MedicaidCoverageHigh impact
Spinal Fusion and Stabilization Surgery - MEDICAID - VIRGINIA (Revised)
Humana·VA · Orthopedics, Neurosurgery, Pain Management·Medicaid
Effective date
Apr 1, 2025
We identified it
Jun 24, 2026
Summary
Humana has revised their Virginia Medicaid policy for spinal fusion and stabilization surgeries, including detailed coverage criteria for procedures like corpectomy, kyphectomy, artificial disc replacement, and sacroiliac joint fusion. The policy outlines specific clinical criteria that must be met for coverage approval and lists numerous CPT codes for these procedures.
Action Required
By April 1, 2025: Billing team must update prior authorization protocols for Virginia Medicaid spinal procedures to ensure all clinical criteria are met before surgery. Update documentation templates to capture required elements like diagnostic imaging confirmation, specific anatomical conditions, and conservative treatment failures. Providers must document evidence of spinal cord/nerve compression and specific qualifying conditions for corpectomy, kyphectomy, and disc replacement procedures. Claims without proper clinical documentation will be denied.