By Counterforce Health Team in Lutathera (lutetium Lu-177 dotatate) —

Resources to Get Lutathera (Lutetium Lu-177 Dotatate) Approved with UnitedHealthcare in Washington: Forms, Portals & Appeals Guide

Answer Box: Getting Lutathera Covered by UnitedHealthcare in Washington

Lutathera requires prior authorization from UnitedHealthcare with strict clinical criteria. The fastest path: Submit through the UnitedHealthcare Provider Portal with complete documentation including SSTR-positive imaging, GEP-NET diagnosis, and disease progression on octreotide. If denied, file internal appeals within 180 days, then request external review through Washington's Office of the Insurance Commissioner. Start today: Verify your plan type and gather required clinical documentation listed below.

Table of Contents

  1. Start Here: Verify Your Plan and Find Forms
  2. Required Forms and Documentation
  3. Submission Portals and Digital Access
  4. Fax Numbers and Mailing Addresses
  5. Specialty Pharmacy Requirements
  6. Support Phone Lines and Contacts
  7. Washington State Appeals and External Review
  8. When to Update Your Resources

Start Here: Verify Your Plan and Find Forms

Before requesting Lutathera coverage, identify your specific UnitedHealthcare plan type. This determines which forms and processes apply to you.

Plan Types in Washington

Commercial Plans: Use standard UnitedHealthcare prior authorization forms through OptumRx Medicare Advantage: May have delegated management through Optum Health Networks or Independent Clinics of Washington Community Plan (Medicaid): Follows Washington state Medicaid guidelines with UnitedHealthcare administration

Tip: Check your member ID card for plan-specific information or log into your member portal to verify coverage details.

Current Policy Requirements

Lutathera requires prior authorization for all UnitedHealthcare members in Washington. The drug must meet these core criteria:

  • Age: 12 years or older (updated April 2024)
  • Diagnosis: Gastroenteropancreatic neuroendocrine tumors (GEP-NETs)
  • Tumor status: Somatostatin receptor-positive confirmed by Ga-68 DOTATATE PET/CT
  • Disease stage: Metastatic or locally advanced, inoperable
  • Prior therapy: Disease progression on octreotide LAR or lanreotide
  • Prescriber: Oncologist or GEP-NET specialist

Required Forms and Documentation

Prior Authorization Package

Primary Form: UnitedHealthcare Prior Authorization Request Form (version varies by plan type)

Required Clinical Documentation:

  • Recent progress notes with treatment history
  • Ga-68 DOTATATE PET/CT or somatostatin receptor scintigraphy results
  • Pathology report confirming GEP-NET diagnosis
  • Ki-67 index results (must be ≤20%)
  • Documentation of octreotide/lanreotide trial and progression
  • Current lab values and imaging studies

Medical Necessity Letter Checklist

Your oncologist should include these elements:

  1. Patient demographics and diagnosis with ICD-10 codes
  2. Prior therapy failures with specific dates and outcomes
  3. Clinical rationale citing FDA labeling and guidelines
  4. SSTR-positive confirmation with imaging details
  5. Treatment plan including dosing schedule and monitoring
  6. Contraindications to alternative therapies
Note: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and plan policies to draft point-by-point rebuttals aligned with payer requirements.

Version Control

Always download the most current forms from UnitedHealthcare's provider resources. Forms are typically updated annually, with mid-year revisions possible for policy changes.

Submission Portals and Digital Access

UnitedHealthcare Provider Portal

Primary submission method for all prior authorizations and appeals.

Access: UnitedHealthcare Provider Portal Account: Requires One Healthcare ID registration Features:

  • Real-time PA status tracking
  • Document upload capability
  • Automated processing for qualifying requests
  • Appeals submission and monitoring

Member Portal Access

Patients can track PA status and submit appeals through their member portal:

  • Log in with member credentials
  • Navigate to "Prior Authorization and Benefits"
  • Upload supporting documents
  • Monitor approval status

OptumRx PreCheck System

For qualifying requests, OptumRx's automated system can approve PAs in under 1 minute when all criteria are electronically verified through EMR integration.

Fax Numbers and Mailing Addresses

Standard Fax Submission

Prior Authorization Fax: (888) 245-2049 Appeals Fax: Listed on denial letter (varies by plan)

Important: Fax numbers may vary based on your specific plan delegation. Check your member ID card or provider administrative guide for plan-specific numbers.

Mailing Addresses

Standard Prior Authorization: UnitedHealthcare Prior Authorization Department P.O. Box 30555 Salt Lake City, UT 84130

Appeals (verify current address): Address provided on denial letter or member portal

Cover Sheet Requirements

Include these details on all fax submissions:

  • Member name and ID number
  • Provider NPI and contact information
  • Request type (PA, appeal, peer-to-peer)
  • Number of pages transmitted
  • Urgent/standard designation

Specialty Pharmacy Requirements

Network Requirements

Lutathera must be sourced through UnitedHealthcare's designated specialty pharmacy network for outpatient administration.

Key Steps:

  1. Verify network participation of your nuclear medicine facility
  2. Coordinate drug procurement with designated specialty pharmacy
  3. Ensure radiation safety compliance at administration site
  4. Confirm billing procedures (pharmacy bills for drug, facility bills for administration)

Nuclear Medicine Facility Standards

Administration facilities must meet these requirements:

  • NRC or state license for therapeutic radiopharmaceuticals
  • Radiation safety protocols and trained staff
  • Proper waste management procedures
  • Patient discharge instruction capabilities

Billing and Coding

  • HCPCS Code: A9513 (per mCi, typically 200 units per dose)
  • Administration: Separate billing by nuclear medicine facility
  • Drug cost: Billed by specialty pharmacy to medical benefit

Support Phone Lines and Contacts

Provider Services

General Provider Line: (800) 842-3211 Prior Authorization: (866) 604-3267 Pharmacy Services: (800) 392-1147

Hours: Monday-Friday, 7 AM - 7 PM PT What to have ready: Provider NPI, member ID, specific drug name

Member Services

General Member Line: (888) 815-7604 Appeals Questions: Number on denial letter Pharmacy Benefits: (855) 828-9834

Case Management

For complex cases requiring coordination: Clinical Case Management: Available through provider portal Peer-to-Peer Reviews: Request through prior authorization department

Washington State Appeals and External Review

Internal Appeals Process

Timeline: 180 days from denial to file internal appeal Levels: Typically 2 internal review levels Submission: Through provider portal, fax, or mail

External Review Rights

If internal appeals are unsuccessful, Washington residents have the right to independent external review.

Washington Office of the Insurance Commissioner

  • Phone: (800) 562-6900
  • Mail: PO Box 40255, Olympia, WA 98504-0255
  • Fax: (360) 586-2018
  • Online: insurance.wa.gov

External Review Process

  1. Complete internal appeals with UnitedHealthcare first
  2. Request external review within 4 months of final denial
  3. Submit documentation to assigned Independent Review Organization (IRO)
  4. Receive decision within 20 days (standard) or 72 hours (expedited)
  5. IRO decision is binding on the insurance company
Washington Advantage: The state's external review process is particularly effective for specialty medications, with medical experts from research institutions often serving as IRO reviewers.

When to Update Your Resources

Regular Review Schedule

Quarterly: Check for form updates and policy changes Annually: Review plan benefits and network changes As needed: When receiving denials or policy notifications

Key Update Triggers

  • Plan renewal periods (January 1)
  • Mid-year formulary changes
  • New FDA approvals or indications
  • Policy bulletin releases

Staying Current

  • Subscribe to UnitedHealthcare provider bulletins
  • Monitor Washington OIC updates
  • Check manufacturer resources for new data
  • Counterforce Health maintains current payer policies and can help identify the most effective appeal strategies when coverage is denied

FAQ: Common Questions About Lutathera Coverage

Q: How long does UnitedHealthcare prior authorization take in Washington? A: Standard reviews take 14 days; urgent requests receive decisions within 72 hours when clinical urgency is documented.

Q: What if Lutathera is non-formulary on my plan? A: Non-formulary drugs can still be covered through medical necessity appeals with comprehensive clinical documentation.

Q: Can I request expedited review for Lutathera? A: Yes, if delay would seriously jeopardize your health. Document clinical urgency in your request.

Q: Does step therapy apply if I tried octreotide outside Washington? A: Prior therapy documentation from any state is typically accepted if properly documented in medical records.

Q: What happens if my appeal is denied? A: You can request external review through Washington's Office of the Insurance Commissioner, where an independent medical expert will review your case.

Coverage Requirements at a Glance

Requirement Details Documentation Needed
Prior Authorization Required for all plans Complete PA form with clinical notes
Age Restriction 12+ years Birth date verification
Diagnosis GEP-NET confirmed Pathology report, ICD-10 codes
SSTR Status Must be positive Ga-68 DOTATATE PET/CT results
Prior Therapy Octreotide/lanreotide trial Treatment records, progression imaging
Prescriber Oncologist/GEP-NET specialist Provider credentials, NPI
Administration Nuclear medicine facility Facility licensing, safety protocols

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and clinical circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For assistance with complex appeals, consider consulting with healthcare coverage specialists who understand payer-specific requirements.

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