Medicare AdvantageCoverageMedium impact
Brain Functional Magnetic Resonance Imaging - Medicare Advantage (Revised)
Humana·Radiology, Neurology, Neurosurgery +2 more·Medicare Advantage
Effective date
Oct 1, 2026
We identified it
Sep 29, 2026
Summary
Humana Medicare Advantage has updated its Brain Functional MRI policy (HUM-1285-001), effective October 1, 2026, establishing specific medical necessity criteria for CPT codes 70554 and 70555. The policy now clearly covers fMRI for eight specific clinical indications including intracranial neoplasm assessment, presurgical planning, eloquent cortex evaluation, epilepsy surgery planning, and radiation therapy planning. This replaces previous guidance that lacked specific fMRI criteria.
Action Required
Before October 1, 2026: Billing team must update authorizations and denial protocols to recognize eight specific covered indications for CPT 70554 and 70555 under Humana Medicare Advantage plans. Providers must document claims with one of the following medical necessity justifications: (1) Assessment of intracranial neoplasm, vascular malformations, or other targeted lesions; (2) Presurgical planning and operative risk assessment; (3) Assessment of eloquent cortex in relation to tumor or focal lesion; (4) Surgical planning for biopsy or resection; (5) Therapeutic follow-up (one-time, post-operative); (6) Evaluation of preserved eloquent cortex; (7) Assessment of eloquent cortex for epilepsy surgery; or (8) Assessment of cerebral vascular reactivity for revascularization consideration. Update claim review rules in billing software to deny requests that do not match these eight criteria. For jurisdictions JH (AR, CO, LA, MS, NM, OK, TX) and JL (DE, DC, MD, NJ, PA), apply MAC LCD L35391 for oncologic cases. Train billers to flag claims lacking proper medical necessity documentation, as services outside these criteria will be denied as not medically reasonable and necessary.