By Counterforce Health Team in Retevmo (selpercatinib) —

The Requirements Checklist to Get Retevmo (selpercatinib) Covered by UnitedHealthcare in Pennsylvania

Answer Box: Fast Track to Approval

To get Retevmo (selpercatinib) covered by UnitedHealthcare in Pennsylvania: 1) Confirm RET fusion-positive status with FDA-approved testing (FoundationOne CDx preferred), 2) Submit prior authorization through UnitedHealthcare provider portal with complete molecular pathology reports and clinical documentation, 3) If denied, file internal appeal within 6 months, then external review through Pennsylvania Insurance Department within 4 months. UnitedHealthcare requires PA but no step therapy for RET-positive cancers. Pennsylvania's new external review program overturns ~50% of denials.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding & Billing Essentials
  5. Documentation Packet
  6. Submission Process
  7. Specialty Pharmacy Coordination
  8. After Submission: Tracking Your Request
  9. Denial Prevention Tips
  10. Appeals Process in Pennsylvania
  11. Quick Reference Checklist

Who Should Use This Checklist

This guide is designed for patients, caregivers, and healthcare providers seeking UnitedHealthcare coverage for Retevmo (selpercatinib) in Pennsylvania. Use this if you have:

  • RET fusion-positive non-small cell lung cancer (NSCLC) that's advanced or metastatic
  • RET-mutant medullary thyroid cancer requiring systemic therapy
  • RET fusion-positive thyroid cancer that's radioactive iodine-refractory or inappropriate for RAI

Expected outcome: With proper documentation, most RET-positive cancer cases meet UnitedHealthcare's clinical criteria. Pennsylvania residents benefit from strong appeal rights—the state's external review program has a 50% overturn rate for initial denials.

Member & Plan Basics

Coverage Requirements

Requirement Details Verification
Active UnitedHealthcare coverage Must be enrolled with current benefits Check member portal or call member services
Prior authorization needed Yes, for all Retevmo prescriptions UnitedHealthcare PA requirements
Formulary status Covered but requires PA OptumRx manages specialty drugs
Step therapy Not required for RET-positive cancers Based on molecular testing results
Note: UnitedHealthcare processes Retevmo through OptumRx specialty pharmacy. Confirm your specific plan's specialty drug benefits and any deductible requirements.

Clinical Criteria Requirements

UnitedHealthcare approves Retevmo when specific clinical criteria are met:

For NSCLC (Non-Small Cell Lung Cancer)

  • Confirmed NSCLC diagnosis
  • Disease is recurrent, advanced, or metastatic
  • RET gene fusion-positive confirmed by FDA-approved testing
  • Initial authorization: 12 months
  • Reauthorization: Requires no disease progression

For Thyroid Cancer

Medullary Thyroid Cancer (MTC):

  • MTC diagnosis with advanced or metastatic disease
  • RET gene mutation confirmed
  • Disease requires systemic therapy

Other Thyroid Cancers:

  • Advanced or metastatic thyroid cancer
  • RET gene fusion-positive
  • RAI-refractory or RAI inappropriate
  • Systemic therapy required

Required Testing

RET alteration must be confirmed using FDA-approved companion diagnostics:

  • FoundationOne CDx (tissue-based NGS) - preferred
  • FoundationOne Liquid CDx (plasma-based) - when tissue unavailable

Coding & Billing Essentials

HCPCS/J-Codes

  • J8999 (Prescription drug, oral, chemotherapeutic, not otherwise specified)
  • C9399 (Hospital outpatient use only)

NDC Numbers by Strength

  • 40 mg capsules: 00002-3977-xx
  • 80 mg capsules: 00002-2980-xx
  • 40 mg tablets: 00002-5340-xx
  • 80 mg tablets: 00002-6082-xx
  • 120 mg tablets: 00002-6120-xx
  • 160 mg tablets: 00002-5562-xx

ICD-10 Codes

  • NSCLC: C34.0–C34.9 (select by specific lung location)
  • Medullary thyroid cancer: C73
Tip: Always document RET fusion-positive or RET-mutant status in clinical notes to support medical necessity.

Documentation Packet

Provider Note Elements

Your oncologist's clinical documentation must include:

  • Specific cancer diagnosis and staging
  • RET alteration test results with laboratory report
  • Prior treatment history and outcomes
  • Current performance status
  • Treatment plan and goals

Letter of Medical Necessity Components

The UnitedHealthcare medical necessity letter must contain:

  1. Patient diagnosis with ICD-10 code
  2. Clinical rationale referencing NCCN Guidelines
  3. RET testing documentation from FDA-approved assay
  4. Treatment history if applicable
  5. Proposed dosing and duration
  6. Provider attestation with signature and credentials

Required Attachments

  • Molecular pathology report confirming RET alteration
  • Staging scans or pathology reports
  • Prior treatment records (if any)
  • Current lab values and performance status notes

Submission Process

Step-by-Step Submission

  1. Access UnitedHealthcare Provider Portal
    • Use Specialty Pharmacy Transactions tile
    • Alternative: Call OptumRx at 888-397-8129
  2. Complete PA Form
    • Use current version from provider portal
    • Ensure all required fields are completed
  3. Upload Documentation
    • Letter of medical necessity
    • RET testing results
    • Clinical notes and staging information
  4. Submit and Confirm
    • Record confirmation number
    • Note submission date for timeline tracking
Important: Incomplete submissions are a leading cause of delays. Double-check all required fields and attachments before submitting.

Specialty Pharmacy Coordination

UnitedHealthcare routes Retevmo through OptumRx specialty pharmacy:

Preferred Vendor Process

  1. Prescription routing - Provider sends to OptumRx
  2. Patient enrollment - OptumRx contacts patient directly
  3. Insurance verification - Confirms PA approval
  4. Shipment coordination - Delivers to patient or clinic

Patient Responsibilities

  • Respond promptly to OptumRx enrollment calls
  • Confirm shipping address and delivery preferences
  • Understand copay/coinsurance requirements
  • Report any delivery issues immediately

After Submission: Tracking Your Request

Timeline Expectations

  • Standard review: 15 days for prior authorization
  • Urgent cases: 72 hours or less
  • Provider portal updates available 24/7

Status Check Schedule

  • Day 3: Confirm receipt via provider portal
  • Day 7: Check for any additional information requests
  • Day 12: Follow up if no decision rendered
  • Day 15: If denied, begin appeal preparation

What to Record

  • Confirmation numbers for all submissions
  • Names and titles of UnitedHealthcare representatives
  • Dates of all phone calls and correspondence
  • Case reference numbers for appeals

Denial Prevention Tips

Five Common Pitfalls and Solutions

Pitfall Prevention Strategy
Missing RET testing Submit FDA-approved companion diagnostic results
Incomplete clinical documentation Include staging, prior treatments, performance status
Wrong tumor type Clearly specify NSCLC vs. thyroid cancer subtype
Insufficient medical necessity Reference NCCN Guidelines and clinical rationale
Coding errors Use correct ICD-10 codes and NDC numbers

Documentation Red Flags

  • Generic "cancer" diagnosis without specificity
  • Missing molecular testing results
  • Incomplete prior treatment history
  • Lack of staging information
  • Unsigned medical necessity letters

Appeals Process in Pennsylvania

Pennsylvania residents have strong appeal rights through the state's new external review program.

Internal Appeals (UnitedHealthcare)

  • Timeline: File within 6 months of denial
  • Decision: 15 days (pre-service) or 30 days (post-service)
  • Expedited: 72 hours for urgent cases
  • Submit via: UnitedHealthcare provider portal or member services

External Review (Pennsylvania Insurance Department)

After internal appeal denial:

  • Timeline: Request within 4 months of final internal denial
  • Success rate: ~50% of appeals overturned in favor of patients
  • Submit via: Pennsylvania Insurance Department portal
  • Decision: Within 45 days (standard) or 72 hours (expedited)

Consumer Assistance

  • Pennsylvania Insurance Department Consumer Services
  • Phone: 1-877-881-6388
  • Email: [email protected]
From our advocates: We've seen cases where patients received approval on external review after providing additional peer-reviewed studies supporting off-label use. The key was demonstrating that the denied treatment aligned with recognized clinical guidelines, even when the insurer's initial review missed this connection. Always include the strongest available evidence in your appeal.

Quick Reference Checklist

Before You Start

  • Active UnitedHealthcare coverage confirmed
  • RET fusion/mutation testing completed with FDA-approved assay
  • Complete medical records gathered
  • Provider willing to submit PA and appeal if needed

Documentation Checklist

  • Letter of medical necessity with all required elements
  • FDA-approved RET testing results
  • Cancer diagnosis and staging documentation
  • Prior treatment records (if applicable)
  • Current clinical notes and lab values
  • Correct ICD-10 and NDC codes

Submission Checklist

  • PA submitted through UnitedHealthcare provider portal
  • Confirmation number recorded
  • OptumRx specialty pharmacy contacted
  • Patient enrolled in specialty pharmacy program
  • Appeal timeline and deadlines noted

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 draft point-by-point rebuttals aligned with payer requirements, pulling the right clinical evidence and meeting procedural deadlines. Learn more at CounterforceHealth.org.

If you're facing challenges getting Retevmo covered, consider working with Counterforce Health to strengthen your appeal with payer-specific documentation and evidence that addresses UnitedHealthcare's specific criteria.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Coverage decisions depend on individual circumstances and plan benefits. Always consult with your healthcare provider and insurance company for specific guidance. For assistance with appeals in Pennsylvania, contact the Pennsylvania Insurance Department Consumer Services at 1-877-881-6388.

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