Humana appeal: Not medically necessary (boilerplate).

The appeal letter (copy and edit)

Copy the body below and paste it into your clinician's portal or word processor. Replace every [BRACKET] placeholder with patient-specific data. Attach the original denial letter, the original PA submission, and any new documentation that directly addresses the denial reason. The letter is from your clinician to the plan, signed by your clinician.

[Today's date]

Humana
Prior Authorization Appeals Department
Submitted via: Humana provider portal, CoverMyMeds or fax 1-877-486-2621

Re: APPEAL of prior authorization denial
Patient: [Patient full name]
Member ID: [Plan member ID]
Date of birth: [Patient DOB]
Original PA reference number: [Reference number from denial letter]
Date of denial: [Denial letter date]
Date of this appeal: [Today]

To the Humana Appeals Review Department,

I am the treating clinician for [Patient name]. I am writing to formally appeal the denial dated [denial date] of my prior authorization request for [drug name] in the indication of [indication name].

The denial reason cited

The denial cites: "Not medically necessary (boilerplate)". The plan's specific stated rationale was: [quote exact language from the denial letter].

This appeal directly addresses that specific reason.

Clinical context

[Insert 2-3 sentences summarizing the patient's clinical picture: BMI, age, comorbidities, prior treatment history and why this medication was prescribed.]

Direct rebuttal to the denial reason

The denial cites lack of medical necessity without articulating a specific clinical objection. The patient meets the FDA-labeled criteria for [Wegovy / Zepbound / Ozempic / Mounjaro] in the [specific indication] indication, supported by patient-specific clinical findings attached. I am requesting that, if the plan upholds this denial on review, the plan provide a specific clinical basis for the denial that addresses the patient's documented [BMI / comorbidity / cardiac history / sleep study] and the evidence supporting treatment, so that this decision can be evaluated on its clinical merits and not on procedural grounds.

Patient-specific supporting findings

  - [Current weight, height, BMI with date measured]
  - [Comorbidity ICD-10 codes and the date each was documented]
  - [Prior treatment trials with dates and outcomes]
  - [Any lifestyle intervention documentation]
  - [Any specialty consultation supporting the requested treatment]

Supporting evidence

  - Patient's specific clinical findings (BMI, comorbidities, prior weight-loss history)
  - Registration trial data (STEP-1 or SURMOUNT-1 for obesity, SUSTAIN or SURPASS for T2D, SELECT for CV, SURMOUNT-OSA for OSA)
  - FDA labeling for the requested medication and indication
  - Plan's own statutory obligation to provide a clinical rationale on appeal review

Procedural points

Per Humana's own appeals process, I am submitting this appeal within the 60 days from denial notice (Medicare Part D) window from the denial notice. I am requesting:

  1. A formal first-level internal appeal review of this denial
  2. Written notification of the appeal decision within the statutory turnaround
  3. If the denial is upheld at first level, automatic escalation to second-level internal review
  4. If the denial is upheld at second level, external review per state insurance law

I am available to discuss this case with the plan's medical director at [Prescriber phone] or [Prescriber email]. A peer-to-peer review is available at your request.

Conclusion

The patient meets the FDA-labeled criteria for this medication and indication. The clinical rationale is documented in the attached records. The denial reason cited does not reflect the documented clinical picture. I respectfully request that this denial be overturned and the prior authorization granted.

Thank you for your attention to this appeal.

Sincerely,

[Prescriber full signature]
[Prescriber printed name, credentials]
[Prescriber NPI]
[Practice name and address]

Attachments:
  - Original denial letter
  - Original prior authorization submission
  - Updated patient measurements and labs
  - Documentation directly addressing the denial reason cited
  - All clinical records supporting the requested treatment

Evidence to cite in the appeal

• Patient's specific clinical findings (BMI, comorbidities, prior weight-loss history)
• Registration trial data (STEP-1 or SURMOUNT-1 for obesity, SUSTAIN or SURPASS for T2D, SELECT for CV, SURMOUNT-OSA for OSA)
• FDA labeling for the requested medication and indication
• Plan's own statutory obligation to provide a clinical rationale on appeal review

The direct-rebuttal paragraph

The paragraph below is the heart of the appeal letter. It is what makes this appeal different from a generic re-submission. Adapt the bracketed clauses to the patient's specific findings.

The denial cites lack of medical necessity without articulating a specific clinical objection. The patient meets the FDA-labeled criteria for [Wegovy / Zepbound / Ozempic / Mounjaro] in the [specific indication] indication, supported by patient-specific clinical findings attached. I am requesting that, if the plan upholds this denial on review, the plan provide a specific clinical basis for the denial that addresses the patient's documented [BMI / comorbidity / cardiac history / sleep study] and the evidence supporting treatment, so that this decision can be evaluated on its clinical merits and not on procedural grounds.

Other appeal templates for Humana

Same denial reason, other plans

Disclaimer

John Samaras, Founder and editorI started GLP Chart after overpaying for a GLP-1 myself. Based in Austin, Texas. About this site · LinkedIn · Contact