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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 state: 
1. Injections performed without image guidance or by ultrasound are not considered reasonable and 
necessary except in cases of documented contraindication to contrast media (e.g., allergy, pregnancy). 
2. ESIs performed with biologicals or other substances not FDA designated for this use is considered 
investigational and not medically reasonable and necessary. 
3. It is not considered medically reasonable and necessary to perform multiple blocks (ESI, sympathetic 
blocks, facet blocks, trigger point injections etc.) during the same session as ESIs, with the exception of 
a facet synovial cyst and ESI performed in the same session. 
4. Use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care (MAC) is 
usually unnecessary or rarely indicated for these procedures and therefore not considered medically 
reasonable and necessary.
 
Even in patients with a needle phobia and anxiety, typically oral anxiolytics 
suffice. In exceptional and unique cases, documentation must clearly establish the need for such 
sedation in the specific patient. 
5. ESIs to treat non-specific low back pain (LBP), axial spine pain, complex regional pain syndrome, 
widespread diffuse pain, pain from neuropathy from other causes, cervicogenic headaches are 
considered investigational and therefore are not considered medically reasonable and necessary. 
6. ESIs are limited to a maximum of four (4) sessions per spinal region in a rolling twelve (12) month 
period. 
7. It is not considered medically reasonable and necessary for more than one spinal region to be injected in 
the same session. 
8. It is not considered medically reasonable and necessary to perform TFESIs at more than two (2) nerve 
root levels during the same session. 
9. It is not considered medically reasonable and necessary to perform CESIs or ILESIs at more than one 
(1) level during the same session. 
10. It is not medically reasonable and necessary to perform CESIs or ILESIs bilaterally. 
11. It is not medically reasonable and necessary to prescribe a predetermined series of ESIs. 
12. Steroid dosing should be the lowest effective amount, it is recommended not to exceed 80mg of 
triamcinolone, 12 mg of betamethasone, 15 mg of dexamethasone per session. 
13. It generally would not be considered medically reasonable and necessary for treatment with ESI to 
extend beyond 12 months.
 
Frequent continuation of epidural steroid injections over 12 months may 
trigger a focused medical review. Use beyond twelve months requires the following:  
a. Pain is severe enough to cause a significant degree of functional disability or vocational 
disability. b. ESI provides at least 50% sustained improvement of pain and/or 50% objective improvement in 
function (using same scale as baseline). 
c. Rationale for the continuation of ESIs including but not limited to patient is high-risk surgical 
candidates, the patient does not desire surgery, recurrence of pain in the same location relieved 
with ESIs for at least three months 
d. The primary care provider must be notified regarding continuation of procedures and prolonged 
repeat steroid use. 
14. ESIs should not be performed when contraindicated including but not limited to: suspected or active 
localized spinal infection, significant systemic infection, compressive lesions of the spinal cord, conus 
medullaris or cauda equina, suspicion or major risk factors for cancer.  
You can find this rule in the Local Coverage Determination (LCD) - Epidural Steroid Injections for Pain 
Management (L38994). 
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.