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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 Epidural Injections are generally performed to treat pain arising from spinal nerve roots. EIs 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:
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.
Pain from Herpes Zoster or suspected radicular pain based on radiation of pain along the dermatome of a
nerve.
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.
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.
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.
*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 ESI for same specific condition.
Limitations
The following Epidural Injections, regardless of approach or indication, are considered not medically
reasonable and necessary and therefore will be denied:
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.
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.
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.
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).
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.
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.
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.
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.
Contraindications to Epidural Injection or Diagnostic Selective Nerve Root Block
Cancer
Medicare considers it not appropriate, as there would be no expected benefit, to perform an EI for a
beneficiary with cancer where the tumor is invading a nerve root.
Epidural injection of local anesthetic or anti-inflammatory agents is not appropriate for the management of
non-lateralizing, non-specific pain or discomfort not related to inflammation, compression, or injury to spinal
nerve roots or their extensions. It is considered not appropriate to perform EIs in the following situations (this
list is not all inclusive):
For patients with lung cancer irritating the pleura.
For patients with large abdominal or pancreatic tumors.
For cancer patients with generalized lateral pain.
For pain due to metastatic disease.
Infection
New onset of neck or back pain with fever in the absence of advanced imaging studies (to rule out local
infection).
Risk factors for spinal infection including fever or history of intravenous drug use.
History of recent or ongoing bacterial or fungal infection.
Immunosuppression.
Cauda Equina Syndrome
New onset of urinary retention, fecal incontinence or saddle anesthesia.
Rapidly progressing (or other) neurologic deficits.
A medical condition that contraindicates the intervention, (e.g., epidural hematoma, subarachnoid
hemorrhage, epidural mass, spinal cord ischemia, trauma).
A co-existing medical condition or therapy that precludes the safe performance of the procedure (e.g.,
uncontrolled coagulopathy or active anti-coagulation therapy, sepsis).
The potential presence of a Central Nervous System process resulting in the presenting symptoms, (e.g.,
transverse myelitis, central demyelination) suggested by numbness or weakness without paresthesia/dysesthesia
or pain.
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.