How to appeal a Humana reconstructive plastic surgery — lymphedema, panniculectomy, burn, mohs, hand 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 reconstructive plastic surgery — lymphedema, panniculectomy, burn, mohs, hand

Cited policy: Humana Medicare Advantage — defers to CMS coverage; reconstruction after Mohs surgery for malignancy is generally covered when functional and follows ACMS Appropriate Use Criteria

Mohs surgery performed for skin malignancy on appropriate-site lesion per ACMS AUC; defect requires complex closure (local flap, skin graft, free flap); cosmetic and functional impact justified.

How Humana denies reconstructive plastic surgery — lymphedema, panniculectomy, burn, mohs, hand — and how to counter it

Where Humana pushes back: 1) Reconstruction lumped with primary excision; 2) Complex flap labeled cosmetic; 3) ACMS AUC not cited; 4) Same-day reconstruction by separate plastic surgeon billed separately questioned.

Counter-arguments that hold up: Quote ACMS Appropriate Use Criteria (Connolly J Am Acad Dermatol 2012) — head/neck/hand/genital/periorificial defects warrant Mohs and frequently require complex reconstruction. Submit Mohs operative report with defect dimensions, depth, and anatomic location. ASPS Position on reconstruction after malignancy. Two-physician concurrent care (Mohs + plastics) is standard of care for complex defects. CPT distinction: 14000-14302 adjacent tissue transfer, 15100+ skin graft, 15756-15758 free flap — code reflects complexity, not cosmesis.

What Humana typically denies for reconstructive plastic surgery — lymphedema, panniculectomy, burn, mohs, hand

Across Humana's commercial and Medicare books, denials cluster around a small number of patterns. For reconstructive plastic surgery — lymphedema, panniculectomy, burn, mohs, hand, 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 reconstructive plastic surgery — lymphedema, panniculectomy, burn, mohs, hand treatments most often flagged for prior auth, step therapy, or medical necessity review:

• VLNT
• LVA / LVB
• LYMPHA
• Lymphedema liposuction
• Charles / debulking
• Panniculectomy

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.