Appeal type: unknown
Decision: unknown

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
Covered Indications
1. Epidural steroid injection (ESI) will be considered medically reasonable and necessary when the
following requirements are met:
o History, physical examination, and concordant radiological image-based diagnostic testing that
supports one of the following5:
 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 stenosis5 OR
 Post-laminectomy syndrome,6-8 OR
 Acute herpes zoster associated pain.6
AND
-
o 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
-
o 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.6,9
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.11
4. Caudal ESIs and interlaminar ESIs (ILESIs) involving a maximum of one level are considered medically reasonable and necessary.11
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.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.
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.1
8. The ESIs should be performed in conjunction with conservative treatments.9
9. Patients should be part of an active rehabilitation program, home exercise program or functional restoration program.10,12
*Note: The scales used to measure pain and/or disability must be documented in the medical record. Acceptable scales include, but are not limited to: Verbal rating scales, Numerical Rating Scale (NRS) and Visual Analog Scale (VAS) for pain assessment, and Pain Disability Assessment Scale (PDAS), Oswestry Disability Index (ODI), Oswestry Low Back Pain Disability Questionnaire (OLBPDQ), Quebec Back Pain Disability Scale (QBPDS), Roland Morris Pain Scale, Back Pain Functional Scale (BPFS), and the Patient-Reported Outcomes Measurement Information System (PROMIS) profile domains to assess function. 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).13-15
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.16 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.6,17,18
6. ESIs are limited to a maximum of four (4) sessions per spinal region in a rolling twelve (12) month period.7
7. It is not considered medically reasonable and necessary for more than one spinal region to be injected in the same session.11
8. It is not considered medically reasonable and necessary to perform TFESIs at more than two (2) nerve root levels during the same session.11
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.11
10. It is not medically reasonable and necessary to perform caudal ESIs or ILESIs bilaterally.14
11. It is not medically reasonable and necessary to prescribe a predetermined series of ESIs.8
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.16
13. It generally would not be considered medically reasonable and necessary for treatment with ESI to extend beyond 12 months.19,20 Frequent continuation of ESIs over 12 months may trigger a focused medical review. Use beyond twelve months requires the following:
-
o Pain is severe enough to cause a significant degree of functional disability or vocational disability.
o The ESI provides at least 50% sustained improvement of pain and/or 50% objective improvement in function (using same scale as baseline).
o 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.
o 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.11
You can find this 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.