Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CPT 64483 injection(s), anesthetic agent(s) and/or 
steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level 
Bilateral L5 and CPT code 64484- injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with 
imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level Bilateral S1. 
 
You asked the Plan to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with 
imaging guidance (fluoroscopy or CT), lumbar or sacral, single level Bilateral L5 and injection(s), anesthetic 
agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, 
each additional level Bilateral S1. The Plan denied your request. The Plan says the member had previously 
undergone ESI to this area in the past and there was no information provided informing on the degree of relief, 
if any, that she had obtained from this type of injection. 
 
The Plan follows Medicare rules.  
 
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 injection(s), anesthetic agent(s) and/or 
steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level 
Bilateral L5 and injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance 
(fluoroscopy or CT), lumbar or sacral, each additional level Bilateral S1. Our reviewer says that epidural 
steroid injections is not medically necessary. Our physician reviewer found that according to the coverage 
criteria, for a repeat ESI to be considered medically reasonable and necessary, there must have been at least 
50% of sustained improvement in pain relief and/or improvement in function from baseline for at least three 
months. In this case, there is clear documentation that the enrollee did not obtain improvement in function or 
pain relief with the prior ESI and there is no explanation as to why a repeat ESI would be beneficial at this 
time. The review indicates that the requested epidural steroid injections do not meet the Medicare LCD 
coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with 
imaging guidance (fluoroscopy or CT), lumbar or sacral, single level Bilateral L5 and injection(s), anesthetic 
agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, 
each additional level Bilateral S1. have not been met. Therefore, we decided that the Plan does not have to pre-
approve CPT 64483 injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging 
guidance (fluoroscopy or CT), lumbar or sacral, single level Bilateral L5 and CPT code 64484- injection(s), 
anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar 
or sacral, each additional level Bilateral S1.