UnitedHealthcare (Commercial) · basivertebral nerve ablation

v1verified 2026-07-24manual-pull source

✗ investigational / not covered · commercial

Criteria checklist

0 of 5 ticked

Indications

enumerated: yes
covered:
investigational:
- intraosseous radiofrequency ablation of the basivertebral nerve (e.g., Intracept) for spinal pain — unproven and not medically necessary (insufficient evidence of efficacy)

Conservative care

required: not stated in the policy
note: n/a — not covered

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: n/a

Quantity limits

applies: no

Payor-specific notes

UHC deems Intracept/BVNA "unproven and not medically necessary due to insufficient evidence of efficacy" (policy 2026T0107II "Ablative Treatment for Spinal Pain" — the same policy that governs facet RFA). This DIVERGES from Medicare (covered under MAC LCDs / R&N) and from Anthem (covered via Carelon). From the actual fetched UHC PDF. (Note: this policy is also the source for UHC facet RFA criteria referenced by uhc-commercial-facet-joint.md.)

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

Dot phrase

UHC (policy 2026T0107II) deems Intracept/BVNA **unproven and not medically necessary** (insufficient evidence). There is no medical-necessity pathway.

.INTRACEPTUHC

This patient is a candidate for basivertebral nerve ablation, but BVNA is not a covered
benefit under this plan: UHC policy 2026T0107II deems it unproven and not medically
necessary on the grounds of insufficient evidence, and there is no medical-necessity
pathway. My clinical rationale is documented here: *** . Alternatives have been discussed
with the patient. An appeal would need to argue against the "unproven" determination with
peer-reviewed evidence and guidelines.

Cautions

Anthem (Carelon) DOES cover BVNA under Modic criteria — relevant if the patient has a choice of plan.
Regenerate if `uhc-commercial-intracept.md` `version` advances.

Prior-auth pathway

required: not stated in the policy
note: n/a — denied as unproven

Provenance

authority:
- type: commercial_policy
- id: UHC 2026T0107II
- title: Ablative Treatment for Spinal Pain
- applies because: UHC commercial policy governs basivertebral nerve ablation (and facet RFA)
source: https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/ablative-treatment-spinal-pain.pdf
archived copy: sources/uhc_ablative-spinal-pain_2026-02-01.pdf (sha256 0c839fd70e90… — kept in the content repo, not served here)
effective: 2026-02-01 · payor last reviewed: 2026-02-01 · we verified: 2026-07-24 · v1

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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
2026-06-29Add commercial Intracept (BVNA) cells: Anthem, UHC, Cigna 6602e687a8