Transforaminal Epidural Injections
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Coverage and medical necessity criteria for diagnostic and therapeutic transforaminal epidural steroid injections (TFESIs), including limits on frequency, levels treated, guidance requirements, and investigational indications; applies to Aetna members/providers.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
COVERAGE CRITERIA
Covered when ALL of the following are met
Diagnostic TFESI
- Clinical findings concordant with nerve root compression within prior 3 months: Loss of named muscle strength OR altered sensation in distribution OR diminished/absent/asymmetric reflexes
At least one required
- Objective testing within timeframe: Either concordant MRI/CT radiologist interpretation within prior 12 months OR electrodiagnostic studies (EMG/NCV) diagnostic of nerve root compression
At least one required
Initial therapeutic TFESI
- Prior conservative therapy: Non-invasive measures such as physical therapy and non-narcotic analgesics have failed or been intolerant
Required before initial therapeutic TFESI
- Clinical-radiologic concordance: Member has radicular pain that is consistent with radiologic findings
Required
At least two of three criteria must be met for >=2 weeks
COVERAGE CRITERIA
Covered when ALL of the following are met
Initial therapeutic TFESI
- Prior conservative therapy: Non-invasive measures such as physical therapy and non-narcotic analgesics have failed or been intolerant
Required before initial therapeutic TFESI
- Clinical-radiologic concordance: Member has radicular pain that is consistent with radiologic findings
Required
Diagnostic TFESI
- Clinical findings concordant with nerve root compression within prior 3 months: Loss of named muscle strength OR altered sensation in distribution OR diminished/absent/asymmetric reflexes
At least one required
- Objective testing within timeframe: Either concordant MRI/CT radiologist interpretation within prior 12 months OR electrodiagnostic studies (EMG/NCV) diagnostic of nerve root compression
At least one required
See repeat therapeutic TFESI criteria for continuation
Continuation/Repeat Therapy
Additional therapeutic TFESIs covered if initial response criteria met
At least two of three criteria must be met for >=2 weeks
Limits
Coverage is limited by the following quantity and frequency rules
Up to four TFESIs per session (eg, two bilateral TFESIs at two contiguous levels) when other criteria met
Each session may include up to four TFESIs when criteria met
When criteria met
Each session may include up to four TFESIs when criteria met
Applies to all spinal regions
Evidence-based coverage considerations
Summarized evidence and clinical inferences
See individual study details in chunks 18-33.
Supported by chunks 18, 20, 22, 24.
Chunks 32-33.
Chunks 24, 26, 27.
The following procedures are considered experimental and investigational because their effectiveness has not been established: diagnostic TFESIs for indications not listed in the Medical Necessity section; intra-operative administration of epidural steroids following percutaneous transforaminal endoscopic discectomy; TESI combined with radiofrequency ablation for lumbar disc herniation; therapeutic TFESIs for indications not listed in Section I; transforaminal or interlaminar epidural steroid injections combined with caudal epidural steroid injections for chronic radicular pain; and ultrasound-guided transforaminal epidural steroid injections.
A technology assessment from the Institute for Clinical Systems Improvement (ICSI) concluded that epidural steroid injections should be performed with imaging guidance and stated that “epidural steroid injections should not be done without fluoroscopic guidance.” Fluoroscopic guidance (or CT guidance as an acceptable alternative) is therefore the expected imaging method for TFESIs performed for diagnostic or therapeutic purposes, and documentation of imaging guidance is recommended.
External links included in this policy are provided for convenience only. Aetna is not responsible or liable for the content, accuracy, or privacy practices of non‑Aetna sites; providers should follow Aetna’s administrative guidance and plan‑specific procedures for prior authorization and documentation requirements rather than relying on external sites.
Coverage is limited by specific procedural and frequency rules. TFESIs at more than two (2) contiguous vertebral levels or more than four (4) TFESIs during a single session are considered not medically necessary. More than three (3) TFESI sessions per episode of pain per spinal region within six (6) months, or more than four (4) sessions per spinal region per twelve (12) months, and TFESI sessions performed more frequently than every two (2) weeks are also considered not medically necessary and may be denied.
The evidence base includes randomized and observational studies showing short‑ to intermediate‑term pain relief with TFESI in selected patients, but limitations exist. A meta‑analysis of randomized trials reported a modest analgesic benefit at ~3 months versus local anesthetic or saline and found no impact on disability or on incidence of surgery at 12 months. Study heterogeneity, small sample sizes in many trials, variable dosing and procedure frequency, and methodological limitations indicate that larger, well‑designed randomized trials are needed to define optimal dosages, number of procedures, and long‑term outcomes.
Billing Codes and Coding Guidance
| 64479 | Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level |
| 64480 | 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 | lumbar or sacral, each additional level (List separately in addition to code for primary procedure) |
| 62320-62323 | Injection(s), of diagnostic or therapeutic substance(s), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid |
| 62324-62327 | Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, interlaminar epidural or subarachnoid |
| 77003 | Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures |
| 77012 | Computed tomography guidance for needle placement, radiological supervision and interpretation |
| 97010-97530 | Physical therapy |
| G56.00-G57.93 | Mononeuropathy of upper and lower limb |
| G58.0-G58.7,G58.9 | Other mononeuropathies |
| M50.00-M50.23,M50.90-M50.93 | Cervical disc disorders |
| M51.04-M51.27,M51.9,M51.A0-M51.A5 | Thoracic, thoracolumbar and lumbosacral intervertebral disc disorders |
| M54.10-M54.18 | Radiculopathy |
| M54.30-M54.42 | Sciatica and lumbago with sciatica |
| M79.2 | Neuralgia and neuritis, unspecified |
Provider Requirements, Documentation, and Billing Alerts
Fluoroscopy/CT guidance expectation
Fluoroscopic (or CT) guidance is expected for both diagnostic and therapeutic TFESIs; epidural steroid injections should not be performed without fluoroscopic guidance per referenced technology assessments.
Prior authorization and policy review
Prior authorization may be required by the payer; reviewers should consult plan-specific requirements and this policy when determining coverage.
- Check member’s plan for prior authorization rules before scheduling TFESI
- This policy effective date: 2006-04-04; most recent review: 09/22/2023; next review: 08/09/2024
Prior authorization
Some plans may require prior authorization for TFESI sessions or for exceeding per-session or frequency limits; obtain authorization when indicated by the member’s benefit plan.
- Obtain prior authorization when required by the member’s plan for TFESI scheduling or for exceeding stated limits
Session frequency limit (6 months)
Session frequency and per-episode limits must be followed: no more than three TFESI sessions per spinal region per 6 months, and sessions no more frequently than every two weeks.
- Maximum of 3 TFESI sessions per spinal region per 6 months
- Minimum interval between sessions: 2 weeks
Policy history and review dates
Policy history and review dates are provided for reference; clinicians and reviewers should use the most recent policy review date when assessing applicability.
- Effective date: 04/04/2006
- Last review: 09/22/2023
- Next review scheduled: 08/09/2024
- Review history and definitions available via the linked resources
No discrete denial criteria present
This section of the policy does not list discrete denial criteria; absence of an explicit denial list does not obviate the need to meet the medical necessity criteria and documentation requirements described elsewhere in the policy.
- No standalone denial criteria block is present in this policy section — denials will be based on failure to meet the documented medical necessity criteria or limits
In studies of diagnostic cervical TFESI
In studies of diagnostic cervical TFESI, many patients experienced meaningful pain reduction and some avoided surgery; evidence indicates roughly half of patients may achieve ≥50% pain reduction at short- to intermediate-term follow-up, though quality of evidence is low.
- Diagnostic CTFESI may predict need for surgery; in one registry 70% did not require subsequent cervical surgery after diagnostic CTFESI (Costandi et al., retrospective)
- Systematic review/meta-analysis (Conger et al., 2020) found ~50% achieved ≥50% pain reduction at 1–3 months but evidence quality was very low
Required clinical outcome documentation
Document clinical outcomes after TFESI per the policy: pain relief (percent reduction and duration), functional improvement, and changes in analgesic use — these data are required to justify additional therapeutic injections.
- Document at least two of the following after an initial therapeutic TFESI for consideration of additional injections: ≥50% pain relief, increased function/physical activity (eg, return to work), reduction in pain medication or adjunctive therapies
- Record outcome duration (eg, ≥2 weeks) and objective measures when available
Conservative measures prerequisite
Conservative measures must be attempted and documented prior to initial therapeutic TFESI: non-invasive measures such as physical therapy and non-narcotic analgesics should have failed or been intolerable.
- Documentation of trial and failure or intolerance of conservative therapy (physical therapy, non-narcotic analgesics) is required before an initial therapeutic TFESI
- Document neurologic exam within prior 3 months and concordant MRI/CT or EMG/NCV within prior 12 months as applicable
Evidence on corticosteroid TFESI and surgery avoidance
Evidence suggests TFESI with corticosteroid is more effective than local anesthetic alone for avoiding surgery in selected lumbar radiculopathy patients; consider TFESI prior to operative intervention in appropriate candidates.
- Riew et al. (2000): bupivacaine plus betamethasone group had significantly lower subsequent surgery rates versus bupivacaine alone
- Consider TFESI with corticosteroid for patients with 1–2 level lumbar radiculopathy prior to surgery when clinically appropriate
Step therapy note
Some plans may implement step therapy or other utilization management approaches; follow plan-level step therapy requirements when applicable.
- Step therapy may require conservative treatments prior to authorization of TFESI — verify plan-specific policies
Links to Aetna resources
Links to Aetna resources and glossary are provided for convenience; documentation requirements may reference these external Aetna resources.
- Glossary: https://www.aetna.com/glossary.html
- Aetna site links for member resources, policies, review history and definitions (see policy header and Additional Information)
Clinical Background and Definitions
Radicular pain (radiculopathy) results from compression or irritation of a spinal nerve root due to causes such as disc herniation, foraminal stenosis, facet cysts, or trauma. Transforaminal epidural steroid injections (TFESIs) are targeted injections of corticosteroid (often with local anesthetic) delivered into the neural foramen around an affected nerve root, typically under fluoroscopic guidance; CT guidance is an acceptable alternative. TFESIs may be used diagnostically to localize a symptomatic nerve root or therapeutically to reduce perineural inflammation and pain as part of a comprehensive pain management program.
Prerequisite Conservative Care and Surgical Considerations
Session and Injection Frequency Limits
Imaging and Procedural Guidance
TFESI imaging requirement: fluoroscopy or CT
Imaging guidance for TFESI must be fluoroscopy or computed tomography (CT); diagnostic and therapeutic TFESIs require imaging guidance per policy.
- Policy: 'imaging guidance (fluoroscopy or CT)'.
- CT and CT fluoroscopy are acceptable alternatives to fluoroscopy for guiding needle placement.
Imaging preference: fluoroscopy preferred; ultrasound feasible only with verification
Fluoroscopy is preferred for TFESI; ultrasound-guided TFESI has been used in feasibility studies but should be verified by fluoroscopy per study methods and is considered investigational in policy exclusions.
- Yang et al (2016) used ultrasound with fluoroscopic verification; success ratio was 85% and radiation dose was lower.
- Policy lists ultrasound-guided TFESI among experimental/investigational procedures.
Imaging modalities discussed: fluoroscopy, CT and MRI referenced
The literature and policy discuss multiple imaging modalities (fluoroscopy, CT, MRI) used for diagnosis and guidance; fluoroscopic guidance is the common requirement for TFESI and selective nerve root blocks.
- Studies reference MRI/CT for diagnostic correlation and fluoroscopy/CT for procedural guidance.
- Fluoroscopic guidance is emphasized as standard in most cited studies and reviews.
Services Considered Experimental or Not Covered
The policy lists specific procedures that are not covered, including ultrasound‑guided transforaminal epidural steroid injections and intra‑operative epidural steroid administration following percutaneous transforaminal endoscopic discectomy. These are classified as investigational because current evidence is insufficient to establish their effectiveness.
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