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Decision: unknown

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 epidural injections and/or infusions will be considered medically reasonable and necessary 
for the following conditions: 
 
-Management of pain caused by intervertebral disc disease with or without myelopathy. 
-Management of pain caused by spinal stenosis. 
-Management of intractable radicular pain due to postlaminectomy syndrome/failed back syndrome. 
-Management of intractable pain due to complex regional pain syndrome. 
-Management of intractable pain due to post herpetic neuralgia and acute herpes zoster. 
-Management of intractable pain due to traumatic neuropathy of the spinal nerve roots. 
-Management of intractable and severe pain secondary to neuropathy from other causes (e.g., diabetic or 
metabolic). 
-Management of severe, intractable pain in patients with advanced stages of cancer with estimated life 
expectancy of four months or less. 
-Management of pain caused by radiculitis (inflammation of the nerve roots). 
 
You can find this rule in the Local Coverage Article (LCA) - Epidural (L33906) - Effective October 1, 2019. 
 
The rules say that 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. You can find this rule in the Local 
Coverage Article (LCA) - Epidural (L33906) - Effective October 1, 2019. 
 
The rules say that 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. You can find this 
rule in the Local Coverage Article (LCA) - Epidural (L33906) - Effective October 1, 2019. 
 
The rules say that 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). You can find this rule in the Local Coverage Article (LCA) - Epidural (L33906) 
- Effective October 1, 2019. 

The rules say that 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 rule in the Local Coverage Article (LCA) - Epidural (L33906) - Effective October 1, 2019. 
 
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.