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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 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 supporting
one of the following:
1.
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 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.
2. 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.
3. 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.
4. Caudal epidural steroid injections (CESIs) and interlaminar epidural steroid injections (ILESIs) involving a
maximum of one level are considered medically reasonable and necessary.
5. It is 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 the
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 epidural steroid injections should include corticosteroids and may
be combined with anesthetics or saline.1
8. The ESIs should be performed in conjunction with conservative treatments.
9. Patient's should be part of an active rehabilitation program, home exercise program or functional restoration
program.
You can find this 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