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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 epidural injections are generally performed to treat pain arising from spinal nerve roots. These injections can be performed via an interlaminar or caudal approach or a transforaminal approach. An epidural injection is considered medically reasonable and necessary with the following conditions: 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: -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 3. 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 Visual Analog Scale (VAS) for pain or Numeric Pain Rating Scale (NPRS) greater than or equal to 3/10 (moderate to severe pain), OR -functional impairment in activities of daily living; AND -the pain or functional impairment is associated with any of the following: a. substantial imaging abnormality, such as a central disc herniation or high intensity zone; b. documented severe degenerative disc disease or central spinal stenosis; c. discogenic pain, not attributable to facet joint or sacroiliac joint pain. You can find this rule in the Local Coverage Determination (LCD) - Epidural Injections for Pain Management (L36920) - Effective July 1, 2020.
The rules say that each patient must be thoroughly evaluated by a physician or non-physician practitioner, whose license and state scope of practice allow evaluation and treatment. 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 epidural injection may still be indicated when the indications above are present. You can find this rule in the Local Coverage Determination (LCD) - Epidural Injections for Pain Management (L36920) - Effective July 1, 2020. The rules say that 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: -pain from Herpes Zoster -Severe pain unresponsive to outpatient medical management; -Inability to tolerate non-surgical, non-injection care due to co-existing medical conditions(s); -At least moderate pain with significant functional loss at work or home; -Prior successful lumbar epidural steroid injection for same specific condition. You can find this rule in the Local Coverage Determination (LCD) - Epidural Injections for Pain Management (L36920) - Effective July 1, 2020. The rules say that 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 sessions: -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. You can find this rule in the Local Coverage Determination (LCD) - Epidural Injections for Pain Management (L36920) - 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.