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You asked about MILD / PILD. Kentucky Medicaid (DMS) is governed by a framework cell — read the per-procedure line inside it.

Kentucky Medicaid (DMS) · all interventional pain

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

✓ conditional · medicaid

Criteria checklist

0 of 1 ticked
Indications
  • enumerated: no
  • description: Kentucky Medicaid adjudicates these procedures against InterQual (mandated by 907 KAR 3:130) plus medical-director review — it does NOT default to Medicare (Medicare is a fallback only for DME under 907 KAR 1:479). KY publishes essentially NO public per-CPT FFS medical-necessity policy for these pain procedures; the operative criteria, frequency limits, and conservative-care floors live inside licensed InterQual content (not publicly quotable). Surgical/implant services generally require PA (MAP-9), administered by Gainwell.
Payor-specific notes

POINTER/framework cell for Kentucky Medicaid. KEY: KY's binding standard is INTERQUAL (907 KAR 3:130), not Medicare (Medicare fallback only for DME, 907 KAR 1:479). So do NOT model KY Medicaid as "follows Medicare," and do NOT reuse the medicare-in-ky-* criteria as the floor. SCS, ITDD, facet (incl. RFA), ESI, kyphoplasty, SI fusion, and PNS are covered with PA via InterQual; DRG, ReActiv8, Intracept, and MILD/PILD carry investigational/non-coverage risk. The per-CPT criteria are inside licensed InterQual (not public) — source of truth is the regulation + InterQual license, not a free PDF (needs_reverification). Note: Anthem is NO LONGER a KY Medicaid MCO (exited 2025-01-01); current MCOs include Aetna Better Health of KY (resolves the reference/payors.md "Aetna Better Health IN or KY?" => KY). Sources: 907 KAR 3:130 / 1:479 / 17:020; KY FFS PA page (Gainwell); MAP-9; 2024 MCO Report Card.

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

Coverage by procedure — framework cell

covered with pa

  • SCS (trial + permanent; psych eval + trial expected per InterQual)
  • ITDD intrathecal pump (implant + device)
  • facet MBB/RFA (64490-64495 / 64633-64636) — InterQual diagnostic-block + frequency gating
  • ESI (62321/62323/64479-64484)
  • kyphoplasty/vertebral augmentation (22513-22515)
  • SI joint fusion (27279) — NASS-style InterQual criteria
  • PNS (64555/64575/64590)

unclear denial risk

  • DRG stimulation (no KY-specific criteria; via InterQual, often bundled under SCS)
  • ReActiv8 restorative neurostimulation (likely investigational)
  • Intracept / basivertebral nerve ablation (no KY criteria located)
  • MILD / PILD (likely non-covered / investigational, mirroring Medicare CED-only)

Managed-care (MCO) overlay

  • note: Predominantly managed care. Per 907 KAR 17:020 §1, each MCO covers Title-907 services at the same amount/duration/scope as FFS (floor), then applies its OWN UM/criteria + PA.
  • mcos 2025 2026:
    • Aetna Better Health of KY
    • Humana Healthy Horizons in KY
    • Passport by Molina
    • UnitedHealthcare Community Plan
    • WellCare of KY (Centene)
  • exited: Anthem exited KY Medicaid 2025-01-01 (older 6-MCO lists are stale)
  • vendor delegation: MCOs commonly delegate spine/MSK/SCS review to third-party benefit managers (eviCore/Cohere-type) + InterQual; per-MCO vendor specifics not publicly verifiable

Prior-auth pathway

  • required: yes
  • pathway: FFS: Gainwell (MAP-9 form); MCO: plan-specific (own MAP-9 variant)

Provenance

  • authority:
    • type: medicaid_policy
    • id: 907 KAR 3:130
    • title: Kentucky DMS — InterQual clinical-appropriateness standard
    • applies because: 907 KAR 3:130 names InterQual (McKesson/Change Healthcare) as the binding clinical-appropriateness standard — NOT Medicare. Medicare criteria are a fallback ONLY for DME when KY criteria are unavailable (907 KAR 1:479 §2(2)(b))
    • pa administration: FFS PA via Gainwell Technologies (CareWise Health subcontractor for a narrow EPSDT/PPEC/NF set); universal FFS PA form = MAP-9
  • source: https://apps.legislature.ky.gov/law/kar/titles/907/003/130/
  • effective: — · payor last reviewed: — · we verified: 2026-07-24 · v1

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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
  • 2026-06-30Add Medicaid (IN/KY) framework cells + resolve Aetna Better Health = KY f4c0e1f476