Tafamidis ATTR denied for missing prior authorization by Humana?

Humana's specific coverage criteria for tafamidis attr 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 Tafamidis (ATTR Amyloidosis) — and How to Navigate It

Humana, like most large commercial insurers, requires prior authorization (PA) for tafamidis because of its high cost and the need to confirm the patient's diagnosis meets the FDA-approved indication. A PA denial at this stage is not a final determination — it is the beginning of a formal review process, and the majority of overturns happen when the appeal is supported by thorough clinical documentation.

PA denials for tafamidis most commonly occur because: (1) the diagnosis subtype was not specified in sufficient detail, (2) required diagnostic workup documentation was not submitted with the initial request, or (3) the plan's clinical criteria were not explicitly addressed in the submission.

## Your Federal Appeal Rights

• Internal appeal (ACA §2719 / ERISA §503): Every adverse PA determination carries the right to a formal internal appeal. Request Humana's specific timelines in writing.
• External review (IRO): After exhausting the internal appeal, you may request independent external review. Federal law provides approximately four months from the adverse determination to request this review. An accredited IRO — not Humana — makes the final call.
• Expedited review: If your clinical situation is urgent, request expedited review at both the internal and external stage simultaneously.

## Documentation to Gather

1. Confirmed ATTR amyloidosis diagnosis — records documenting the diagnostic method (nuclear scintigraphy, cardiac biopsy, or genetic testing), the subtype (wild-type or hereditary/variant), and the date of diagnosis. 2. Cardiac assessment records — echocardiograms, cardiac MRI, or functional assessments documenting disease severity. Your prescriber should summarize clinical findings in a medical-necessity letter without requiring you to cite specific numeric thresholds — the chart facts speak for themselves. 3. Prior treatment history — document any prior therapies tried, their dates, and outcomes. 4. Prescriber letter — your cardiologist should address each of Humana's published PA criteria for tafamidis point by point. Obtain Humana's current coverage policy (available on humana.com or by written request) and map every criterion to a specific chart entry. 5. FDA label — attach the current FDA-approved prescribing information confirming the indication.

## Criteria-Mapping Structure

Build your appeal as a table:

| Humana PA Criterion | Documented Evidence from Chart | |---|---| | Confirmed ATTR amyloidosis diagnosis | [Diagnostic report date and method] | | Disease subtype specified | [Wild-type or hereditary confirmed by] | | Prescriber specialty | [Cardiologist name and NPI] | | FDA-approved indication match | [Attached FDA label, highlighted indication] |

Obtain Humana's exact published criteria — do not rely on what was verbally communicated — and ensure each line has a corresponding chart citation.