UnitedHealthcare (Commercial) · peripheral nerve stimulation

v1verified 2026-07-24manual-pull source

✗ investigational / not covered · commercial

Criteria checklist

0 of 5 ticked

Indications

enumerated: yes
covered:
investigational:
- percutaneous peripheral nerve stimulation (PNS) — unproven and not medically necessary
carve out: PNS for occipital neuralgia / headache is addressed by a SEPARATE UHC policy (not this one)

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 (2026T0126UU) deems percutaneous PNS unproven/not medically necessary. (The InterQual mention in this policy applies only to TENS.) PNS for occipital neuralgia/headache is covered by a separate UHC policy. ReActiv8 restorative neurostimulation is in this same policy and is also investigational (separate cell). More restrictive than Medicare (NCD 160.7-A covers PNS). From the fetched UHC PDF.

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

Dot phrase

UHC (2026T0126UU) deems percutaneous PNS **unproven/not medically necessary**.

.PNSUHC

This patient would be a candidate for peripheral nerve stimulation, but generic PNS is not a
covered benefit under this plan: UHC 2026T0126UU deems percutaneous PNS unproven and not
medically necessary. My clinical rationale is documented here: *** . Alternatives have been
discussed with the patient.

Cautions

EXCEPTION: PNS for occipital neuralgia / headache is governed by a SEPARATE UHC policy — check that policy if the indication applies. Medicare covers PNS under NCD 160.7-A.
Regenerate if `uhc-commercial-pns.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 2026T0126UU
- title: Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
- applies because: UHC commercial policy governs PNS (and restorative neurostimulation)
source: https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/electrical-stimulation-treatment-pain-muscle-rehabilitation.pdf
archived copy: sources/uhc_estim-pain_2026-03-01.pdf (sha256 d9494143d7b0… — kept in the content repo, not served here)
effective: 2026-03-01 · payor last reviewed: 2026-03-01 · 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 PNS cells: Anthem, UHC, Cigna (all deny generic PNS) afaa8358cc