UHC non-invasive ventilation: prior authorization, denials and appeals

When a prior authorization is required for NIV, how long decisions take, and what happens after UHC denies a ventilator request.

United Healthcare (UHC) requires a prior authorization before any new non-invasive ventilation (NIV) order is delivered. Synapse Health submits the request; subcontractors supply the documentation that supports it.

This article covers the prior authorization process and decision timelines, what to do if the request is denied, who can appeal, the appeal deadlines, and the contacts for a peer-to-peer review or a fast appeal.

When prior authorization is required for NIV

Yes – a prior authorization (PA) is required before delivery for all new orders of non-invasive ventilation (NIV). This applies to orders from prescriber offices, clinics, and facilities at discharge.

How the prior authorization process works

1. Subcontractors send supporting documentation to Synapse Health.
2. Synapse Health submits the PA request to the health plan.
3. The health plan reviews the request and issues a decision.
4. Synapse Health communicates the decision to the patient, subcontractor, prescriber, and other appropriate parties.
5. The health plan sends written notification directly to the prescriber and patient.

How long prior authorization decisions take

Processing timelines are set by CMS for all Medicare Advantage members.

What subcontractors provide for a PA submission

Subcontractors play important roles in keeping the process on track and avoid delays:

• Provide all documentation needed to demonstrate medical necessity as quickly as possible.
• Respond promptly if additional information is requested.

Subcontractors should follow CMS documentation requirements outlined in the applicable National Coverage Determination (NCD). Reference: CMS – Noninvasive Positive Pressure Ventilation (NIPPV) in the Home for the Treatment of Chronic Respiratory Failure consequent to COPD, at https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=315

What happens if a PA request is not approved

If the health plan issues a denial:

• The denial letter includes instructions for how the patient or prescriber can file an appeal.
• Synapse Health provides a guide on how to file an appeal, request a peer-to-peer review, and consider alternative treatment options.

Who has appeal rights

• Patients and prescribers may file an appeal directly with the health plan following the instructions included in the denial letter.
• Synapse Health and subcontractors may share these instructions to ensure patients and prescribers understand their available options.

Someone else can appeal on the patient’s behalf. A patient may designate a representative by completing the CMS Appointment of Representative (AOR) form or an equivalent form. This allows a chosen representative to submit an appeal on their behalf.

Responsibilities after a denial

Synapse Health

Following a denial, Synapse Health educates prescribers and patients on next steps, which may include:

• Requesting a peer-to-peer review with UHC
• Filing an appeal directly with the health plan
• Considering clinically appropriate alternative treatment options

Prescriber

• Review and discuss the denial with the patient
• Determine the most appropriate next steps based on clinical needs

These steps may include:

• Requesting a peer-to-peer review
• Filing an appeal
• Ordering alternative treatment options when appropriate and medically necessary

Subcontractor

Subcontractors should help educate patients and prescribers about the available options following a denial.

Appeal filing and decision timelines

Documentation required for appeals

Key contacts for peer-to-peer review and fast appeals

Synapse Health continues to partner with UHC Clinical to improve access to non-invasive ventilation, advocate for patient needs, and ensure alignment with CMS guidelines.