Inspire HGNS denied as non-formulary 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 as Non-Formulary

A non-formulary denial for an implantable surgical device is somewhat unusual — formulary structures are designed primarily for pharmaceuticals — but it reflects a plan architecture where Humana has either not listed HGNS as a covered benefit tier, or has categorized it in a tier requiring an exception. This denial is worth appealing because (a) surgical device coverage is often governed by medical policy rather than drug formulary rules, and (b) formulary exceptions are available when a non-formulary item is medically necessary and no formulary alternative is adequate.

For Inspire HGNS specifically: there is no formulary equivalent. CPAP and other PAP devices are a different category of treatment; they are not an equivalent surgical alternative to a hypoglossal nerve stimulator. If Humana cannot name a formulary alternative that provides equivalent benefit for your specific clinical situation, the non-formulary basis weakens substantially.

## Federal Appeal Rights

• Formulary exception / prior authorization appeal: Most plans allow a formulary exception request supported by medical necessity documentation. This is often a separate pathway from, and faster than, a standard coverage appeal.
• Internal appeal (ACA §2719 / ERISA §503): You have the right to a full internal review of any adverse coverage determination.
• External review: After exhausting internal appeals, you may request independent external review, typically within approximately four months of the final internal denial.
• Expedited track: Available if delay would seriously jeopardize your health or ability to regain maximum function.

## What to Gather

1. Diagnosis and severity — polysomnography confirming OSA diagnosis and severity, from your sleep specialist. 2. PAP failure documentation — objective evidence of PAP non-adherence or clinical failure, including device download data and chart notes with dates and duration of prior trials. 3. No adequate formulary alternative — a statement from your prescribing physician explaining that no listed formulary alternative provides medically equivalent treatment for your specific clinical profile (anatomy, PAP failure history). 4. Prescriber letter of medical necessity — addressing both the medical need for HGNS and the absence of an equivalent covered alternative. 5. Humana's coverage and formulary documents — download both the current HGNS medical coverage policy and the applicable benefit summary from humana.com to confirm how the device is categorized and what exception pathway exists.

## Criteria-Mapping Structure

| Humana Requirement | Your Documentation | |---|---| | Medical necessity criteria (from Humana's coverage policy) | [Chart evidence per criterion] | | No adequate formulary alternative | [Physician statement explaining why PAP/other options are not equivalent] | | Clinical severity justifying exception | [Sleep study findings, comorbidities, functional impact] |

In your appeal letter, state plainly: Inspire HGNS has no formulary equivalent in the surgical device category. The non-formulary denial does not identify an alternative that would adequately treat the condition for this patient. Request that Humana identify any specific formulary alternative it contends is equivalent, so your physician can address that claim directly.