Appeal a Humana Outpatient Rehabilitation (Physical Therapy, Occupational Therapy) - Medicare Advantage Denial

Q: Why did Humana deny my Outpatient Rehabilitation (Physical Therapy, Occupational Therapy) - Medicare Advantage claim?

Humana reviews Outpatient Rehabilitation (Physical Therapy, Occupational Therapy) - Medicare Advantage under policy HUM-1186-008. Denials usually mean the submitted documentation did not clearly show one of the policy's covered criteria was met. Your appeal should map your clinical facts to the specific criterion you satisfy.

Q: Can I appeal a Humana Outpatient Rehabilitation (Physical Therapy, Occupational Therapy) - Medicare Advantage denial?

Yes. You have the right to a formal internal appeal, and the strongest appeals cite Humana's own HUM-1186-008 criteria plus clinical evidence. CareCost Appeals generates this letter for free.

Humana decides coverage for Outpatient Rehabilitation (Physical Therapy, Occupational Therapy) - Medicare Advantage under policy HUM-1186-008. The most effective appeal shows, point by point, that you meet Humana's own criteria below.

What Humana requires for coverage

Humana considers Outpatient Rehabilitation (Physical Therapy, Occupational Therapy) - Medicare Advantage medically necessary when the following criteria (from HUM-1186-008) are met:

Services must be reasonable and necessary for diagnosis and treatment of illness or injury or to improve functioning of a malformed body member
PT services must be restorative in nature or for specific purposes of designing and teaching a maintenance program
Services must relate to a complex, written treatment plan requiring the judgment, knowledge and skills of a physical therapist (or MD/DO)
Amount, frequency and duration of PT services must be medically appropriate for the specific treatment regimen
Services must be performed by a licensed physical therapist or supervised PTA
OT services must relate to a complex, written treatment plan requiring judgment, knowledge and skills of an occupational therapist
OT includes helping individual learn/relearn specific daily living skills (ADLs) such as dressing, eating, personal hygiene, self-care and mobility/transfers
OT includes task-oriented therapeutic activities to restore physical function of shoulder, elbow, wrist and/or hand lost due to illness or injury
Humana applies applicable National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs)
For jurisdictions without LCD, medical necessity for OT based on LCD - Outpatient Occupational Therapy (L34427)
For jurisdictions without LCD, medical necessity for PT based on LCD - Outpatient Physical Therapy (L34428)
Humana may consider MCG Guidelines for visits per episode

Covered procedure codes

How to appeal this denial

Frame your appeal around the specific criterion you satisfy. Quote the HUM-1186-008 language above, then show — with your physician's records and clinical evidence — exactly how your situation meets it. Demand that Humana either approve the claim or identify the precise criterion they believe you fail. CareCost Appeals assembles this automatically: it cites the policy, pulls verified clinical evidence, and applies your state and federal appeal rights.

Source: Humana medical policy HUM-1186-008 — view the published policy.

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How to Appeal a Humana Outpatient Rehabilitation (Physical Therapy, Occupational Therapy) - Medicare Advantage Denial

What Humana requires for coverage

Covered procedure codes

How to appeal this denial