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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 for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. You can see this in the Medicare Program Integrity Manual Chapter 3 Section 3.3.2.1.

The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. You can find this rule at 42 CFR Section 424.5.

The rules state that epidural injections (EIs) 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. 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.

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 pain greater than or equal to 3 out of 10 (moderate to severe pain), or
- functional impairment in activities of daily living (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.

You can find these rules in 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.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.