How to appeal a Humana growth hormone replacement therapy denial

The framework that applies to your appeal

Medicare Advantage plans follow a separate appeal track from commercial plans. Reconsideration must be requested within 60 days; if the plan misses its deadline, the case auto-forwards to the IRE (Maximus).

Humana-specific note: Heavily Medicare Advantage focused. MA-specific appeal track (42 CFR Part 422 Subpart M) applies — 60 days to request reconsideration, NOT the 180 days for commercial plans. Auto-forward to IRE (Maximus) if Humana misses deadline.

What Humana's policy requires for growth hormone replacement therapy

Cited policy: Humana Increlex (Mecasermin rhIGF-1) PA — Severe Primary IGF-1 Deficiency / Laron Syndrome

Pediatric severe primary IGF-1 deficiency: height SDS ≤-3, IGF-1 SDS ≤-3, normal or elevated GH on stim testing (excludes GHD). Laron syndrome / GHR mutation / post-receptor defect / STAT5b / ALS deficiency. Endocrinologist Rx. Reauth annually with growth response (HV >=2 cm/yr over baseline). Not for GHD, ISS, or SGA.

How Humana denies growth hormone replacement therapy — and how to counter it

Where Humana pushes back: 1) Increlex experimental / off-label; 2) Try GH (somatropin) first; 3) Insufficient IGF-1 deficiency severity (SDS not ≤-3).

Counter-arguments that hold up: Increlex FDA-approved Aug 30 2005 specifically for severe primary IGF-1 deficiency / Laron — this is NOT GH-responsive disease (GHR mutation / post-receptor defect blocks GH signaling). Chernausek Backeljauw Frane Kuntze Underwood JCEM 2007 — long-term efficacy + safety in 76 patients. GH would be ineffective and is therefore not a required step. Endocrine Society 2016 (Grimberg) Section 6.4 endorses Increlex for confirmed severe primary IGF-1 deficiency. Submit: GHR gene sequencing, IGF-1 generation test (failure to rise on rhGH), GH stim showing normal/elevated GH, and IGF-1 + IGFBP-3 SDS measurements.

What Humana typically denies for growth hormone replacement therapy

Across Humana's commercial and Medicare books, denials cluster around a small number of patterns. For growth hormone replacement therapy, expect:

• MA plan step therapy on Part B drugs
• Skilled nursing facility days
• Prior auth on specialty drugs
• OON emergency reduction

Treatments most often denied in this category

These are the growth hormone replacement therapy treatments most often flagged for prior auth, step therapy, or medical necessity review:

• Norditropin (daily)
• Genotropin (daily)
• Humatrope (daily)
• Saizen (daily)
• Omnitrope (biosimilar daily)
• Nutropin AQ (daily)

How to submit the appeal to Humana

1. Read the denial letter — note the exact denial reason code and the appeal deadline (60 days from the date on the letter).
2. Gather supporting documentation: physician letter of medical necessity, relevant clinical notes, peer-reviewed citations supporting the treatment for your indication, and the policy or coverage document Humana cited in the denial.
3. File the appeal through Humana's portal (members: https://www.humana.com ; providers: https://www.humana.com/provider). Standard decision returns within 30 days; expedited urgent appeals return within 72 hours.
4. If denied again, request external review by an independent reviewer within 4 months of the final internal denial. In KY, the state insurance department coordinates external review for fully-insured plans; ERISA self-funded plans use a federal external review through DOL/EBSA.

Clinician or prior-auth team handling this on the practice side? See Humana's prior-authorization criteria by drug: Humana PA criteria on ApprovalHelp.