Back Pain Procedures - Epidural Injections Form

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Back and Neck Pain Procedures-Epidural Injection Medical
Guideline

Service: Back and Neck Pain Procedures-Epidural Injection (Caudal Epidural, Selective Nerve Root Block, Interlaminar, Transforaminal, Translaminar Epidural Injection)

PUM 250-0015-1706

Medical Guideline Committee Approval Q2-06/2025 Effective Date 09/01/2025

Related Medical Guidelines: • Back Pain Procedures-Sacroiliac Injections and Coccydynia Treatments Medical Guideline • Back and Nerve Pain Procedures-Radiofrequency Ablation, Facet and Other Injections Medical Guideline • Non-covered Services and Procedures Medical Guideline

NOTE: These services are subject to medical necessity review. If a limit is not specified in the member health plan, the maximum follows the medical necessity guidelines in this guideline.

NOTE: This guideline addresses Epidural Steroid Injection (ESI) and Hardware Injection. This guideline does not address obstetric or surgical anesthetic epidural injection.

Coverage for epidural steroid injections may vary across plans. Refer to the member’s benefit plan document for coverage details.

Description:

An epidural injection is an injection of a medication into the epidural space of the spine to treat swelling, pain, and inflammation associated with physical conditions that affect the spinal cord and/or nerve roots, causing radicular pain/radiculopathy.

Radicular pain (for purposes of this guideline) is pain that radiates from the spine into the extremity along the course of the spinal nerve root. The pain should follow the pattern of the sensory dermatome associated with the irritated nerve root(s) identified. The pain may also be described as a burning or tingling sensation. Radiculopathy is a term often used interchangeably with the term radicular pain. Radiculopathy is radicular pain accompanied by sensory or motor findings (such as decreased or absent reflex or decreased sensation).

For purposes of this guideline, caudal epidural, selective nerve root block, interlaminar, transforaminal epidural, and translaminar epidural injections are all considered epidural injections.

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Indications of Coverage:

A. One (1) epidural session at the cervical (neck), thoracic (mid to upper back) or lumbosacral (lower back) spinal nerve region is considered medically necessary if ALL of the following (1 through 4 below) are documented:

1. Cervical, thoracic, or lumbosacral radicular pain that follows the dermatomal distribution of each level of location(s) to be injected.

2. Physical exam findings follow the dermatomal distribution and are consistent with radiculopathy such as positive straight leg raise or seated slump test in the lumbar spine, positive Spurling’s test in the cervical spine, diminished dermatomal sensation, asymmetric decreased or absent reflex, or muscle weakness. Note: The positive physical exam requirement may be waived at the discretion of the Health Plan’s Medical Director.

3. Within the last 12 months, the individual has completed a 6-week trial of medications such as anti-inflammatories, muscle relaxants, analgesics, opioids, gabapentin, and pregabalin.

4. Within the last 12 months, the individual has completed a 6-week trial of physical therapy (PT) or chiropractic manipulations (performed after the current episode of symptoms started and directed at the spinal area of the current complaint) or there is documentation the individual can’t tolerate or is too disabled for physical therapy or chiropractic manipulations.

   Note: Documentation of therapy administered by a Certified Athletic Trainer or regular participation in a program such as the Arthritis Foundation Exercise Program may also meet medical criteria for therapy.

   B. Subsequent Epidural Injections: Repeat cervical, thoracic, or lumbosacral epidural injection within 12 months of the prior injection at the same location for the same specific condition is considered medically necessary when ALL of the following (1 and 2 below) are met:

5. The previous injection improved function or decreased pain and symptoms by at least 50 percent; but the pain or decreased functional status has returned.

6. At least two (2) weeks have passed since the previous injection.

7. If 1 and 2 are not met then a different approach or level may be attempted (usually within 3-7 days).

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Injection Limits:

A maximum of three (3) injection sessions (epidural) per covered spinal region (cervical, thoracic, or lumbosacral) in a rolling 12-month period will be considered medically necessary when criteria (Indications of Coverage) are met for each injection. It is our guideline to only review individual ESI sessions, and a request for a series of ESI’s would be considered not medically necessary. Subsequent injections would need to be submitted and reviewed for medical necessity.

A session is defined as one date of service in which there is a single level caudal epidural steroid injection (ESI), OR a single level interlaminar ESI, OR up to two (2) level TFESIs (unilateral or bilateral), performed during the same session. Services in excess of these thresholds will require Medical Director review on a case by case basis.

A session may involve the lumbosacral, thoracic, or cervical region, but only one region on the same date of service.

Limitations of Coverage:

Benefit Limitations: Please note that in listing services or examples, when we say “this includes,” it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list “is limited to.”

A. Review health plan and endorsements for exclusions and prior authorization or benefit requirements.

B. If requested/used for a condition or diagnosis other than is listed in the Indications of Coverage, it will be considered experimental, investigational, and unproven to affect health outcomes.

C. If requested/used for a condition or diagnosis that is listed in the Indications of Coverage; but the criteria are not met, it will be considered not medically necessary.

D. If requested/used for post-herpetic neuralgia or reflex sympathetic dystrophy (also known as complex regional pain syndrome), it will be considered not medically necessary.

E. More than 3 sessions per covered spinal region (cervical, thoracic or lumbosacral) in a 12-month period are considered not medically necessary. Services in excess of these thresholds will require Medical Director review on a case by case basis.

F. Epidural injection for non-radicular pain (outside of the setting of spinal stenosis) is considered experimental, investigational and unproven to affect health outcomes.

G. An epidural injection (ESI) provided less than two (2) weeks after the previous injection will be considered not medically necessary. Services in excess of these thresholds will require Medical Director review on a case by case basis.

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H. Epidural injections provided without the use of fluoroscopic or computed tomography (CT) guidance are considered unproven to affect health outcomes. Except during pregnancy ultrasound can be used.

I. Epidurography is considered a component of an epidural injection and is not reimbursed separately.

J. Perioperative epidural injections associated with spinal surgery are considered not medically necessary.

K. If more than one (1) type of pain treatment is requested/performed on the same day, only one (1) type will be considered medically necessary at the discretion of the Medical Director. Services in excess of these thresholds will require Medical Director review on a case by case basis.

L. It is considered not medically necessary to inject more than 2 vertebral levels during a single session. Services in excess of these thresholds will require Medical Director review on a case by case basis.

M. Performing an interlaminar or caudal epidural steroid injection in the same session, on the same date of service, as a transforaminal epidural steroid injection is considered not medically necessary.

N. Amniotic fluid injections will be considered experimental, investigational, and unproven to affect health outcomes.

O. Dorsal Root Ganglion (DRG) blocks will be considered experimental, investigational, and unproven to affect health outcomes.

P. Stem cells and/or Platelet-rich plasma (PRP) injections.

Documentation Required:

• Standard Written Order (SWO), prescribed by a qualified healthcare provider concerning the member’s diagnosis.
• Medical record information (including continued need/use if applicable) and medical necessity. • Correct coding for the item/service that meets all the coding guidelines.

Disclaimer: This guideline is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this guideline. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical guideline in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.

Medical guidelines are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in

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administering health benefits. This medical guideline and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com. Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven are therefore not considered medically necessary under the terms of the clinical guidelines and will not be covered.

Epidural steroid injections are considered medically necessary only when indicated per the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.

State mandates, laws or benchmark supersede this medical guideline.

Guideline Review History:

Implemented 10/01/15, 08/21/17, 10/01/18, 10/01/19, 09/01/20, 06/01/21, 06/01/22, 09/01/23, 06/01/24, 09/01/25 Medical Guideline Committee Approval 06/13/14, 06/12/15, 06/03/16, 06/16/17, 06/15/18, 05/31/19, 05/28/20, 05/27/21, 05/26/22, 05/17/23, 5/30/24, 06/26/25 Reviewed

06/13/14, 06/12/15, 06/03/16, 06/16/17, 06/15/18, 05/31/19, 05/28/20, 05/27/21, 05/26/22, 05/17/23, 5/30/24, 06/26/25 Revised 06/12/15, 06/03/16, 06/16/17, 06/15/18, 05/31/19, 05/28/20, 05/27/21 Note: For review/revision history prior to 2014 see previous Medical Guideline

Approved by the Medical Director

Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes. Code Description 62280 INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, PHENOL, ICED SALINE SOLUTIONS), WITH OR WITHOUT OTHER THERAPEUTIC SUBSTANCE; SUBARACHNOID 62281 INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, PHENOL, ICED SALINE SOLUTIONS), WITH OR WITHOUT OTHER THERAPEUTIC SUBSTANCE; EPIDURAL, CERVICAL OR THORACIC 62282 INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, PHENOL, ICED SALINE SOLUTIONS), WITH OR WITHOUT OTHER THERAPEUTIC SUBSTANCE; EPIDURAL, LUMBAR, SACRAL (CAUDAL)

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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 (IE, 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 (IE, FLUOROSCOPY OR CT) 64479 INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE LEVEL 64480 INJECTION(S), ANESTHETIC AGENT 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 AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE LEVEL 64484 INJECTION(S), ANESTHETIC AGENT 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) 3E0R33Z INTRODUCTION OF ANTI-INFLAMMATORY INTO SPINAL CANAL, PERCUTANEOUS APPROACH 3E0R3BZ INTRODUCTION OF ANESTHETIC AGENT INTO SPINAL CANAL, PERCUTANEOUS APPROACH 3E0R3GC INTRODUCTION OF OTHER THERAPEUTIC SUBSTANCE INTO SPINAL CANAL, PERCUTANEOUS APPROACH