delays could seriously jeopardize your health. Both internal appeals and external reviews offer expedited timelines (72 hours for decisions).

Does step therapy apply if I failed treatments outside Georgia? Yes, documented treatment failures from any location are considered for step therapy exceptions, provided adequate documentation is available.

What costs should I expect for Uplizna? List price is approximately $140,248 per dose. Year one costs about $420,000 for three doses. Patient responsibility depends on insurance coverage and copay assistance programs.

How do I access manufacturer support programs? Visit Amgen By Your Side or call their patient support program for copay assistance and financial aid applications.

For additional support with complex appeals and documentation strategies, Counterforce Health provides specialized assistance in turning insurance denials into successful approvals through targeted, evidence-based appeal strategies.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for specific coverage decisions. Coverage policies and requirements may change. Verify current information with UnitedHealthcare and the Georgia Department of Insurance before making coverage decisions.

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