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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The rules say that 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 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 
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. 
2. The ESIs must be performed under computed tomography (CT) or fluoroscopy image guidance with 
contrast
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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.
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9. Patients should be part of an active rehabilitation program, home exercise program or functional 
restoration program. 
Local Coverage Determination (LCD): Epidural Steroid Injections for Pain Management (L36920). 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.