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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 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 Center for Disease Control (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 epidural space lies outside the dural membrane inside the spinal canal. It runs the length of the spine and, 
in addition to the exiting nerve roots, contains fatty tissue and blood vessels. The spinal nerve roots can be 
affected by a number of processes as they travel through the epidural space, including but not limited to, 
compression from herniation of the nucleus pulposus of the intervertebral discs, degenerative changes 
involving combinations of the spinal ligaments, discs, zygapophyseal (facet) joints, intraspinal synovial cysts, 
osteophytes, and mechanical derangements of the spine such as spondylolisthesis. As a result of mechanical 
irritation, inflammation, injury to a spinal nerve root or other processes, the spinal nerve roots can become a 
significant and disabling source of radicular pain. 
 
Epidural steroid injections (ESIs) have been used as a non-surgical modality to treat low back and neck pain. 
These procedures typically involve the injection of a solution containing corticosteroids and/or anesthetic into 
the epidural space, although saline may be included at times. 
 
The ESI can be performed in three ways. Interlaminar approaches the epidural space from the posterior spine 
between the two vertebral laminae near the midline. In the transforaminal approach, the injectant is delivered 
through the neuroforamen dorsal to the nerve root within the intervertebral foramen. The caudal approach 
(caudal ESI) enters through the sacral hiatus at the sacral canal to access the epidural space. 
 
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. 
 Covered Indications 
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 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 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. 
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. 
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. 
Caudal ESIs and interlaminar ESIs (ILESIs) involving a maximum of one level are considered medically 
reasonable and necessary. 
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. 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. 
The ESIs should be performed in conjunction with conservative treatments. 
Patients should be part of an active rehabilitation program, home exercise program or functional restoration 
program. 
You can find these rules 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. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.