UnitedHealthcare (Commercial) · dorsal root ganglion stimulation

Dot phrase

Lean narrative A&P attestation. `***` = fill-in. UHC's public policy fixes the DRG indication (CRPS I/II only); the operative trial/psych/conservative gates are InterQual (gated) — this phrase intentionally states no numeric gates.

.DRGUHC

Assessment: *** — CRPS type *** (I or II only), chronic pain involving the ___ region,
present *** and refractory to treatment. DRG stimulation is proven for CRPS I/II and
unproven for any other indication.

Medical necessity per UHC 2026T0567DD (Implanted Electrical Stimulator for the Spinal Cord,
which covers DRG): the covered indication above is documented, and history, imaging, and
prior-treatment records are on file. Conservative measures — pharmacologic therapy,
physical therapy, and interventional treatment as appropriate — have been tried with
unsatisfactory response: *** . UHC's published policy sets no conservative-care duration
floor, no trial-response threshold, and no psychological-evaluation posture; those gates
are adjudicated under InterQual (CP: Procedures, Spinal Cord Stimulator Insertion).

Plan: Percutaneous DRG stimulation trial. Trial response and functional status will be
assessed and documented to support permanent implantation under the InterQual SCS Insertion
criteria. Risks, benefits, and alternatives discussed; consent obtained.

Where this payor diverges from the Medicare baseline

• diagnosis line (DRG proven for CRPS I/II ONLY; any other DRG indication unproven)
• psych-eval line (delegated to gated InterQual — no public posture to chart)
• conservative-care line (delegated to gated InterQual — no public duration floor)
• trial line (delegated to gated InterQual — no public threshold; the 50%/VAS evidence-review figures must not be charted)

Cautions

• [!] Trial / psych-eval / conservative-care gates delegated to gated InterQual (CP: Procedures, Spinal Cord Stimulator Insertion) — NOT in UHC's public policy; re-verify the operative criteria with UM/billing. These are the SHARED gates of UHC's combined SCS+DRG policy (2026T0567DD) — the DRG cell derives them from `uhc-commercial-scs.md`. Do not chart the 50%/VAS responder figures that appear in UHC's evidence review — they describe published studies, not coverage gates. Not covered (unproven per policy): DRG stimulation for any condition other than CRPS I/II. UHC prior authorization required; medical necessity reviewed against InterQual SCS Insertion. Regenerate if `uhc-commercial-drg.md` `version` advances past `source_version` above.