How to Appeal a Humana Advanced Imaging (MRI/CT) - Medicare Advantage (Spine, Head/Neck, Chest) Denial

What Humana requires for coverage

Humana considers Advanced Imaging (MRI/CT) - Medicare Advantage (Spine, Head/Neck, Chest) medically necessary when the following criteria (from HUM-1276-002 / HUM-1281-001 / HUM-1277-001) are met:

• Services must be reasonable and necessary for diagnosis/treatment of illness or injury per Medicare requirements
• Humana applies applicable NCDs (220.1 Computed Tomography, 220.2 Magnetic Resonance Imaging) and LCDs by jurisdiction
• CT of spine: Back pain with red flags (urinary retention, bilateral weakness, constitutional symptoms, cancer history, fracture risk, infection risk, saddle anesthesia)
• CT of spine: Neck pain with red flags (coagulopathy, constitutional symptoms, elevated inflammatory markers, fracture risk, infection risk, malignancy, vascular etiology)
• CT of spine: Alignment abnormalities (kyphosis/scoliosis for surgical planning, spondylolisthesis for fracture diagnosis)
• CT of spine: Degenerative changes when MRI cannot be obtained
• CT of spine: Imaging guidance for preoperative planning, interventional procedures, postoperative evaluation
• CT of spine: Suspected infection when MRI cannot be obtained
• CT of spine: Inflammatory back pain / axial spondyloarthritis
• CT of spine: Low back pain after 4 weeks conservative treatment (pharmacotherapy or PT) when MRI unavailable
• CT of spine: Neoplastic conditions - initial diagnosis, staging, treatment response, follow-up, surveillance
• CT of spine: Trauma (blunt cervical/thoracolumbar, follow-up, osteoporotic falls)
• CT of spine: Vertebral compression fractures (new back pain with history of treated/multiple VCFs, new symptomatic VCF on radiograph)
• MRI of spine: Alignment disorders for bone/spinal cord/soft tissue abnormalities

…and 14 more criteria in the full policy.

Covered procedure codes

How to appeal this denial

Frame your appeal around the specific criterion you satisfy. Quote the HUM-1276-002 / HUM-1281-001 / HUM-1277-001 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-1276-002 / HUM-1281-001 / HUM-1277-001 — view the published policy.