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 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). 
 
The epidural space lies outside the dural membrane inside the spinal canal. It runs the length of the spine and, 
in addition to the exiting nerve roots, contains fatty tissue and blood vessels. The spinal nerve roots can be 
affected by a number of processes as they travel through the epidural space, including but not limited to 
compression from herniation of the nucleus pulposus of the intervertebral discs, degenerative changes 
involving combinations of the spinal ligaments, discs, zygapophyseal (facet) joints, intraspinal synovial cysts, 
osteophytes, and mechanical derangements of the spine such as spondylolisthesis. As a result of mechanical 
irritation, inflammation, injury to a spinal nerve root or other processes, the spinal nerve roots can become a 
significant and disabling source of radicular pain 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 (IESI) 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 (CESI) 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. 
 
Covered Indications 
     Epidural steroid injection (ESI) will be considered medically reasonable and necessary when the following 
three (3) requirements are met: 
        History, physical examination, and concordant radiological image-based diagnostic testing and supporting 
one of the following: 
            Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic claudication due to central 
disc herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing foraminal or 
central spinal stenosis; OR 
            Post-laminectomy syndrome 
            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 repeated 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 CT or fluoroscopy image guidance with contrast unless the patient has a 
documented contrast allergy or pregnancy where ultrasound guidance without contrast may be considered. 
    Transforaminal EPIDURAL steroid injections (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 EPIDURAL steroid injections (CESIs) and interlaminar EPIDURAL steroid injections (ILESIs) 
involving a maximum of one level are considered medically reasonable and necessary. 
    It is 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% 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. 
    An initial injection of contrast is required to confirm epidural placement, unless the patient has a 
contraindication to contrast. The subsequent epidural steroid injections 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 these rules 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.