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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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say Covered Indications: 
 
Epidural steroid injection (ESI) will be considered medically reasonable and necessary when the following 
requirements are met: 
History, physical examination, and concordant radiological image-based diagnostic testing that supports one of 
the following: 
Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic claudication due to disc 
herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing foraminal or 
central spinal stenosis OR 
Post-laminectomy syndrome, OR 
Acute herpes zoster associated pain. 
AND 
 
Radiculopathy, radicular pain and/or neurogenic claudication is severe enough to greatly impact quality of life 
or function. An objective pain scale or functional assessment must be performed at baseline (prior to 
interventions). The same scale* must be used at each follow-up for assessment of response. 
AND 
 
Pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative care or medical 
documentation of failure to respond to four (4) weeks of noninvasive conservative care or acute herpes zoster 
refractory to conservative management where a four (4) week wait is not required. The ESIs must be performed under computed tomography (CT) or fluoroscopy image guidance with contrast10 
unless the patient has a documented contrast allergy or pregnancy where ultrasound guidance without contrast 
may be considered. 
Transforaminal ESIs (TFESIs) involving a maximum of two (2) levels in one spinal region are considered 
medically reasonable and necessary. It is important to recognize that most conditions would not ordinarily 
require ESI at two (2) levels in one spinal region. 
Caudal ESIs and interlaminar ESIs (ILESIs) involving a maximum of one level are considered medically 
reasonable and necessary. 
It is considered medically reasonable and necessary to perform TFESIs bilaterally only when clinically 
indicated. 
Repeat ESI when the first injection directly and significantly provided improvement of the condition being 
treated may be considered medically reasonable and necessary when the medical record documents at least 50 
percent of sustained improvement in pain relief and/or improvement in function measured from baseline using 
SAME scale* for at least three months.7,8 If a patient fails to respond well to the initial ESI, a repeat ESI after 
14 days can be performed using a different approach, level and/or medication, if appropriate, with the rationale 
and medical necessity for the second ESI documented in the medical record. 
An initial injection of contrast is required to confirm epidural placement, unless the patient has a 
contraindication to contrast. The subsequent ESI should include corticosteroids and may be combined with 
anesthetics or saline. 
The ESIs should be performed in conjunction with conservative treatments. 
Patients should be part of an active rehabilitation program, home exercise program or functional restoration 
program. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Epidural Steroid 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.