How to appeal a Humana radiation oncology — proton, sbrt, brachytherapy, imrt, iort 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 radiation oncology — proton, sbrt, brachytherapy, imrt, iort

Cited policy: Humana Medicare Advantage — Radiation Therapy: defers to applicable CMS LCD where present and to Humana-specific medical necessity criteria for IORT, MRI-LINAC, and APBI

IORT / APBI covered for early-stage breast cancer meeting ASTRO APBI suitability criteria; MRI-LINAC covered when on-table adaptive replanning is medically required (pancreas, liver, prostate with daily anatomic change). Standard radiation modalities follow CMS LCD.

How Humana denies radiation oncology — proton, sbrt, brachytherapy, imrt, iort — and how to counter it

Where Humana pushes back: 1) IORT alleged investigational; 2) MRI-LINAC alleged duplicative of CBCT-IGRT; 3) APBI excluded as 'cosmetic alternative'.

Counter-arguments that hold up: For IORT cite TARGIT-A long-term (Vaidya BMJ 2020) and ELIOT (Veronesi Lancet Oncol 2013); ASTRO APBI Consensus 2023 update lists IORT as an APBI option in selected low-risk patients. For MRI-LINAC cite ASTRO + AAPM TG-264 quality program plus SMART pancreas (Parikh PRO 2023). Demonstrate daily anatomic change requiring on-table replanning. Map indication to CMS LCD where present.

What Humana typically denies for radiation oncology — proton, sbrt, brachytherapy, imrt, iort

Across Humana's commercial and Medicare books, denials cluster around a small number of patterns. For radiation oncology — proton, sbrt, brachytherapy, imrt, iort, 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 radiation oncology — proton, sbrt, brachytherapy, imrt, iort treatments most often flagged for prior auth, step therapy, or medical necessity review:

• Proton beam therapy
• SBRT prostate
• SBRT lung/liver/spine
• SRS brain
• LDR brachytherapy
• HDR brachytherapy

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.