By Counterforce Health Team in Tecentriq (atezolizumab) —

UnitedHealthcare's Coverage Criteria for Tecentriq (atezolizumab) in Pennsylvania: What Counts as "Medically Necessary"?

Answer Box: Getting Tecentriq Covered by UnitedHealthcare in Pennsylvania

UnitedHealthcare requires prior authorization for Tecentriq (atezolizumab) with specific medical necessity criteria including FDA-approved indication, PD-L1 testing (when required), and oncologist prescribing. If denied, Pennsylvania's Independent External Review Program has overturned 53% of denials. Start today: Gather your pathology report, PD-L1 test results, and prior treatment history, then submit through the UnitedHealthcare Provider Portal.

Table of Contents

  1. UnitedHealthcare Policy Overview
  2. FDA Indication Requirements
  3. Step Therapy & Medical Exceptions
  4. Quantity and Frequency Limits
  5. Required Diagnostics
  6. Site of Care Requirements
  7. Evidence for Medical Necessity
  8. Sample Medical Necessity Letter
  9. Pennsylvania Appeals Process
  10. Common Denial Reasons & Solutions
  11. Costs & Patient Assistance

UnitedHealthcare Policy Overview

UnitedHealthcare manages Tecentriq (atezolizumab) through medical benefits, not pharmacy benefits. This means your oncology team will purchase and bill the medication directly rather than routing through OptumRx specialty pharmacy.

Plan Types and Coverage

  • Commercial plans: Prior authorization required through UnitedHealthcare Provider Portal
  • Medicare Advantage: Similar PA requirements with expedited review options
  • Medicaid managed plans: State-specific criteria may apply
Note: Tecentriq uses HCPCS code J9022 (10 mg units) and cannot be dispensed through retail or specialty pharmacies.

FDA Indication Requirements

UnitedHealthcare typically covers FDA-approved indications for Tecentriq, which include:

Approved Cancer Types

  • Non-small cell lung cancer (NSCLC): Adjuvant therapy after surgery and chemotherapy; metastatic disease with specific biomarker criteria
  • Extensive-stage small cell lung cancer: In combination with carboplatin and etoposide
  • Hepatocellular carcinoma: With bevacizumab for first-line unresectable or metastatic disease
  • Urothelial carcinoma: Various settings including maintenance therapy
  • Triple-negative breast cancer: PD-L1 positive, unresectable locally advanced or metastatic

Off-Label Considerations

UnitedHealthcare may cover off-label uses supported by:

  • NCCN Guidelines (Category 1 or 2A recommendations)
  • Peer-reviewed literature demonstrating efficacy
  • Recognized drug compendia listings

Step Therapy & Medical Exceptions

While specific step therapy requirements for Tecentriq aren't publicly detailed in UnitedHealthcare policies, oncology medications often require documentation of:

First-Line Therapy Documentation

  • NSCLC: Previous platinum-based chemotherapy (unless contraindicated)
  • HCC: Confirmation this is first-line systemic therapy
  • SCLC: Concurrent use with standard carboplatin/etoposide

Medical Exception Pathways

You can bypass step therapy requirements if:

  • Prior therapies are contraindicated due to allergies or medical conditions
  • Previous treatments failed or caused intolerable side effects
  • Clinical guidelines support Tecentriq as first-line therapy

Documentation needed: Detailed treatment history with dates, doses, outcomes, and reasons for discontinuation.

Quantity and Frequency Limits

Standard Dosing Approved by UnitedHealthcare

Indication Dose Frequency Units (J9022)
Most indications 1200 mg IV Every 3 weeks 120 units
Alternative dosing 840 mg IV Every 2 weeks 84 units
Extended dosing 1680 mg IV Every 4 weeks 168 units

Renewal Requirements

  • Initial authorization typically covers 6-12 months
  • Renewal requires documentation of:
    • Disease stability or response
    • Acceptable toxicity profile
    • Continued oncologist supervision

Required Diagnostics

PD-L1 Testing Requirements

For certain indications, UnitedHealthcare requires PD-L1 testing using the FDA-approved VENTANA PD-L1 (SP142) assay:

  • Adjuvant NSCLC: PD-L1 ≥1% on tumor cells
  • Metastatic NSCLC: PD-L1 ≥50% tumor cells OR ≥10% immune cells (for post-chemotherapy use)

Testing logistics: Order through Quest Diagnostics or Labcorp with 2-4 day turnaround.

Additional Required Tests

  • Complete pathology report with ICD-10 diagnosis codes
  • Staging studies (CT/MRI/PET scans within 30 days)
  • ECOG performance status documentation
  • Baseline laboratory values (CBC, CMP, LFTs)

Site of Care Requirements

Tecentriq must be administered at UnitedHealthcare network-approved infusion centers. The medication follows a buy-and-bill model where your oncology practice:

  1. Purchases Tecentriq directly from the manufacturer
  2. Administers the infusion at their facility
  3. Bills UnitedHealthcare using medical benefit codes

Network Verification

Before starting treatment, verify your infusion center is in-network by:

  • Checking the UnitedHealthcare provider directory
  • Calling member services to confirm coverage
  • Requesting a site-of-care exception if your preferred center is out-of-network

Evidence for Medical Necessity

Clinician Corner: Building Your Case

When submitting prior authorization, include evidence from these sources:

Primary Sources:

  • FDA prescribing information for approved indications
  • NCCN Guidelines supporting the specific use
  • Peer-reviewed studies demonstrating efficacy

Clinical Documentation:

  • Pathology report confirming diagnosis
  • Biomarker testing results (PD-L1, genetic mutations)
  • Prior treatment history with response/toxicity data
  • Performance status and staging information

Sample Medical Necessity Letter

Template Structure

Patient: [Name], DOB [Date], Member ID [Number]
Diagnosis: [Primary cancer diagnosis with ICD-10 code]

Clinical Summary:
[Patient] has [specific cancer type and stage] confirmed by pathology on [date]. PD-L1 testing shows [percentage] expression by VENTANA SP142 assay. ECOG performance status is [0-2].

Prior Treatments:
- [Treatment 1]: [Dates, response, reason for discontinuation]
- [Treatment 2]: [Dates, response, reason for discontinuation]

Medical Necessity:
Tecentriq is FDA-approved for [specific indication] and recommended by NCCN Guidelines as [category level]. The patient meets all criteria including [list specific requirements].

Requested Treatment:
Tecentriq 1200 mg IV every 3 weeks for up to 12 months or until disease progression.

Pennsylvania Appeals Process

If UnitedHealthcare denies your Tecentriq request, Pennsylvania offers robust appeal options through its Independent External Review Program.

Internal Appeals (Required First Step)

Timeline Action Required
Within 180 days File internal appeal with UnitedHealthcare
10-14 business days UnitedHealthcare issues decision
72 hours Expedited review for urgent cases

Submit appeals through the UnitedHealthcare Provider Portal or member portal.

Pennsylvania External Review

After receiving a Final Adverse Benefit Determination, you can request external review through the Pennsylvania Insurance Department.

Key advantages:

  • 53% overturn rate in first year
  • No cost to patients
  • Independent physician review
  • Binding decisions on insurers

Timeline:

  • Standard review: 45 days from assignment
  • Expedited review: 72 hours for urgent cases
  • Filing deadline: 4 months from final denial

Common Denial Reasons & Solutions

Denial Reason Solution Documentation Needed
"Not FDA-approved" Provide FDA label citation Link to official prescribing information
"Missing PD-L1 testing" Submit biomarker results VENTANA SP142 assay report
"Experimental/investigational" Cite NCCN Guidelines Category 1 or 2A recommendation
"Step therapy not met" Document contraindications Prior treatment failure records
"Site of care not approved" Request exception Clinical justification for specific facility

Counterforce Health specializes in turning these denials into successful appeals by analyzing payer policies and crafting targeted, evidence-backed responses. Our platform helps identify the specific denial basis and drafts point-by-point rebuttals aligned to UnitedHealthcare's own criteria.

Costs & Patient Assistance

Manufacturer Support

Genentech offers patient assistance through:

  • Tecentriq Co-pay Card: May reduce out-of-pocket costs for eligible patients
  • Patient Foundation: Financial assistance for qualifying individuals

Pennsylvania State Resources

  • Pennsylvania Insurance Department: Free assistance with appeals and coverage disputes
  • Pennsylvania Health Law Project: Legal advocacy for complex cases
From our advocates: "We've seen the strongest approvals when clinicians submit PD-L1 testing results upfront, even for indications where it's not strictly required. This proactive approach demonstrates thorough evaluation and often prevents initial denials."

When facing coverage challenges, consider working with specialized advocacy services. Counterforce Health helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements by analyzing denial letters and crafting evidence-backed appeals that align with each payer's specific criteria.

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take for Tecentriq? Standard review takes 10-14 business days. Expedited review is available within 72 hours for urgent cases.

What if Tecentriq is non-formulary on my plan? Tecentriq is billed through medical benefits, not pharmacy formularies. Coverage depends on medical necessity criteria rather than formulary status.

Can I request expedited appeal in Pennsylvania? Yes, both UnitedHealthcare internal appeals and Pennsylvania external reviews offer expedited tracks for urgent medical situations.

Does step therapy apply if I failed treatments outside Pennsylvania? Treatment history from any location counts toward step therapy requirements. Provide documentation from all previous providers.

What happens if the external review overturns the denial? UnitedHealthcare must immediately provide coverage, including retroactive coverage if you paid out-of-pocket during appeals.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual circumstances and plan details. Always consult with your healthcare provider and insurance plan for specific guidance. For assistance with coverage appeals, contact the Pennsylvania Insurance Department at the resources linked above.

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