Appeal type: unknown
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 an epidural injection is considered medically reasonable and necessary with the following 
conditions: 
 
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: 
o Pain severe enough to cause some degree of functional deficit; 
o Failure of at least four weeks of noninvasive care*; 
o Imaging demonstrating a correlative region of nerve/cord impingement. 
3. Pain from Cervicothoracic or Lumbar radicular pain with any of the following: 
o Pain severe enough to cause some degree of functional deficit; 
o Failure of at least four weeks of non-invasive care*; 
o 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: 
o documented VAS for pain or NPRS greater than or equal to 3/10 (moderate to severe pain), OR 
o functional impairment in ADLs; 
AND 
o the pain or functional impairment is associated with any of the following: 
&#9642; substantial imaging abnormality, such as a central disc herniation or high intensity zone; 
&#9642; documented severe degenerative disc disease or central spinal stenosis; 
&#9642; discogenic pain, not attributable to facet joint or sacroiliac joint pain. 
*It is generally accepted that the majority of back radicular pain will improve with conservative treatment over 
a four-week period. All appropriate non-surgical, non-injection treatments which includes appropriate oral 
medications and physical therapy (to the extent tolerated) should be considered along with a rationale for 
interventional treatment. Exceptions to the four week non-surgical/non-injection care prior to initiation of 
epidural injection therapy, should be documented. These may include, but are not limited to one or more of the 
following: 
o Pain from Herpes Zoster; 
o Severe pain unresponsive to outpatient medical management; 
o Inability to tolerate non-surgical, non-injection care due to co-existing medical conditions(s); 
o At least moderate pain with significant functional loss at work or home; 
o Prior successful lumbar ESI for same specific condition. 
 
 
You can find this rule in the Local Coverage Determination (LCD): Epidural Injections for Pain Management 
(LL36920) effective July 1, 2020. 
 
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.