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 an ESI is covered when: 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 You can find this rule at Local Coverage Determination (LCD) L36920: Epidural Steroid Injections for Pain Management (eff. 12/12/21).  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.