Inspire HGNS denied as not medically necessary by Humana?

Humana's specific coverage criteria for inspire hgns 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 Denies Inspire HGNS for Medical Necessity

A medical necessity denial means Humana's reviewer concluded that the clinical information submitted does not demonstrate that hypoglossal nerve stimulation is medically required for your specific condition — either because documentation was insufficient, or because Humana's medical policy criteria were not addressed item by item in the prior authorization submission. This is the most common denial type and among the most successfully appealed, because the clinical need can almost always be better documented.

Humana's coverage policy for HGNS lists specific patient selection criteria drawn from FDA labeling and clinical evidence. These typically address OSA severity, airway anatomy findings, and PAP therapy history. If the prior authorization submission did not explicitly address each criterion with corresponding chart documentation, Humana's reviewer may deny based on incomplete information — not because you don't qualify, but because your file didn't prove it.

## Federal Appeal Rights

• Internal appeal: You have the right to a full internal appeal. Submit within the deadline shown on your denial letter (commonly 60–180 days depending on plan type).
• External review (ACA §2719 / ERISA §503): After a final internal denial, you may request independent external review — typically within approximately four months of the final determination.
• Expedited review: Available if your condition is urgent or deteriorating; decisions are issued within days rather than weeks.
• Full-and-fair review right: Under ERISA, Humana must provide you with all clinical criteria, guidelines, and evidence it relied upon in the denial. Request this in writing.

## What to Gather

1. OSA diagnosis and severity — polysomnography (sleep study) report confirming diagnosis, and a statement of severity classification from your sleep physician. 2. PAP therapy failure documentation — objective PAP device download data (showing usage hours and/or residual events), chart notes documenting duration of PAP trial, reasons for failure or intolerance, and any alternative PAP modes attempted. 3. Airway evaluation — drug-induced sleep endoscopy (DISE) or equivalent evaluation report from your surgeon confirming airway anatomy findings relevant to the Inspire labeling criteria. Confirm the findings with your physician. 4. Clinical severity impact — chart notes documenting how OSA is affecting your health, including any comorbidities, cardiovascular concerns, or functional impairment. 5. Prescriber letter of medical necessity — a detailed letter from your implanting surgeon and/or sleep physician that: (a) lists each of Humana's coverage criteria verbatim, (b) states how your chart satisfies each criterion, and (c) explains the clinical rationale for why HGNS is medically necessary for you. 6. Humana's published coverage policy — download the current HGNS/Inspire coverage determination from humana.com.

## Criteria-Mapping Structure

Organize the appeal around Humana's own policy language:

| Humana Coverage Criterion (exact text) | Chart Evidence Meeting That Criterion | |---|---| | [Criterion 1 verbatim from policy] | [Sleep study date, finding, physician note] | | [Criterion 2 verbatim from policy] | [DISE report date and finding] | | [Criterion 3 verbatim from policy] | [PAP trial dates, duration, compliance data, outcome] |

Address every criterion in Humana's policy. A denial is far harder to sustain when the appeal responds to each requirement with a specific, dated chart fact.