Coverage grid — what's built, what's flagged

Recent content changes

• 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 · 6 files
• 2026-07-24aetna/scs v2: CPB 0194 read LIVE via browser (Incapsula gate passed) at current 2026-05-21 review; the 2019-cache cell was materially out of date - corrected conservative floor 12mo->6mo + expanded med classes + in-person PT + psych therapies; ADDED ODI>=21%, thoracic CT/MRI + rule-out gates, FBSS prior-surgery imaging, intractable-angina indication, DTM waveform; needs_reverification cleared; dot phrase regenerated · 2 files
• 2026-07-24anthem/mild v3: live-page check caught SURG.00071 revision (eff 2026-07-01, renamed 'Percutaneous Spinal Surgery', endoscopic removed from scope -> 62380 dropped); MILD/PILD coverage position UNCHANGED (investigational, no CED); dot phrase resynced · 2 files
• 2026-07-24anthem pns/reactiv8/itdd: verified live via browser (JS-gated HTML) - SURG.00158 + CG-SURG-79 dates & criteria unchanged; last_verified 2026-07-24 (itdd needs_reverification kept: local-instance adoption unconfirmable) · 3 files
• 2026-07-24uhc/itdd v2: successor policy 2026T0626M->2026T0626N (eff 07/01/2026) fetched+archived; full-text diff editorial-only, medical-necessity gates unchanged; bump reflects effective-date/policy-number change; dot phrase resynced to source_version 2 · 2 files
• 2026-07-24anthem/si-fusion: re-archive Carelon SIJ PDF (2026-01-29 reaffirmation) + update source_hash; diff = General-Clinical-Guideline boilerplate only, SI-fusion criteria unchanged (non-material, no version bump); last_verified 2026-07-24 · 1 file
• 2026-07-24commercial cells: re-verify 27 source PDFs by SHA-256 (Carelon/eviCore/UHC/Cigna) - all unchanged vs committed archive; last_verified -> 2026-07-24 · 27 files
• 2026-07-24endoscopic-transection/medicare: verified via MCP - still no transection LCD; R&N posture unchanged; last_verified 2026-07-24 · 1 file
• 2026-07-24reactiv8/medicare: verified via MCP - still no restorative-neurostim LCD anywhere; R&N posture unchanged; last_verified 2026-07-24 · 1 file
• 2026-07-24intracept/medicare v2: peer L40302 v2->v3 drift diffed via MCD browser pull - core gates unchanged; v3 adds multidisciplinary+psych screening + granular exclusions (synced, attributed as non-binding peer standard); quantity limit refined (4 bodies per procedure); R&N posture unchanged, needs_reverification stays; dot phrase regenerated · 2 files
• 2026-07-24si-fusion/medicare v2: LCD bodies verified via MCD browser pull (WPS L36000 v21, CGS L39802 v8 + delegated L39383 v13, WPS article A57596); criteria NOT harmonized - restructured per state (IN: 6-mo intensive care, structured test battery, TWO >=75% blocks, hip films; KY: 3-mo pain/4-wk care, 3-of-6 tests incl Yeoman, ONE >=75% block + >=50% therapeutic trial, pelvis AP); 27278/non-transfixation resolved NOT covered both states; needs_reverification cleared; dot phrase regenerated per-state · 2 files
• 2026-07-24kyphoplasty/medicare v2: LCD bodies verified via MCD browser pull (first direct read); WPS L38213 v11 + CGS L38201 v25 NOT fully harmonized - traumatic VCF WPS-only, pregnancy absolute(CGS)/relative(WPS), 2-of-6 vs 2-of-4 factor lists; cell trued-up (30-day imaging recency, NRS>=8/NRS>=5+factors gate, continuum-of-care, full exclusions); removed point-tenderness criterion (not in WPS/CGS text); needs_reverification cleared; dot phrase regenerated · 2 files
• 2026-07-24esi/medicare v2: LCD bodies verified via MCD browser pull (first direct read); WPS L39054 v17 + CGS L39015 v16 materially identical; cell trued-up (post-laminectomy + herpes-zoster indications, contrast-allergy/pregnancy ultrasound exception, level/region caps, 14-day failed-initial repeat, >12-month continuation gate, sedation limits); removed unsupported electrodiagnostics evidence route; needs_reverification cleared; dot phrase regenerated · 2 files
• 2026-07-24facet/medicare v2: LCD bodies verified via MCD browser pull (first direct read); CGS L38773 v31->v32 = typo fix (pending_change resolved, non-material); cell trued-up vs source (2-wk block spacing, MBB-preferred, diagnostic session cap, 1-2 levels/1 region per session, therapeutic-RFA-justification gate, sedation limits, expanded non-covered); needs_reverification cleared; dot phrase regenerated · 2 files
• 2026-07-24mild/medicare: verified vs NCD 150.13 v2 text (MCP) - CED-only confirmed, 2026-04-30 transmittal administrative (NCD 250.4 only); last_verified 2026-07-24 · 1 file
• 2026-07-24itdd/medicare: verified vs NCD 280.14 B.2 text (MCP) - indications/trial/contraindications match; last_verified 2026-07-24 · 1 file
• 2026-07-24pns/medicare: NCD 160.7-A side verified (MCP); operational gates still web-grounded (needs_reverification stays); last_verified 2026-07-24 · 1 file
• 2026-07-24drg/medicare: verified vs NCD 160.7-B text (MCP) - no change; last_verified 2026-07-24 · 1 file
• 2026-07-24scs/medicare: verified vs NCD 160.7 text (MCP) - criteria+dates match, no change; last_verified 2026-07-24 · 1 file
• 2026-07-23Medicare LCD cells: correct billing-article MAC attributions (verified via CMS MCP) · 4 files
• 2026-07-23naming/precision: SCS row pinned to NCD 160.7-B; HealthKeepers Plus -> Anthem HIP · 1 file
• 2026-07-23va: 11 -> 12 grid procedures; add endoscopic transection to the CPG lump line · 1 file
• 2026-07-23si-fusion/cigna: resolve cpt_caution hedge with the CPT 2026 mapping · 1 file
• 2026-07-23kyphoplasty/uhc: prose said '>1/3 height loss' — source says vertebra <1/3 original height · 1 file
• 2026-07-23dot-phrases/drg: drop stale delta-instruction note from the Medicare phrase · 1 file
• 2026-07-23dot-phrases/drg: convert 2 second-order delta phrases to self-contained · 2 files
• 2026-07-23dot-phrases/esi: convert 3 commercial phrases to self-contained · 3 files
• 2026-07-23dot-phrases/facet-joint: convert 3 commercial phrases to self-contained · 3 files
• 2026-07-23dot-phrases/si-fusion: convert 3 commercial phrases to self-contained · 3 files
• 2026-07-23dot-phrases/kyphoplasty: convert 3 commercial phrases to self-contained · 3 files
• 2026-07-23dot-phrases/scs: convert 4 commercial phrases to self-contained · 4 files
• 2026-07-23dot-phrases/reactiv8: convert Anthem phrase to self-contained · 1 file
• 2026-07-23dot-phrases/intracept: convert Anthem phrase to self-contained · 1 file
• 2026-07-23dot-phrases/itdd: convert 3 commercial phrases to self-contained · 3 files
• 2026-07-23si-fusion/medicare: fix L39812 citation typo, align provocative-test lists to 6 · 2 files
• 2026-07-23Medicare base phrases: strip invented criteria, unbind the 50% convention framing · 3 files
• 2026-07-23intracept/medicare: annotate peer LCD L40302 v3 (pub 2026-07-16) + MAC rename · 1 file
• 2026-07-23facet-joint/medicare: flag CGS L38773 v32 (eff 2026-07-23) as pending_change · 1 file
• 2026-07-23medicaid/in v2: resolve PA self-contradiction — PA is per-procedure, not blanket · 1 file
• 2026-07-23facet-joint/cigna v2: min_duration_months encoded chronicity, not the conservative floor · 2 files