How to appeal a Humana neuropsychological & psychological testing — adhd, tbi, dementia, asd, presurgical eval 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 neuropsychological & psychological testing — adhd, tbi, dementia, asd, presurgical eval

Cited policy: Humana Medicare Advantage — defers to CMS coverage of presurgical neuropsych evaluation as part of bundled epilepsy / DBS / bariatric surgical workup; case-by-case medical necessity

Surgeon's letter requesting presurgical neuropsych; level-3/4 epilepsy center for epilepsy surgery; pre-DBS per Bronstein 2011; pre-bariatric per ASMBS standards.

How Humana denies neuropsychological & psychological testing — adhd, tbi, dementia, asd, presurgical eval — and how to counter it

Where Humana pushes back: 1) Pre-surgical eval 'not separately billable'; 2) 'Investigational' for fMRI language mapping vs Wada; 3) Hours/CPT codes denied for comprehensive battery.

Counter-arguments that hold up: AAN/AES Practice Parameter for Presurgical Eval requires neuropsych for lateralization, baseline, and post-resection risk prediction. Engel 2003 + NAEC standards. Bronstein 2011 explicitly requires neuropsych pre-DBS to identify cognitive contraindications. ASMBS standards require psych eval pre-bariatric. fMRI language mapping has been validated as Wada-equivalent in multiple validation studies (Janecek et al., Neurology 2013; Bauer Epilepsia 2014). Submit surgeon's letter + epilepsy center designation + indication-specific guideline.

What Humana typically denies for neuropsychological & psychological testing — adhd, tbi, dementia, asd, presurgical eval

Across Humana's commercial and Medicare books, denials cluster around a small number of patterns. For neuropsychological & psychological testing — adhd, tbi, dementia, asd, presurgical eval, 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 neuropsychological & psychological testing — adhd, tbi, dementia, asd, presurgical eval treatments most often flagged for prior auth, step therapy, or medical necessity review:

• Comprehensive neuropsych battery
• ADHD neuropsych eval
• Post-concussion / mTBI eval
• Moderate-severe TBI eval
• Dementia workup
• ASD diagnostic eval

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.