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 state 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 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 this rule 
in the Medicare Local Coverage Determination (LCD)- L38994, Epidural Steroid Injections for Pain 
Management. 
 
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.