Neurology & Neurosurgery — Coverage Criteria and Policy Updates (Spine Fusion, Neuromodulation, DBS, MEG)
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Summarizes new and revised neurology/neurosurgery medical policies, investigational determinations, coding and prior authorization updates, and changes to InterQual applicability that affect BCBSMA providers and prior authorization processes.
New medical policy describing medically necessary indications for spine fusions (cervical, lumbar and thoracic) will be used; prior authorization remains required.
InterQual criteria for fusion: cervical, lumbar and thoracic will not be applicable effective 4/1/26.
InterQual criteria for decompression/spine fusion will only be applicable for a specified list of procedures (e.g., corpectomy, facetectomy, foraminotomy, hemilaminectomy, discectomy, laminectomy, etc.).
New investigational statement: Remote electrical activation as a treatment for restless legs syndrome refractory to medication is considered investigational (effective March 1, 2026).
Magnetoencephalography recording and analysis codes 95965 and 95966 were added and require prior authorization through Carelon.
Deep Brain Stimulation policy updated; adaptive deep brain stimulation in Parkinson disease is listed as investigational.
Coverage Criteria and Investigational Determinations
Spine fusion policy / InterQual applicability
Policy changes governing spine fusion and applicability of InterQual criteria:
InterQual criteria for fusion (cervical, lumbar, thoracic) will not be applicable effective 04/01/2026; InterQual criteria will remain applicable only for a specified list of decompression/spine fusion procedures (e.g., corpectomy, facetectomy, foraminotomy, hemilaminectomy, discectomy, laminectomy, laminoforaminotomy, laminoplasty, laminotomy, microdiscectomy, transpedicular decompression).
Investigational: Remote electrical activation for RLS
Investigational determinations:
Effective 03/01/2026.
DBS investigational statements
DBS policy updates and investigational statements:
Policy updated with literature review through 03/04/2025; effective 09/01/2025.
The policy update for Deep Brain Stimulation includes an explicit investigational determination for adaptive deep brain stimulation in Parkinson disease. This means adaptive DBS is listed as investigational and is excluded from medically necessary coverage under the DBS policy update effective 09/01/2025. The investigational statement and the supporting literature review through March 4, 2025 are documented in the policy update.
Remote electrical activation as a treatment for restless legs syndrome (RLS) refractory to medication is categorized as investigational. This investigational determination is effective March 1, 2026, and the policy update indicates that such remote electrical activation approaches are not considered medically necessary for RLS that has failed medication therapy.
Coding and Prior Authorization for Procedures
Actions for Providers and Prior Authorization Requirements
Cross‑reference Medicare Advantage and pharmacy step therapy policies
See Medicare Advantage Part B Step Therapy policy (Policy 020) and Pharmacy Prior Authorization policies (Pharmacy Policy 033 / Policy 034) for applicable step therapy or pharmacy prior authorization requirements that may apply to related treatments.
Follow outpatient prior authorization lists and Carelon processes
Providers must follow the Outpatient Prior Authorization Code List (Policy 072) and use Carelon’s prior authorization processes and referenced Carelon Advanced Imaging/Radiology code lists when requesting authorization for advanced imaging and listed procedures.
- Follow Policy 072 - Outpatient Prior Authorization Code List.
- Use Carelon (formerly AIM) Advanced Imaging/Radiology policy/code lists (e.g., Policies #968, #931, #934) when applicable.
Prior authorization required for spine fusions (effective 04/01/2026)
Prior authorization remains required for spine fusion procedures under the new spine fusion policy effective 04/01/2026; performing spine fusion without following the new medically necessary indications and prior authorization processes may risk denial.
- InterQual criteria for fusion will not be applicable effective 4/1/2026 but prior authorization is unchanged and still required.
- Ensure authorization follows the new medical policy describing medically necessary indications for cervical, lumbar, and thoracic fusions.
Background and Scope
This document is a Neurology and Neurosurgery medical policy group meeting summary and policy update digest that summarizes multiple device- and procedure-related policy changes. It highlights new and revised medical policies (for example, a new spine fusion policy and investigational determinations for neuromodulation approaches), changes to the applicability of InterQual criteria for fusion procedures effective 04/01/2026, additions to coding that require prior authorization (such as magnetoencephalography codes 95965 and 95966), and investigational policy statements (including adaptive deep brain stimulation for Parkinson disease). The summary is intended to inform providers and operational teams about effective dates, prior authorization expectations, and which policies include newly clarified or revised coverage positions.
Definitions and Terminology
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.