MedicaidCoverageHigh impact
Spinal Decompression Surgery - MEDICAID - INDIANA (New)
Humana·IN · Neurosurgery, Orthopedics, Pain Management +1 more·Medicaid
Effective date
Jul 22, 2026
We identified it
Jul 23, 2026
Summary
Humana Indiana Medicaid released new coverage criteria for spinal decompression surgery effective 07/22/2026. This policy establishes specific medical necessity requirements for discectomy, laminectomy, foraminectomy, and related procedures, including diagnostic imaging confirmation and conservative treatment trials (6 weeks minimum for radicular pain). Billing teams must verify patient eligibility against these criteria before submitting claims to avoid denials.
Action Required
By July 22, 2026: Billing team must update authorization and claims submission workflows for Humana Indiana Medicaid spinal decompression procedures. (1) Implement pre-authorization review requirements: verify diagnostic imaging documentation (MRI/CT confirming compression), confirm appropriate clinical symptoms (myelopathy signs, radicular pain, neurological deficits), and validate 6-week conservative treatment trial for radicular pain cases (epidural injections, NSAIDs, PT) before submitting claims for CPT 63055, 63064, 63066, 63077, 63078, 63172, 63173, 63295, 63185, 63190, 22100, 22103. (2) Providers must document in medical records: specific diagnostic imaging findings, corresponding clinical symptoms, and conservative treatment attempts with dates. (3) Billing software administrators must create claim edit rules to flag missing documentation and require attachment of imaging reports, clinical notes, and conservative treatment records. (4) Front desk staff should update patient intake forms to ask about prior PT or injections. Claims submitted without evidence of meeting medical necessity criteria will be denied by Humana Indiana Medicaid.