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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 each patient must be thoroughly evaluated by a physician or non-physician practitioner whose
license and state scope of practice allow evaluation and treatment outlined in this LCD. A central or systemic
source of pain or neurologic deficit shall be determined prior to epidural injection. If a central or systemic
process is present, but the pain or neurologic deficit is clearly unrelated, injection therapy or EI may still be
indicated when at least one of the indications listed below is present.
1. Pain from Herpes Zoster or suspected radicular pain based on radiation of pain along the dermatome of a
nerve.
2. Pain from Neurogenic claudication that includes any of the following:
3. Pain severe enough to cause some degree of functional deficit;
Failure of at least four weeks of noninvasive care*;
Imaging demonstrating a correlative region of nerve/cord impingement.
Pain from CervicoThoracic or Lumbar radicular pain with any of the following:
Pain severe enough to cause some degree of functional deficit;
Failure of at least four weeks of non-invasive care*;
Imaging demonstrating a correlative region of nerve impingement.
4. Back pain without lower extremities symptoms and failure of four weeks of non-surgical, non-injection
care* with either:
documented VAS for pain or NPRS greater than or equal to 3/10 (moderate to severe pain), OR
functional impairment in ADLs;
AND
the pain or functional impairment is associated with any of the following:
substantial imaging abnormality, such as a central disc herniation or high intensity zone;
documented severe degenerative disc disease or central spinal stenosis;
discogenic pain, not attributable to facet joint or sacroiliac joint pain.
Limitations
The following Epidural Injections, regardless of approach or indication, are considered not medically
reasonable and necessary and therefore will be denied:
1. For a patient with back pain only, the radiologic findings of a simple disc bulge without correlating
symptoms is insufficient to justify performance of an epidural diagnostic or therapeutic injection.
2. Injections are performed independently based on the patient's symptoms and response to prior injections
and approach (if performed). There is no role for a routine "series of 3" or undocumented response "test
dosing." Repeat or serial test or diagnostic injections without documented response are not considered
reasonable and necessary. Response to each epidural injection should be determined prior to determining the
value of a repeat injection and the specific methods used for subsequent epidurals.
3. If a prior epidural injection procedure provided limited or no relief (i.e., NPRS less than 3, less than 50%
symptom improvement, insignificant or indiscernible relief), a second epidural injection utilizing the same
method, technique or medication to the same level will be considered not medically reasonable and necessary.
A second injection involving a change in technique or medication will be considered following re-evaluation of
the patient. If a patient does not obtain significant relief with a diagnostic selective nerve root block (DSNRB),
therapeutic injections (EI) in that same area will be considered not medically necessary.
4. For caudal or interlaminar injections, only one level may be performed, and NOT in conjunction with
transforaminal injection in the same region. Caudal or interlaminar injection is not considered medically
reasonable and necessary in conjunction with transforaminal injections at the same session, for the same level,
or within three contiguous levels of the same region (lumbosacral or cervicothoracic).
5. It should not be necessary to perform both transforaminal epidural and paravertebral facet joint injections
at the same spinal level at the same encounter, unless a synovial cyst is compressing the nerve root. In this
situation, EI may provide relief for the radicular pain while the cyst rupture allows nerve root decompression. It
is not expected that additional injection whether EI or Paravertebral Facet Joint at a different level would be
performed on the same day. When a facet joint injection and an epidural injection are performed for the
purpose of rupturing a cyst, the facet joint injection counts as one of the two injections allowed on the same
day. For additional information on facet joint injections please refer to LCD L34892, Facet Joint Interventions
for Pain Management.
6. If the muscles surrounding the lumbar joint are injected in lieu of the epidural space, an epidural injection
should not be reported as this would not support the service. A transforaminal injection without documentation
of imaging will be considered not medically reasonable and necessary. Please refer to LCD L35010, Trigger
Point Injections, for additional information.
7. It is considered not medically reasonable and necessary to perform more than 2 epidural injections in a
single setting (e.g., single level bilaterally or two levels unilaterally).
Levels per session:
No more than two epidural injections may be performed at a single session (i.e., single level bilaterally or
two levels unilaterally).
One caudal or interlaminar injection, not in conjunction with a transforaminal injection of the same region,
may be performed per session.
8. For each session, doses less than or equal to 80 mg of triamcinolone, or 80 mg of methylprednisolone, or
12 mg of betamethasone, or 15 mg of dexamethasone or equivalent corticosteroid are considered standard of
care. Administration of dosing greater than these levels is considered not medically reasonable and necessary.
You can find this information in Medicare's Local Coverage Determination (LCD): Epidural Injections for Pain
Management (L36920).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.