How to appeal a Humana thyroid eye disease (ted) — tepezza (teprotumumab) and igf-1r therapy 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 thyroid eye disease (ted) — tepezza (teprotumumab) and igf-1r therapy

Cited policy: Humana Medicare Advantage — Teprotumumab Medical Necessity Review (defers to FDA label and applicable LCD)

FDA-labeled indication 'thyroid eye disease'; EUGOGO moderate-to-severe activity in clinical practice; documented thyroid status; standard pre-treatment safety baselines.

How Humana denies thyroid eye disease (ted) — tepezza (teprotumumab) and igf-1r therapy — and how to counter it

Where Humana pushes back: 1) Diagnosis 'unstable thyroid status'; 2) Prior steroid not documented; 3) Audiogram not on file; 4) Re-treatment denied as 'experimental'.

Counter-arguments that hold up: Document euthyroid status ≥6 weeks pre-Tepezza with TSH and free T4 values. Submit EUGOGO methylpred log with response and AEs or contraindication. Submit baseline audiogram and glucose / A1c. For re-treatment cite Sears / Diniz / Ozzello plus FDA label which does not restrict to single course. Map to FDA-approved indication.

What Humana typically denies for thyroid eye disease (ted) — tepezza (teprotumumab) and igf-1r therapy

Across Humana's commercial and Medicare books, denials cluster around a small number of patterns. For thyroid eye disease (ted) — tepezza (teprotumumab) and igf-1r therapy, 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 thyroid eye disease (ted) — tepezza (teprotumumab) and igf-1r therapy treatments most often flagged for prior auth, step therapy, or medical necessity review:

• Tepezza standard course
• Tepezza re-treatment
• Tepezza chronic-stable
• IV methylprednisolone
• Oral prednisone
• Orbital radiotherapy

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.