MedicaidPrior AuthHigh impact
Spinal Fusion and Stabilization Surgery - MEDICAID - OHIO (New)
Humana·OH · Neurosurgery, Orthopedics, Pain Management·Medicaid
Effective date
Jul 22, 2026
We identified it
Jul 23, 2026
Summary
Humana Healthy Horizons Ohio Medicaid has established a new clinical coverage policy for spinal fusion and stabilization surgery effective July 22, 2026. The policy outlines medical necessity criteria, prior authorization requirements, and coverage guidelines for procedures including artificial intervertebral disc replacement, corpectomy, facet joint replacement, and sacroiliac joint fusion. Billing teams must verify prior authorization requirements through the Ohio Medicaid Prior Authorization and Notification List and ensure all supporting documentation is submitted with authorization requests.
Action Required
By July 22, 2026: Billing team must implement the following changes for all Ohio Medicaid spinal fusion and stabilization surgery claims: (1) Verify all requested primary CPT codes against the Ohio Medicaid Prior Authorization and Notification List to determine if prior authorization is required; (2) Update billing system rules to automatically deny any secondary/related codes if the primary code is denied for lack of medical necessity; (3) Ensure medical necessity documentation and clinical rationale are submitted with every prior authorization request; (4) Configure system to route urgent prior authorization requests to providers when delays could be detrimental to member health; (5) Verify that all implanted devices (artificial discs, facet joint implants, sacroiliac joint systems) have FDA approval before billing; (6) Train billing staff and providers that services provided without prior authorization may be subject to retrospective medical necessity review and could result in claim denials and financial penalties. Contact Humana provider services at 877-856-5707 to obtain the complete list of codes requiring prior authorization and current medical necessity criteria.