Tumor Genomic Profiling denied as not medically necessary by Humana?

Humana's specific coverage criteria for tumor genomic profiling 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 Denied Tumor Genomic Profiling for Medical Necessity

A medical-necessity denial for tumor genomic profiling typically means Humana's reviewer concluded that the clinical record submitted did not sufficiently justify why profiling is required to guide treatment for your specific cancer type, stage, or line of therapy. This is one of the most common denials for genomic testing and one of the most reversible — because the denial often reflects missing documentation rather than a genuine clinical disagreement.

Humana's coverage policy for genomic profiling generally ties medical necessity to specific cancer types, tumor stages, prior treatment history, and whether the results would meaningfully change clinical management. If your submitting provider did not address all of those elements in the prior-authorization request, the denial can often be overturned on appeal with a more complete clinical package.

## Federal Appeal Framework

Under ACA Section 2719, you have the right to a full internal appeal and, if denied, independent external review. File your internal appeal within 180 days of the denial notice. After exhausting internal appeals, you typically have approximately 4 months to request external review by an accredited IRO. If a treatment decision is time-sensitive, request expedited review — decisions are generally required within days rather than weeks. ERISA employer plans carry parallel rights under Section 503.

## Concrete Appeal Steps

1. Read the denial letter carefully — identify every stated reason the test was deemed not medically necessary. 2. Request Humana's current coverage policy for tumor genomic profiling (it is a public document you are entitled to). 3. Have your oncologist prepare a letter that addresses each denial criterion directly and explicitly. 4. Compile the full supporting clinical record described below. 5. Submit the internal appeal and set a calendar reminder for the external review deadline.

## Documentation to Gather

• Diagnosis confirmation: Pathology report with tumor type, grade, and any available biomarker results; staging documentation.
• Prior treatment history: List of prior therapies with start/end dates, doses (from the clinical record), and outcomes — particularly evidence of progression or treatment failure.
• Clinical severity: Performance status, disease burden, and any urgent clinical indicators documented in the chart.
• Treatment-change rationale: A clear statement from your oncologist explaining how genomic profiling results will directly inform treatment selection — i.e., that management cannot be optimized without the test.
• Guideline alignment: Reference to the applicable NCCN guideline or equivalent oncology society guidance recommending genomic testing for your cancer type and stage, with your oncologist confirming your case meets those criteria.

## Criteria-Mapping Structure

Obtain Humana's full coverage policy. Create a two-column table: left column = each policy requirement; right column = the specific chart fact, document, or oncologist statement that satisfies it. A criteria-by-criteria response is the single most effective structure for a medical-necessity appeal, because it eliminates the reviewer's ability to overlook any element.