Ratg denied for missing prior authorization by Humana?

Humana Medicare Advantage plans must follow CMS coverage guidelines, and services must be provided according to Medicare coverage guidelines established by the Centers for Medicare & Medicaid Services (CMS), under which all medical care, services, supplies and equipment must be medically necessary . Under CMS NCD 260.7, the FDA has approved lymphocyte immune globulin, anti-thymocyte globulin (equine) for the management of allograft rejection episodes in renal transplantation, it is covered under Medicare when used for this purpose, and other forms of lymphocyte globulin preparation that the FDA approves for this indication may be covered . The FDA-labeled indication for rabbit ATG is that Thymoglobulin (anti-thymocyte globulin, rabbit) is indicated for the prophylaxis and treatment of acute rejection in adult and pediatric patients receiving a kidney transplant in conjunction with concomitant immunosuppression , with the approved regimen being 1.5 mg/kg of body weight administered daily for 4 to 7 days . Per FDA labeling, Thymoglobulin is contraindicated in patients with a history of allergy or anaphylaxis to rabbit proteins or to any product excipients, or who have active acute or chronic infections that contraindicate any additional immunosuppression , and dose reductions are required when the WBC count is between 2,000 and 3,000 cells/mm3 or if the platelet count is between 50,000 and 75,000 cells/mm3 . Humana requires prior authorization through its transplant network: preauthorization requests will be reviewed by the Humana National Transplant Network and can be submitted by fax to 502-508-9300 or by phone at 866-421-5663 , and Humana MA may apply step therapy requirements for some drugs under its Part B Step Therapy Preferred Drug List. To prevent disruption of care, Humana does not require prior authorization for basic Medicare benefits during the first 90 days of a new member's enrollment for active courses of treatment that started prior to enrollment, though Humana may review services furnished during an active course of treatment against permissible coverage criteria when determining payment .

- For kidney transplant rejection prophylaxis or treatment, the request aligns squarely with the FDA label: Thymoglobulin is indicated for the prophylaxis and treatment of acute rejection in adult and pediatric patients receiving a kidney transplant in conjunction with concomitant immunosuppression , and the drug is indicated for management of allograft rejection episodes in renal transplantation and is covered under Medicare when used for this purpose per CMS NCD 260.7 - KDIGO clinical practice guidelines support ATG-based induction in kidney transplant recipients, particularly those at high immunologic risk; anti-thymocyte globulin is a highly efficient induction agent that can prevent acute rejection and delayed graft function and is widely used for biopsy-confirmed acute rejection reversal and steroid-resistant rejection - For steroid-resistant or vascular rejection, ATG is the guideline-endorsed standard: ATG is a pivotal immunosuppressive therapy utilized in the management of T-cell-mediated rejection and steroid-resistant rejection among renal transplant recipients ; an IL-2 receptor antagonist (basiliximab) is not an appropriate substitute for treatment of established rejection, so step-therapy requirements should be waived - Dosing requested matches the FDA-approved regimen of 1.5 mg/kg of body weight administered daily for 4 to 7 days for induction, or a 7 to 14 day course of daily infusion of 1.5 mg/kg of Thymoglobulin for treatment of acute rejection, consistent with the package insert and LiverTox/NIH summaries - Thymoglobulin is preferred over equine ATG in high-risk recipients: multiple studies have indicated that thymoglobulin is favored in comparison to other induction agents for patients who have increased risk of developing post-transplant complications, such as elderly patients, patients undergoing a repeat transplantation, and patients in which minimization of use of steroids or CNIs post-operation is recommended — relevant for the Medicare Advantage population - Humana's own policy framework grants continuity-of-care protection: Humana does not require prior authorization for basic Medicare benefits during the first 90 days of a new member's enrollment for active courses of treatment that started prior to enrollment , and members can request expedited exception reviews for step therapy prior authorization requests - Contraindication-based denials should be rebutted with documentation that the patient has no history of allergy or anaphylaxis to rabbit proteins or to any product excipients, or active acute or chronic infections that contraindicate any additional immunosuppression , satisfying the only FDA-labeled contraindications

## Why Humana Denied rATG for "Prior Authorization Required" — and How to Appeal

Rabbit anti-thymocyte globulin (rATG) is a high-cost biologic immunosuppressive agent, and Humana requires prior authorization (PA) for its use as a standard utilization-management measure. A "prior-auth-required" denial means that rATG was administered or prescribed without an active, approved PA in place — or that the PA application was denied for failure to meet Humana's clinical criteria at the time of review.

This is one of the most common denial types for specialty biologics and is frequently resolved on appeal, particularly in transplant and hematology settings where the clinical necessity of rATG is well-supported by professional society protocols.

## Why This Denial Is Appealable

If rATG was used in an inpatient or emergent setting (such as acute rejection treatment) where obtaining PA in advance was not feasible, retrospective authorization is often available and Humana is generally required to consider it. If PA was denied prospectively, the appeal should focus on demonstrating that each of Humana's clinical criteria was met at the time of the request. In transplant medicine, the treating team's clinical judgment about the need for rATG carries significant weight when properly documented.

## Federal Appeal Framework

• Internal appeal: File within the deadline on your Explanation of Benefits (EOB), typically 180 days from the denial date.
• ACA §2719 / external review: After a final internal denial, you are entitled to independent external review. The standard window is approximately four months from the final internal denial. Expedited review (72-hour decision) is available for urgent clinical situations — particularly relevant for rATG, which is often used in time-sensitive rejection episodes.
• ERISA §503: Employer-sponsored plan members are entitled to full disclosure of every criterion applied in the PA determination and a full-and-fair appeal review.

## Concrete Appeal Steps

1. Determine whether a PA was submitted, and if so, obtain the PA submission record, the Humana decision letter, and the criteria cited. 2. If no PA was obtained due to clinical urgency, document the clinical circumstances that made advance authorization impractical and request retrospective review. 3. Ask the prescribing clinician to write a medical-necessity letter addressing each of Humana's PA criteria explicitly. 4. Compile the full clinical record supporting the rATG indication. 5. File the internal appeal (and any retrospective PA request) before the EOB deadline. 6. If denied, proceed to external review promptly.

## Documentation to Gather

• PA submission records: Any prior-authorization requests, reference numbers, submission dates, and Humana decision letters or denial notices.
• Clinical urgency documentation (if applicable): If rATG was used without advance PA due to an emergent situation, chart notes documenting the clinical circumstances, the timeline, and the treating team's reasoning.
• Diagnosis and indication records: Chart notes, biopsy or pathology reports, transplant records, laboratory results, or other objective documentation confirming the indication for rATG.
• Prescriber medical-necessity letter: A letter from the transplant physician, hematologist, or treating specialist explicitly addressing each of Humana's PA criteria and confirming that the patient met them at the time rATG was prescribed.
• Prior-treatment history: Documentation of prior immunosuppressive regimens and outcomes, supporting the clinical decision to use rATG.
• Professional society guideline reference: Citation to the applicable guideline organization (by name) supporting rATG use in the specific clinical context.

## Criteria-Mapping Structure

Obtain Humana's published PA criteria for rATG. Build a two-column table: left column lists every PA criterion; right column cites the chart note, laboratory result, or clinician letter paragraph that satisfies it. For retrospective PA requests, add a row documenting the clinical circumstances that prevented advance authorization. This structured response makes it easy for Humana's reviewer — and, if needed, an external reviewer — to confirm that the clinical necessity of rATG was established at the time of the request.