Denials in pulmonology center on biologics for severe asthma (gated behind controller step therapy and biomarker criteria such as eosinophil count or IgE) and on home oxygen (gated behind qualifying blood-gas or oxygen-saturation criteria under a coverage rule), along with pulmonary rehabilitation criteria. ATS guidance supports these for the appropriate patients; the denial typically flags a missing controller trial, biomarker, or qualifying test.
Why these denials happen
Plans require a documented trial of standard controller therapy plus biomarker or severity criteria before a severe-asthma biologic, and a qualifying blood-gas or oxygen-saturation result before home oxygen under the coverage rule. ATS guidance and Medicare LCDs are the reference points. The denial is generally a documentation gap — the controller trail, the eosinophil/IgE value, or the qualifying oxygen test isn't mapped to the plan's policy.
The common denials
- Severe-asthma biologic denied for step therapy — standard controller trial not documented.
- Biomarker criteria (eosinophil count, IgE) for the biologic not established.
- Home oxygen denied — qualifying blood-gas or oxygen-saturation result not documented to the coverage rule.
- Pulmonary rehabilitation criteria not met in the record.
- Reauthorization denied — continued response or qualifying test not re-documented.
Is it worth appealing?
Often worth appealing
How to appeal
- 1
Document the controller step trail
For a biologic, show the trial, failure, intolerance, or contraindication of the standard controller therapy the plan requires.
- 2
Attach the biomarker or qualifying test
Include the eosinophil count or IgE for a biologic, or the qualifying blood-gas/oxygen-saturation result for home oxygen.
- 3
Map to the coverage rule and ATS guidance
Tie the documentation to the plan's criteria or the Medicare LCD and the ATS recommendation, point by point.
Frequently asked
My severe-asthma biologic was denied — what carries the appeal?
Why was my home oxygen denied?
Sources
Clinical-coverage patterns and guideline references are summarized for plain-language reference and vary by plan and payer policy. This is general information for clinicians and billing staff, not medical, legal, or coding advice — confirm against the governing coverage policy and the current guideline for each claim.
When the appeal has to be written, and cited
Upload the denied EOB and Merits returns a complete, citation-verified appeal letter — the clinical argument, the payer's own coverage criteria, and your federal appeal rights — in about a minute.