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You asked about Spinal cord stimulation (SCS). 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) — spinal cord stimulation

v1verified 2026-07-24

✓ conditional · medicare ncd

Criteria checklist

0 of 7 ticked
Indications
  • enumerated: no
  • description: chronic intractable pain; best suited to neuropathic pain
Conservative care
  • required: yes
  • satisfied by:
    • tried and unsatisfactory
    • judged unsuitable or contraindicated
  • modalities named:
    • pharmacologic
    • surgical
    • physical
    • psychological
  • min duration months: not stated in the policy
Trial
  • required: yes
  • min duration days: not stated in the policy
  • success criteria:
    • logic: (pain_reduction OR med_reduction) AND functional_improvement
    • pain reduction pct: 50
    • med reduction pct: 50
    • functional improvement: required
  • threshold is binding: no
Psychological evaluation
  • required: yes
  • must clear: yes
  • note posture: ordered at trial; pending; patient referred; result routed to authorization
Screening
  • multidisciplinary team: required
  • late or last resort: yes
Quantity limits
  • applies: no
Device / waveformagnostic
Payor-specific notes

Governed by NCD 160.7, not an LCD. The universally-expected documentation standard (>=50% pain or analgesic reduction + functional gain) derives from the Noridian/Palmetto LCDs and should still be documented though not formally binding here. Trial is the hurdle: once a trial is approved and successful, implant approval follows and is templated separately.

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

Dot phrase

Lean narrative A&P attestation. `***` = fill-in. Every clinical assertion maps to an NCD 160.7 condition.

.SCSTRIALMCARE
.SCSTRIALMCARE

Assessment: *** — chronic intractable pain, predominantly neuropathic, involving the
___ region, present *** and refractory to treatment.

Medical necessity per Medicare NCD 160.7 (Electrical Nerve Stimulators): this patient has
been managed with pharmacologic therapy, physical therapy, and interventional treatment
including ESI / nerve blocks where appropriate — *** — with unsatisfactory response, or
these measures were contraindicated. Spinal cord stimulation is pursued as a late-resort
therapy. Multidisciplinary screening is complete; psychological evaluation was ordered at
the time of trial, the patient has been referred, and the result is pending and will be
forwarded to authorization. History, imaging, and screening documentation are on file.

Plan: Percutaneous SCS trial. Trial response — targeting >=50% reduction in target pain
and/or >=50% reduction in analgesic use with functional improvement — will be assessed and
documented to support permanent implantation. Risks, benefits, and alternatives discussed;
consent obtained.

Where this payor diverges from the Medicare baseline

  • diagnosis line
  • psych-eval line
  • conservative-care line

Cautions

  • The >=50% figure is the multi-MAC LCD documentation convention, not NCD 160.7 text — the policy records `threshold_is_binding: false`. Document it (protective), but it is not a hard NCD gate. NCD 160.7 sets no pain-duration floor and no imaging-pathology requirement — do not add numbers the record can't support. Regenerate if `medicare-in-ky-scs.md` `version` advances past `source_version` above.

Prior-auth pathway

  • required: yes
  • pathway: OPD prior auth list (hospital outpatient)

Provenance