UnitedHealthcare (Commercial) · facet joint interventions

Dot phrase

Lean narrative A&P attestation. `***` = fill-in. Fully self-contained — rendered from UHC 2026T0004VV. SCOPE: this policy covers DIAGNOSTIC medial branch blocks only, and only with RFA as the planned endpoint; ALL therapeutic facet/MBB injections are not covered. The RFA itself is governed by the separate UHC "Ablative Treatment for Spinal Pain" policy (not restated here).

.FACETUHC

Assessment: *** — suspected facet-mediated *** (cervical / thoracic / lumbar) pain,
exacerbated by facet-loading maneuvers, with other causes excluded on imaging. The index
segment is not fused and there is no untreated radiculopathy at the same level (facet
synovial cyst excepted).

Medical necessity per UHC 2026T0004VV: conservative care has failed or was contraindicated
over >=4 weeks — pharmacotherapy, physical therapy or home exercise, and activity
modification: *** — with residual pain >=3/10. I am proceeding with a diagnostic medial
branch block (64490-64495) with radiofrequency ablation as the planned endpoint, using
<=0.5 mL of anesthetic per block; a positive block is >=50% relief lasting at least the
duration of the anesthetic used. This falls within the limit of <=2 diagnostic blocks per
level and side. Guidance is fluoroscopic or CT; ultrasound is not covered.

Plan: Diagnostic medial branch block at level(s) and side ***, date ***. If positive, RFA
will follow under the separate UHC "Ablative Treatment for Spinal Pain" policy. Risks,
benefits, and alternatives discussed; consent obtained.

Where this payor diverges from the Medicare baseline

• scope (diagnostic blocks ONLY; facet RFA lives in a separate UHC ablation policy)
• diagnosis line (facet-loading maneuvers + imaging rule-out)
• conservative-care line (>=4 wk floor with residual pain >=3/10)
• diagnostic-block line (>=50% positivity; <=0.5 mL; <=2 per level/side)
• therapeutic-injection ban (all regions)

Cautions

• Beyond 2 blocks per level/side the injections count as THERAPEUTIC and are not covered. Therapeutic facet/MBB injections in all regions, and diagnostic blocks used as treatment, are unproven / not covered. Confirm the separate ablation policy's gates before scheduling RFA. Prior auth: not stated in this policy — check the separate UHC Advance Notification / Prior Authorization list. Regenerate if `uhc-commercial-facet-joint.md` `version` advances past `source_version`.