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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that covered indications for lumbar epidural injections include:
1. Pain associated with Herpes Zoster and/or Suspected radicular pain, based on radiation of pain along the dermatome (sensory distribution) of a nerve and/or Neurogenic claudication and/or Low back pain, NPRS greater than or equal to 3/10 (moderate to severe pain) associated with significant impairment of activities of daily living (ADLs) and one of the following: a. substantial imaging abnormalities such as a central disc herniation, b. severe degenerative disc disease or central spinal stenosis. 2. Failure of four weeks (counting from onset of pain) of non-surgical, non-injection care, which includes appropriate oral medication(s) and physical therapy to the extent tolerated.
Exceptions to the 4-week wait may include:
a. pain from Herpes Zoster
b. at least moderate pain with significant functional loss at work or home.
c. severe pain unresponsive to outpatient medical management.
d. inability to tolerate non-surgical, non-injection care due to co-existing medical condition(s)
e. prior successful injections for same specific condition with relief of at least 3 months' duration.
Procedure Requirements
1. An appropriately comprehensive evaluation of all potential contributing pain generators and treatment in accordance with an established and documented treatment plan.
2. Plain films to rule out red flag conditions may be appropriate if potential issues of trauma, osteomyelitis or malignancy are a concern.
3. Real-time imaging guidance, fluoroscopy or computed tomography, with the use of injectable radio-opaque contrast material is required for all steroid injections and all transforaminal injections. Its use is urged but not required for other epidural injections.
4. Contrast medium should be injected during epidural injection procedures unless patient has contraindication to injection. The reasons for not using contrast must be documented in the procedure report.
5. Films that adequately document final needle position and injectate flow must be retained and made available upon request.
6. For each session, no more than 80mg of triamcinolone, 80 mg of methylprednisolone, 12 mg of betamethasone, 15 mg of dexamethasone or equivalent corticosteroid dosing may be used
7. When a diagnostic spinal nerve block is performed, post-block assessment of percentage pain relief must be documented.
8. Levels per session: a. No more than two transforaminal injections may be performed at a single setting (e.g. single level bilaterally or two levels unilaterally) b. One caudal or lumbar interlaminar injection per session and not in conjunction with a lumbar transforaminal injection.
9. Frequency: a. No more than 3 epidurals may be performed in a 6-month period of time. b. No more than 6 epidural injection sessions (therapeutic epidurals and/or diagnostic transforaminal injections) may be performed in a 12-month period of time regardless of the number of levels involved. c. If a prior epidural provided no relief, a second epidural is allowed following reassessment of the patient and injection technique.
10. Local anesthesia or minimal conscious sedation may be appropriate. Use of moderate sedation and Monitored Anesthesia Care (MAC) is usually unnecessary. Documentation must clearly establish the need for such sedation in the specific patient.
Limitations
1. For a patient with low back pain only, a simple disc bulge or annular tear/fissure is insufficient to justify performance of an epidural.
2. Patient must not have major risk factors for spinal cancer (e.g., LBP with fever) or, if cancer is present, but the pain is clearly unrelated, an epidural may be indicated if one of the "Indications" previously listed is present.
3. A co-existing medical or other condition that precludes the safe performance of the procedure precludes coverage of the procedure, e.g., new onset of LBP with fever, risk factors for, or signs of, cauda equina syndrome, rapidly progressing (or other) neurological deficits.
4. Numbness and/or weakness without paresthesia/dysesthesia or pain precludes coverage.
5. There is no role for "series of three" epidurals. Response to each epidural should be determined prior to determining the value of a repeat epidural and the specific methods used for subsequent epidurals.
You can find this rule in the Local Coverage Determination (LCD): Lumbar Epidural Injections (L34980).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.