Clinical Policy: Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections Form

# Clinical Policy: Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections
Reference Number: CP.MP.165  
Date of Last Revision: 07/25  

[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  
Transforaminal epidural steroid injections (TFESIs) and selective nerve root blocks (SNRBs) are alternatives to interlaminar epidural steroid injections for the treatment of radicular pain. SNRBs consist of a small amount of local anesthetic injected adjacent to a spinal nerve root and are most often used to diagnose the source of pain.¹ During a TFESI, a larger amount of local anesthetic or corticosteroid is injected into the intervertebral foramen, where the injectate spreads to target multiple nerves. SNRBs and TFESIs share similar safety considerations, procedural techniques, and anatomical benchmarks.¹  

**Note:** For guidelines for caudal or interlaminar epidural steroid injections (ESIs), reference CP.MP.164 Caudal or Interlaminar Epidural Steroid Injections.  

## Policy/Criteria  
It is the policy of health plans affiliated with Centene Corporation® that invasive pain management procedures performed by a physician are **medically necessary** when the relevant criteria are met and only one procedure is performed per visit; with radiographic guidance.  

**Note:** Discontinuing anticoagulation therapy or anti-platelet therapy is a clinical decision balancing risks and benefits of the procedure on therapy, versus the underlying medical condition if not treated appropriately.  

  

 When more definitive therapies cannot be tolerated or provided, consideration will be made on a case-by-case basis.  

#### F. TFESIs for any other indication are considered **not medically necessary** because effectiveness has not been established.  

## Table 1: Particulate and Non-Particulate Steroids²⁶  
| Particulate | | Non-Particulate | |
| --- | --- | --- | --- |
| Generic | Brand | Generic | Brand |
| Betamethasone acetate | Celestone Soluspan, Betaject | Dexamethasone | Decadron, Adrenocot, Decajec |
| Methylprednisolone acetate | Depo-Medrol, Solu-Medrol, Duralone, Medralone | Betamethasone sodium phosphate | N/A |
| Triamcinolone acetonide | Kenalog | Dexamethasone palmitate | N/A |

The distinction between particulate and non-particulate is based on studies looking at particle aggregation size relative to a red blood cell.  

## Background  
### Epidural steroid injections/selective nerve root blocks  
There is great controversy regarding the effectiveness of invasive interventions for spinal pain. Epidural glucocorticoid injections have been used for pain control in patients with radiculopathy, spinal stenosis, and nonspecific low back pain despite inconsistent results as well as heterogeneous populations and interventions in randomized trials. Epidural injections are performed utilizing three approaches in the lumbar spine: caudal, interlaminar, and transforaminal. 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. Epidural steroid injections have been used in the treatment of spinal stenosis for many years, and no validated long-term outcomes have been reported to substantiate their use. However, significant improvement in pain scores have been reported in short-term outcomes up to three months after injection. A selective nerve root block (SNRB) is primarily used to diagnose the specific source of nerve root pain. In a SNRB, a local anesthetic is used. When used for therapeutic indications, a steroid is added, and it is usually referred to as a selective transforaminal epidural steroid injection.  

A 2015 meta-analysis was conducted to assess the effects of various surgical and nonsurgical modalities, including epidural injections, used to treat lumbar disc herniation (LDH) or radiculitis.³ A systematic literature search was conducted to identify RCTs which compared the effect of local anesthetic with or without steroids. The outcomes included pain relief, functional improvement, opioid intake, and therapeutic procedural characteristics. The reviewers concluded that the meta-analysis confirms that epidural injections of local anesthetic with or without steroids have beneficial but similar effects in the treatment of patients with chronic low back and lower extremity pain.³  

Results of a two-year follow-up of three randomized, double-blind, controlled trials, with a total of 360 patients with chronic persistent pain of disc herniation receiving either caudal, lumbar interlaminar or transforaminal epidural injections, showed similar efficacy of the three techniques with local anesthetic alone or local anesthetic with steroid.⁴ Interlaminar injections with steroids were superior to transforaminal at 12 months.⁴  

## 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 |
| --- | --- |
| 64479 | Injection(s), anesthetic agent(s) and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, single level |
| 64480 | Injection(s), anesthetic agent(s) and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, each additional level (List separately in addition to code for primary procedure) |
| 64483 | Injection(s), anesthetic agent(s) and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level |
| 64484 | Injection(s), anesthetic agent(s) and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level (List separately in addition to code for primary procedure) |

## Reviews, Revisions, and Approvals  
| Reviews, Revisions, and Approvals | Revision Date | Approval Date |
| --- | --- | --- |
| SNRB and TFESI criteria reviewed and updated in CP.MP.118. | 04/18 | 04/18 |
| Minor revision to description of CPT 64479, 64480, 64483 and 64484. Replaced “member” with “members/enrollee” in the disclaimer. | 04/21 |  |
| Annual review. References reviewed and updated. In policy statement, removed option for procedures “without radiographic guidance.” Reviewed by specialist. Changed “Last Review Date” in header to “Date of Last Revision” and changed “Date” in Revision log to “Revision Date”. | 08/21 | 08/21 |
| Annual review. Criteria updated with grammatical and abbreviation changes. Background updated with no impact on criteria. Dashes removed from code ranges. References reviewed and updated. | 08/22 | 08/22 |
| Annual review. ICD-10 Code table removed. Minor edits with no clinical significance. References reviewed and updated. Reviewed by internal specialist. | 08/23 | 08/23 |
| Annual review. In I.B.4.a. and c. and II.B.5.a. and c. changed duration from six weeks to four weeks. Added Table 1 to give examples of particulate and non-particulate steroids. References reviewed and updated. Reviewed by external specialist. | 07/24 | 07/24 |
| Annual review. Added note in Description regarding policy for caudal or interlaminar epidural steroid injections. Removed anticoagulation therapy requirement in Criteria and added anticoagulation therapy as a note in Criteria. Updated Criteria II.D.3. from two months to three months regarding relief and functional improvement. Removed Criteria II.D.4. regarding length of time since last transforaminal epidural steroid injection (TFESI). Coding and descriptions reviewed. References reviewed and updated. Reviewed by internal specialist. | 07/25 | 07/25 |

  
22. Manchikanti L, Knezevic NN, Navani A, et al. Epidural Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Comprehensive Evidence Based Guidelines. Pain Physician. 2021;24(S1):S27-S208.  
23. Evolving Evidence since. Epidural steroid injections for the treatment of thoracic spine pain. Hayes. www.hayesinc.com. Published July 23, 2021 (annual review August 13, 2024). Accessed June 25, 2025.  
24. American Society of Anesthesiologists. Practice Guidelines for Chronic Pain Management. Anesthesiology. 2010;112(4):810-833.  
25. Derby R, Lee SH, Date ES, Lee JH, Lee CH. Size and aggregation of corticosteroids used for epidural injections. Pain Med. 2008;9(2):227-234. doi:10.1111/j.1526-4637.2007.00341.x  
26. Dietrich, T.J., Sutter, R., Froehlich, J.M. et al. Particulate versus non-particulate steroids for lumbar transforaminal or interlaminar epidural steroid injections: an update. Skeletal Radiol 44, 149–155 (2015). https://doi.org/10.1007/s00256-014-2048-6  
27. Local coverage determination: epidural steroid injections for pain management (L39240). Centers for Medicare and Medicaid Services Web site. http://www.cms.hhs.gov/med/search.asp. Published June 19, 2022. Accessed June 25, 2025.  
28. American Society of Interventional Pain Physicians. An Algorithmic Approach to Epidural Steroid Injections. https://aipp.org/an-algorithmic-approach-to-epidural-steroid-injections-2/. Accessed June 25, 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 members/enrollees. This clinical policy is not intended to recommend treatment for members/enrollees. Members/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 are strictly prohibited. Providers, members/enrollees and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such applicable contract exists, providers, members/enrollees and their representatives agree to be bound by such terms and conditions by providing services to members/enrollees and/or submitting claims for payment for such services.  

**Note:** For Medicaid members/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 members/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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