By Counterforce Health Team in Retevmo (selpercatinib) —

Work With Your Doctor to Get Retevmo (selpercatinib) Covered by Humana in California: Templates, Timelines & Appeal Scripts

Quick Answer: Getting Retevmo (selpercatinib) Covered by Humana in California

Humana Medicare Advantage requires prior authorization for Retevmo (selpercatinib) for RET fusion-positive cancers. Your oncologist must submit documentation proving RET alteration status through Evolent's portal or by calling 844-926-4528. If denied, you have 65 days to appeal and can request California's Independent Medical Review (IMR) through the DMHC. First step today: Confirm your RET testing results are complete and schedule a visit to discuss the medical necessity letter with your oncologist.

Table of Contents

  1. Set Your Goal: What Approval Requires
  2. Visit Prep: Organizing Your Medical History
  3. Building Your Evidence Kit
  4. Medical Necessity Letter Structure
  5. Supporting Peer-to-Peer Reviews
  6. After Your Visit: Documentation
  7. Respectful Persistence: Follow-Up Strategy
  8. Appeals Playbook for California
  9. Common Denial Reasons & Solutions

Set Your Goal: What Approval Requires

Getting Retevmo (selpercatinib) covered by Humana requires a collaborative effort between you and your oncologist. Here's what Humana specifically looks for:

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Must be approved before filling Humana PA List
Oncologist Involvement Prescribed by or in consultation with oncologist Humana policy requirements
RET Status Documentation Positive RET fusion or mutation test FDA-approved or validated testing
Clinical Indication NSCLC, medullary thyroid, or thyroid cancer FDA label indications
Submission Portal Evolent manages requests Evolent Portal

Your role is to ensure your oncologist has complete information to make the strongest possible case. This isn't about convincing anyone—it's about presenting clear evidence that Retevmo is medically necessary for your specific situation.

Note: For new Humana enrollees already on Retevmo, prior authorization isn't required for the first 90 days if you provide records showing ongoing treatment.

Visit Prep: Organizing Your Medical History

Before meeting with your oncologist, organize your medical story into a clear timeline. This preparation makes your appointment more productive and ensures nothing important gets overlooked.

Essential Information to Gather

Symptom Timeline:

  • When did you first notice symptoms?
  • How have they progressed or changed?
  • What impact do they have on daily activities?

Treatment History:

  • List all cancer treatments you've tried (chemotherapy, radiation, surgery)
  • Document responses: Did treatments work initially? For how long?
  • Note any treatments you couldn't tolerate and why (nausea, neuropathy, fatigue)

Current Status:

  • Recent imaging results or lab values
  • Performance status or functional limitations
  • Other medications you're taking

Create a one-page summary with dates. Your oncologist can reference this while writing the medical necessity letter, ensuring accuracy and completeness.

Building Your Evidence Kit

Strong prior authorization requests rely on objective evidence. Work with your care team to compile these essential documents:

Required Documentation Checklist

✓ RET Testing Results

  • Tissue-based NGS panel results showing RET fusion or mutation
  • If liquid biopsy was negative, tissue testing results (liquid biopsy misses up to 30% of RET alterations)
  • Laboratory name and test method used

✓ Pathology Reports

  • Original cancer diagnosis with staging
  • Histologic confirmation of cancer type
  • ICD-10 codes for your specific diagnosis

✓ Treatment Records

  • Chemotherapy administration records
  • Imaging showing treatment response or progression
  • Documentation of treatment failures or intolerances

✓ Current Clinical Status

  • Recent clinic notes from your oncologist
  • Performance status assessment
  • Lab results (liver function, kidney function)
  • ECG if available (Retevmo can affect heart rhythm)

Counterforce Health helps patients and providers organize this documentation efficiently, turning complex medical records into targeted appeals that address payer requirements directly.

Medical Necessity Letter Structure

Your oncologist's medical necessity letter is the cornerstone of your prior authorization request. Here's what should be included:

Essential Letter Components

Patient Information Block:

  • Full name, date of birth, Humana member ID
  • Diagnosis with ICD-10 codes
  • Prescribing oncologist's NPI and contact information

Clinical Justification Section:

1. Confirmed RET fusion-positive [cancer type]
   - Testing method and laboratory
   - Specific fusion type if known (e.g., KIF5B-RET)

2. Prior treatment history and outcomes
   - Standard therapies tried and duration
   - Reasons for discontinuation (progression, toxicity)
   - Current disease status

3. Rationale for Retevmo
   - FDA approval for this indication
   - Expected clinical benefit
   - Why alternatives aren't suitable

4. Safety considerations addressed
   - Baseline cardiac assessment
   - Drug interaction review
   - Monitoring plan for QT prolongation

Supporting Evidence:

  • Reference to NCCN guidelines for your cancer type
  • FDA label information for Retevmo
  • Published studies supporting use in your situation

Clinician Corner: Key Documentation Points

For Healthcare Providers: Humana's Evolent system specifically looks for:Documentation that you've prescribed by or consulted with an oncologistProof of RET alteration by validated testingClear statement that patient hasn't received prior RET-targeted therapyAssessment of QT prolongation risk and drug interactions

Submit via Evolent portal or call 844-926-4528, option 5.

Supporting Peer-to-Peer Reviews

If Humana requests a peer-to-peer review, your oncologist will speak directly with a Humana medical director. You can help by preparing a concise case summary.

Peer-to-Peer Preparation

Offer Availability Windows:

  • Ask your oncologist's scheduler about preferred times
  • Understand that these calls often happen with short notice
  • Provide contact information for urgent questions

Prepare a One-Page Summary:

  • Patient age, cancer type, and stage
  • RET testing details (lab, method, result)
  • Previous treatments and outcomes
  • Current clinical status and treatment goals

Key Points to Emphasize:

  • FDA approval for your specific indication
  • Lack of effective alternatives given your treatment history
  • Urgency based on disease progression or symptoms

After Your Visit: Documentation

After your oncologist submits the prior authorization request, stay organized and proactive.

What to Save and Track

Keep These Documents:

  • Copy of the medical necessity letter
  • Prior authorization submission confirmation
  • Any correspondence from Humana or Evolent
  • Records of phone calls (date, time, reference numbers)

Portal Communication:

  • Use your patient portal to ask follow-up questions
  • Request copies of any additional documents submitted
  • Ask for updates on submission status

Timeline Tracking:

  • Humana must respond within 7 days starting January 2026
  • Current standard timeline is typically 14 days
  • Mark your calendar for follow-up dates
Tip: Screenshot your Humana member portal showing the prior authorization request status. This creates a record of submission dates and responses.

Respectful Persistence: Follow-Up Strategy

Effective follow-up balances advocacy with professional courtesy. Here's how to stay engaged without overwhelming your care team.

Follow-Up Schedule

Week 1: Confirm submission

  • Call Evolent (844-926-4528) to verify receipt
  • Ask for reference number and expected timeline

Week 2: Status check

  • Contact your oncologist's office for updates
  • Check Humana member portal for determination

Week 3+: Escalation if needed

  • If no response, call Humana member services
  • Prepare for potential denial and appeal process

Communication Scripts

For Calling Evolent: "Hi, I'm calling to check the status of a prior authorization request for Retevmo submitted for [patient name], member ID [number]. Can you confirm it was received and provide a reference number?"

For Following Up with Your Oncologist's Office: "I wanted to check if you've heard back about my Retevmo prior authorization. Is there anything additional I can provide to support the request?"

Appeals Playbook for California

If your initial request is denied, California offers strong appeal rights through multiple levels.

Appeal Timeline and Process

Level Timeline How to Submit Decision Time
Internal Appeal 65 days from denial Humana appeals portal 7 days (expedited)
External Review (IMR) After internal denial DMHC website 45 days (7 for urgent)

California's Independent Medical Review (IMR)

California's IMR process provides independent physician review of coverage denials. For Humana Medicare Advantage members:

When to Use IMR:

  • After Humana upholds a denial through internal appeal
  • For disputes about medical necessity
  • For experimental/investigational treatment denials

How to Apply:

  • File online at healthhelp.ca.gov
  • Call DMHC Help Center: 888-466-2219
  • No fee required—insurers pay for the review

Success Rates:

  • Overall IMR overturn rates are typically 20-30% for major insurers
  • Specialty cancer drugs have lower success rates (under 15%)
  • Strong clinical evidence and guideline support improve odds
Important: California's IMR decisions are binding on Humana. If the independent reviewers determine Retevmo is medically necessary, Humana must provide coverage.

Common Denial Reasons & Solutions

Understanding typical denial reasons helps you address them proactively.

Denial Reason How to Address Required Documentation
Missing RET testing Submit validated test results NGS panel or PCR results from certified lab
Wrong cancer type Clarify FDA-approved indication Pathology report with correct histology
Prior therapy not documented Provide treatment records Chemotherapy administration records, imaging
QT risk not assessed Submit cardiac evaluation ECG, electrolyte levels, drug interaction review
Not prescribed by oncologist Confirm specialist involvement Oncologist consultation note or prescription

From Our Advocates

In our experience helping patients navigate coverage challenges, the most successful Retevmo appeals include three key elements: comprehensive RET testing documentation from a validated laboratory, detailed records of prior treatment failures or intolerances, and a clear statement from the oncologist about why this specific therapy is medically necessary now. While outcomes vary, thorough preparation significantly improves the chances of approval.

When Coverage Is Approved

Once Humana approves Retevmo, work with your care team to coordinate:

Pharmacy Coordination:

  • Specialty pharmacy will contact you directly
  • Confirm shipping address and preferred delivery times
  • Understand storage requirements (room temperature)

Monitoring Plan:

  • Schedule baseline ECG and lab work
  • Understand signs of side effects to report
  • Plan follow-up visits to assess response

Cost Support:

  • Lilly Cares Foundation may provide additional assistance
  • Retevmo savings programs available for eligible patients

Sources & Further Reading

Disclaimer: This information is for educational purposes only and is not medical advice. Coverage decisions depend on individual circumstances and policy terms. Always consult with your healthcare provider and insurance plan for specific guidance. Counterforce Health provides tools and resources to help patients and providers navigate insurance approval processes more effectively.

For additional help with California insurance issues, contact the DMHC Help Center at 888-466-2219 or visit healthhelp.ca.gov.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.