Aetna Medicare (Medicare Advantage) · all interventional pain

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

✓ conditional · medicare advantage

Criteria checklist

0 of 1 ticked

Indications

enumerated: no
description: Aetna Medicare Advantage applies the Traditional Medicare coverage FLOOR. For procedures with an NCD/LCD (SCS, DRG, PNS, ITDD, MILD/PILD, facet, ESI, kyphoplasty, SI fusion), use the SAME criteria as the corresponding `policies/<procedure>/medicare-in-ky-*.md` cell — the plan cannot be more restrictive — plus Aetna MA's prior-authorization process. For R&N procedures where Medicare is silent (Intracept, ReActiv8, endoscopic nerve transection), the plan MAY apply its own publicly- posted internal criteria (e.g., Aetna's commercial CPB stance) — pull the plan's policy for those.

Payor-specific notes

POINTER cell. Criteria = the Traditional Medicare cell per procedure (NCD/LCD floor) + Aetna MA's PA process. The 2024 CMS rule bars MA plans from applying internal criteria more restrictive than a governing NCD/LCD; internal criteria are permitted only for R&N procedures (Intracept, ReActiv8, endoscopic). For those R&N procedures, Aetna MA likely applies Aetna's commercial CPB positions — confirm via billing. Plan PA process/vendor not independently verified (needs_reverification).

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

Prior-auth pathway

required: yes
pathway: Aetna Medicare Advantage prior authorization (confirm process/vendor)

Provenance

authority:
- type: medicare_advantage
- floor: Traditional Medicare NCD/LCD per procedure — see policies/<procedure>/medicare-in-ky-*.md
- plan um: Aetna Medicare prior authorization / utilization management (vendor/process to confirm)
- applies because: Per CMS-4201-F (2024) / 42 CFR 422.101, an MA plan must follow Traditional Medicare coverage criteria where an NCD/LCD fully establishes them, and cannot be more restrictive; plan internal criteria are allowed 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) — restorative neurostimulation

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: yes
covered:
- - name: Chronic mechanical low back pain from lumbar multifidus dysfunction
  - criteria:
    - chronic lbp min months: 6
    - etiology: mechanical/nociceptive LBP with multifidus dysfunction (ICD-10 M62.85); e.g., positive prone instability test
    - conservative care failed: >=90 days refractory to medical management incl. physical therapy
    - no radicular pain: yes
    - no prior lumbar surgery: yes
    - severity: moderate-to-severe pain/disability (e.g., VAS/ODI thresholds per ISASS)
investigational:
- current radicular pain / radiculopathy
- prior lumbar spine surgery
- another dominant pain generator (e.g., stenosis, fracture, malignancy, infection)
- non-mechanical / inflammatory back pain

Documented pathology (objective basis)required

Conservative care

required: yes
min duration months: 3
satisfied by:
- tried and failed >=90 days
- contraindicated
modalities named:
- physical therapy
- pharmacologic
- activity modification

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

Device / waveformnot_applicable

Payor-specific notes

ReActiv8 (Mainstay Medical) restorative neurostimulation stimulates the L2 medial branch to rehabilitate the lumbar multifidus — mechanistically and by indication DISTINCT from pain-masking neurostimulation. No NCD and no IN/KY LCD govern it (WPS/CGS publish nothing), so Traditional Medicare adjudicates under §1862(a)(1)(A) reasonable-and-necessary. The criteria here are the de facto standard from FDA labeling and the ISASS 2025 guideline (chronic mechanical LBP >=6 months from multifidus dysfunction [ICD-10 M62.85], >=90 days failed conservative care, NO radicular pain, NO prior lumbar surgery) — not a binding policy. IMPORTANT: this shares CPT 64555/64590 with generic PNS but is a SEPARATE coverage cell (the documented PNS-vs-ReActiv8 split). Commercial payors frequently deem ReActiv8 investigational — flag when the commercial cells are built. Confirm current MAC posture before clinical use (needs_reverification). Criteria sources: ISASS 2025 guideline (IJSS 19(6):760); Mainstay Medical labeling; ReActiv8 trials.

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 in IN/KY — documents to FDA labeling + ISASS 2025 under Medicare's reasonable-and-necessary standard. Distinct from generic PNS.

.REACTIV8MCARE

.REACTIV8MCARE

Assessment: *** — chronic mechanical low back pain present >=6 months arising from lumbar
multifidus dysfunction (ICD-10 M62.85), supported by *** (e.g., positive prone instability
test / imaging). There is no radicular pain, no prior lumbar spine surgery, and no other
dominant pain generator.

Medical necessity under Medicare's reasonable-and-necessary standard (no NCD or LCD binds;
documented to FDA labeling and the ISASS 2025 restorative-neurostimulation criteria):
conservative and medical management has been tried and has failed over >=90 days — physical
therapy, pharmacologic therapy, and activity modification: *** . Pain and disability are at
threshold (VAS/ODI ***), and the etiology is mechanical (nociceptive). Alternative pain
generators — stenosis, fracture, malignancy, infection, and inflammatory disease — are
excluded.

Plan: Implantation of the ReActiv8 restorative neurostimulation system (bilateral L2 medial
branch leads 64555 x2 plus generator 64590). Risks, benefits, and alternatives discussed;
consent obtained.

Where this payor diverges from the Medicare baseline

diagnosis line (multifidus dysfunction)
exclusions (radicular/prior surgery)
no trial / no psych eval

Cautions

No externalized trial and no psychological evaluation apply. Bills the same codes as generic PNS but is a separate coverage cell. Regenerate if `medicare-in-ky-reactiv8.md` `version` advances.

Prior-auth pathway

required: no
verified: no
note: Not on the OPD prior-auth list (that list = implanted SPINAL neurostimulators). Confirm if hospital-outpatient.

Provenance

authority:
- type: none
- id: not stated in the policy
- title: No NCD or IN/KY LCD; coverage adjudicated case-by-case under SSA §1862(a)(1)(A) (reasonable and necessary) by the local MAC
- applies because: No NCD for restorative neurostimulation; WPS (J8) and CGS (J15) publish no LCD (CMS MCD 'restorative neurostimulation' search = 0, verified 2026-06-28)
- peer lcds:
source: https://www.ijssurgery.com/content/19/6/760
effective: — · payor last reviewed: — · we verified: 2026-07-24 · v1