How to appeal a Humana interventional radiology — ufe, pae, tips, y-90, tumor ablation, kyphoplasty 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 interventional radiology — ufe, pae, tips, y-90, tumor ablation, kyphoplasty

Cited policy: Humana Medicare Advantage — defers to AASLD / EASL / Baveno VII; case-by-case medical necessity for TIPS

Refractory / recurrent variceal bleeding (>=2 episodes despite endoscopic + medical therapy); refractory ascites or hepatic hydrothorax; selected Budd-Chiari, hepatorenal syndrome, hepatopulmonary syndrome considerations. MELD typically <18-20 for elective; relative contraindications: severe HE, severe RHF, severe pulmonary HTN, portal vein thrombosis (relative).

How Humana denies interventional radiology — ufe, pae, tips, y-90, tumor ablation, kyphoplasty — and how to counter it

Where Humana pushes back: 1) MELD too high; 2) HE risk; 3) Other modalities (large-volume paracentesis, BRTO) preferred; 4) Refractory definition not met.

Counter-arguments that hold up: Cite AASLD Portal Hypertensive Bleeding Guideline (Garcia-Tsao Hepatology 2017); AASLD ascites guidance; Baveno VII (de Franchis 2022); EASL Vascular Diseases of the Liver. Document MELD, Child-Pugh, prior endoscopic banding sessions, beta-blocker therapy / contraindication, paracentesis frequency, refractory ascites criteria. Pre-TIPS gradient measurement and post-TIPS target. Address HE risk with patient selection (no severe baseline HE) and protein modification / lactulose plan.

What Humana typically denies for interventional radiology — ufe, pae, tips, y-90, tumor ablation, kyphoplasty

Across Humana's commercial and Medicare books, denials cluster around a small number of patterns. For interventional radiology — ufe, pae, tips, y-90, tumor ablation, kyphoplasty, 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 interventional radiology — ufe, pae, tips, y-90, tumor ablation, kyphoplasty treatments most often flagged for prior auth, step therapy, or medical necessity review:

• UFE (uterine fibroid embolization)
• PAE (prostate artery embolization)
• TIPS
• Y-90 radioembolization
• TACE (HCC)
• Cryoablation

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.