CurrentColorado Rocky Mountain Health PlansPolicy 2026T0004VV

Facet Joint and Medial Branch Block Injections for Spinal Pain – Commercial and Individual Exchange Medical Policy

Defines medical necessity and exclusion criteria for diagnostic and therapeutic facet joint injections and medial branch blocks for spinal pain for UnitedHealthcare Commercial and Individual Exchange plans; includes definitions, supporting evidence, guidance on ultrasound use, and applicable procedure and diagnosis codes. This is part 1 of 2.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyFacet Joint and Medial Branch Block Injections for Spinal Pain – Commercial and Individual Exchange Medical Policy

Policy CodePolicy 2026T0004VV

Change TypeRevised (supporting information and references)

Effective DateMay 1, 2026

Next Review Date

Key ActionDocument at least 4 weeks of conservative care and that pain remains >=3/10; record facet-loading positive exam and imaging excluding other causes.

SourceLink

POLICY UPDATE CHANGES

Updated Description of Services, Clinical Evidence, and References sections to reflect current information; archived previous policy version 2026T0004UU.

1Diagnostic injections covered with criteria

1Therapeutic injections not covered

1Ultrasound guidance not covered

limits