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UnitedHealthcare (Commercial) · epidural steroid injection

v1verified 2026-07-24needs re-verificationmanual-pull source

✓ conditional · commercial

Criteria checklist

0 of 6 ticked
Indications
  • enumerated: yes
  • covered:
      • name: Radicular back pain with nerve-root involvement
      • criteria:
        • pain pattern: radicular pain by history + exam
        • conservative min weeks: 4
        • nerve root evidence: structural/functional nerve-root involvement by imaging OR electrodiagnostics
        • imaging guided: fluoroscopy or CT
  • investigational:
    • ultrasound guidance
    • ESI for any other (non-radicular) spinal indication
  • contraindications:
    • spinal neoplasm
    • rapidly progressing neurologic deficit
    • epidural abscess
Conservative care
  • required: yes
  • min duration months: not stated in the policy
  • min duration weeks: 4
  • satisfied by:
    • failed >=4 weeks (pharmacotherapy OR activity modification OR PT/home exercise)
    • contraindicated
  • modalities named:
    • pharmacotherapy
    • activity modification
    • physical therapy / home exercise
Trial
  • required: no
  • min duration days: not stated in the policy
  • success criteria: not stated in the policy
  • threshold is binding: no
Psychological evaluation
  • required: no
  • must clear: no
  • note posture: not required
Imaging guidance
  • required: yes
  • modalities:
    • fluoroscopy
    • CT
  • excluded:
    • ultrasound
Quantity limits
  • applies: yes
  • sessions per region per 12mo: 4
  • repeat requires: >=50% relief / functional improvement from the prior injection (re-evaluate if benefit <3 months)
Payor-specific notes

UHC commercial ESI policy — radicular pain with imaging/EDX nerve-root involvement, >=4 weeks conservative care, fluoro/CT guidance. Codifies a 4-session/region/rolling-12mo cap and a >=50% repeat gate. Ultrasound and non-radicular indications unproven. Criteria stated in-policy (not InterQual-delegated). From the actual fetched UHC PDF; confirm the exact policy number.

Ticks are a documentation aid — nothing is stored; they reset on reload.

Dot phrase

Lean narrative A&P attestation. `***` = fill-in. Fully self-contained — rendered from the UHC commercial "Epidural Steroid Injections for Spinal Pain" policy (Commercial / Individual Exchange; criteria stated in-policy, not InterQual-delegated).

.ESIUHC
.ESIUHC

Assessment: *** — radicular *** (C/T/L-S) pain by history and examination, with structural
or functional nerve-root involvement at *** demonstrated on imaging or electrodiagnostics.
There is no spinal neoplasm, rapidly progressing neurologic deficit, or epidural abscess.

Medical necessity per the UHC policy "Epidural Steroid Injections for Spinal Pain"
(Commercial / Individual Exchange): conservative care has failed or was contraindicated over
>=4 weeks — pharmacotherapy, activity modification, or physical therapy / home exercise:
*** . The injection will be placed under fluoroscopy or CT; ultrasound is not covered. The
indication treated here is radicular; ESI for non-radicular spinal pain is unproven and not
covered.

Plan: *** epidural steroid injection — transforaminal (64483/64484 lumbar-sacral;
64479/64480 cervical-thoracic) or interlaminar (62320-62323) — at level ***, under
fluoroscopic/CT guidance, within <=4 sessions per region (cervical / thoracic / lumbosacral)
per rolling 12 months regardless of level or side. [If repeat:] the prior ESI gave >=50%
relief or functional improvement; benefit lasting <3 months prompts re-evaluation. Risks,
benefits, and alternatives discussed; consent obtained.

Where this payor diverges from the Medicare baseline

  • diagnosis line (nerve-root involvement by imaging OR electrodiagnostics)
  • conservative-care line (>=4 wk, OR-modality list)
  • session/frequency limits (<=4/region/12mo regardless of level/side)
  • repeat-relief gate (>=50%; re-evaluate if benefit <3 months)
  • contraindications line (neoplasm, progressing deficit, abscess)

Cautions

  • Prior auth: not stated in this policy — check the separate UHC Advance Notification / Prior Authorization list. Regenerate if `uhc-commercial-esi.md` `version` advances past `source_version`.

Prior-auth pathway

  • required: not stated in the policy
  • note: not stated in-policy; governed by a separate UHC PA list

Provenance

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Change history

  • 2026-07-24commercial cells: re-verify 27 source PDFs by SHA-256 (Carelon/eviCore/UHC/Cigna) - all unchanged vs committed archive; last_verified -> 2026-07-24 3615c231f0
  • 2026-06-30Archive commercial source PDFs into sources/ + wire source_file/source_hash c5466694c8
  • 2026-06-28Add commercial ESI cells: Anthem(Carelon), UHC, Cigna(eviCore) ecc9a1b23e