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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 limitations for epidural steroid injections include: 
 
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).13-15 
ESIs performed with biologicals or other substances not FDA designated for this use is considered 
investigational and not medically reasonable and necessary. 
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. 
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.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, cervicogenic headaches are considered investigational 
and therefore are not considered medically reasonable and necessary.6,17,18 
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.11 
It is not considered medically reasonable and necessary to perform TFESIs at more than 2 nerve root levels 
during the same session.11 
It is not considered medically reasonable and necessary to perform CESIs or ILESIs at more than 1 level during 
the same session.11 
It is not medically reasonable and necessary to perform CESIs 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.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 epidural steroid injections over 12 months may trigger a focused medical review. Use beyond 12 months requires the following: 
Pain is severe enough to cause a significant degree of functional disability or vocational disability. 
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 candidates, the 
patient does not desire surgery, recurrence of pain in the same location relieved with ESIs for at least 3 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. 
 
You can find this information in the Local Coverage Determination (LCD) Epidural Steroid Injections for Pain 
Management L39054. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.