By Counterforce Health Team in Synagis (palivizumab) —

UnitedHealthcare's Coverage Criteria for Synagis (Palivizumab) in Washington: What Counts as "Medically Necessary"?

Answer Box: Getting Synagis Covered by UnitedHealthcare in Washington

UnitedHealthcare requires prior authorization for all Synagis (palivizumab) prescriptions with strict high-risk pediatric criteria. You must prove why Beyfortus (nirsevimab) isn't appropriate first. Fast track: Submit PA through the UnitedHealthcare Provider Portal with complete cardiology/pulmonology notes, birth certificate, and medical necessity letter addressing specific denial reasons. If denied, you have 60 days to appeal internally, then can request external review through Washington's Independent Review Organization (IRO). Start today: Call UnitedHealthcare at 866-889-8054 to initiate prior authorization.

Table of Contents

Policy Overview

UnitedHealthcare covers Synagis (palivizumab) across all plan types—HMO, PPO, and Medicare Advantage—but with stringent prior authorization requirements. The medication costs approximately $1,820 per 50 mg vial, making it one of the most expensive pediatric preventive therapies.

Plan Coverage Details:

  • Commercial Plans: Prior authorization required through OptumRx
  • Medicare Advantage: Subject to Part B step therapy requirements starting January 2026
  • Medicaid (Apple Health): Follows state Medicaid guidelines with UnitedHealthcare administration

All requests must be submitted through the UnitedHealthcare Provider Portal or by calling 866-889-8054. Standard decisions take 1-7 business days, with expedited reviews available for urgent cases.

High-Risk Eligibility Requirements

Coverage is limited to pediatric patients meeting at least one of these high-risk conditions:

Premature Infants with Respiratory Compromise

  • Born at less than 29 weeks gestation and under 12 months at RSV season onset
  • Born at less than 32 weeks gestation with chronic lung disease requiring >21% oxygen for at least 28 days

Chronic Lung Disease

  • Infants under 2 years old with chronic lung disease of prematurity
  • Must have required medical therapy (oxygen, bronchodilators, diuretics, or steroids) within the past 6 months

Congenital Heart Disease

  • Infants under 12 months with hemodynamically significant congenital heart disease
  • Includes those receiving heart failure medications or requiring cardiac procedures
  • Heart transplant recipients under 2 years old during RSV season

Other Qualifying Conditions

  • Congenital airway abnormalities compromising respiratory clearance
  • Cystic fibrosis with chronic lung disease evidence
  • Profound immunocompromise (chemotherapy, transplant, severe immunodeficiency)
Note: Age limits are strictly enforced. Children must meet age criteria at the start of RSV season (typically November).

Step Therapy: Beyfortus First Rule

UnitedHealthcare mandates documentation of why Beyfortus (nirsevimab) is not appropriate before approving Synagis. This is the most common denial reason.

Acceptable Beyfortus Exclusion Reasons:

  • Child is over 8 months old (outside Beyfortus indication)
  • Previous adverse reaction to nirsevimab
  • Specific contraindications documented by specialist
  • Local supply limitations confirmed by pharmacy
  • Already received Beyfortus during current RSV season

Your provider must explicitly address this requirement in the prior authorization request with specific clinical justification.

Dosing and Quantity Limits

Standard Dosing Protocol:

  • Dose: 15 mg/kg intramuscularly
  • Frequency: Monthly (every 28-30 days)
  • Maximum: 5 doses per RSV season
  • Season Duration: November through March (Northern Hemisphere)

Coverage Limitations:

  • Authorization expires March 31st annually
  • No coverage for doses exceeding 15 mg/kg
  • Minimum 26-day interval between injections required
  • Additional doses only approved for cardiopulmonary bypass procedures

The 5-dose limit aligns with clinical evidence showing protective antibody levels persist 20-24 weeks with monthly dosing.

Required Clinical Documentation

Specialist Documentation Requirements

Cardiology Notes Must Include:

  • Hemodynamic significance of cardiac defect
  • Current heart failure medications
  • Specific defect type (acyanotic/cyanotic)
  • Pediatric cardiology recommendation for RSV prophylaxis
  • Notes dated within 3 months of submission

Pulmonology Notes Must Include:

  • Type and severity of chronic lung disease
  • Current respiratory support requirements
  • Ongoing medication regimen
  • Evidence of continued medical need

Supporting Documents Checklist

  • ✅ Birth certificate showing gestational age
  • ✅ NICU discharge summary detailing respiratory/cardiac support
  • ✅ Current prescription with proper dosing
  • ✅ Medical necessity letter addressing UnitedHealthcare's criteria
  • ✅ Specialist notes within 3 months
  • ✅ Documentation of Beyfortus contraindication
Clinician Corner: Your medical necessity letter should directly address UnitedHealthcare's specific denial reasons point-by-point. Generic letters citing only general RSV risk often fail.

Site of Care and Specialty Pharmacy

Synagis is typically dispensed through OptumRx specialty pharmacy for UnitedHealthcare members. The medication requires:

  • Cold chain storage (2-8°C)
  • Monthly delivery coordination with injection schedule
  • Provider administration in clinic or hospital setting
  • Proper handling protocols to maintain efficacy

Contact OptumRx at 1-855-427-4682 to verify enrollment and coordinate delivery logistics before the first dose.

Medical Necessity Evidence

Guidelines to Reference

  • FDA labeling for palivizumab indications
  • American Academy of Pediatrics (AAP) RSV prevention guidelines
  • CDC surveillance reports for local RSV activity
  • Pediatric cardiology/pulmonology society recommendations

Key Evidence Points

  • Cite specific AAP risk stratification criteria
  • Reference FDA-approved indications for high-risk groups
  • Include local RSV epidemiology data when available
  • Document failed or contraindicated alternatives

When appealing denials, Counterforce Health helps families and providers build evidence-backed appeals by analyzing denial letters and crafting targeted rebuttals using payer-specific criteria and current medical literature.

Appeals Process in Washington

Internal Appeals with UnitedHealthcare

  • Deadline: 60 calendar days from denial letter
  • Response Time: 28 calendar days for standard review
  • Expedited Review: Available for urgent cases (call 1-877-542-8997)
  • Submission: Written appeal required with signature

Washington State External Review

If UnitedHealthcare denies your internal appeal, you can request independent review by a certified IRO (Independent Review Organization):

  • Deadline: 180 days from final internal denial
  • Process: Submit request to Washington Office of Insurance Commissioner
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Authority: IRO decision is binding on UnitedHealthcare

Washington OIC Consumer Advocacy: 1-800-562-6900 for appeal assistance and guidance.

The Washington Office of Insurance Commissioner provides template appeal letters and step-by-step guidance for challenging denials.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
"Outside high-risk criteria" Provide specialist confirmation of qualifying condition Cardiology/pulmonology notes confirming specific risk factors
"Beyfortus not tried first" Document contraindication or age exclusion Letter explaining why nirsevimab inappropriate
"Insufficient medical necessity" Submit comprehensive clinical justification Complete medical history, prior treatments, specialist recommendations
"Exceeds quantity limits" Justify need for additional doses Documentation of cardiopulmonary bypass or special circumstances
"Outside RSV season" Provide epidemiologic justification CDC surveillance data or local outbreak information

FAQ

How long does UnitedHealthcare prior authorization take in Washington? Standard PA decisions take 1-7 business days. Electronic submissions through the provider portal are typically faster than fax submissions.

What if Synagis is non-formulary on my plan? Synagis requires prior authorization regardless of formulary status. Non-formulary placement doesn't prevent coverage if medical necessity is established.

Can I request an expedited appeal if my child needs Synagis urgently? Yes. Call UnitedHealthcare at 1-877-542-8997 for expedited review if your child's health is at risk. Expedited appeals receive decisions within 72 hours.

Does step therapy apply if we've tried other RSV prevention outside Washington? Yes. UnitedHealthcare's step therapy requirements apply regardless of where previous treatments were tried. Document all prior therapies and outcomes.

What happens if we move to Washington mid-RSV season? Contact UnitedHealthcare immediately to transfer authorization. Provide documentation of previous approvals and current medical need to continue therapy.

How much will Synagis cost with UnitedHealthcare coverage? Costs vary by plan. Specialty tier copays typically range from $100-500 per injection. Contact member services at the number on your insurance card for specific cost-sharing details.

From Our Advocates: One family we worked with faced repeated denials because their cardiologist's notes didn't explicitly state "hemodynamically significant" heart disease—even though the child clearly met criteria. After we helped them request updated documentation using UnitedHealthcare's exact terminology, the approval came through within days. Sometimes it's about speaking the payer's language.

For complex denials or appeals, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and payer policies to identify the specific criteria needed for approval, then drafts point-by-point rebuttals aligned to each plan's requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with UnitedHealthcare and consult your healthcare provider for medical decisions. For additional help with appeals in Washington, contact the Office of Insurance Commissioner at 1-800-562-6900.

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