Tumor Genomic Profiling denied for missing prior authorization 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: Prior Authorization Required

A prior-authorization (PA) denial for tumor genomic profiling means the test was ordered and performed — or is pending — without Humana's advance approval, which the policy requires before the test is covered. This is a procedural denial rather than a clinical one, but it can result in full non-coverage if not properly addressed. In some cases the test may already have been performed, shifting the appeal into a retrospective review.

Humana requires prior authorization for many comprehensive genomic profiling tests because they are high-cost and the insurer wants to verify that coverage criteria are met before the test is run. If authorization was not obtained due to administrative error, provider oversight, or urgent clinical circumstances, the appeal should address both the procedural gap and the underlying clinical eligibility.

## Federal Appeal Framework

Under ACA Section 2719, you retain full internal appeal rights and access to independent external review even for procedural denials when coverage is at stake. File the internal appeal within 180 days of the denial. External review is available within approximately 4 months of the final internal denial. For prospective PA denials where the test has not yet been performed, expedited review may be requested if delay would adversely affect your health. ERISA plans carry equivalent protections under Section 503.

## Concrete Appeal Steps

1. Determine whether the denial is prospective (test not yet done) or retrospective (test already performed). 2. If prospective: submit a PA request immediately with a full clinical package — do not delay while appealing. 3. If retrospective: gather evidence of (a) why PA was not obtained and (b) that coverage criteria were clinically met at the time of service. 4. Request Humana's prior-authorization criteria document for tumor genomic profiling. 5. Have your oncologist submit a medical-necessity letter demonstrating that all PA criteria were satisfied.

## Documentation to Gather

• Diagnosis confirmation: Pathology report, cancer type, and staging.
• Clinical urgency documentation: Any documentation showing that the clinical situation did not permit delay for PA processing, if applicable.
• Provider records: Evidence of any PA submission attempt, including submission dates, confirmation numbers, and any Humana response.
• Oncologist medical-necessity letter: Should confirm that the clinical criteria required for PA approval were present at the time of ordering.
• Prior treatment history: Relevant prior therapies and outcomes to demonstrate the clinical context in which the test was ordered.
• Guideline support: Applicable NCCN or equivalent guideline supporting the test for your cancer type.

## Criteria-Mapping Structure

Obtain Humana's prior-authorization clinical criteria for tumor genomic profiling. For a retrospective denial, map each criterion to the clinical record at the time of the order — demonstrating that authorization would and should have been granted had it been requested. This retrospective eligibility demonstration is the core of a successful PA appeal.