By Counterforce Health Team in Acthar Gel (repository corticotropin injection) —

Work With Your Doctor to Get Acthar Gel Approved by UnitedHealthcare in Pennsylvania: Complete Provider Collaboration Guide

Answer Box: Fast Track to Acthar Gel Approval

Getting Acthar Gel covered by UnitedHealthcare in Pennsylvania requires strong provider partnership. Your doctor must submit prior authorization showing failed corticosteroids and medical necessity for your specific condition (infantile spasms, MS exacerbation, or other labeled indication). If denied, you have internal appeals (within 6 months) and Pennsylvania's external review (within 4 months of final denial). Start today: Schedule a visit to review your treatment history and discuss Acthar's role in your care plan.

Table of Contents

  1. Set Your Goal: Understanding Approval Requirements
  2. Visit Prep: Organizing Your Medical Story
  3. Evidence Kit: Building Your Clinical Case
  4. Medical Necessity Letter Structure
  5. Peer-to-Peer Review Support
  6. After-Visit Action Items
  7. Respectful Persistence and Follow-Up
  8. Appeals Playbook for Pennsylvania
  9. FAQ: Common Questions

Set Your Goal: Understanding Approval Requirements

UnitedHealthcare's Acthar Gel Policy

UnitedHealthcare requires prior authorization for Acthar Gel with strict medical necessity criteria. Your partnership with your doctor centers on proving:

  • FDA-approved indication: Infantile spasms (under age 2), MS exacerbations, or specific autoimmune conditions
  • Failed alternatives: Documented trials of corticosteroids with inadequate response or intolerance
  • Medical necessity: Clear rationale why Acthar is appropriate for your situation

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Acthar uses UHC Provider Portal
Step Therapy Must try corticosteroids first (most conditions) Repository Corticotropin Policy
Specialist Requirement Often neurologist, rheumatologist, or relevant specialist Policy documents
Duration Limits 3-4 weeks (MS/infantile spasms), up to 12 months (other conditions) Clinical Policy

Visit Prep: Organizing Your Medical Story

Create Your Treatment Timeline

Before your appointment, organize your medical history chronologically. Your doctor needs this information to build a compelling case:

Symptom History

  • When did your condition start?
  • How has it progressed?
  • What triggers worsen symptoms?
  • How does it affect daily activities, work, or school?

Previous Treatments Tried Document every therapy you've attempted:

  • Medication names and doses
  • Duration of treatment
  • Why each was stopped (ineffective, side effects, allergic reaction)
  • Hospitalizations or emergency visits related to your condition
Tip: Use a simple table format with columns for Drug Name, Dates, Dose, Outcome, and Reason for Stopping. This makes it easy for your doctor to reference during the prior authorization process.

Functional Impact Documentation

Prepare specific examples of how your condition affects your life:

  • Work or school absences
  • Activities you can no longer do
  • Sleep disruption
  • Mobility limitations
  • Cognitive effects (for MS or seizure disorders)

Evidence Kit: Building Your Clinical Case

Essential Medical Records

Work with your doctor's office to gather:

Laboratory Results

  • Recent blood work showing disease activity
  • Inflammatory markers (ESR, CRP for autoimmune conditions)
  • Kidney function tests (for nephrotic syndrome)
  • Any specialized testing relevant to your diagnosis

Imaging Studies

  • MRI results (for MS patients)
  • X-rays or other imaging showing disease progression
  • EEG reports (for infantile spasms)

Specialist Consultations

  • Neurologist evaluations
  • Rheumatology assessments
  • Any subspecialist opinions supporting Acthar use

Published Guidelines and Evidence

Your doctor can strengthen the case by referencing:

  • FDA labeling for Acthar Gel showing approved indications
  • Medical society guidelines supporting repository corticotropin use
  • Published studies demonstrating efficacy in your condition

Counterforce Health helps patients and providers compile this evidence-based documentation to turn insurance denials into targeted appeals that align with payer policies.

Medical Necessity Letter Structure

Key Components Your Doctor Should Include

Patient Information and Diagnosis

  • Your name, date of birth, and insurance details
  • Specific diagnosis with ICD-10 codes
  • Disease severity and current status

Clinical History

  • Detailed symptom progression
  • Objective findings from exams and tests
  • Impact on quality of life and function

Treatment History Documentation Your doctor must explicitly document:

  • Each corticosteroid tried (prednisone, methylprednisolone, etc.)
  • Doses and duration of treatment
  • Specific reasons for failure or discontinuation
  • Any contraindications to further steroid use

Medical Necessity Rationale

  • Why Acthar Gel is appropriate for your condition
  • Alignment with FDA labeling or published guidelines
  • Risks of delaying effective treatment
  • Expected benefits and monitoring plan
Note: UnitedHealthcare often denies reauthorization requests automatically for certain conditions, requiring appeals through their pharmacy team. Your doctor should plan for this from the start.

Peer-to-Peer Review Support

When Peer-to-Peer Reviews Happen

If UnitedHealthcare initially denies your prior authorization, they may offer a peer-to-peer review where your doctor speaks directly with their medical reviewer.

How You Can Support Your Doctor

Scheduling Flexibility

  • Offer to help coordinate timing that works for your provider
  • Be available if additional information is needed during the call

Clinical Summary Preparation Help your doctor prepare a one-page summary including:

  • Your diagnosis and key symptoms
  • Chronological list of failed treatments
  • Specific reasons Acthar is medically necessary
  • References to guidelines or studies supporting use

Documentation of the Call Ask your doctor to document:

  • Date and time of the peer-to-peer review
  • Name and credentials of the UnitedHealthcare reviewer
  • Specific criteria discussed
  • Outcome and next steps

After-Visit Action Items

What to Save and Track

Portal Access

  • Log into your UnitedHealthcare member portal
  • Monitor prior authorization status
  • Save all communications and determination letters

Documentation Organization Keep copies of:

  • Prior authorization submission
  • Medical necessity letter
  • Supporting test results and records
  • Any correspondence with UnitedHealthcare

Communication with Your Provider's Office

Preferred Contact Methods

  • Use patient portal messaging for non-urgent updates
  • Call during designated hours for urgent issues
  • Provide multiple contact options for insurance callbacks

Status Check Schedule

  • Week 1: Confirm submission received
  • Week 2: Follow up if no initial determination
  • Week 3+: Discuss appeal strategy if denied

Respectful Persistence and Follow-Up

Working Effectively with Your Care Team

Regular Updates

  • Check in weekly during the prior authorization process
  • Share any new symptoms or changes in your condition
  • Report any insurance communications you receive directly

Escalation Guidelines If the process stalls:

  • Request to speak with the office's prior authorization specialist
  • Ask about expedited review options for urgent cases
  • Discuss involving the practice's patient advocate

When to Request Expedited Review

UnitedHealthcare must provide faster decisions for urgent cases. Work with your doctor to request expedited review if:

  • Delay could seriously jeopardize your health
  • You're having frequent seizures (infantile spasms)
  • MS exacerbation is worsening rapidly
  • You're at risk of hospitalization

Appeals Playbook for Pennsylvania

Internal Appeals with UnitedHealthcare

Timeline and Requirements

  • Deadline: Within 6 months of denial for Pennsylvania-regulated plans
  • Decision timeframe: 30 days for pre-service appeals, 60 days for post-service
  • Submission: Via UHC Provider Portal or addresses listed in denial letter

What Your Doctor Should Include

  • Detailed response to each denial reason
  • Additional medical evidence not in original submission
  • Updated clinical assessment
  • Request for peer-to-peer review if not already conducted

Pennsylvania External Review Process

If UnitedHealthcare issues a final denial after internal appeals, Pennsylvania offers an independent external review process with strong success rates.

Eligibility and Timeline

  • Available for Pennsylvania-regulated commercial plans (not Medicare or Medicaid)
  • Must request within 4 months of final adverse determination
  • Submit online or by mail to Pennsylvania Insurance Department

Success Rates Pennsylvania's external review program reports approximately 50% of appealed denials are overturned, with insurers required to provide coverage immediately when decisions favor patients.

Required Documentation

  • Copy of UnitedHealthcare's final adverse determination letter
  • Completed external review request form
  • Additional supporting medical records
  • Provider statement of medical necessity
From our advocates: We've seen patients successfully overturn Acthar denials by organizing their treatment history chronologically and having their specialist clearly explain why corticosteroids failed or caused intolerable side effects. The key is showing the reviewer a clear progression of treatment attempts and why Acthar represents the next logical step, not just an expensive alternative.

FAQ: Common Questions

How long does UnitedHealthcare prior authorization take in Pennsylvania? Standard requests: 15 days for pre-service, 30 days for post-service claims. Urgent cases must be decided within 72 hours.

What if Acthar Gel is not on my formulary? Your doctor can request a formulary exception, which follows similar prior authorization processes but may require additional justification for why formulary alternatives aren't appropriate.

Can I request an expedited appeal? Yes, if delay could seriously jeopardize your health or ability to regain function. Your doctor must provide clinical documentation supporting the urgent need.

Does step therapy apply if I failed corticosteroids outside Pennsylvania? Yes, UnitedHealthcare accepts documented treatment failures from other providers and locations, as long as the medical records clearly show inadequate response or intolerance.

What happens if my doctor leaves the practice during the appeal process? The new provider can continue the appeal using existing medical records, but you may need to establish care and have them review your case to provide continued support.

How much does Acthar Gel cost without insurance? Acthar Gel is extremely expensive (tens of thousands of dollars per treatment course), making insurance coverage essential. The manufacturer offers patient assistance programs for eligible individuals.

Can I get help with the appeals process? Yes, contact the Pennsylvania Insurance Department Consumer Services for guidance, or consider working with Counterforce Health to develop targeted appeal strategies.

What if I have UnitedHealthcare Medicare Advantage? Medicare Advantage plans follow Medicare appeal processes, not Pennsylvania's external review system. You have different timelines and procedures for appeals.

Counterforce Health specializes in helping patients and providers navigate complex prior authorization requirements for specialty medications like Acthar Gel. By analyzing denial letters, plan policies, and clinical notes, they identify the specific denial basis and draft targeted appeals that align with each payer's criteria, significantly improving approval rates for medically necessary treatments.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and state regulations can change. Always verify current requirements with UnitedHealthcare and the Pennsylvania Insurance Department. Consult with your healthcare provider about treatment decisions and work with qualified professionals for complex appeals.

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