Inspire HGNS denied for missing prior authorization 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 Requires Prior Authorization for Inspire HGNS

Humana requires prior authorization (PA) for hypoglossal nerve stimulation before the procedure is performed. A denial with the reason "prior authorization required" typically means either: (a) the procedure was performed without obtaining PA in advance, or (b) a PA was submitted but was denied because the documentation did not satisfy Humana's coverage criteria. The path forward depends on which situation applies to you.

If PA was not obtained before surgery: The appeal is harder but not impossible. You may be able to argue retroactive authorization based on urgent or emergent circumstances, or that the denial of retroactive PA was arbitrary. Consult with your surgeon's billing team and consider engaging a patient advocate.

If PA was submitted and denied: This is a standard medical-necessity appeal. Humana's coverage policy lists specific patient selection criteria for HGNS; the PA denial means those criteria were not demonstrated to Humana's satisfaction in the submission. The appeal should resubmit with comprehensive documentation addressing every criterion.

## Federal Appeal Rights

• Internal appeal (ERISA §503 / ACA §2719): You have the right to appeal any adverse PA determination. Submit within the deadline on your denial notice.
• Concurrent / expedited review: If the procedure is scheduled and medically urgent, request expedited review — decisions are typically issued within 72 hours or less.
• External review: After a final internal denial, independent external review is available, generally within approximately four months of the final determination.
• Right to clinical criteria: Humana must provide all clinical criteria, guidelines, and evidence relied upon in the denial. Request this in writing if not already provided.

## What to Gather

1. Complete PA submission record — obtain the original PA request and all supporting documents submitted to Humana, so you can identify gaps. 2. OSA diagnosis and severity — polysomnography report with severity classification from a board-certified sleep physician. 3. PAP therapy failure documentation — objective download data showing PAP usage and/or residual events; chart notes documenting duration, adherence attempts, and clinical outcome of PAP trial; documentation of any alternative PAP modalities tried. 4. Airway evaluation — drug-induced sleep endoscopy (DISE) report or equivalent from your surgeon, confirming anatomical findings relevant to the Inspire labeling criteria. 5. Prescriber letter of medical necessity — a detailed letter from the implanting surgeon that maps each of Humana's coverage criteria (copied verbatim from the policy) to a specific chart finding, date, and result. 6. Humana's published HGNS coverage policy — download the current version from humana.com before drafting the appeal.

## Criteria-Mapping Structure

| Humana PA Criterion (exact text from policy) | Supporting Documentation | |---|---| | [Criterion 1 verbatim] | [Specific test, date, finding, physician note] | | [Criterion 2 verbatim] | [PAP trial duration, compliance data, dates] | | [Criterion 3 verbatim] | [DISE findings, surgeon note] |

A successful PA appeal resubmission reads as a direct, criterion-by-criterion response to Humana's own policy. The goal is to leave no criterion unanswered and no supporting fact undocumented.