How to Appeal a Humana Psychiatric Inpatient Hospitalization - Medicare Advantage Denial
Humana decides coverage for Psychiatric Inpatient Hospitalization - Medicare Advantage under policy HUM-9000-003. The most effective appeal shows, point by point, that you meet Humana's own criteria below.
What Humana requires for coverage
Humana considers Psychiatric Inpatient Hospitalization - Medicare Advantage medically necessary when the following criteria (from HUM-9000-003) are met:
- Services must be reasonable and necessary per Medicare requirements
- Psychiatric inpatient hospitalization provides 24 hours of daily care in a structured, intensive, and secure setting
- For individuals who cannot be safely and/or adequately managed at a lower level of care
- Setting provides daily physician (MD/DO) supervision and 24-hour availability of diagnostic services
- Evaluation and observation as well as psychotherapeutic and medical interventions provided by nursing/treatment team
- Two-midnight benchmark: Admitting physician reasonable expectation that patient requires medically necessary hospital care crossing two midnights, based on complex medical factors supported by medical record documentation
- Complex medical factors include: medical history and current needs; types of facilities available and relative appropriateness; severity of signs and symptoms; medical predictability of adverse events; need for diagnostic studies; availability of diagnostic procedures
- Medical necessity per Medicare Benefit Policy Manual Chapters 1 and 2 (Inpatient Hospital Services Covered Under Part A, Inpatient Psychiatric Hospital Services)
- For jurisdictions without LCD, medical necessity based on LCD L33624 - Psychiatric Inpatient Hospitalization
- Additional LCDs by jurisdiction: L34183 (KY, OH), L34570 (AL, GA, TN, NC, SC, VA, WV), L33975 (FL, PR, US VI)
How to appeal this denial
Frame your appeal around the specific criterion you satisfy. Quote the HUM-9000-003 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-9000-003 — view the published policy.