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UnitedHealthcare (Commercial) · intrathecal drug delivery

v2verified 2026-07-24needs re-verificationmanual-pull source

✓ conditional · commercial

Delegated gates: cancer pain + severe spasticity -> InterQual CP: Epidural or Intrathecal Catheter Placement. The cell does not state numbers for delegated gates — confirm the operative criteria with UM/billing.

Criteria checklist

0 of 5 ticked
Indications
  • enumerated: yes
  • covered:
      • name: Chronic non-malignant pain
      • criteria:
        • age: >18
        • etiology documented: yes
        • surgery: further surgery not indicated or refused
        • conservative: failure after a >=6-month conservative trial
        • psych: no untreated psychological issues
        • pump requires: completed trial + documented >50% pain reduction
        • replacement: criteria met AND device nonfunctional/unrepairable/out-of-warranty
      • name: Cancer pain (per InterQual)
      • name: Severe spasticity (per InterQual)
Conservative care
  • required: yes
  • min duration months: 6
  • satisfied by:
    • failed >=6-month conservative trial
    • contraindicated
  • modalities named:
    • systemic analgesics
    • other non-invasive management
Trial
  • required: yes
  • min duration days: not stated in the policy
  • success criteria:
    • logic: pain_reduction
    • pain reduction pct: 50
  • threshold is binding: yes
Psychological evaluation
  • required: yes
  • must clear: yes
  • note posture: no untreated psychological issues (in-policy for non-malignant pain)
Quantity limits
  • applies: yes
  • replacement: criteria met + device nonfunctional/unrepairable/out-of-warranty
Payor-specific notes

UHC (2026T0626N) covers intrathecal pumps. For chronic NON-MALIGNANT pain the in-policy gates are explicit: age >18, documented etiology, surgery not indicated/refused, failure after a >=6-MONTH conservative trial, no untreated psych, and a completed trial with >50% pain reduction before the permanent pump. Cancer pain and severe spasticity gates are delegated to InterQual (Epidural or Intrathecal Catheter Placement) — not in the public doc. From the fetched UHC PDF.

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

Dot phrase

Lean narrative A&P attestation. `***` = fill-in. Maps to UHC 2026T0626N (eff 2026-07-01). In-policy gates exist ONLY for chronic non-malignant pain; no life-expectancy requirement in 2026T0626N.

.ITDDUHC
.ITDDUHC  [NON-MALIGNANT PAIN]

Assessment: *** — chronic non-malignant pain of documented etiology *** , refractory to
>=6 months of conservative management. The patient is older than 18 years. Further surgery
is not indicated, or has been refused by the patient.

Medical necessity per UHC 2026T0626N (Implanted Spinal Drug Delivery Systems): a >=6-month
conservative trial of systemic analgesics and other non-invasive management has failed, and
there are no untreated psychological issues. A pump trial was completed on *** with
documented >=50% pain reduction, as required before the permanent implant.

Plan: Implantation of a programmable intrathecal drug-delivery pump and catheter
(62362 + 62350). Risks, benefits, and alternatives discussed; consent obtained.

---
.ITDDUHC  [REPLACEMENT] — swap the plan sentence:
Plan: Replacement of the existing intrathecal drug-delivery pump. The criteria above remain
met and the current device is nonfunctional, unrepairable, or out of warranty.

Where this payor diverges from the Medicare baseline

  • age gate (>18)
  • conservative care (>=6-month floor)
  • psych (no untreated psychological issues)
  • surgery line (further surgery not indicated / refused)
  • cancer + spasticity gates delegated to InterQual
  • replacement gate (nonfunctional/unrepairable/out-of-warranty)
  • no life-expectancy gate

Cautions

  • Cancer pain + severe spasticity: gates delegated to InterQual (Epidural or Intrathecal Catheter Placement) — gated; confirm InterQual criteria before drafting. Not rendered here. PA not stated in-policy — check the separate UHC prior-authorization list. Regenerate if `uhc-commercial-itdd.md` `version` advances past `source_version`.

Prior-auth pathway

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

Provenance

Report an issue with this cell

Change history

  • 2026-07-24uhc/itdd v2: successor policy 2026T0626M->2026T0626N (eff 07/01/2026) fetched+archived; full-text diff editorial-only, medical-necessity gates unchanged; bump reflects effective-date/policy-number change; dot phrase resynced to source_version 2 86fe7c0372
  • 2026-06-30Archive commercial source PDFs into sources/ + wire source_file/source_hash c5466694c8
  • 2026-06-29Add commercial ITDD cells: Anthem, UHC, Cigna (all covered) 3a15b25784