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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 CFR 422.101.
The rules say that indications for coverage of a lumbar epidural steroid injection include: 1. Suspected radicular pain and/or 2. Neurogenic claudication and/or 3. Low back pain with one of the following: substantial imaging abnormalities such as a central disc herniation, severe degenerative disc disease or central spinal stenosis. For a patient with low back pain only, a simple disc bulge or annular tear/ fissure is insufficient to justify performance of a lumbar ESI, unless other indications in this section are present. 4. Documented Visual Analog Scale (VAS) for pain or Numeric Pain Rating Scale (NPRS) &#8805; 3/10 (moderate to severe pain) with functional impairment in activities of daily living (ADLs). 5. Failure of four weeks of non-surgical, non-injection care. All appropriate non-surgical, non-injection treatments should be considered along with a rationale for interventional treatment. Exceptions to the 4 week wait, beginning at the onset of pain, before receiving a lumbar ESI exist, but should be documented. These would include, but are not limited to: a. At least moderate pain with significant functional loss at work and/or home. b. Severe pain unresponsive to outpatient medical management. c. Inability to tolerate non-surgical, non-injection care due to co-existing medical condition(s) d. Prior successful lumbar ESI for same specific condition. 6. Discogenic pain, after ruling out facet joint and sacroliac joint pain. Imaging Requirements: 1. Minimum criteria: Plain films to rule out red flag condition. 2. Advanced imaging (MRI, CT) may be appropriate prior to performing an ESI Levels per session 1. No more than two transforaminal injections may be performed at a single setting (e.g. single level bilaterally or two levels unilaterally) 2. One caudal or lumbar interlaminar injection per session and not in conjunction with a transforaminal injection. Frequency with criteria 1. . No more than 2 epidural injections may be performed in the diagnostic phase per region (lumbar and sacral is considered as a separate region). 2. With documentation of at least 6 weeks of improvement with first 2 epidural injections in the diagnostic phase, therapeutic epidural injections may be performed not exceeding 4 per year with documentation of at least 2 to 3 months of pain relief greater than 50% with documentation of improvement in functional status (therapeutic phase starts with first therapeutic injection) for repeat injections. 3. For transforaminal epidural injections, a maximum of 2 levels will be reimbursed, unilateral or one bilateral irrespective of the levels utilized and irrespective of the nerves blocked in one region. You can find this rule in the Local Coverage Determination (LCD): Lumbar Epidural Steroid Injections (ESI) (L34807) effective December 26, 2019.
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.