HumanaChoice (Medicare Advantage, PPO) · all interventional pain

v1verified 2026-07-24needs re-verificationmanual-pull source

✓ conditional · medicare advantage

Criteria checklist

0 of 1 ticked

Indications

enumerated: no
description: HumanaChoice (PPO MA) applies the Traditional Medicare coverage FLOOR. NCD/LCD procedures use the corresponding `medicare-in-ky-*` criteria + Humana MA PA (cannot be more restrictive). For R&N procedures (Intracept, ReActiv8, endoscopic), the plan may apply its own internal criteria — pull the policy. PPO: out-of-network allowed at higher cost-share; same medical-necessity floor.

Payor-specific notes

POINTER cell. Same model as Humana Gold Plus but the PPO product (HumanaChoice) — Gold ≠ Choice (HMO vs PPO; the medical-necessity floor is identical, network/cost-share differ). Criteria = the Traditional Medicare cell per procedure + Humana MA PA; internal criteria only for R&N procedures. Plan PA vendor/process not independently verified (needs_reverification).

Ticks are a documentation aid — nothing is stored; they reset on reload.

Prior-auth pathway

required: yes
pathway: Humana MA prior authorization (MSK/spine often Cohere Health — confirm)

Provenance

authority:
- type: medicare_advantage
- floor: Traditional Medicare NCD/LCD per procedure — see policies/<procedure>/medicare-in-ky-*.md
- plan um: Humana MA prior authorization / utilization management (MSK/spine PA often via Cohere Health — confirm)
- applies because: Per CMS-4201-F (2024) / 42 CFR 422.101, MA must follow Traditional Medicare coverage criteria where an NCD/LCD fully establishes them; plan internal criteria only where Medicare is silent (R&N procedures)
source: https://www.ecfr.gov/current/title-42/section-422.101
effective: 2024-01-01 · payor last reviewed: — · we verified: 2026-07-24 · v1

Report an issue with this cell

Change history

2026-07-24framework cells (MA x3, Medicaid IN/KY, VA): re-reviewed regulatory basis 2026-07-24 (42 CFR 422.101/CMS-4201-F, 405 IAC Art.5, KY KAR 907:3:130, 38 CFR 17.38(b) all current); plan/state-specific operational details (MA PA vendor, Medicaid interactive fee-schedule PA flags + MCO scopes, VA gated SEOC catalog/Optum manual/image-only CPG) remain gated -> needs_reverification kept; last_verified 2026-07-24 86bd4bd0b9
2026-06-29Add Medicare Advantage pointer cells (Aetna, Humana Gold HMO, HumanaChoice PPO) 86a5e15292

Embedded cell · Traditional Medicare baseline

Medicare (Traditional Part A & B) — dorsal root ganglion stimulation

v1verified 2026-07-24

✓ conditional · medicare ncd

Criteria checklist

0 of 7 ticked

Indications

enumerated: no
description: Chronic intractable pain treated by central-nervous-system (dorsal column / spinal) neurostimulation. In practice DRG stimulation is FDA-labeled and used for CRPS type I/II (causalgia / RSD) of the LOWER EXTREMITIES — narrower than SCS; document the CRPS diagnosis and the distribution. Coverage conditions are the NCD 160.7-B set (identical to SCS).

Conservative care

required: yes
satisfied by:
- tried and unsatisfactory
- judged unsuitable or contraindicated
modalities named:
- pharmacologic
- surgical
- physical
- psychological
min duration months: not stated in the policy

Trial

required: yes
min duration days: not stated in the policy
success criteria:
- logic: (pain_reduction OR med_reduction) AND functional_improvement
- pain reduction pct: 50
- med reduction pct: 50
- functional improvement: required
threshold is binding: no

Psychological evaluation

required: yes
must clear: yes
note posture: ordered at trial; pending; patient referred; result routed to authorization

Screening

multidisciplinary team: required
late or last resort: yes

Quantity limits

applies: no

Device / waveformagnostic

Payor-specific notes

DRG stimulation shares NCD 160.7 AND CPT 63650/63685/63688 with SCS but is a DISTINCT grid cell (per ROADMAP). Coverage conditions are the NCD 160.7-B central-nervous-system-stimulator set, identical to the SCS cell: late resort, conservative measures tried/unsuitable, multidisciplinary + psychological screening, and a successful temporary-electrode trial before permanent implant. The practical divergence is the INDICATION: DRG is FDA-labeled for CRPS I/II of the lower limbs, so the diagnosis line is narrower than SCS. The >=50% trial standard derives from the Noridian/Palmetto SCS LCDs (documented though not NCD-binding here). Trial is the gate; a successful trial leads to implant (templated separately).

Ticks are a documentation aid — nothing is stored; they reset on reload.

Dot phrase

Lean narrative A&P attestation. `***` = fill-in. Same NCD 160.7-B gate as SCS; the only change is a CRPS-narrowed diagnosis line.

.DRGTRIALMCARE

.DRGTRIALMCARE

Assessment: *** — CRPS type I/II (causalgia / RSD) of the *** lower extremity, chronic
intractable neuropathic pain present *** , meeting clinical criteria (Budapest where
applicable).

Medical necessity per Medicare NCD 160.7 (Electrical Nerve Stimulators, Sec. B): this
patient has been managed with pharmacologic therapy, physical therapy, and interventional
treatment including sympathetic blocks where appropriate — *** — with unsatisfactory
response, or these measures were contraindicated. DRG stimulation is pursued as a
late-resort therapy. Multidisciplinary screening is complete; psychological evaluation was
ordered at the time of trial, the patient has been referred, and the result is pending and
will be forwarded to authorization. History, imaging, and screening documentation are on
file.

Plan: Percutaneous DRG stimulation trial. Trial response — targeting >=50% reduction in
target pain and/or >=50% reduction in analgesic use with functional improvement — will be
assessed and documented to support permanent implantation. Risks, benefits, and
alternatives discussed; consent obtained.

Where this payor diverges from the Medicare baseline

diagnosis line (CRPS I/II lower-limb)

Cautions

Indication is narrower than SCS (DRG is FDA-labeled for CRPS I/II of the lower limbs). The >=50% figure derives from peer LCDs, not NCD text (`threshold_is_binding: false`); NCD 160.7 sets no pain-duration floor — document actual duration, don't assert a fabricated ">6 mo" gate. Regenerate if `medicare-in-ky-drg.md` `version` advances past `source_version`.

Prior-auth pathway

required: yes
pathway: OPD prior-auth list — implanted spinal neurostimulators (hospital outpatient)

Provenance

authority:
- type: ncd
- id: 160.7
- title: Electrical Nerve Stimulators
- section: B — Central Nervous System Stimulators (Dorsal Column)
- applies because: DRG stimulation is epidural spinal neurostimulation governed by NCD 160.7-B; WPS (J8) and CGS (J15) publish no DRG-specific LCD
- excluded:
  - DRG/SCS LCDs of other jurisdictions are not applicable to IN/KY
source: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=240
effective: 1995-08-07 · payor last reviewed: 2023-08-17 · we verified: 2026-07-24 · v1