How to appeal a Humana solid-organ transplant 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 solid-organ transplant

Cited policy: Humana Letermovir (Prevymis) Prior Authorization for CMV Prophylaxis

Indications per FDA label: (1) HSCT CMV-seropositive adult recipients (Nov 2017 original); (2) high-risk D+/R- adult kidney transplant recipients (Jun 6, 2023 expanded label). 480 mg PO/IV daily (or 240 mg with cyclosporine). Duration up to 200 days post-tx per label.

How Humana denies solid-organ transplant — and how to counter it

Where Humana pushes back: 1) Letermovir only for HSCT, not solid organ; 2) Use valganciclovir instead (cheaper); 3) D+/R- not high enough risk.

Counter-arguments that hold up: FDA label was EXPANDED Jun 6, 2023 to include adult kidney transplant recipients at high risk for CMV (D+/R- serostatus mismatch) for prophylaxis up to 200 days post-tx. Pivotal data: Limaye Chemaly et al. NEJM 2023 — letermovir non-inferior to valganciclovir for clinically significant CMV infection at week 52 (10.4% vs 11.8%) with significantly LESS myelosuppression (leukopenia 26% vs 64%) — critical advantage in transplant recipients on MMF/MPA. AST IDCOP CMV consensus (Razonable Clin Transplant 2019) + ISHLT 2018/2023 endorse extended prophylaxis in high-risk D+/R- kidney recipients. Document D+/R- serostatus + post-tx day.

What Humana typically denies for solid-organ transplant

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

• Basiliximab (Simulect)
• rATG (Thymoglobulin)
• Alemtuzumab (Campath)
• Tacrolimus IR (Prograf)
• Tacrolimus ER (Astagraf-XL)
• Tacrolimus ER (Envarsus-XR)

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.