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: 
1. Epidural steroid injection (ESI) will be considered medically reasonable and necessary when the 
following three (3) requirements are met: 
o History, physical examination, and concordant radiological image-based diagnostic testing and 
supporting one of the following: 
 Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic 
claudication due to central disc herniation, osteophyte or osteophyte complexes, severe 
degenerative disc disease, producing foraminal or central spinal stenosis; OR 
 Post-laminectomy syndrome 
 Acute herpes zoster associated pain 
AND 
o 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 repeated at each follow-
up for assessment of response. 
AND 
o 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. 
2. The ESIs must be performed under 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. 3. Transforaminal EPIDURAL steroid injections (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. 
4. Caudal EPIDURAL steroid injections (CESIs) and interlaminar EPIDURAL steroid injections (ILESIs) 
involving a maximum of one level are considered medically reasonable and necessary. 
5. It is medically reasonable and necessary to perform TFESIs bilaterally only when clinically indicated. 
6. 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. 
7. An initial injection of contrast is required to confirm epidural placement, unless the patient has a 
contraindication to contrast. The subsequent epidural steroid injections should include corticosteroids 
and may be combined with anesthetics or saline. 
8. 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. 
*Note: The scales used to measure of 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 (OSW), Quebec Back Pain Disability Scale 
(QUE), Roland Morris Pain Scale, Back Pain Functional Scale (BPFS), and the PROMIS profile domains to 
assess function. 
Limitations 
1. 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). 
2. ESIs performed with biologicals or other substances not FDA designated for this use is considered 
investigational and not medically reasonable and necessary. 
3. 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. 
4. 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. 
5. 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. 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. 
8. It is not considered medically reasonable and necessary to perform TFESIs at more than two (2) nerve 
root levels during the same session. 
9. It is not considered medically reasonable and necessary to perform CESIs or ILESIs at more than one 
(1) level during the same session. 10. It is not medically reasonable and necessary to perform CESIs or ILESIs bilaterally. 
11. It is not medically reasonable and necessary to prescribe a predetermined series of ESIs. 
12. 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. 
13. 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: 
a. Pain is severe enough to cause a significant degree of functional disability or vocational 
disability. 
b. ESI provides at least 50% sustained improvement of pain and/or 50% objective improvement in 
function (using same scale as baseline). 
c. 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 
d. The primary care provider must be notified regarding continuation of procedures and prolonged 
repeat steroid use. 
14. 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 at the Medicare Local Coverage Determination (LCD) L39242: 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.