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You asked about Facet joint interventions (MBB/RFA). VA Community Care Network (CCN) — Region 2 / Optum (IN & KY) is governed by a framework cell — read the per-procedure line inside it.

VA Community Care Network (CCN) — Region 2 / Optum (IN & KY) · all interventional pain

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

✓ conditional · va

Criteria checklist

0 of 2 ticked
Indications
  • enumerated: no
  • description: VA community care is authorized per a SEOC (Standardized Episode of Care): the community pain practice MUST have a VA referral + authorization (verify in HSRM) BEFORE the procedure, and may bill only services within the authorized SEOC; out-of-scope services require a Request for Service (RFS, VA Form 10-10172) clinically reviewed by VA before delivery. Clinical necessity is judged by 38 CFR 17.38(b) (generally accepted standards of medical practice) + VA's CDI Library where a CDI exists + the VA/DoD Clinical Practice Guidelines. NONE of these 12 procedures currently has its own VA CDI, so they are governed by the SEOC scope + standard of care + the relevant CPG. VA approves devices that have at least FDA 510(k) clearance.
Device / waveformFDA 510(k)-cleared (or better) required
Payor-specific notes

Framework cell for VA Community Care (the pathway a community pain practice uses for Veterans). KEY: this is AUTHORIZATION-driven, not a published per-procedure coverage policy — get the VA referral + SEOC authorization BEFORE the procedure and bill only within it (out-of-scope -> RFS first), or it is not reimbursed. VA's clinical standard is its OWN (38 CFR 17.38 + CDI Library + VA/DoD CPGs), NOT Medicare (Medicare is pricing only) and NOT MCG/InterQual. None of the 12 grid procedures has a VA CDI today, so SEOC + standard of care + the LBP CPG govern; note the CPG is comparatively restrictive (against SCS for LBP, against most ESI, against steroid facet injections — but for medial-branch RFA). IN and KY are both CCN Region 2 (Optum). Optum's provider manual and the SEOC catalog are gated (needs_reverification); re-pull the exact VA/DoD CPG recommendation strengths from the source PDF. Sources: VA CDI Library; CCN Fact Sheet 26-03 (SEOC); 38 CFR 17.38; RFS (Form 10-10172); VA CCN region map (Optum R1-3 / TriWest R4-5, updated 2026-06-03); VA/DoD Low Back Pain CPG (2022).

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

Authorization model (VA SEOC)

  • seoc required: yes
  • referral auth before procedure: required (urgent/emergent excepted); verify authorization in HSRM
  • out of scope: submit RFS (VA Form 10-10172) to the authorizing VAMC before delivering care
  • ccn region: Region 2 (Optum) for IN and KY — submit claims to Optum, not VA
  • claims: 180-day timely filing from DOS; no balance billing (VA payment is payment-in-full); return records to the VAMC via HSRM
  • pricing: contract rate -> Medicare/CMS-MAC rate -> VA fee schedule -> % billed (Medicare = pricing basis only, NOT coverage)

VA/DoD CPG positions

  • SCS: VA/DoD Low Back Pain CPG suggests AGAINST for low back pain (Weak Against); VA does use neurostim for CRPS/post-amputation (no CDI)
  • ESI: CPG recommends AGAINST except a very short-term effect (<=2 weeks); insufficient evidence for radicular (no CDI)
  • Facet: CPG suggests FOR lumbar medial-branch / sacral lateral-branch RFA (Weak For) but AGAINST steroid facet/MBB injections (no CDI)
  • SI joint: insufficient evidence for injections; no VA policy on SI fusion (no CDI)
  • DRG / PNS / ReActiv8 / Intracept / ITDD / kyphoplasty / MILD / endoscopic nerve transection: no VA policy and no CDI — adjudicated via SEOC scope + standard of care

Prior-auth pathway

  • required: yes
  • pathway: VA referral + authorization (SEOC); RFS for out-of-scope; administered by Optum (Region 2, IN/KY)

Provenance

  • authority:
    • type: va
    • id: 38 CFR 17.38(b) + VA CDI Library + VA/DoD CPGs
    • title: VA community care — SEOC-scoped authorization; VA clinical criteria (not Medicare)
    • applies because: VA care by a community provider is referral-and-authorization driven, scoped by a SEOC. Clinical standard = 38 CFR 17.38(b) (generally accepted standards) + VA's CDI Library where a CDI exists + VA/DoD CPGs. VA does NOT adopt Medicare coverage (Medicare used only for pricing); not MCG/InterQual.
    • ccn admin: Region 2 = Optum (UnitedHealth) — covers BOTH Indiana and Kentucky
  • source: https://department.va.gov/vha/community-care/cdi-library-eua/cdi-library/
  • effective: — · payor last reviewed: — · we verified: 2026-07-24 · v1

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Change history

  • 2026-07-24framework cells (MA x3, Medicaid IN/KY, VA): re-reviewed regulatory basis 2026-07-24 (42 CFR 422.101/CMS-4201-F, 405 IAC Art.5, KY KAR 907:3:130, 38 CFR 17.38(b) all current); plan/state-specific operational details (MA PA vendor, Medicaid interactive fee-schedule PA flags + MCO scopes, VA gated SEOC catalog/Optum manual/image-only CPG) remain gated -> needs_reverification kept; last_verified 2026-07-24 86bd4bd0b9
  • 2026-07-23va: 11 -> 12 grid procedures; add endoscopic transection to the CPG lump line 52427f1092
  • 2026-06-30Add VA Community Care framework cell (IN/KY = Region 2 / Optum) 84c28de0ed