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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 than 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 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: 
 
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 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 ESI for same specific condition 
 
You can find this rule in 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).  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. You can find this rule in 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.