How to appeal a Humana stroke & neuro rehab 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 stroke & neuro rehab

Cited policy: Humana Botulinum Toxin Spasticity Coverage (Upper- and Lower-Limb)

Modified Ashworth Scale >=2 + functional impairment + therapist documentation. Reauth based on response (modified Ashworth Scale reduction + functional outcome).

How Humana denies stroke & neuro rehab — and how to counter it

Where Humana pushes back: 1) Lower-limb denied — only upper-limb covered; 2) Insufficient functional impairment.

Counter-arguments that hold up: FDA approved onabotulinumtoxinA for adult lower-limb spasticity Jan 21, 2016 (supplement BLA 103000) — equal-weight to upper-limb (Mar 9, 2010 approval). AAN Practice Guideline (Simpson Neurology 2016) Level A for both upper + lower limb post-stroke spasticity. Submit Modified Ashworth Scale (MAS) >=2 + functional impact (ankle/toe flexor → gait abnormality + falls + AFO need). Brashear NEJM 2002;347:395 pivotal.

What Humana typically denies for stroke & neuro rehab

Across Humana's commercial and Medicare books, denials cluster around a small number of patterns. For stroke & neuro rehab, 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 stroke & neuro rehab treatments most often flagged for prior auth, step therapy, or medical necessity review:

• Acute thrombectomy / tPA
• IRF admission
• LTACH
• SNF sub-acute
• Outpatient PT/OT/SLP
• CIMT

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.