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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 1. Pain associated with 
      Herpes Zoster and/or 
      Suspected radicular pain, based on radiation of pain along the dermatome (sensory distribution) of a nerve 
and/or 
 
Neurogenic claudication and/or 
  Low back pain, NPRS = 3/10 (moderate to severe pain) associated with significant impairment of activities of 
daily living (ADLs) and one of the following: 
      a. substantial imaging abnormalityies such as a central disc herniation, 
      b. severe degenerative disc disease or central spinal stenosis. 
 
2. Failure of four weeks (counting from onset of pain) of non-surgical, non-injection care, which includes 
appropriate oral medication(s) and physical therapy to the extent tolerated. 
 
Exceptions to the 4 week wait may include: 
 
   a. pain from Herpes Zoster 
   b. at least moderate pain with significant functional lossat work or home. 
   c. severe pain unresponsive to outpatient medical management. 
    d. inability to tolerate non-surgical, non-injection care due to co-existing medical condition(s) 
  e. prior successful injections for same specific condition with relief of at least 3 months' duration. 
 
Procedure Requirements 
 
1. An appropriately comprehensive evaluation of all potential contributing pain generators and treatment in 
accordance with an established and documented treatment plan. 
   2. Plain films to rule out red flag conditions may be appropriate if potential issues of trauma, osteomyelitis or 
malignancy are a concern. 
   3. Real-time imaging guidance, fluoroscopy or computed tomography, with the use of injectable radio-
opaque contrast material is required for all steroid injections and all transforaminal injections. Its use is urged 
but not required for other epidural injections. 
    4. Contrast medium should be injected during epidural injection procedures unless patient has 
contraindication to injection. The reasons for not using contrast must be documented in the procedure report. 
    5. Films that adequately document final needle position and injectate flow must be retained and made 
available upon request. 
   6. For each session, no more than 80mg of triamcinolone, 80 mg of methylprednisolone, 12 mg of 
betamethasone, 15 mg of dexamethasone or equivalent corticosteroid dosing may be used 
   7. When a diagnostic spinal nerve block is performed, post-block assessment of percentage pain relief must 
be documented. 
   8. Levels per session: 
    a. No more than two transforaminal injections may be performed at a single setting (e.g. single level 
bilaterally or two levels unilaterally) 
    b. One caudal or lumbar interlaminar injection per session and not in conjunction with a lumbar 
transforaminal injection. 
   9. Frequency: 
    a. No more than 3 epidurals may be performed in a 6-month period of time. 
    b. No more than 6 epidural injection sessions (therapeutic epidurals and/or diagnostic transforaminal 
injections) may be performed in a 12-month period of time regardless of the number of levels involved. 
    c. If a prior epidural provided no relief, a second epidural is allowed following reassessment of the patient 
and injection technique. 
   10. Local anesthesia or minimal conscious sedation may be appropriate. Use of moderate sedation and 
Monitored Anesthesia Care (MAC) is usually unnecessary. Documentation must clearly establish the need for 
such sedation in the specific patient. 
 
Provider Qualifications 
The CMS Manual System, Pub. 100-8, Program Integrity Manual, Chapter 13, Section 5.1 
(http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf) states that "reasonable and necessary" services 
are "ordered and/or furnished by qualified personnel." Services will be considered medically reasonable and 
necessary only if performed by appropriately trained providers. 
 
Patient safety and quality of care mandate that healthcare professionals who perform Epidural Steroid 
Injections are appropriately trained and/or credentialed by a formal residency/fellowship program and/or are 
certified by either an accredited and nationally recognized organization or by a post-graduate training course 
accredited by an established national accrediting body or accredited professional training program. If the 
practitioner works in a hospital facility at any time and/or is credentialed by a hospital for any procedure, the 
practitioner must be credentialed to perform the same procedure in the outpatient setting. (At a minimum, 
training must cover and develop an understanding of anatomy and drug pharmacodynamics and kinetics as well 
as proficiency in diagnosis and management of disease, the technical performance of the procedure and 
utilization of the required associated imaging modalities). 
 
Limitations 
 
   1. For a patient with low back pain only, a simple disc bulge or annular tear/fissure is insufficient to justify 
performance of an epidural. 
    2. Patient must not have major risk factors for spinal cancer (e.g., LBP with fever) or, if cancer is present, 
but the pain is clearly unrelated, an epidural may be indicated if one of the "Indications" previously listed is 
present. 
   3. A co-existing medical or other condition that precludes the safe performance of the procedure precludes 
coverage of the procedure, e.g., new onset of LBP with fever, risk factors for, or signs of, cauda equina 
syndrome, rapidly progressing (or other) neurological deficits. 
    4. Numbness and/or weakness without paresthesiae/dysesthesiae or pain precludes coverage. 
    5. There is no role for "series of three"? epidurals. Response to each epidural should be determined prior to 
determining the value of a repeat epidural and the specific methods used for subsequent epidurals. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Lumbar Epidural Injections 
(L34980). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.