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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 state that: 
1. ESI will be considered medically reasonable and necessary when the following 3 requirements are met: 
o History, physical examination, and concordant radiological image-based diagnostic testing and 
supporting 1 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 
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 repeated at each follow-up for 
assessment of response. 
AND 
o Pain duration of at least 4 weeks, and the inability to tolerate noninvasive conservative care or 
medical documentation of failure to respond to 4 weeks of noninvasive conservative 
care or acute herpes zoster refractory to conservative management where a 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. TFESIs involving a maximum of 2 levels in 1 spinal region are considered medically reasonable and 
necessary. It is important to recognize that most conditions would not ordinarily require ESI at 2 levels 
in 1 spinal region. 
4. CESIs and ILESIs involving a maximum of 1 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 SAME scale* for at least 3 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 ESIs 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. 
Limitations 
1. Injections performed without image guidance or by ultrasound are not considered reasonable and 
necessary except in cases of documented contraindication to contrast media (e.g., allergy, pregnancy). 
2. ESIs performed with biologicals or other substances not Food and Drug Administration (FDA) 
designated for this use is considered investigational and not medically reasonable and necessary. 
3. It is not considered medically reasonable and necessary to perform multiple blocks (ESI, sympathetic 
blocks, facet blocks, trigger point injections, etc.) during the same session as ESIs, with the exception of 
a facet synovial cyst and ESI performed in the same session. 
4. Use of moderate or deep sedation, general anesthesia, and monitored anesthesia care (MAC) is usually 
unnecessary or rarely indicated for these procedures and, therefore, not considered medically reasonable 
and necessary. Even in patients with a needle phobia and anxiety, typically oral anxiolytics suffice. In 
exceptional and unique cases, documentation must clearly establish the need for such sedation in the 
specific patient. 
5. ESIs to treat non-specific LBP, axial spine pain, complex regional pain syndrome, widespread diffuse 
pain, pain from neuropathy from other causes, cervicogenic headaches are considered investigational 
and therefore are not considered medically reasonable and necessary. 
6. ESIs are limited to a maximum of 4 sessions per spinal region in a rolling 12 month period. 
7. It is not considered medically reasonable and necessary for more than 1 spinal region to be injected in 
the same session. 
8. It is not considered medically reasonable and necessary to perform TFESIs at more than 2 nerve root 
levels during the same session. 
9. It is not considered medically reasonable and necessary to perform CESIs or ILESIs at more than 1 
level during the same session. 
10. It is not medically reasonable and necessary to perform CESIs or ILESIs bilaterally. 
11. It is not medically reasonable and necessary to prescribe a predetermined series of ESIs. 
12. Steroid dosing should be the lowest effective amount; it is recommended not to exceed 80 mg of 
triamcinolone, 12 mg of betamethasone, 15 mg of dexamethasone per session. 
13. It generally would not be considered medically reasonable and necessary for treatment with ESI to 
extend beyond 12 months. Frequent continuation of ESIs over 12 months may trigger a focused medical 
review. Use beyond 12 months requires the following: 
a. Pain is severe enough to cause a significant degree of functional disability or vocational 
disability. b. ESI provides at least 50% sustained improvement of pain and/or 50% objective improvement in 
function (using same scale as baseline). 
c. Rationale for the continuation of ESIs including but not limited to patient is high-risk surgical 
candidates, the patient does not desire surgery, recurrence of pain in the same location relieved 
with ESIs for at least 3 months. 
d. The primary care provider must be notified regarding continuation of procedures and prolonged 
repeat steroid use. 
14. ESIs should not be performed when contraindicated including but not limited to suspected or active 
localized spinal infection, significant systemic infection, compressive lesions of the spinal cord, conus 
medullaris or cauda equina, suspicion or major risk factors for cancer. 
You can find this rule at 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.