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You asked about Endoscopic nerve transection. Indiana Medicaid (IHCP) is governed by a framework cell — read the per-procedure line inside it.

Indiana Medicaid (IHCP) · all interventional pain

v2verified 2026-07-24needs re-verificationmanual-pull source

✓ conditional · medicaid

Criteria checklist

0 of 1 ticked
Indications
  • enumerated: no
  • description: Indiana Medicaid (IHCP) FFS adjudicates these procedures under its OWN medical-necessity criteria (405 IAC Art. 5) — it does NOT adopt Medicare NCD/LCD and uses no named commercial UM vendor. Whether a covered code needs prior auth is read off the Fee Schedule PA indicator; FFS PA is reviewed by Acentra Health. Newer technologies IHCP has not separately addressed risk denial as experimental/investigational under 405 IAC 5-29-1.
Payor-specific notes

POINTER/framework cell for Indiana Medicaid. KEY: IHCP uses its OWN criteria (405 IAC), not Medicare — so do NOT reuse the medicare-in-ky-* criteria as the Medicaid floor. SCS, ITDD, facet, ESI, and PNS are covered, with PA varying BY PROCEDURE (SCS/ITDD need no FFS PA — SCS device L-codes do; facet/ESI/PNS per the Fee Schedule indicator); SI fusion and facet RFA are unclear (verify per fee schedule); DRG, ReActiv8, Intracept, and MILD/PILD are not separately addressed and carry high experimental-denial risk (405 IAC 5-29-1). ~90% of members are in managed care — confirm the specific MCE's PA criteria (Anthem->Carelon, MHS->Centene+InterQual). Per-CPT PA flags live in the gated interactive Fee Schedule; InterQual/plan criteria are not public — needs_reverification. Sources: IHCP PA page; Banner BR202236 (SCS); Surgical Services Codes (SCS ICD-10); Medical Policy Manual (ITDD); 405 IAC 5-29-1 (experimental); IHCP managed-care roster; MDwise PA list; MHS policies.

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

Coverage by procedure — framework cell

covered

  • SCS (63650/63685 — FFS PA REMOVED 2022; device L-codes L8680/L8687/L8688 still need PA + meet the SCS ICD-10 indication list)
  • ITDD intrathecal pump (FFS PA not required; own criteria — failed less-invasive + successful intrathecal trial; 405 IAC 5-25-1)
  • facet MBB/injections (64490-64495) — PA per fee schedule / MCO
  • ESI (62320-62323) — PA per fee schedule / MCO
  • PNS (64555/64575 + L-codes) — PA where listed

unclear verify

  • facet RFA (64633-64636) — PA per fee-schedule indicator (not confirmed from a public table)
  • SI joint fusion (27279/27280) — contested; a KY/IN MCO history shows non-coverage; Carelon historically carved out 'except Indiana Medicaid'
  • kyphoplasty/vertebroplasty (22510-22515) — likely covered with medical-necessity review; FFS PA flag not verified

not addressed denial risk

  • DRG stimulation
  • ReActiv8 restorative neurostimulation
  • Intracept / basivertebral nerve ablation
  • MILD / PILD

Managed-care (MCO) overlay

  • note: ~90% of IHCP enrollment is managed care (Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, PathWays). MCEs cover at least the state floor but set their OWN PA + criteria.
  • mces 2026:
    • Anthem HIP (Healthy Indiana Plan; 'HealthKeepers Plus' is Anthem's VIRGINIA Medicaid brand — do not use for IN)
    • CareSource
    • MHS (Centene)
    • UnitedHealthcare
  • exited: MDwise (left 2026-01-01)
  • vendor delegation: Anthem -> Carelon for MSK/spine/pain (historical 'except Indiana Medicaid' carve-outs on some guidelines); MHS -> Centene clinical policies (e.g., CP.MP.117) + InterQual fallback; CareSource/UHC -> own policies

Prior-auth pathway

  • required: not stated in the policy
  • note: varies by procedure & delivery system — see coverage_by_procedure (e.g., SCS/ITDD FFS PA not required, but SCS device L-codes DO need PA; facet/ESI/PNS per Fee Schedule indicator; every MCE sets its own PA)
  • pathway: FFS: Acentra Health (Atrezzo); MCE: plan-specific. PA requirement per Fee Schedule indicator.

Provenance

  • authority:
    • type: medicaid_policy
    • id: 405 IAC Article 5
    • title: Indiana Health Coverage Programs (IHCP) — own medical-necessity criteria
    • applies because: IHCP applies its OWN coverage/medical-necessity criteria (405 IAC Art. 5) — NOT Medicare adoption and no named commercial UM vendor; experimental/investigational non-covered per 405 IAC 5-29-1
    • pa administration: FFS non-pharmacy PA reviewer = Acentra Health (since 2023-07-01); PA requirement read off the Professional/Outpatient Fee Schedule PA indicator (no single master PA list)
  • source: https://www.in.gov/medicaid/providers/clinical-services/prior-authorization/
  • effective: — · payor last reviewed: — · we verified: 2026-07-24 · v2

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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
  • 2026-07-23naming/precision: SCS row pinned to NCD 160.7-B; HealthKeepers Plus -> Anthem HIP a8eaddb0ee
  • 2026-07-23medicaid/in v2: resolve PA self-contradiction — PA is per-procedure, not blanket fe955e2c1d
  • 2026-06-30Add Medicaid (IN/KY) framework cells + resolve Aetna Better Health = KY f4c0e1f476