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 state that the following Epidural Injections, regardless of approach or indication, are considered not 
medically reasonable and necessary and therefore will be denied: 
1. For a patient with back pain only, the radiologic findings of a simple disc bulge without correlating 
symptoms is insufficient to justify performance of an epidural diagnostic or therapeutic injection. 
2. Injections are performed independently based on the patients symptoms and response to prior 
injections and approach (if performed). There is no role for a routine series of 3 or undocumented 
response test dosing. Repeat or serial test or diagnostic injections without documented response are 
not considered reasonable and necessary. Response to each epidural injection should be determined 
prior to determining the value of a repeat injection and the specific methods used for subsequent 
epidurals. 
3. If a prior epidural injection procedure provided limited or no relief (i.e., NPRS less than 3, less 
than 50% symptom improvement, insignificant or indiscernible relief), a second epidural injection 
utilizing the same method, technique or medication to the same level will be considered not medically 
reasonable and necessary. A second injection involving a change in technique or medication will be 
considered following re-evaluation of the patient. If a patient does not obtain significant relief with a 
diagnostic selective nerve root block (DSNRB), therapeutic injections (EI) in that same area will be 
considered not medically necessary. 
4. For caudal or interlaminar injections, only one level may be performed, and NOT in conjunction with 
transforaminal injection in the same region. Caudal or interlaminar injection is not considered medically 
reasonable and necessary in conjunction with transforaminal injections at the same session, for the same 
level, or within three contiguous levels of the same region (lumbosacral or cervicothoracic). 
5. It should not be necessary to perform both transforaminal epidural and paravertebral facet joint 
injections at the same spinal level at the same encounter, unless a synovial cyst is compressing the 
nerve root. In this situation, EI may provide relief for the radicular pain while the cyst rupture allows 
nerve root decompression. It is not expected that additional injection whether EI or Paravertebral Facet 
Joint at a different level would be performed on the same day. When a facet joint injection and an 
epidural injection are performed for the purpose of rupturing a cyst, the facet joint injection counts as 
one of the two injections allowed on the same day. For additional information on facet joint injections 
please refer to LCD L34892, Facet Joint Interventions for Pain Management. 
6. If the muscles surrounding the lumbar joint are injected in lieu of the epidural space, an epidural 
injection should not be reported as this would not support the service. A transforaminal injection 
without documentation of imaging will be considered not medically reasonable and necessary. Please 
refer to LCD L35010, Trigger Point Injections, for additional information. 7. It is considered not medically reasonable and necessary to perform more than 2 epidural injections in a 
single setting (e.g., single level bilaterally or two levels unilaterally). 
Levels per session: 
o No more than two epidural injections may be performed at a single session (i.e., single level 
bilaterally or two levels unilaterally). 
o One caudal or interlaminar injection, not in conjunction with a transforaminal injection of the 
same region, may be performed per session. 
8. For each session, doses less than or equal to 80 mg of triamcinolone, or 80 mg of methylprednisolone, 
or 12 mg of betamethasone, or 15 mg of dexamethasone or equivalent corticosteroid are considered 
standard of care. Administration of dosing greater than these levels is considered not medically 
reasonable and necessary. 
You can find this rule at Centers for Medicare and Medicaid Services, Local Coverage Determination (LCD) 
L36920, Epidural 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.