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UnitedHealthcare (Commercial) · spinal cord stimulation

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

✓ conditional · commercial

Delegated gates: trial, psych_eval, conservative_care -> InterQual CP: Procedures, Spinal Cord Stimulator (SCS) Insertion (licensed/gated; NOT in the public UHC policy). The cell does not state numbers for delegated gates — confirm the operative criteria with UM/billing.

Criteria checklist

0 of 6 ticked
Indications
  • enumerated: yes
  • covered:
      • name: Complex regional pain syndrome (CRPS)
      • name: Painful diabetic neuropathy
      • name: Failed back surgery syndrome (FBSS)
      • name: DRG stimulation — CRPS I/II only
  • investigational:
    • chronic intractable back pain WITHOUT prior spine surgery
    • refractory angina pectoris
    • DRG stimulation for any condition other than CRPS I/II
Conservative care
  • required: not stated in the policy
  • min duration months: not stated in the policy
  • note: delegated to InterQual CP: SCS Insertion (gated); not specified in the public UHC policy
Trial
  • required: not stated in the policy
  • min duration days: not stated in the policy
  • success criteria: not stated in the policy
  • threshold is binding: not stated in the policy
  • note: delegated to InterQual CP: SCS Insertion (gated)
Psychological evaluation
  • required: not stated in the policy
  • must clear: not stated in the policy
  • note posture: delegated to InterQual (gated); not specified in the public UHC policy
Quantity limits
  • applies: yes
  • replacement: battery/generator covered only when malfunctioning, not repairable, and out of warranty
Device / waveformagnostic
Payor-specific notes

UHC's PUBLIC commercial policy (2026T0567DD) enumerates the proven indications (CRPS, painful diabetic neuropathy, FBSS; DRG for CRPS I/II only) and the not-medically-necessary list (nonsurgical back pain without prior surgery; refractory angina; DRG for non-CRPS), but it DELEGATES the granular medical-necessity gating — trial requirement/threshold, psychological evaluation, and conservative- care duration — to InterQual (CP: Procedures, Spinal Cord Stimulator Insertion), a licensed/gated product not contained in the public document. Those schema fields are therefore null with a delegation note; pull the InterQual criteria (billing/UM) to complete them (needs_reverification). IMPORTANT: do not encode the 50%/VAS responder figures from the UHC evidence-review section as coverage gates — they describe published studies, not UHC criteria. Source = actual fetched UHC PDF.

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

Dot phrase

Lean narrative A&P attestation. `***` = fill-in. UHC's public policy fixes the indication list; the operative trial/psych/conservative gates are InterQual (gated) — this phrase intentionally states no numeric gates.

.SCSTRIALUHC
.SCSTRIALUHC

Assessment: *** — covered (proven) indication (select one): CRPS | painful diabetic
neuropathy | failed back surgery syndrome; for DRG stimulation, CRPS I/II only. Chronic
pain involving the ___ region, present *** and refractory to treatment.

Medical necessity per UHC 2026T0567DD (Implanted Electrical Stimulator for the Spinal
Cord): the covered indication above is documented, and history, imaging, and prior-treatment
records are on file. Conservative measures — pharmacologic therapy, physical therapy, and
interventional treatment as appropriate — have been tried with unsatisfactory response:
*** . UHC's published policy sets no conservative-care duration floor, no trial-response
threshold, and no psychological-evaluation posture; those gates are adjudicated under
InterQual (CP: Procedures, Spinal Cord Stimulator Insertion).

Plan: Percutaneous SCS trial. Trial response and functional status will be assessed and
documented to support permanent implantation under the InterQual SCS Insertion criteria.
Risks, benefits, and alternatives discussed; consent obtained.

Where this payor diverges from the Medicare baseline

  • diagnosis line (enumerated proven list: CRPS, painful diabetic neuropathy, FBSS; DRG CRPS I/II only)
  • psych-eval line (delegated to gated InterQual — no public posture; no pending-referral language to reuse)
  • conservative-care line (delegated to gated InterQual — no public duration floor)
  • trial line (delegated to gated InterQual — no public threshold; Medicare's >=50% framing must not be charted)

Cautions

  • [!] Trial / psych-eval / conservative-care gates delegated to gated InterQual (CP: Procedures, Spinal Cord Stimulator Insertion) — NOT in UHC's public policy; re-verify the operative criteria with UM/billing. Source = UHC public policy (fetched). Do not chart the 50%/VAS responder figures that appear in UHC's evidence review — they describe published studies, not coverage gates. Not covered (unproven per policy): chronic intractable back pain WITHOUT prior spine surgery; refractory angina; DRG stimulation for any condition other than CRPS I/II. Regenerate if `uhc-commercial-scs.md` `version` advances past `source_version` above.

Prior-auth pathway

  • required: yes
  • pathway: UHC prior authorization; medical-necessity reviewed against InterQual SCS Insertion

Provenance

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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
  • 2026-06-28Add UnitedHealthcare Commercial SCS cell (policy + InterQual delegation) f7f39b7d54