Art Cabenuva LA denied for missing prior authorization by Humana?

Humana's specific coverage criteria for art cabenuva la are defined in its own published medical/coverage policy and the FDA-approved prescribing label. A successful appeal documents that your medical records satisfy each criterion those sources list — confirmed diagnosis, any required prior treatments (with dates and outcomes), and clinical severity. If the exact criteria weren't included with your denial, request them in writing; your appeal then maps each requirement to the matching fact in your chart.

## Why Humana Denied Cabenuva (Long-Acting) for Prior Authorization

A prior-authorization (PA) denial means your prescription was dispensed or requested without obtaining Humana's advance approval, or that a PA request was submitted and Humana determined the clinical criteria were not met. PA is Humana's standard gatekeeping process for higher-cost or specialty medications. The denial is not a final word — it is the beginning of the appeal process.

For Cabenuva, Humana's PA criteria will typically require documentation of HIV-1 diagnosis, treatment history, virologic status, resistance testing, and clinical justification for long-acting injectable over oral therapy. If the PA was denied on clinical grounds, those grounds must be specified in the denial letter, and your appeal must address each one directly.

## Your Federal Appeal Rights

• Internal appeal: Under ACA §2719 and ERISA §503, you have the right to a full-and-fair internal review of any adverse benefit determination, including a denied PA. File your appeal in writing within the deadline on your denial letter.
• Urgent/concurrent care: If you are already on treatment or need urgent initiation, a concurrent-care or expedited appeal is available. Your prescriber must document why standard timelines jeopardize your health.
• External review: After an adverse internal decision, you may request independent external review. Federal law provides approximately four months from the original denial; your plan documents control the exact window. The IRO's decision is binding on Humana.
• Expedited external review: 72-hour turnaround when medically urgent.

## What to Gather

1. Humana's PA criteria document: Request the exact criteria Humana applied. If the PA was denied without specifying which criterion was unmet, your appeal should open by demanding that specificity — plans are legally required to provide it. 2. HIV-1 diagnosis confirmation: Current lab results and clinical documentation from your chart. 3. Complete ART treatment history: Every regimen, with start/stop dates and clinical reason for each change, formatted chronologically. 4. Viral load and resistance testing: Most recent results, and any prior resistance genotype/phenotype testing relevant to cabotegravir and rilpivirine susceptibility. 5. Clinical justification for injectable therapy: Chart notes and a prescriber letter explaining why the long-acting injectable format is medically indicated for this patient — not merely preferred. 6. FDA prescribing label: Attach the current label to anchor the clinical argument in the drug's approved indication.

## Criteria-Mapping Structure

Obtain Humana's PA criteria checklist. Create a parallel document: each PA requirement on the left; the specific clinical evidence satisfying it on the right, with chart dates. Your prescriber's letter should walk through this same structure. A PA appeal that addresses every criterion point-by-point is far more likely to succeed than a narrative letter that argues generally for the drug's value.