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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 low back pain is highly prevalent, with reports of 50-84% of adults experiencing back pain at 
some point, with a high prevalence in adults 65 and older and the highest cause of disability globally. Low back 
and neck pain can influence the quality of life and function and is associated with depression and anxiety. In a 
2018 National Health Interview Survey, the CDC reported 28% of men and 31.6% of women age = 18 had 
lower back pain in the past three months. There is debate and a lack of consensus on which modalities are best 
to treat chronic low back pain (CLBP). 
 
Epidural steroid injections (ESIs) have been used as a non-surgical modality to treat low back and neck pain. 
These procedures typically involve the injection of a solution containing corticosteroids and/or anesthetic into 
the epidural space, although saline may be included at times. The ESI can be performed in three ways. 
Interlaminar (ILESI) approaches the epidural space from the posterior spine between the two vertebral laminae 
near the midline. In the transforaminal approach (TFESI), the injectant is delivered through the neuroforamen 
dorsal to the nerve root within the intervertebral foramen. The caudal approach (caudal ESI) enters through the 
sacral hiatus at the sacral canal to access the epidural space. 
 
The treatment of individuals with spinal disorders, including pain, can be complex, and it is recommended that 
all individuals being considered for interventional spinal procedures undergo a thorough evaluation and be 
treated following development of a comprehensive care plan. 
 
    1. 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. 
 
    2. 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. 
    3. 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. 
    4. Caudal ESIs and interlaminar ESIs (ILESIs) involving a maximum of one level are considered medically 
reasonable and necessary. 
    5. It is considered medically reasonable and necessary to perform TFESIs bilaterally only when clinically 
indicated. 
    6. 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% of sustained improvement in pain relief and/or improvement in function measured from baseline using 
SAME scale* for at least three months. 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. 
    7. 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. 
    8. The ESIs should be performed in conjunction with conservative treatments. 
    9. Patients should be part of an active rehabilitation program, home exercise program or functional 
restoration program. 
 
Limitations 
 
    1. Injections performed without image guidance or by ultrasound are not considered medically 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 designated by the United States (U.S.) Food and 
Drug Administration (FDA) for this use are considered investigational and are considered not medically 
reasonable and necessary. 
    3. It is not considered medically reasonable and necessary to perform multiple blocks (ESIs, 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, or Monitored Anesthesia Care (MAC) is usually 
unnecessary or rarely indicated for these procedures and therefore, is 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, or 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 caudal ESIs or ILESIs at more than 
one (1) level during the same session.     10. It is not medically reasonable and necessary to perform caudal ESIs 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 80 mg of 
triamcinolone, 12 mg of betamethasone, or 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 ESIs over 12 months may trigger a focused medical 
review. Use beyond twelve months requires the following: 
 
        Pain is severe enough to cause a significant degree of functional disability or vocational disability. 
        The ESI provides at least 50% sustained improvement of pain and/or 50% objective improvement in 
function (using same scale as baseline). 
        Rationale for the continuation of ESIs including, but not limited to, patient is high-risk surgical candidate, 
the patient does not desire surgery, recurrence of pain in the same location relieved with ESIs for at least three 
months. 
        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 these rules in the 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.