CurrentArizona Complete HealthPolicy CP.MP.164

Caudal or Interlaminar Epidural Steroid Injections

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Defines medical necessity, coverage criteria, and coding guidance for caudal and interlaminar epidural steroid injections for acute and chronic radicular/spinal pain for members/enrollees of the Health Plan.

Policy Summary

PayerArizona Complete Health

PolicyCaudal or Interlaminar Epidural Steroid Injections

Policy CodePolicy CP.MP.164

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization with documentation of indication, conservative therapy, imaging (for chronic radicular pain), and timing/response to prior injections.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

one/visitlimit

≤4max in 12 months

≥50%success threshold

≥3 monthschronic definition

≥4 wksconservative therapy

Coverage Criteria for Caudal and Interlaminar Epidural Steroid Injections

inv-01: Acute pain indication

Covered when ALL of the following are met

Acute pain ESI: One caudal or interlaminar ESI for acute pain (pain lasting < three months)

Severe radicular pain that interferes substantially with activities of daily living (ADLs); severe pain persists after NSAID and/or opiate trial (both ≥ 3 days) or these agents are contraindicated/not tolerated; member cannot tolerate chiropractic or physical therapy and injection is intended as a bridge to therapy.

inv-02: Initial ESI for chronic pain

Covered when ALL of the following are met

Initial chronic ESI: Request is for one caudal or interlaminar ESI at one level in the cervical, thoracic or lumbar region

Persistent radicular pain caused by spinal stenosis, disc herniation, or degenerative vertebral changes confirmed by physical exam and imaging; pain interferes with ADLs and has lasted ≥ 3 months; failed conservative therapy including: (a) ≥ 4 weeks chiropractic, physical therapy, or prescribed home exercise program; (b) NSAID for ≥ 3 weeks or NSAID contraindicated/not tolerated; (c) ≥ 4 weeks activity modification.

inv-03: Second ESI when first ineffective

Covered when ALL of the following are met

Second ESI (no improvement): Request is for a caudal or interlaminar ESI at one level in the cervical, thoracic or lumbar regionAt least 2 weeks since the first ESI

Used when chronic pain did not improve from the first ESI.

inv-04: Subsequent ESI after prior successful response

Covered when ALL of the following are met

Subsequent ESI for recurrence: Injection for recurrence of chronic pain that had improved from prior ESI(s)Initial injection(s) provided ≥ 50% pain relief and functional improvement for at least two months; at least 2 months since last ESI; less than 4 injections administered within 12 months; less than 12 months since the initial injection at the level requested.

inv-05: Not medically necessary

Not medically necessary: Third or subsequent caudal or interlaminar ESI for chronic pain that did not improve from the first two ESIs; continuation of injections beyond 12 months or more than four therapeutic injections; ESI for any other indication or location not supported by evidence.

Consideration may be given on a case‑by‑case basis when more definitive therapies cannot be tolerated or provided.

It is the policy of the Health Plan that caudal or interlaminar epidural steroid injections (ESI) for any indication or anatomic location not specified in the coverage criteria are not medically necessary because effectiveness has not been established.

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. Additionally, continuation of injections beyond 12 months or administering more than four therapeutic injections within any 12‑month period is considered not medically necessary because effectiveness and safety have not been established; exceptions may be considered on a case‑by‑case basis when definitive therapies cannot be tolerated or provided.

Conservative Treatment Required Before Injections

inv-18: Complete conservative therapy before initial chronic ESI

Complete conservative therapy is required before an initial chronic ESI; duration varies by modality

Conservative therapy prerequisites: Member has completed conservative therapy prior to initial chronic ESIDuration: ≥4 weeks for chiropractic, physical therapy, or prescribed home exercise; ≥3 weeks for NSAID therapy (or NSAID contraindicated/not tolerated); ≥4 weeks activity modification

These conservative measures must be documented in the clinical record before authorizing an initial chronic ESI.

Frequency and Interval Limits for Epidural Steroid Injections

inv-19: caudal or interlaminar ESI — No more than four therapeutic injections in 12 months

Frequency limitNo more than four therapeutic caudal or interlaminar epidural steroid injections in any 12‑month period.

Per‑visit ruleOnly one caudal or interlaminar ESI procedure is performed per visit.

Imaging guidanceProcedures generally require imaging guidance (CT or standard fluoroscopy) except in rare, documented instances.

Continuation limitContinuation of injections beyond 12 months is considered not medically necessary unless case‑by‑case justification when definitive therapies cannot be tolerated.

inv-20: repeat caudal or interlaminar ESI — Minimum intervals between injections and spacing rules

Minimum interval after first ineffective ESIAt least 2 weeks must have passed since the first ESI before a second ESI is considered when the first was ineffective.

Interval after a successful ESIAt least 2 months must pass since the last ESI when prior injection(s) provided ≥50% pain relief and functional improvement.

Count limit for subsequent injectionsLess than four injections administered within 12 months is required for coverage of a subsequent ESI for recurrence.

Time since initial injectionLess than 12 months must have elapsed since the initial injection at the requested level for subsequent ESI coverage for recurrence.

Procedure Codes and Pain-Relief Thresholds

Referenced CPT procedure codesCPT

62320	Injection(s) interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance.
62321	Injection(s) interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance.
62322	Injection(s) interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance.
62323	Injection(s) interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance.
62324	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance (description truncated in policy).
62325	Interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (description in policy).
62326	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance.
62327	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance.

inv-09: Pain relief threshold for repeat injections — ≥ 50% pain relief and functional improvement for at least two months

Pain relief and function thresholdRepeat/subsequent injection covered only if prior injection(s) produced ≥ 50% pain relief and functional improvement.

Duration of benefitThe ≥50% pain relief and functional improvement must have been maintained for at least two months.

Timing requirementAt least two months must have passed since the last ESI before a subsequent injection for recurrence is considered.

Provider Actions, Documentation, and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for caudal or interlaminar epidural steroid injections (ESIs). Requests must document that only one procedure will be performed per visit and that imaging guidance will be used (or provide documented justification if imaging guidance is not used).

Prior authorization required for caudal/interlaminar ESIs
Only one procedure per visit
Imaging guidance generally required; if not used, provide documented justification

Note

Conservative Therapy Requirement

For initial chronic pain ESI requests, the member must have attempted conservative therapy prior to authorization, including physical therapy/chiropractic or a prescribed home exercise program, a trial of NSAID therapy, and activity modification. A single caudal or interlaminar ESI may be authorized for acute pain (<3 months) only when severe radicular pain interferes with ADLs and NSAIDs/opioids have been tried (≥3 days) or are contraindicated, and the patient cannot tolerate PT/chiropractic.

Conservative therapy required before initial chronic ESI: ≥4 weeks chiropractic/PT or prescribed home exercise; NSAID ≥3 weeks (or contraindicated/not tolerated); ≥4 weeks activity modification
Acute pain (<3 months): one ESI allowed when severe radicular pain interferes with ADLs, NSAID/opiate therapy tried (≥3 days) or contraindicated, and injection used as bridge to therapy

Documentation Required

Required Clinical Documentation

Authorization requests must include clinical documentation supporting the indication and severity of symptoms, how pain affects activities of daily living, dates and details of prior conservative therapies (including start and end dates), imaging confirming the anatomic cause (e.g., disc herniation, spinal stenosis, degenerative changes), and documentation of response to prior ESIs when applicable. Requests for second or subsequent ESIs must document time elapsed since prior injections and degree/duration of benefit (≥50% relief and functional improvement for continuation criteria).

Document indication and severity and impact on ADLs
Provide dates and details of prior conservative therapy attempts
Include imaging that confirms the anatomic source of radicular pain
For subsequent ESIs, document elapsed time since prior ESI(s) and objective benefit (e.g., ≥50% pain relief for continuation)

Imaging Guidance for Epidural Steroid Injections

Billing Rule

Imaging guidance (fluoroscopy or CT) required for caudal/interlaminar ESIs

Fluoroscopy or CT imaging guidance is required for caudal or interlaminar ESIs except in rare instances with documented justification; procedures are expected to be performed by a physician using imaging guidance.

Standard fluoroscopy or CT should be used for procedural guidance.
Deviations require documented justification.

Documentation Required

Imaging confirmation required to support initial chronic ESI

For an initial ESI for chronic radicular pain, imaging confirmation of the causative pathology (e.g., disc herniation or stenosis) is required to support medical necessity.

Physical exam and imaging must confirm spinal stenosis, disc herniation, or degenerative vertebral changes.

Definitions

inv-16: Epidural steroid injection (ESI) — definition of administration and approaches

DefinitionEpidural steroid injection (ESI) is the administration of a glucocorticoid and/or anesthetic via needle into the space between the ligamentum flavum and the dura.

ApproachesCommon approaches include caudal and interlaminar (lumbar spine also includes transforaminal; policy focuses on caudal and interlaminar).

Imaging for administrationComputed tomography (CT) or standard fluoroscopy can be used during administration to provide guidance and anatomic detail; imaging guidance is generally required.

inv-17: Chronic pain — defined as pain lasting ≥ three months and interfering with ADLs

Duration defining chronic painChronic pain is pain that has lasted for at least three months.

Functional impactChronic pain is defined by pain that interferes with activities of daily living (ADLs).

Context for ESIFor chronic radicular pain, persistent symptoms must be confirmed by physical exam and imaging to support an initial ESI request.

Background

Epidural steroid injections deliver a glucocorticoid and/or anesthetic into the epidural space via caudal or interlaminar approaches. These procedures are used for radiculopathy, spinal stenosis, disc herniation, and related radicular pain to provide short‑term pain relief and functional improvement, particularly for patients with significant impairment of activities of daily living who have not responded to conservative therapies.

Not Covered / Exclusions

The policy lists the following conditions as not covered: third or subsequent caudal or interlaminar ESIs for chronic pain when there was no improvement after the first two injections; continuation of injections beyond 12 months; and more than four therapeutic injections within any 12‑month period. The policy states these are not medically necessary because effectiveness and safety have not been established.

Policy Summary

PayerArizona Complete Health

PolicyCaudal or Interlaminar Epidural Steroid Injections

Policy CodePolicy CP.MP.164

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization with documentation of indication, conservative therapy, imaging (for chronic radicular pain), and timing/response to prior injections.

SourceLink

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