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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 medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o).
The use of imaging guidance, particularly fluoroscopy or computed tomography, with the use of injectable radio-opaque contrast material has been shown to enhance the accuracy and safety of needle placement for all epidural steroid injection (ESI) procedures. The use of this type of image guidance is considered an integral part of transforaminal injections, which cannot reliably be performed without image guidance. There are circumstances, however, where the use of imaging guidance with contrast media is contraindicated. 1. Suspected radicular pain 2. Neurogenic claudication 3. Post Laminectomy Syndrome 4. Low back pain with one of the following: substantial imaging abnormalities such as a central disc herniation, severe degenerative disc disease, high grade annular tears, the presence of osteophytes, facet hypertrophy and lateral disc herniation, or any other imaging abnormalities that result in either foraminal or central spinal canal stenosis. For a patient with low back pain only, a simple disc bulge or minor annular tear/ fissure is insufficient to justify performance of a lumbar epidural steroid injection (LESI), unless other indications in this section are present. In the case of foraminal stenosis, the injections should only be repeated or continued as long as the patient responds to or shows significant improvement after the injection. Lack of response to additional injections in the face of foraminal stenosis may indicate end stage foraminal stenosis for which epidural injections may no longer be of value and therefore not medically reasonable and necessary. 5. Documented Visual Analog Scale (VAS) for pain or Numeric Pain Rating Scale (NPRS) &#8805; 3/10 (moderate to severe pain) with functional impairment in activities of daily living (ADLs).
6. Failure of at least four weeks of non-surgical, non-injection care. All appropriate non-surgical, non-injection
treatments should be considered along with a rationale for interventional treatment. Exceptions to waiting 4
weeks since the onset of pain before receiving an LESI exist, but circumstances should be clearly documented
in the medical record. These would include, but are not limited to:
a. At least moderate pain with significant functional loss at work and/or home.
b. Severe pain unresponsive to outpatient medical management.
c. Unable to tolerate non-surgical, non-injection care due to co-existing medical condition(s).
d. Prior successful LESI for same specific condition.
You can find this information in Local Coverage Determination (LCD): Lumbar Epidural Steroid Injections
(L35148).
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.