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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 Covered Indications:
1. Epidural steroid injection (ESI) will be considered medically reasonable and necessary when the following
requirements are met:
History, physical examination, and concordant radiological image-based diagnostic testing that supports
one of the following:
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 used 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 computed tomography (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 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.
4. Caudal ESIs and interlaminar ESIs (ILESIs) involving a maximum of one level are considered medically
reasonable and necessary 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. 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.
8. The ESIs should be performed in conjunction with conservative treatments.
9. Patients should be part of an active rehabilitation program, home exercise program or functional
restoration program.
*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. You can
find this information in 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.