MedicaidPrior AuthHigh impact
Spinal Decompression Surgery - MEDICAID - OHIO (New)
Humana·OH · Neurosurgery, Orthopedics, Pain Management +1 more·Medicaid
Effective date
Aug 5, 2026
We identified it
Aug 6, 2026
Summary
Humana Healthy Horizons Ohio Medicaid has issued a new clinical coverage policy for spinal decompression surgery effective 08/05/2026. The policy establishes medical necessity criteria and prior authorization requirements for various spinal decompression procedures including laminectomy, laminotomy, foraminectomy, foraminotomy, and related surgeries. The policy document is incomplete (appears truncated), but establishes that procedures require prior authorization and must meet specific clinical criteria to be covered.
Action Required
By 08/05/2026: (1) Billing team must update prior authorization requirements in billing system to flag all spinal decompression surgery codes (laminectomy, laminotomy, foraminectomy, foraminotomy, and related procedures) as requiring prior authorization before submission. (2) Providers must obtain complete medical necessity documentation from treating physicians for all spinal decompression cases, including documentation of symptoms, imaging results, conservative treatment attempts, and patient age/clinical status per policy criteria. (3) Update provider encounter forms and templates to include checklist for required clinical documentation before surgery scheduling. (4) Verify all submitted authorization requests include medical necessity rationale with patient health status and delivery system assessment information. (5) Configure system to deny related secondary codes automatically if primary code is denied for lack of medical necessity. CONSEQUENCE: Claims submitted without prior authorization or incomplete medical necessity documentation will be denied, resulting in financial penalties for the practice and reduced benefits for members. NOTE: The policy document appears incomplete and does not provide full coverage determination criteria for all procedure types mentioned—contact Humana provider services at 877-856-5707 or OHMCDUM@humana.com to obtain complete medical necessity criteria before implementing.