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You asked about Endoscopic nerve transection. HumanaChoice (Medicare Advantage, PPO) is governed by a framework cell — read the per-procedure line inside it and the embedded Traditional-Medicare criteria below.

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) — endoscopic nerve transection

v1verified 2026-07-24needs re-verification
No NCD/LCD governs this procedure (reasonable-and-necessary, MAC-adjudicated). The MA plan may apply its own publicly-posted internal criteria here — pull the plan policy; the peer-MAC standard below is not binding.

✓ conditional · medicare rn

Criteria checklist

0 of 7 ticked
Indications
  • enumerated: no
  • description: Transection or avulsion of an extradural spinal/peripheral nerve (CPT 64772). Two practical uses: (1) endoscopic MEDIAL BRANCH transection (MBT) as a surgical alternative to facet radiofrequency ablation — supported by the same diagnostic logic (positive medial branch blocks); and (2) transection for intractable neuropathic/peripheral-nerve pain (e.g., painful neuroma, refractory neuralgia) as a late/last resort after failed less-invasive options. No NCD/LCD establishes criteria; document chronicity, the failed prior interventions, and the rationale.
Documented pathology (objective basis)required
Conservative care
  • required: yes
  • min duration months: not stated in the policy
  • satisfied by:
    • less-invasive options tried and failed (incl. RFA where applicable)
    • contraindicated
  • modalities named:
    • pharmacologic
    • physical therapy
    • injections / RFA where applicable
Trial
  • required: no
  • min duration days: not stated in the policy
  • success criteria: not stated in the policy
  • threshold is binding: no
Psychological evaluation
  • required: no
  • must clear: no
  • note posture: not required
Quantity limits
  • applies: yes
  • mue: CPT 64772 MUE = 6 units (raised from 2, eff 2026-01-01); MAC adoption timing varies
Device / waveformnot_applicable
Payor-specific notes

Endoscopic nerve transection (CPT 64772, transection/avulsion of other spinal nerve, extradural) has no NCD and no IN/KY LCD — Traditional Medicare adjudicates under §1862(a)(1)(A) R&N, and reimbursement is determined regionally by each MAC (claims often reviewed given the procedure is uncommon and invasive). The endoscopic application includes medial branch transection (MBT) as a surgical alternative to facet RFA; for that use, the facet diagnostic logic (positive medial branch blocks) supports medical necessity — see the facet-joint cell. CMS raised the 64772 MUE from 2 to 6 units effective 2026-01-01 (a utilization edit, not a coverage policy); MAC adoption timing varies. No peer LCDs exist. Confirm MAC posture before scheduling (needs_reverification).

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

Dot phrase

Lean narrative A&P attestation. `***` = fill-in. No NCD/LCD binds — Medicare R&N; document failed less-invasive options thoroughly (claims are reviewed).

.ENDONERVEMCARE
.ENDONERVEMCARE  [MEDIAL BRANCH TRANSECTION]

Assessment: *** — facet (zygapophyseal) joint-mediated chronic axial *** pain with prior
positive medial branch blocks at *** (and/or a prior response to RFA), now refractory.

Medical necessity under Medicare's reasonable-and-necessary standard (no NCD or LCD binds):
less-invasive options have been tried and have failed — conservative care, positive
diagnostic medial branch blocks, and radiofrequency ablation where applicable: *** . My
rationale for endoscopic medial branch transection over repeat RFA is: *** .

Plan: Endoscopic medial branch nerve transection at *** (CPT 64772). Risks, benefits, and
alternatives discussed; consent obtained.

---
.ENDONERVEMCARE  [PERIPHERAL NERVE] — swap the assessment and necessity sentences:
Assessment: *** — intractable neuropathic pain / painful neuroma of the *** nerve, refractory
to medical and interventional management. Transection is undertaken as a last resort after
failed *** options.

Where this payor diverges from the Medicare baseline

  • last-resort framing
  • no NCD/LCD basis
  • MBT leans on facet diagnostic logic

Cautions

  • R&N, MAC-adjudicated (claims reviewed); 64772 MUE = 6 units (eff 2026-01-01), MAC adoption varies. Regenerate if `medicare-in-ky-endoscopic-nerve-transection.md` `version` advances.

Prior-auth pathway

  • required: no
  • verified: no
  • note: Not on the OPD prior-auth list; uncommon/invasive -> claims frequently reviewed; submit full medical-necessity documentation.

Provenance