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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 state that Low back pain may also be produced by "Myofascial Pain Syndrome" in which case there is not nerve root pathology and epidural injections are not reasonable and necessary. If there is a doubt in the differential diagnosis, the diagnosis of radiculopathy can be confirmed by an EMG/nerve conduction/small fiber testing or appropriate radiological study. Degenerative Disk Disease without root compression has been shown to be a significant cause of low back and/or radicular pain; some patients will respond to Epidural Steroid Injection in this situation. Epidural injections, with the exception of interlaminar injections, should be performed under fluoroscopic or CT-guided imaging. It is expected that providing an epidural block in conjunction with multiple facet joint blocks, bilateral sacroiliac joint injections, trigger point injections, and/or lumbar sympathetic blocks in any combination to a patient on the same day is not considered medically necessary, unless the patient has recently discontinued anticoagulant therapy for the purpose of interventional pain management. It is expected that interlaminar, transforaminal or caudal epidural injections are not performed on the same date of service at the same level. Procedures performed during the diagnostic phase should be limited to two (2) injections. Once a structure is proven to be negative as a pain generator, no repeat interventions should be directed at that structure unless there is a new clinical presentation with symptoms, signs, and diagnostic studies of known reliability and validity that implicate the structure. In the treatment or therapeutic phase, a series of three (3) injections may be given at a minimum interval of two (2) weeks to the suspect level. If a positive response (per ASIPP guidelines) is not obtained, then a repeat series of injections at that level is considered not medically necessary. It is not expected that a patient would undergo an epidural injection at more than two (2) levels (unilateral or bilateral) on any given date of service. (A level is defined as the articulation between two vertebrae i.e., C4-5; or L2- 3). A series of three (3) epidural injections may be repeated at six (6) month intervals (assuming there was a positive response as defined by the ASIPP guidelines) to the first series of three (3) injections. Caution should
be used to monitor the side effects of frequent steroid use. Under unusual circumstances with a recurrent injury, carcinoma, or reflex sympathetic dystrophy, blocks may be repeated more frequently in the treatment phase after stabilization. Documentation must be present in the medical record to support the more frequent use of such therapy in this setting. You can find this information in Local Coverage Determination (LCD): Epidural (L33906).
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.