CurrentAetnaPolicy 0722

Transforaminal Epidural Injections

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.

Policy Summary

PayerAetna

PolicyTransforaminal Epidural Injections

Policy CodePolicy 0722

Change TypeNo material change

Effective DateApr 4, 2006

Next Review DateAug 9, 2024

Key ActionDocument prior failure or intolerance of non-invasive measures (eg, physical therapy and non-narcotic analgesics) before initial therapeutic TFESI.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12max TFESIs per region per episode

3sessions per region per 6 months

4max TFESIs per session

2min interval (weeks)

52trials in 2015 review

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

RCTs in 2015 meta-analysis

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

Repeat therapeutic TFESI: Additional therapeutic TFESIs with imaging guidance are medically necessary if the initial injection resulted in at least two of the following for at least two weeks: (1) >=50% pain relief, (2) increased level of function/physical activity, (3) reduction in use of pain medication or other medical therapies

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

Continuation/Repeat Therapy

Additional therapeutic TFESIs covered if initial response criteria met

Repeat therapeutic TFESI: Additional therapeutic TFESIs with imaging guidance are medically necessary if the initial injection resulted in at least two of the following for at least two weeks: (1) >=50% pain relief, (2) increased level of function/physical activity (eg, return to work), (3) reduction in the use of pain medication and/or additional medical therapies (eg, physical therapy)

At least two of three criteria must be met for >=2 weeks

Limits

Coverage is limited by the following quantity and frequency rules

Per-session limits: No more than two contiguous vertebral levels or more than four TFESIs during a single session are medically necessary

Up to four TFESIs per session (eg, two bilateral TFESIs at two contiguous levels) when other criteria met

Session frequency limits (6 months): No more than three TFESI sessions per episode of pain per spinal region per 6 months

Each session may include up to four TFESIs when criteria met

Episode maximum: Maximum of twelve TFESIs per spinal region administered during a maximum of three sessions for an episode of pain lasting six months

When criteria met

Annual session limit: No more than four TFESI sessions per spinal region per 12 months

Evidence-based coverage considerations

Summarized evidence and clinical inferences

General evidence summary: Randomized and observational studies show TFESI can provide short- to intermediate-term pain relief for lumbar and cervical radicular pain; magnitude varies by study and patient selection.

See individual study details in chunks 18-33.

Patient groups with reported benefit: Patients with foraminal degenerative stenosis, disc herniation, early radicular pain (<1 year), post-diskectomy recurrent radiculopathy without recurrent herniation, and selected zygapophyseal cyst-related radicular pain have reported benefit in series and trials.

Supported by chunks 18, 20, 22, 24.

Comparative outcomes: Meta-analysis of 8 RCTs found a modest analgesic benefit of transforaminal steroids versus local anesthetic/saline at ~3 months but no effect on disability or surgery incidence at 12 months.

Chunks 32-33.

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

Covered CPT Codes (if selection criteria met)CPTCovered

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)

CPT Codes Not Covered for Indications ListedCPTNot Covered

64635	Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint
64636	lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)

Other related CPT/HCPCS Codesmixed

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

ICD-10 Codes (examples covered if criteria met)ICD-10Covered

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

Billing Rule

CPT codes requiring criteria

CPT codes for transforaminal epidural steroid injections (TFESI) require that the selection criteria in this policy are met for coverage.

Covered CPT codes when criteria are met: 64479, 64480, 64483, 64484
Other related CPT/HCPCS: 62320-62327, 77003, 77012

Documentation Required

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.

Fluoroscopy or CT guidance required for TFESI procedures (see covered CPTs above)

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.

Radiculopathy definition

DefinitionPain, dysaesthesias, or paresthesias in a specified dermatomal distribution of an involved named spinal root causing significant functional limitations (diminished quality of life and impaired, age-appropriate activities of daily living).

Clinical contextMay be caused by disc herniation, stenosis, facet cysts, or trauma and is the primary indication for TFESI when concordant with imaging or electrodiagnostic studies.

Actionable thresholdRequires clinical findings or objective testing concordant with nerve root compression for diagnostic or therapeutic procedures per policy criteria.

Prerequisite Conservative Care and Surgical Considerations

Session and Injection Frequency Limits

TFESI sessions per 6 months

Allowed sessions per 6 monthsNo more than three (3) TFESI sessions per episode of pain, per spinal region per six (6) months.

Per-session injectionsEach session may include up to four (4) TFESIs (e.g., two bilateral TFESIs at two contiguous levels) when other criteria are met.

Denial riskMore than three sessions per spinal region per 6 months is considered not medically necessary and may be denied.

Maximum TFESIs per spinal region (12 over up to 3 sessions per 6-month episode)

Maximum per spinal regionMaximum of twelve (12) TFESIs per spinal region administered during a maximum of three (3) sessions for an episode of pain lasting six (6) months.

Session compositionEach session may include up to four (4) TFESIs (e.g., two bilateral TFESIs at two contiguous levels) when other criteria are met.

Imaging and Procedural Guidance

Billing Rule

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.

Documentation Required

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.

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.

Policy Summary

PayerAetna

PolicyTransforaminal Epidural Injections

Policy CodePolicy 0722

Change TypeNo material change

Effective DateApr 4, 2006

Next Review DateAug 9, 2024

Key ActionDocument prior failure or intolerance of non-invasive measures (eg, physical therapy and non-narcotic analgesics) before initial therapeutic TFESI.

SourceLink

On This Page

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

Therapeutic continuation criteria: Therapeutic TFESIs should be part of a comprehensive pain management program

See repeat therapeutic TFESI criteria for continuation

Each session may include up to four TFESIs when criteria met

Minimum interval: TFESI sessions should not be performed more frequently than every two weeks for any spinal region

Applies to all spinal regions

Guidance on imaging/technique: ICSI and other reviews recommend fluoroscopic guidance for epidural steroid injections; ultrasound-guided approaches are feasible but lack large definitive effectiveness trials.

77003 (fluoroscopic guidance) and 77012 (CT guidance) are the appropriate guidance codes

Prior Authorization

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

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

Billing Rule

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

Note

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

Denial Risk

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

Note

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

Documentation Required

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

Documentation Required

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

Note

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

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

Note

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)

Therapeutic TFESI definition

DefinitionAn injection with imaging guidance (fluoroscopy or CT) intended to reduce inflammation and pain around a spinal nerve root as part of a comprehensive pain management program.

IndicationInitial therapeutic TFESI is covered when non-invasive measures (physical therapy and non-narcotic analgesics) have failed or been intolerable and radicular pain is consistent with radiologic findings.

DocumentationTherapeutic TFESIs should be administered as part of a comprehensive pain management program; response criteria are required for repeat injections.

Diagnostic TFESI definition

DefinitionA selective transforaminal epidural steroid injection with imaging guidance (fluoroscopy or CT) used to identify the etiology of pain in patients with symptoms suggestive of chronic radiculopathy when diagnosis remains uncertain after standard evaluation.

Standard evaluationStandard evaluation includes neurological examination, radiological and neurodiagnostic studies; diagnostic TFESI is used when these are inconclusive.

PurposeTo establish the diagnosis of radiculopathy when clinical findings and imaging/neurodiagnostic tests are discordant or nondiagnostic.

Fluoroscopically guided ESI definition

DefinitionEpidural steroid injections performed under fluoroscopic imaging control; considered generally safe when performed by an experienced physician in a controlled setting.

RecommendationICSI technology assessment: epidural steroid injections should not be done without fluoroscopic guidance.

Common agentsCommonly used corticosteroids include methylprednisolone and betamethasone as noted in the ICSI assessment.

Ultrasound-guided TFEI note

DefinitionTransforaminal epidural injection performed using ultrasound visualization; feasibility and reduced radiation have been reported in small studies but clinical effectiveness requires further research.

Study findingsYang et al (2016): ultrasound-guided lumbar TFEI was feasible, safe, had lower radiation exposure and shorter procedure time but was a feasibility study needing larger trials for effectiveness confirmation.

VerificationIn the referenced study ultrasound-guided injections were verified by fluoroscopy, indicating combined verification was used.

TFESI (abbreviation/term)

TermTFESI = Transforaminal epidural steroid injection (steroid injected via the neural foraminal/transforaminal approach, usually under fluoroscopic guidance, targeted to the affected nerve root).

UsageUsed diagnostically to localize symptomatic nerve roots and therapeutically to reduce perineural inflammation and pain.

ImagingTypically performed under fluoroscopic guidance; CT is an acceptable alternative.

CESI (abbreviation/term)

TermCESI = Caudal epidural steroid injection (steroid delivered via a caudal/sacral epidural approach).

Relation to TFESICESI may be combined with TFESI in some studies for treatment of chronic radicular pain; comparative effectiveness varies by study.

Clinical noteUsed as an alternative epidural approach depending on clinical circumstances and anatomy.

RFA (abbreviation/term)

TermRFA = Radiofrequency ablation — a thermal lesioning technique to disrupt nociceptive pathways; sometimes combined with TFESI in treatment of lumbar disc herniation.

Clinical useCombined TFESI + RFA has been used in retrospective studies with reported longer-term improvement in pain and function compared with TFESI alone.

Evidence noteLarger, multicenter trials are needed to confirm long-term benefits of combined approaches.

Applies toLimit applies per spinal region (cervical, thoracic, or lumbar) for an episode of pain.

TFESI sessions per 12 months

Allowed sessions per 12 monthsNo more than four (4) TFESI sessions per spinal region per twelve (12) months.

Per-session injectionsEach session may include up to four (4) TFESIs when other criteria are met.

Denial riskMore than four sessions per spinal region per 12 months is considered not medically necessary and may be denied.

Minimum interval between sessions

Minimum intervalTFESI sessions should not be performed more frequently than every two (2) weeks for any spinal region.

Denial riskSessions performed more frequently than every two weeks are considered not medically necessary and may be denied.

Applies toThis interval requirement applies to cervical, thoracic, and lumbar regions.

Study settings allowed up to 4 injections in trial settings

Trial settings noteSome trials allowed up to four (4) injections (patients were permitted to receive as many as four injections in Riew et al. and other studies had variability in frequency and number of procedures).

ContextThese trial allowances influenced study outcomes but do not override policy frequency limits used for coverage determinations.

Evidence variabilityThere is variability across studies in dose, frequency, and number of procedures; meta-analyses note heterogeneity in protocols.

CTFESI literature note (fluoroscopic emphasis, no numeric limits)

CTFESI literature noteFluoroscopically guided cervical transforaminal epidural steroid injection (CTFESI) cohort studies report approximately 48–55% of patients achieving ≥50% pain relief at short- to intermediate-term follow-up, but evidence quality is very low and randomized controlled comparisons are lacking.

Imaging emphasisPolicy and cited reviews emphasize fluoroscopic guidance for CTFESI; studies often lack numeric frequency limits and vary in protocol.

Research needAuthors recommend randomized trials with placebo/sham or active comparison groups to determine effectiveness and efficacy of CTFESI.

Note

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.