Humana · Appeal · Updated May 25
Humana appeal: Step therapy requirement not met.
Plan is requiring documented trial of phentermine, orlistat or another lower-cost agent before approving Wegovy or Zepbound.
Rebuttal strategy: Rebut on one of three grounds: (1) prior trial of a step-therapy agent (often years ago, still counts), (2) documented contraindication to the step-therapy agent (cardiovascular disease for phentermine; malabsorption for orlistat) or (3) intolerance documented at any time. If none of those apply, the cheapest path is often to run a documented 4-12 week phentermine trial and re-apply rather than appeal.
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: "Step therapy requirement not met". 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 failure to meet step-therapy criteria. The patient has documented [prior phentermine trial with intolerance / contraindication to phentermine due to (specific cardiovascular condition with ICD-10) / contraindication to orlistat due to (specific GI condition with ICD-10)]. Per the plan's own PA criteria document, prior trial or documented contraindication satisfies the step-therapy requirement. The relevant documentation is attached. 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 - American Gastroenterological Association 2022 clinical practice guideline: phentermine has cardiovascular contraindications that disqualify many obesity patients - Endocrine Society 2015 obesity guideline (still current): step therapy through older anti-obesity agents is not clinically required for GLP-1 candidates with established comorbidities - Most plan-specific PA bulletins explicitly waive step therapy when the patient has documented prior trial OR contraindication 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
- American Gastroenterological Association 2022 clinical practice guideline: phentermine has cardiovascular contraindications that disqualify many obesity patients
- Endocrine Society 2015 obesity guideline (still current): step therapy through older anti-obesity agents is not clinically required for GLP-1 candidates with established comorbidities
- Most plan-specific PA bulletins explicitly waive step therapy when the patient has documented prior trial OR contraindication
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 failure to meet step-therapy criteria. The patient has documented [prior phentermine trial with intolerance / contraindication to phentermine due to (specific cardiovascular condition with ICD-10) / contraindication to orlistat due to (specific GI condition with ICD-10)]. Per the plan's own PA criteria document, prior trial or documented contraindication satisfies the step-therapy requirement. The relevant documentation is attached.
Other appeal templates for Humana
Same denial reason, other plans
Disclaimer
Educational templates only. Not legal or medical advice. Appeal letters must be signed by the treating clinician (MD, DO, NP, PA) with prescribing authority. Every plan reads the appeal carefully because the alternative is an external review the plan is statutorily required to lose if the evidence supports the patient. Address the specific denial reason in the first paragraph. Do not fabricate clinical findings.
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