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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 and/or infusions will be considered medically reasonable and necessary
for the following conditions:
Management of pain caused by intervertebral disc disease with or without myelopathy.
Management of pain caused by spinal stenosis.
Management of intractable radicular pain due to post-laminectomy syndrome/failed back syndrome.
Management of intractable pain due to complex regional pain syndrome.
Management of intractable pain due to post herpetic neuralgia and acute herpes zoster.
Management of intractable pain due to traumatic neuropathy of the spinal nerve roots.
Management of intractable and severe pain secondary to neuropathy from other causes (e.g., diabetic or
metabolic).
Management of severe, intractable pain in patients with advanced stages of cancer with estimated life
expectancy of 4 months or less.
Management of pain caused by radiculitis (inflammation of the nerve roots).
Limitations
Low back pain may also be produced by "Myofascial Pain Syndrome" in which case there is not nerve root
pathology and epidural injections are not reasonable and necessary. If there is a doubt in the differential
diagnosis, the diagnosis of radiculopathy can be confirmed by an EMG/nerve conduction/small fiber testing or
appropriate radiological study. Degenerative Disk Disease without root compression has been shown to be a
significant cause of low back and/or radicular pain; some patients will respond to Epidural Steroid Injection in
this situation.
Epidural injections, with the exception of interlaminar injections, should be performed under fluoroscopic or
CT-guided imaging.
It is expected that providing an epidural block in conjunction with multiple facet joint blocks, bilateral
sacroiliac joint injections, trigger point injections, and/or lumbar sympathetic blocks in any combination to a
patient on the same day is not considered medically necessary, unless the patient has recently discontinued
anticoagulant therapy for the purpose of interventional pain management. It is expected that interlaminar,
transforaminal or caudal epidural injections are not performed on the same date of service at the same level.
Procedures performed during the diagnostic phase should be limited to two (2) injections. Once a structure is
proven to be negative as a pain generator, no repeat interventions should be directed at that structure unless
there is a new clinical presentation with symptoms, signs, and diagnostic studies of known reliability and
validity that implicate the structure. In the treatment or therapeutic phase, a series of three (3) injections may be
given at a minimum interval of two (2) weeks to the suspect level. If a positive response (per ASIPP
guidelines) is not obtained, then a repeat series of injections at that level is considered not medically necessary.
It is not expected that a patient would undergo an epidural injection at more than two (2) levels (unilateral or
bilateral) on any given date of service. (A level is defined as the articulation between two vertebrae i.e., C4-5;
or L2- 3). A series of three (3) epidural injections may be repeated at six (6) month intervals (assuming there
was a positive response as defined by the ASIPP guidelines) to the first series of three (3) injections. Caution
should be used to monitor the side effects of frequent steroid use. Under unusual circumstances with a recurrent
injury, carcinoma, or reflex sympathetic dystrophy, blocks may be repeated more frequently in the treatment
phase after stabilization. Documentation must be present in the medical record to support the more frequent use
of such therapy in this setting. As published in the CMS IOM Publication 100-08, Medicare Program Integrity
Manual, Chapter 13, Section 13.5.4, an item or service may be covered by a contractor LCD if it is reasonable
and necessary under the Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe
the circumstances under which the item or service is considered reasonable and necessary. You can find this
information in Medicare's Local Coverage Determination (LCD): Epidural (L33906).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.