Blvr Valves denied as not medically necessary by Humana?

Humana's specific coverage criteria for blvr valves 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 BLVR Valves as "Not Medically Necessary" — and How to Appeal

A medical-necessity denial for bronchoscopic lung volume reduction (BLVR) valves from Humana typically means one of three things: the submitted documentation did not establish that the patient meets every clinical criterion in Humana's coverage policy; a Humana physician reviewer concluded that less-invasive alternatives had not been adequately tried or documented; or the patient's anatomy was not documented as suitable (e.g., the heterogeneity of emphysema distribution and absence of collateral ventilation are commonly required elements that must be explicitly addressed in the record).

Because Humana's medical-necessity criteria for BLVR are detailed and specific, appeals that succeed tend to be the ones that methodically address every criterion with corresponding chart documentation rather than making a general argument about the treatment's value.

## Your Federal Appeal Rights

ACA §2719 and ERISA §503 guarantee your right to internal appeal and, if unsuccessful, binding external review by an Independent Review Organization (IRO). The internal appeal window is generally 180 days from the denial notice. After a final adverse internal decision, you typically have four months to request external review. Expedited review is available — and appropriate for patients with severe emphysema who cannot tolerate delay.

## Documentation to Gather

• Pulmonary function testing: Current spirometry, lung volumes (including hyperinflation measures), and DLCO results from your chart — these are standard criteria elements. Do not invent numbers; reference the actual test report by date.
• CT imaging report: A radiology report documenting emphysema distribution (heterogeneous vs. homogeneous), location, and severity. Many Humana policies require heterogeneous or upper-lobe predominant emphysema; your radiologist's report should use that language if it accurately reflects the imaging.
• Collateral ventilation assessment: Documentation of the Chartis procedure or equivalent assessment establishing absence of collateral ventilation in the target lobe — this is a key safety and efficacy criterion that, if undocumented, frequently triggers denial.
• Prior optimization history: Records showing the patient is on maximally tolerated guideline-directed medical therapy and pulmonary rehabilitation — per the treating pulmonologist's assessment and chart notes.
• Prescriber medical-necessity letter: A structured letter from the interventional pulmonologist that mirrors Humana's policy criteria and maps each one to a specific chart finding.

## Criteria-Mapping Structure

Obtain Humana's current BLVR coverage policy. Create a numbered list of every criterion in that policy. For each, write the exact chart evidence — test name, date, result as documented — that satisfies it. Submit this as the centerpiece of your appeal, with the supporting documents tabbed and labeled to match.