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 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). 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. 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. ESIs are limited to a 
maximum of four (4) sessions per spinal region in a rolling twelve (12) month period. It is not considered 
medically reasonable and necessary for more than one spinal region to be injected in the same session. It is not 
considered medically reasonable and necessary to perform TFESIs at more than two (2) nerve root levels 
during the same session. It is not medically reasonable and necessary to perform CESIs or ILESIs bilaterally.    
It is not medically reasonable and necessary to prescribe a predetermined series of ESIs. Steroid dosing should 
be the lowest effective amount, it is recommended not to exceed 80mg of triamcinolone, 12 mg of 
betamethasone, 15 mg of dexamethasone per session. It generally would not be considered medically 
reasonable and necessary for treatment with ESI to extend beyond 12 months. Frequent continuation of 
epidural steroid injections 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. 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 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. You can find this rule in 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.