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You asked about MILD / PILD. 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) — percutaneous image guided lumbar decompression

v2verified 2026-07-24

✓ conditional · medicare ncd

Criteria checklist

0 of 8 ticked
Indications
  • enumerated: yes
  • covered:
      • name: Symptomatic lumbar spinal stenosis — enrolled in a CMS-approved CED clinical study
      • criteria:
        • diagnosis: symptomatic lumbar spinal stenosis (LSS)
        • conservative care failed: unresponsive to conservative therapy
        • ced enrollment: REQUIRED — beneficiary enrolled in a CMS-approved PILD study (prospective longitudinal study using an FDA-cleared device that completed a CMS-approved RCT); registered on ClinicalTrials.gov
  • investigational:
    • PILD for LSS performed OUTSIDE a CMS-approved CED clinical study (nationally non-covered per NCD 150.13 §C)
Documented pathology (objective basis)required
Conservative care
  • required: yes
  • min duration months: not stated in the policy
  • satisfied by:
    • tried and failed
    • contraindicated
  • modalities named:
    • pharmacologic
    • physical therapy
    • epidural steroid injection where appropriate
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: no
Coverage with Evidence Development (CED)
  • required: yes
  • basis: Social Security Act §1862(a)(1)(E) (Coverage with Evidence Development)
  • requirements:
    • enrollment in a CMS-approved PILD study
    • FDA-approved/cleared device
    • study registered on ClinicalTrials.gov
Device / waveformnot_applicable
Payor-specific notes

PILD — the "mild" percutaneous image-guided lumbar decompression (Vertos Medical), billed G0276 under CED (CPT 0275T deleted 2026-01-01; Cat-I 62330/62331 replaced it) — is governed by NCD 150.13 and is covered by Medicare ONLY through Coverage with Evidence Development: the beneficiary must be enrolled in a CMS-approved clinical study (FDA-cleared device, registered on ClinicalTrials.gov). Outside such a study, CMS has determined PILD for LSS is NOT reasonable-and-necessary (§1862(a)(1)(A)) — i.e., nationally non-covered. WPS/CGS add no LCD; the NCD governs directly (authoritative text fetched via MCP). NOTE the scope limit: OPEN lumbar decompression and ENDOSCOPICALLY-assisted laminotomy/laminectomy (direct visualization) are OUTSIDE this NCD and are at contractor discretion — do not conflate them with PILD. The 2026-04-30 transmittal touching this NCD record was administrative (concerned NCD 250.4), not a PILD policy change. NCD last substantively reviewed December 2016 (very low churn).

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

Dot phrase

Lean narrative A&P attestation. `***` = fill-in. Maps to NCD 150.13. The CED study-enrollment line is the gate — without it, the procedure is non-covered. Do not use for open/endoscopic decompression.

.MILDMCARE
.MILDMCARE

Assessment: *** — symptomatic lumbar spinal stenosis with neurogenic claudication,
imaging-confirmed at ***, unresponsive to conservative therapy.

Medical necessity per Medicare NCD 150.13 (PILD for LSS, Coverage with Evidence
Development): conservative therapy has been tried and has failed, or was contraindicated —
pharmacologic therapy, physical therapy, and epidural steroid injection where appropriate:
*** . The patient is enrolled in the CMS-approved PILD study *** (study name / NCT number),
using an FDA-cleared device and registered on ClinicalTrials.gov; that enrollment is what
makes this procedure covered.

Plan: Percutaneous image-guided lumbar decompression (mild), billed G0276 (CED), under the
CED-approved study protocol above. Risks, benefits, and alternatives discussed; consent
obtained.

Where this payor diverges from the Medicare baseline

  • CED study-enrollment gate (unique)
  • non-covered outside a study

Cautions

  • Outside a CMS-approved CED study, PILD for LSS is NON-COVERED. This phrase does NOT apply to open or endoscopically-assisted decompression. Regenerate if `medicare-in-ky-mild.md` `version` advances.

Prior-auth pathway

  • required: no
  • verified: no
  • note: Not on the OPD prior-auth list; coverage hinges on CED study enrollment, not prior auth.

Provenance

  • authority:
    • type: ncd
    • id: 150.13
    • title: Percutaneous Image-Guided Lumbar Decompression for Lumbar Spinal Stenosis
    • applies because: PILD (the mild procedure) is governed nationally by NCD 150.13; covered ONLY under Coverage with Evidence Development (CED). WPS/CGS have no separate LCD.
  • source: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=358
  • effective: 2016-12-07 · payor last reviewed: 2016-12-01 · we verified: 2026-07-24 · v2