← Lookup
You asked about Peripheral nerve stimulation (PNS). Humana Gold Plus (Medicare Advantage, HMO) is governed by a framework cell — read the per-procedure line inside it and the embedded Traditional-Medicare criteria below.

Humana Gold Plus (Medicare Advantage, HMO) · all interventional pain

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

✓ conditional · medicare advantage

Criteria checklist

0 of 1 ticked
Indications
  • enumerated: no
  • description: Humana Gold Plus (HMO MA) applies the Traditional Medicare coverage FLOOR. NCD/LCD procedures (SCS, DRG, PNS, ITDD, MILD, facet, ESI, kyphoplasty, SI fusion) 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. HMO: in-network + referral rules apply.
Payor-specific notes

POINTER cell. Criteria = the Traditional Medicare cell per procedure + Humana MA PA. Gold Plus is the HMO product (contrast HumanaChoice PPO). Per CMS-4201-F, no internal criteria stricter than a governing NCD/LCD; internal criteria only for R&N procedures (Intracept, ReActiv8, endoscopic). MSK/spine PA may route through Cohere Health in some Humana markets — confirm (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) — peripheral nerve stimulation

v1verified 2026-07-24needs re-verification

✓ conditional · medicare ncd

Criteria checklist

0 of 7 ticked
Indications
  • enumerated: no
  • description: Implanted peripheral nerve stimulator (electrodes at a NAMED peripheral nerve) for chronic intractable pain of peripheral-nerve origin. Applied Medicare standard: chronic, severe pain >=3 months; documented failure of less-invasive treatments and medications; no surgical contraindication (infection, medical risk); informed consent; and a successful trial (>=50% pain reduction) before permanent generator implant. Distinct from ReActiv8 restorative neurostimulation (separate R&N cell despite identical CPT).
Conservative care
  • required: yes
  • min duration months: not stated in the policy
  • satisfied by:
    • tried and failed
    • judged unsuitable or contraindicated
  • modalities named:
    • pharmacologic
    • physical therapy
    • interventional / less-invasive options
Trial
  • required: yes
  • min duration days: not stated in the policy
  • success criteria:
    • logic: pain_reduction
    • pain reduction pct: 50
  • threshold is binding: no
Psychological evaluation
  • required: no
  • must clear: no
  • note posture: not required for peripheral nerve stimulators
Quantity limits
  • applies: no
Investigational / non-covered variants
  • peripheral nerve FIELD stimulation (PNfS) / subcutaneous field stimulation
  • stimulation not targeting a named peripheral nerve
  • indications outside chronic intractable peripheral-nerve pain
Device / waveformagnostic
Payor-specific notes

Governed by NCD 160.7 Section A (implanted peripheral nerve stimulators, prosthetic device benefit); the trial assessment is covered as a diagnostic service under §160.7.1. Unlike the CNS-stimulator provision (Section B, which governs SCS/DRG), Section A does NOT impose the multidisciplinary + psychological screening — so the PNS note drops the psych-eval line. The applied gates (>=3 months chronic severe pain, failed conservative care, >=50% trial response) derive from the Medicare PNS billing/coding standard (A55531 family), not NCD text. Modern percutaneous/temporary PNS and peripheral nerve FIELD stimulation are contested — WPS/CGS have no LCD, so those variants are adjudicated under R&N; confirm current MAC posture (needs_reverification). This is the GENERIC PNS cell — ReActiv8 (restorative neurostimulation) is a separate cell under R&N despite sharing CPT 64555/64590. Criteria sources: NCD 160.7 text (MCP); CMS billing article A55531; device reimbursement guides.

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

Dot phrase

Lean narrative A&P attestation. `***` = fill-in. Maps to NCD 160.7-A. NO psych eval (unlike SCS/DRG). Name the target peripheral nerve. Generic PNS only — ReActiv8 is a different cell.

.PNSTRIALMCARE
.PNSTRIALMCARE

Assessment: *** — severe chronic intractable pain in the distribution of the *** (named
peripheral nerve), present >=3 months, with an objective basis documented on ***.

Medical necessity per Medicare NCD 160.7-A (Implanted Peripheral Nerve Stimulators):
less-invasive treatments and medications have been tried and have failed, or were
contraindicated — pharmacologic therapy, physical therapy, and interventional treatment:
*** . There is no surgical contraindication: no active infection and no prohibitive medical
risk. The stimulation targets a named peripheral nerve, not field or subcutaneous
stimulation.

Plan: Percutaneous peripheral nerve stimulation trial at the *** nerve (64555). Trial
response — targeting >=50% pain reduction — will be assessed and documented to support
permanent generator implant (64555 + 64590). Risks, benefits, and alternatives discussed;
consent obtained.

Where this payor diverges from the Medicare baseline

  • diagnosis line (named peripheral nerve)
  • psych-eval line REMOVED
  • simpler trial gate

Cautions

  • No psychological evaluation is required for peripheral nerve stimulators (Section A). Peripheral nerve FIELD stimulation is investigational. The >=50% figure derives from the A55531 billing/coding standard, not NCD text (`threshold_is_binding: false`) — document it, but it is not a hard NCD gate. Regenerate if `medicare-in-ky-pns.md` `version` advances.

Prior-auth pathway

  • required: no
  • verified: no

Provenance

  • authority:
    • type: ncd
    • id: 160.7
    • title: Electrical Nerve Stimulators
    • section: A — Implanted Peripheral Nerve Stimulators (trial assessment per §160.7.1)
    • applies because: Implanted peripheral nerve stimulators are covered under the prosthetic device benefit by NCD 160.7-A; WPS (J8) and CGS (J15) publish no PNS LCD
    • note: Only Noridian publishes a PNS LCD (other jurisdiction). Percutaneous/temporary PNS (e.g., 60-day systems) and peripheral nerve FIELD stimulation sit in a contested space — adjudicated under R&N.
  • 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