Humana’s Review of Medical Necessity

Determinations and Experimental Procedures

Humana defines medical necessity in terms of a member’s certi-ficate of coverage. Clinical decisions concerning medical necessity are based upon national criteria developed by such organizations as the Centers for Disease Control, American Academy of Pediatrics, the American College of Cardiology, the American Heart Association and similar specialty organizations. These guidelines can be reviewed by going to Humana’s Web site, under Provider Tools, Clinical & Healthcare Resources.

Humana requires preauthorization of some outpatient procedures and all inpatient admissions as well as additional defined services. These are spelled out in the “Commercial Preauthorization and Notification List” , to access the list click here.

Additionally, Humana maintains a formulary of drugs that need preauthorization before a physician can prescribe one of those drugs to a patient. Preauthorization can be obtained either through the Web site click here or through the use of the interactive voice response (IVR) line listed on the back of the member’s ID card. If the physician has questions about drug preauthorization, there is a special prior authorization number for pharmacy: (800) 555-2546.

Review of medical necessity is conducted using the nationally published criteria as guidelines (if the member’s plan covers such a benefit). If the physician or patient wishes to challenge a denial of coverage, Humana first has the case reviewed by one of its medical directors. The medical director will speak directly with the physician involved to review the case, the plan of treatment and the clinical basis for that treatment. If there is no resolution, the review can remain internal at Humana and go to a physician who handles appeals on a more regional basis. Further review, especially in a specialty area of expertise, goes to an external review organization (ERO) where the reviewing physician is from Ohio (if the policy is written in Ohio).

New technologies are reviewed once there is Food & Drug Administration (FDA) approval. Generally, Humana considers FDA approval as the starting point for review as to whether a new drug, technology, device or procedure is a covered benefit. Even with FDA approval, it could still be considered experimental until reviewed and approved by Humana's Clinical Review team. A physician or practice that wants to determine whether something is a covered benefit should contact Humana's Provider Services to verify coverage. If a physician would like a new technology reviewed by Humana's Clinical Review team, he or she should send any supporting clinical data to one of Humana's medical directors. He or she, in turn, will have it reviewed by the Clinical Review team which meets quarterly at the national level.