Humana Coverage Overview
Humana is one of the nation’s largest health insurers, with particular strength in Medicare Advantage plans. For knee osteoarthritis patients, Humana generally covers hyaluronic acid injections when medical necessity criteria are satisfied.
Coverage specifics vary between Humana’s commercial plans and their Medicare Advantage offerings—understanding your specific plan type is essential.
Quick Coverage Summary
| Treatment | Coverage Status | Prior Auth Required |
|---|---|---|
| Hyaluronic acid (gel shots) | Covered with criteria | Usually yes |
| Cortisone injections | Covered | Usually no |
| Physical therapy | Covered | Varies |
| PRP injections | Not covered | N/A |
| Stem cell injections | Not covered | N/A |
Humana Medicare Advantage Coverage
Why This Matters
Humana is one of the largest Medicare Advantage insurers in the country. If you’re 65+ with a Humana Medicare Advantage plan, your HA injection coverage largely follows Medicare guidelines.[1]
Medicare Advantage HA Coverage Criteria:
Humana Gold Plus, Choice, and Other MA Plans
Most Humana Medicare Advantage plans—including Humana Gold Plus, Humana Choice PPO, and others—follow the same basic coverage framework:
- Part B equivalent coverage for HA injections
- Prior authorization requirements may vary by plan
- In-network preferences with PPO options for out-of-network care
- Cost-sharing based on your specific plan’s structure
Commercial Plan Coverage
Employer-Sponsored Humana Plans
If you have Humana through your employer, coverage depends on the specific plan your employer selected:
- Some plans cover HA injections with standard prior auth
- Others may require step therapy (trying cortisone first)
- Certain plans may have specific brand preferences
- Visit limits or annual caps may apply
Check your Summary Plan Description (SPD) or call Humana member services for specifics.
Individual/Marketplace Plans
Humana individual plans purchased through the ACA marketplace vary by:
- Metal tier (Bronze, Silver, Gold, Platinum)
- State-specific benefit requirements
- Network restrictions
Prior Authorization Requirements
How Humana’s Prior Auth Works
Submits documentation through Humana’s provider portal or fax
Humana evaluates against medical policy (typically 2-5 business days)
Approval, denial, or request for more information
Proceed with injection once authorization received
Documentation Needed
Your provider should include:
Costs and Out-of-Pocket
Medicare Advantage Cost Structure
Typical Humana Medicare Advantage Costs:
| Cost Component | Typical Range |
|---|---|
| Part B deductible | $0-$240 (plan-specific) |
| Specialist copay | $20-$50 per visit |
| Coinsurance for procedures | 20% after deductible |
| Out-of-pocket maximum | $3,500-$8,850 |
Many Humana MA plans have $0 Part B deductible
Commercial Plan Costs
Commercial plan costs vary more widely:
| Cost Component | Typical Range |
|---|---|
| Annual deductible | $500-$5,000+ |
| Specialist copay | $35-$75 |
| Coinsurance | 20-40% |
| Out-of-pocket max | $4,000-$9,100+ |
In-Network vs. Out-of-Network
Network Matters:
- HMO plans: Must use in-network providers (except emergencies)
- PPO plans: Can use out-of-network, but pay more
- POS plans: Referral may be needed for specialists
Using in-network providers typically saves 30-50% on out-of-pocket costs.
If You’re Denied
Common Denial Reasons
- Prior authorization missing - Treatment occurred without authorization
- Documentation insufficient - Not enough proof of conservative care failure
- Medical necessity not met - Criteria not satisfied per clinical policy
- Network issues - Out-of-network provider used inappropriately
- Timing issues - Repeat injection requested too soon
The Appeal Process
Humana Appeal Steps:
Level 1 - Standard Appeal:
- Review your Explanation of Benefits (EOB) for denial reason
- Gather supporting documentation
- Submit written appeal within 60 days (Medicare Advantage) or per your plan terms (commercial)
Level 2 - Reconsideration:
- If Level 1 denied, request second level review
- Additional documentation may be submitted
External Review:
- Available after internal appeals exhausted
- Independent review organization evaluates claim
Expedited Review:
- Available if standard timeline would jeopardize health
- Decision required within 72 hours
Contact Information
- Medicare Advantage Members: 1-800-457-4708
- Commercial Members: Number on your ID card
- Provider Services: Humana.com provider portal
Humana’s Wellness Focus
CenterWell and Humana’s Care Approach
Humana emphasizes integrated care through its CenterWell senior primary care centers and partnerships. This can benefit knee OA patients through:
- Coordinated care between primary care and specialists
- Care management programs for chronic conditions
- Home health services when appropriate
- Wellness programs that complement medical treatment
Coverage for Related Services
Many Humana plans also cover:
- Physical therapy - Important for comprehensive OA management
- Home health - If medically necessary
- Durable medical equipment - Knee braces, assistive devices
- Fitness benefits - SilverSneakers or similar programs
Plan Comparison
Humana vs. Other Major Insurers
| Factor | Humana MA | Traditional Medicare | Other MA Plans |
|---|---|---|---|
| HA coverage | Yes (with criteria) | Yes (with criteria) | Varies |
| Prior auth | Usually required | Not required | Varies |
| Added benefits | Often included | Part B only | Varies |
| Network restrictions | Varies by plan | None | Varies |
Key Takeaways
Humana Coverage Summary
Good news for Humana members:
- HA injections are generally covered when medically necessary
- Medicare Advantage plans follow established CMS guidelines
- Appeals process available if initially denied
- Integrated care approach can support comprehensive treatment
What you need to do:
- Verify your specific plan benefits - Call Humana or check online
- Confirm in-network status of your provider
- Ensure prior authorization is obtained before treatment
- Document conservative treatments thoroughly
- Keep copies of all records for potential appeals
Find Humana In-Network Providers
Locate providers who accept Humana and specialize in knee injections.
Your information is secure. See our Privacy Policy and Terms of Service.
Thank You!
We've received your request. A provider specialist will contact you within 1-2 business days to help you find the right care.
What happens next?
- 1 We'll verify your insurance coverage
- 2 Match you with quality providers in your area
- 3 Contact you to discuss your options
Questions? Browse our guides:
How to Choose a ProviderReferences
-
CMS Local Coverage Determination L39529 - Viscosupplementation for Knee OA. Medicare Coverage Database
-
Humana Medical Coverage Policy - Viscosupplementation.
Insurance Updates
Get alerts when insurance coverage policies change for joint pain treatments.
Join 10,000+ readers. No spam.