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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 covered indications for epidural steroid injections include: 
 
    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 following5: 
            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 stenosis5 OR 
            Post-laminectomy syndrome,6-8 OR 
            Acute herpes zoster associated pain.6 
 
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.6,9 
 
    The ESIs must be performed under computed tomography (CT) or fluoroscopy image guidance with 
contrast10 unless the patient has a documented contrast allergy or pregnancy where ultrasound guidance 
without contrast may be considered. 
    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.11 
    Caudal ESIs and interlaminar ESIs (ILESIs) involving a maximum of one level are considered medically 
reasonable and necessary.11 
    It is considered 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.7,8 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 ESI should include corticosteroids and may be combined with 
anesthetics or saline.1 
    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.10,12 
 
*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. 
 
Limitations 
 
    Injections performed without image guidance or by ultrasound are not considered medically reasonable and 
necessary except in cases of documented contraindication to contrast media (e.g., allergy, pregnancy).13-15 
    ESIs performed with biologicals or other substances not designated by the United States (U.S.) Food and 
Drug Administration (FDA) for this use are considered investigational and are considered not medically 
reasonable and necessary. 
    It is not considered medically reasonable and necessary to perform multiple blocks (ESIs, 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. 
    Use of Moderate or Deep Sedation, General Anesthesia, or Monitored Anesthesia Care (MAC) is usually 
unnecessary or rarely indicated for these procedures and therefore, is not considered medically reasonable and 
necessary.16 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. 
    ESIs to treat non-specific low back pain (LBP), axial spine pain, complex regional pain syndrome, 
widespread diffuse pain, pain from neuropathy from other causes, or cervicogenic headaches are considered 
investigational and therefore are not considered medically reasonable and necessary.6,17,18 
    ESIs are limited to a maximum of four (4) sessions per spinal region in a rolling twelve (12) month period.7 
    It is not considered medically reasonable and necessary for more than one spinal region to be injected in the 
same session.11 
    It is not considered medically reasonable and necessary to perform TFESIs at more than two (2) nerve root 
levels during the same session.11 
    It is not considered medically reasonable and necessary to perform caudal ESIs or ILESIs at more than one 
(1) level during the same session.11 
    It is not medically reasonable and necessary to perform caudal ESIs or ILESIs bilaterally.14 
    It is not medically reasonable and necessary to prescribe a predetermined series of ESIs.8 
    Steroid dosing should be the lowest effective amount. It is recommended not to exceed 80 mg of 
triamcinolone, 12 mg of betamethasone, or 15 mg of dexamethasone per session.16 
    It generally would not be considered medically reasonable and necessary for treatment with ESI to extend 
beyond 12 months.19,20 Frequent continuation of ESIs over 12 months may trigger a focused medical review. Use beyond twelve months requires the following: 
 
        Pain is severe enough to cause a significant degree of functional disability or vocational disability. 
        The ESI provides at least 50% sustained improvement of pain and/or 50% objective improvement in 
function (using same scale as baseline). 
        Rationale for the continuation of ESIs including, but not limited to, patient is high-risk surgical candidate, 
the patient does not desire surgery, recurrence of pain in the same location relieved with ESIs for at least three 
months. 
        The primary care provider must be notified regarding continuation of procedures and prolonged repeat 
steroid use. 
 
    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.11 
 
You can find this information in the 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.