Prior Authorization
Humana Prior Authorization for CPT 96365
IV infusion for therapy, prevention, or diagnosis, initial up to 1 hour · Standard commercial plans
Source
Humana Commercial Preauthorization and Notification List (July 2024)Not medical advice. PA policies change frequently. Always confirm against the payer's current policy before submitting. d3rx pulls directly from publicly published policy PDFs and refreshes daily.
Clinical criteria
Humana requires prior authorization for IVIG infusion (96365). Covered for primary immunodeficiency (documented IgG deficiency or recurrent infections), CIDP after failed steroids, ITP with platelets <30K, Guillain-Barre syndrome, myasthenia gravis exacerbation. Dose per evidence-based guidelines. Home infusion or outpatient center preferred.
Documentation checklist
- ✓Confirmed diagnosis with supporting lab values (immunoglobulin levels, NCS, platelet counts)
- ✓Documentation of prior treatment failures for second-line indications
- ✓Prescribing physician specialty relevant to condition
- ✓Requested dose, frequency, and duration
- ✓Site of care justification if hospital outpatient
Submission channels
Phone
1-800-444-9137Fax
1-877-418-05062026 Medicare rate for CPT 96365
Office (non-facility)
$67.14
Facility
$67.14
Total RVUs (office)
2.01
Conversion factor
$33.4009
National Medicare Physician Fee Schedule amounts (GPCI 1.0). Humana's commercial allowable is negotiated against this benchmark — see the full RVU and locality breakdown on the CPT 96365 code page.
How to submit the PA
- 1Verify the requirement against the current clinical policy linked above.
- 2Gather documentation: Confirmed diagnosis with supporting lab values (immunoglobulin levels, NCS, platelet counts), Documentation of prior treatment failures for second-line indications, Prescribing physician specialty relevant to condition….
- 3Submit via phone or fax, or the payer portal.
- 4Document the reference number and follow up within 5 business days if no determination is received.
FAQ
- Does Humana require prior authorization for CPT 96365?
- Yes. Humana requires prior authorization for CPT 96365 (IV infusion for therapy, prevention, or diagnosis, initial up to 1 hour) under Standard commercial plans per its published clinical policy.
- What documentation does Humana require for CPT 96365?
- Confirmed diagnosis with supporting lab values (immunoglobulin levels, NCS, platelet counts); Documentation of prior treatment failures for second-line indications; Prescribing physician specialty relevant to condition; Requested dose, frequency, and duration; Site of care justification if hospital outpatient
- How much does Medicare pay for CPT 96365 in 2026?
- In 2026, the national Medicare allowable for CPT 96365 is $67.14 in an office setting and $67.14 in a facility. Commercial allowables for Humana are typically negotiated against this benchmark.
- What if Humana denies the PA for CPT 96365?
- Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.
Other Humana PA lookups
CPT 96365 prior authorization by payer
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