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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 an anatomic spinal region for epidurals is defined as cervical/thoracic (CPT codes 62321, 
64479 and 64480) or lumbar/sacral (CPT codes 62323, 64483 and 64484). 
 
When CPT codes 62321, 62323, 64479, 64480, 64483 or 64484 are used to report postoperative pain 
management, the diagnosis code restrictions in this article do not apply when reporting these codes with ICD-
10 codes G89.12 (acute post-thoracotomy pain) or G89.18 (other acute postprocedural pain). 
 
If epidural injection (CPT code 62323) is used for an implantable infusion pump trial for severe spasticity, the 
restrictions in this article do not apply as coverage is determined by NCD 280.14 Infusion Pumps. 
 
When the epidural injection (CPT code 62323) is used for cerebrospinal fluid flow imaging, cisternography 
(CPT code 78630), the diagnosis code restrictions in this article do not apply. These services should be billed 
on the same claim. 
 
Consistent with the LCD, it is not medically reasonable and necessary to perform caudal ESIs or interlaminar 
ESIs bilaterally, therefore CPT codes 62321 and 62323 are not bilateral procedures. 
Consistent with the LCD, CPT codes 62321 and 62323 may only be reported for one level per session. 
 
No more than 4 epidural injection sessions (CPT codes 62321, 62323, 64479, 64480, 64483, or 64484) may be 
reported per anatomic region in a rolling 12-month period regardless of the number of levels involved. You can 
find this rule in the Local Coverage Article Billing and Coding Epidural Steroid Injections for Pain 
Management A56681. 
 
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.1,2 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.3 There is debate and a lack of consensus on which modalities are best to 
treat chronic low back pain (CLBP).4 
 
 
 
 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.1 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.1,4 
 
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. You can find this rule in the Local Coverage 
Determination (LCD) Epidural Steroid Injections for Pain Management L39036. 
 
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.