MedicaidPrior AuthHigh impact
Spinal Decompression Surgery - MEDICAID - SOUTH CAROLINA (Revised)
Humana·SC · Neurosurgery, Orthopedics, Pain Management +1 more·Medicaid
Effective date
Jul 22, 2026
We identified it
Jul 23, 2026
Summary
Humana revised its South Carolina Medicaid spinal decompression surgery coverage policy effective July 22, 2026, establishing specific medical necessity criteria for discectomy, laminectomy, foraminectomy, and related procedures. The policy defines coverage requirements based on diagnosis (herniated disc, myelopathy, fractures, infections, tumors), requires documented conservative treatment failure (6 weeks minimum), and specifies clinical and objective findings needed for approval. Billing teams must ensure prior authorization requests include diagnostic imaging confirmation and evidence of conservative treatment attempts before surgery.
Action Required
By July 22, 2026: Billing team must update prior authorization workflows for all spinal decompression procedures (CPT 63055, 63064, 63077, 63173, 63190, 63011, 63268, 63273, 63278, 63283, 63003, 63016, 63046, 63197, 63251, 63266, 63271, 63276, 63281, 63286) in the Medicaid system. For discectomy cases, require documentation of: (1) diagnostic imaging confirming herniated disc or neural compression, (2) 6 weeks of conservative treatment (epidural injections, NSAIDs, PT), (3) clinical symptoms (radicular pain, myelopathy signs, etc.), and (4) objective neurological findings. Update authorization request templates and provider education materials to reflect these criteria. Coordinate with providers to ensure surgical requests include imaging results and conservative treatment records. Claims submitted without prior authorization based on these criteria will be denied. Contact Humana SC Medicaid for any clarification on documentation requirements.