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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 low back pain is highly prevalent, with reports of 50-84% of adults experiencing back pain at 
some point, with a high prevalence in adults 65 and older and the highest cause of disability globally. Low back 
and neck pain can influence the quality of life and function and is associated with depression and anxiety. In a 
2018 National Health Interview Survey, the CDC reported 28% of men and 31.6% of women age = 18 had 
lower back pain in the past three months. There is debate and a lack of consensus on which modalities are best 
to treat chronic low back pain (CLBP). 
 
The treatment of individuals with spinal disorders, including pain, can be complex, and it is recommended that 
all individuals being considered for interventional spinal procedures undergo a thorough evaluation and be 
treated following development of a comprehensive care plan. 
 
1. 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: 
            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. 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. 
 
You can find these rules 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.