Appeal type: Practitioner Services
Decision: Partially Favorable

 You asked the Plan to pre-approve epidural injections. You say that you are appealing with supporting records. 
The Plan says that the denial of authorization for these services is correct, because repeat injection is not 
supported unless the last series of 3 injections provided greater than 50% pain relief for at least 6 weeks and the 
series was completed at least 6 months ago. 
 
We decided that the Plan has to pre-approve one level bilaterally of epidural injections.  
 
The Plan follows Medicare rules. Medicare rules state that repeat epidural steroid injection (ESI) may be 
considered medically reasonable and necessary when the record documents at least 50% sustained 
improvement in pain relief and/or function.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve epidural injections. Our reviewer says 
that the enrollee meets the Medicare criteria for one of the requested epidural steroid injection levels. Our 
physician reviewer found on August 2, 2021, the enrollee had bilateral transforaminal epidural steroid 
injections at L3/L4 and L4/L5. She achieved over 50% pain relief for 6 weeks. The enrollee meets the criteria 
of 50% pain relief for 6 weeks from the previous injections. Therefore, one level bilaterally is deemed 
medically reasonable and necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural injections have been met. Therefore, we decided that the Plan has to 
pre-approve epidural injections.  
 
We also decided that the Plan does not have to pre-approve additional levels of epidural injections 
beyond this. 
 
The Plan follows Medicare rules. Medicare rules state that it is not considered medically reasonable and 
necessary for more than one spinal region to be injected in the same session.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve epidural injections. Our reviewer says 
that the enrollee does not meet the Medicare criteria for additional levels of epidural steroid injections. Our 
reviewer found that only one set of epidural steroid injections may be performed, and the results need to be 
evaluated before repeating the injections  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional epidural injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural injections. 
 
 
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.