Clinical Policy: Caudal or Interlaminar Epidural Steroid Injections Form

# Clinical Policy: Caudal or Interlaminar Epidural Steroid Injections  
Reference Number: CP.MP.164  
Date of Last Revision: 05/25  

[Coding Implications](Coding Implications)  
[Revision Log](Revision Log)  

See [Important Reminder](Important Reminder) at the end of this policy for important regulatory and legal information.  

## Description  
Epidural steroid injections (ESIs) are a non-surgical treatment that involve the administration of a glucocorticoid, or steroid, and/or anesthetic via a needle inserted in the space between the ligamentum flavum and the dura.²⁴ Epidural injections are performed utilizing three approaches in the lumbar spine: caudal, interlaminar, and transforaminal.²⁵ Computed tomography (CT) or standard fluoroscopy can be used during administration to provide guidance and anatomic detail.²²  

Note: For guidelines for transforaminal ESIs, reference CP.MP.165 Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections.  

  

II. It is the policy of health plans affiliated with Centene Corporation that a third or subsequent caudal or interlaminar ESI for chronic pain that **did not improve** from the first two ESIs is considered **not medically necessary** because effectiveness has not been established.  

III. It is the policy of health plans affiliated with Centene Corporation that continuation of injections beyond 12 months or more than four therapeutic injections is considered **not medically necessary** because effectiveness and safety have not been established. When more definitive therapies cannot be tolerated or provided, consideration will be made on a case-by-case basis.  

IV. It is the policy of health plans affiliated with Centene Corporation that caudal or interlaminar ESI for any other indication or location is considered **not medically necessary** because effectiveness has not been established.  

## Background  
There is much debate on the efficacy and medical necessity of multiple interventions for managing spinal and low back pain. Epidural glucocorticoid injections have been used for pain control in individuals with radiculopathy, spinal stenosis, and nonspecific low back pain. However, efficacy is difficult to understand due to inconsistent results as well as heterogeneous populations and injections in randomized controlled trials (RCTs). Generally, candidates for epidural steroid injection are individuals who have acute radicular symptoms or neurogenic claudication unresponsive to traditional analgesics and rest, with significant impairment in activities of daily living.²¹ Epidural steroid injections have been used in the treatment of spinal stenosis for many years, but no validated long-term outcomes substantiate their use.⁵,⁸,²² However, significant improvement in pain scores have been reported at three months after injection.⁵,²¹,²² Additionally, in a systematic review of studies, epidural steroid injections were not found to improve pain or function in individuals with nonspecific low back pain.⁴,⁵  

## Coding Implications  
This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2024, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.  

| **CPT Codes** | **Description** |
|---------------|-----------------|
| 62320 | Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance |
| 62321 | Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (i.e., fluoroscopy or CT) |
| 62322 | Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance |
| 62323 | Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (i.e., fluoroscopy or CT) |
| 62324 | Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance |
| 62325 | Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (i.e., fluoroscopy or CT) |
| 62326 | Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance |
| 62327 | Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (i.e., fluoroscopy or CT) |

## Reviews, Revisions, and Approvals  

| Reviews, Revisions, and Approvals | Revision Date | Approval Date |
|----------------------------------|---------------|---------------|
| Caudal and interlaminar ESI criteria reviewed in CP.MP.118 | 04/18 | 04/18 |
| In policy statement, changed “with or without radiographic guidance” to “with imaging, (except in rare instances, with documented justification).” Added, “Request is not for cervical interlaminar ESI above C7” to B.5, C.3 and D.5. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” References reviewed and updated. Replaced “member” with “member/enrollee” in all instances. Specialist review. | 07/21 | 07/21 |
| Removed “Request is not for cervical interlaminar ESI above C7” from B.5, C.3 and D.5. | 09/21 | 09/21 |
| Annual review. Note added regarding guidelines for transforaminal ESIs. Background updated with no impact on criteria. References reviewed and updated. | 07/22 | 07/22 |
| Annual review. ICD-10 diagnosis code table removed. References reviewed and updated. Reviewed by external specialist. | 07/23 | 07/23 |
| Annual review. Updated week requirement criteria I.B.4.a.-c. Coding reviewed. References reviewed and updated. | 06/24 | 06/24 |
| Annual review. Description and background updated with no clinical significance. Removed “and the member/enrollee is not currently being treated with full anticoagulation therapy. If on warfarin, international normalized ratio (INR) should be ≤ 1.4 prior to the procedure” from criteria. Other sections of criteria updated with no clinical significance. Coding reviewed. References reviewed and updated. Internal specialists reviewed. External specialist reviewed. | 05/25 | 05/25 |

  
6. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society [published correction appears in Ann Intern Med. 2007;147:478 to 491. doi:10.7326/0003-4819-147-7-200710200-00006] Ann Intern Med. 2007;147:478 to 491. doi:10.7326/0003-4819-147-7-200710200-00006  
7. Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine (Phila Pa 1976). 2009;34(10):1066 to 1077. doi:10.1097/BRS.0b013e3181a1390d  
8. Chou R, Hashimoto R, Friedly J, et al. Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-analysis. Ann Intern Med. 2015;163(5):373 to 381. doi:10.7326/M15-0934  
9. Heggess MH. AAOS endorses back pain guidelines. AAOS Now. https://www.mainegeneral.org/app/files/public/6460f387-09dc-4968-b162-eee6121a1497/aaosbackpainguideines.pdf. Published September 2010. Accessed April 14, 2025.  
10. Manchikanti L, Datta S, Derby R, et al. A critical review of the American Pain Society clinical guidelines for interventional techniques: part 1. Diagnostic interventions. Pain Physician. 2010;13(3):E141 to E174.  
11. Manchikanti L, Datta S, Gupta S, et al. A critical review of the American Pain Society clinical guidelines for interventional techniques: part 2. Therapeutic interventions. Pain Physician. 2010;13(4):E215 to E264.  
12. Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician.2013;16(2 Suppl):S49 to S283.  
13. Novak S, Nemeth WC. The basis for recommending repeating epidural steroid injections for radicular low back pain: a literature review. Arch Phys Med Rehabil. 2008;89(3):543 to 552. doi:10.1016/j.apmr.2007.11.008  
14. Sharma AK, Vorobeychik Y, Wasserman R, et al. The Effectiveness and Risks of Fluoroscopically Guided Lumbar Interlaminar Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data. Pain Med. 2017;18(2):239 to 251. doi:10.1093/pm/pnw131  
15. Staal JB, de Bie R, de Vet HC, Hildebrand J, Nelemans P. Injection therapy for subacute and chronic low-back pain. Cochrane Database Syst Rev. 2008;2008(3):CD001824. Published 2008 Jul 16. doi:10.1002/14651858.CD001824.pub3  
16. Vorobeychik Y, Sharma A, Smith CC, et al. The Effectiveness and Risks of Non-Image-Guided Lumbar Interlaminar Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data. Pain Med. 2016;17(12):2185 to 2202. doi:10.1093/pm/pnw091  
17. Kreiner DS, Hwang S, Easa JE, et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar spinal herniation with radiculopathy. Spine J. 2014;14(1):180 to 191. doi:10.1016/j.spinee.2013.08.003  
18. Smith CC, Booker T, Schauffle MK, Weiss P. Interlaminar versus transforaminal epidural steroid injections for the treatment of symptomatic lumbar spinal stenosis. Pain Med. 2010;11(10):1511to 1515. doi:10.1111/j.1526-4637.2010.00932.x  
19. Schauffle MK, Hatch L, Jones W. Interlaminar versus transforaminal epidural injections for the treatment of symptomatic lumbar intervertebral disc herniations. Pain Physician. 2006;9(4):361 to 366.  
20. Chang-Chien GC, Knezevic NN, McCormick Z, Chu SK, Trescot AM, Candido KD. Transforaminal versus interlaminar approaches to epidural steroid injections: a systematic review of comparative studies for lumbosacral radicular pain. Pain Physician. 2014;17(4):E509 to E524.  
21. Levin K, Hsu PS. Acute lumbosacral radiculopathy: Treatment and prognosis. UpToDate. www.uptodate.com. Published November 29, 2022. Updated February 25, 2025. Accessed April 14, 2025.  
22. Kothari MJ, Chuang, K. Treatment and prognosis of cervical radiculopathy. UpToDate. www.uptodate.com. Published February 28, 2023. Updated April 1, 2025. Accessed April 14, 2025.  
23. North American Spine Society (NASS). Coverage Policy Recommendations: Epidural Steroid Injections and Selective Spinal Nerve Blocks. 2020.  
24. Local coverage determination: Epidural Steroid Injections for Pain Management. (L39015). Centers for Medicare and Medicaid Services Web site. http://www.cms.hhs.gov/med/search.asp. Published December 5, 2021. Revised on November 9, 2023. Accessed April 14, 2025.  

## Important Reminder  
This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.  

The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures.  

This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time.  

This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of member/enrollees. This clinical policy is not intended to recommend treatment for member/enrollees. Member/enrollees should consult with their treating physician in connection with diagnosis and treatment decisions.  

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan.  

This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein is strictly prohibited. Providers, member/enrollees and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, member/enrollees and their representatives agree to be bound by such terms and conditions by providing services to member/enrollees and/or submitting claims for payment for such services.  

Note: For Medicaid member/enrollees, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.  

Note: For Medicare member/enrollees, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at http://www.cms.gov for additional information.  

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