Arizona Complete Health TFESI/SNRB Coverage Update

Medical Necessity Criteria

inv-01: SNRB — Acute — One SNRB for acute pain management (pain < 3 months) is medically necessary when ALL of the following are met.

One SNRB for acute pain management (pain < 3 months) is medically necessary when ALL of the following are met:

SNRB Acute Criteria: 1. Severe radicular pain in a specific nerve root distribution that interferes substantially with activities of daily living (ADLs); 2. Severe pain persists after treatment with NSAIDs and/or opiate (both ≥ three days or contraindicated/not tolerated); 3. Cannot tolerate chiropractic or physical therapy, and the injection is intended as a bridge to therapy.pain duration < 3 months

SNRB limited to one per visit and requires radiographic guidance per policy statement.

inv-02: SNRB — Chronic / Diagnostic — One SNRB for chronic pain to establish diagnosis is medically necessary when ALL of the following are met.

One SNRB for chronic pain to establish diagnosis is medically necessary when ALL of the following are met:

SNRB Chronic Criteria: 1. Request is for an SNRB with a local anesthetic at a single nerve root; 2. Persistent radicular pain in a defined nerve root level, and the diagnosis remains uncertain after standard evaluation (neurologic examination, radiological studies and electrodiagnostic studies); 3. Pain interferes with ADLs and has lasted for at least three months; 4. Failure to respond to conservative therapy, including: (a) ≥ four weeks chiropractic, physical therapy or prescribed home exercise program; (b) NSAIDs ≥ three weeks or NSAID contraindicated/not tolerated; (c) ≥ four weeks activity modification.pain duration ≥ 3 months

A second SNRB is medically necessary when multilevel pathology is suspected and at least two weeks have passed since prior injection. SNRBs for other indications are not medically necessary.

inv-03: TFESI — Acute — One TFESI for acute pain management (pain < 3 months) is medically necessary when ALL of the following are met.

One TFESI for acute pain management (pain < 3 months) is medically necessary when ALL of the following are met:

TFESI Acute Criteria: 1. Severe radicular pain in a specific nerve root distribution that interferes substantially with activities of daily living (ADLs); 2. If a cervical TFESI is requested, non-particulate steroid must be used and the procedure must be conducted with real-time imaging (e.g., fluoroscopy); 3. Severe pain persists after treatment with NSAID and/or opiate (both ≥ three days or contraindicated/not tolerated); 4. Cannot tolerate chiropractic or physical therapy, and the injection is intended as a bridge to therapy.pain duration < 3 months

Only one procedure per visit; radiographic guidance required.

inv-04: TFESI — Chronic — One TFESI for chronic pain is medically necessary when ALL of the following are met.

One TFESI for chronic pain is medically necessary when ALL of the following are met:

TFESI Chronic Criteria: 1. TFESI is requested for a single level bilaterally or up to two levels unilaterally; 2. If a cervical TFESI is requested, non-particulate steroid must be used and the procedure must be conducted with real-time imaging (e.g., fluoroscopy); 3. There is persistent radicular pain caused by disc herniation in a defined nerve root level or spinal stenosis confirmed by physical exam and imaging; 4. Pain interferes with ADLs and has lasted for at least three months; 5. Failure to respond to conservative therapy including: (a) ≥ four weeks chiropractic, physical therapy or prescribed home exercise program; (b) NSAID ≥ three weeks or NSAID contraindicated/not tolerated; (c) ≥ four weeks activity modification.pain duration ≥ 3 months

TFESI limited to specified levels; documentation of imaging/diagnosis and conservative therapy required.

inv-05: TFESI — Second Injection (no improvement) — A second TFESI for chronic pain that did not improve from the initial injection is medically necessary when ALL of the following are met.

A second TFESI for chronic pain that did not improve from the initial injection is medically necessary when ALL of the following are met:

Second TFESI Criteria: 1. Request is for a TFESI at one level bilaterally or up to two levels unilaterally; 2. If a cervical TFESI is requested, non-particulate steroid must be used and the procedure must be conducted with real-time imaging (e.g., fluoroscopy); 3. At least two weeks have passed since the first TFESI.

Intended for cases that did not improve from initial injection.

inv-06: TFESI — Subsequent after improvement — Subsequent TFESIs for recurrence of chronic pain that had improved from the first or second TFESI are medically necessary when ALL of the...

Subsequent TFESIs for recurrence of chronic pain that had improved from the first or second TFESI are medically necessary when ALL of the following are met:

Subsequent TFESI Criteria: 1. TFESI requested at a single level bilaterally or up to two levels unilaterally; 2. If a cervical TFESI is requested, non-particulate steroid must be used and the procedure must be conducted with real-time imaging (e.g., fluoroscopy); 3. There was ≥50% relief and functional improvement for at least three months since the last injection; 4. Less than four injections have been given at the same site within 12 months; 5. Less than 12 months have elapsed since the initial injection at the level requested.

Continuation beyond 12 months or more than 4 therapeutic injections is considered not medically necessary except on a case-by-case basis when definitive therapies cannot be tolerated.

SNRBs and TFESIs are not medically necessary for any indication other than those explicitly listed in the policy because effectiveness has not been established. This exclusion applies to both diagnostic and therapeutic uses that fall outside the specified criteria set forth for acute and chronic indications.

When providers, members, or their representatives provide services to members or submit claims for payment, they agree to be bound by the terms and conditions of this clinical policy even if no separate contract exists. For Medicaid members, state Medicaid coverage provisions take precedence if they conflict with this clinical policy. The Health Plan may change, amend, or withdraw this policy at its discretion; providers should verify current requirements and prior authorization expectations with the Health Plan.

Continuation of TFESIs beyond 12 months or more than 4 therapeutic injections at the same site within 12 months is considered not medically necessary because effectiveness and safety have not been established. Exceptions may be considered on a case‑by‑case basis only when more definitive therapies cannot be tolerated or provided.

Codes and Coding Notes

Referenced CPT CodesCPT

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).

Referenced external coverage (CMS LCD)mixed

No codes listed

Relief duration threshold for repeat TFESI

Repeat TFESI relief thresholdAt least 3 months of ≥50% pain relief and documented functional improvement after the prior TFESI

Minimum relief magnitude≥50% reduction in pain compared with baseline after prior TFESI

Minimum functional responseDocumented improvement in activities of daily living or functional status for the ≥3-month period

Time window for eligibilityRelief and functional improvement must be sustained for at least three months since the last injection

Provider Requirements and Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required and must be verified with the Health Plan prior to scheduling selective nerve root blocks (SNRB) or transforaminal epidural steroid injections (TFESI). The Health Plan determines the effective date of this clinical policy and may change or withdraw the policy at any time; verify current authorization requirements and effective dates with the Health Plan.

Affected CPT codes: 64479, 64480, 64483, 64484
Authorization must demonstrate medical necessity per policy criteria and be obtained before the procedure

Documentation Required

Required Documentation

Document the clinical rationale and the supporting clinical findings in the medical record. Required documentation must clearly support the specific nerve root distribution of radicular pain, results of neurologic examination, pertinent imaging findings (e.g., MRI/CT reports identifying disc herniation or spinal stenosis), and any electrodiagnostic testing when applicable.

Required Conservative Treatments Before Intervention

inv-25: Must be documented prior to SNRB/TFESI for chronic pain — 4 weeks (therapy/home exercise/activity modification); 3 weeks (NSAID).

Prior to SNRB or TFESI for chronic pain, documentation must show failure of the following conservative therapies:

Conservative Therapy Requirements: 1. ≥ four weeks of chiropractic care, physical therapy, or a prescribed home exercise program; 2. NSAIDs for ≥ three weeks, or documentation of NSAID contraindication or intolerance; 3. ≥ four weeks of activity modification.4 weeks (therapy/home exercise/activity modification); 3 weeks (NSAID)

These conservative therapy durations must be documented prior to authorization for SNRB/TFESI for chronic pain.

Limits on Number and Timing of Procedures

TFESI frequency limit (same site per 12 months)

Maximum injections per siteLess than four therapeutic TFESI injections at the same site within a 12-month period

12-month measurement periodCount injections at the same anatomical site over any rolling 12-month interval

Continuation beyond limitsContinuation of injections beyond 12 months or >4 therapeutic injections is considered not medically necessary except on case-by-case basis

Interval before second TFESI when initial injection ineffective

Minimum interval when initial ineffectiveAt least two weeks must have passed since the first TFESI before a second TFESI is considered medically necessary if the initial injection did not produce improvement

Applicability

Imaging and Guidance Requirements

Billing Rule

Perform SNRB/TFESI with fluoroscopy or CT; real-time imaging for cervical TFESI

Use fluoroscopy or CT for SNRB and TFESI; cervical TFESIs must be performed with real-time imaging (e.g., fluoroscopy) and use non‑particulate steroid.

Imaging guidance required: fluoroscopy or CT
Cervical TFESI requires real-time imaging (fluoroscopy) and non-particulate steroid

Note

Consult cited guidelines and reviews for imaging/technique details

Refer to specialty society guidelines and the policy’s cited systematic reviews for imaging and technical considerations (ASIPP, ASA, CMS LCD); providers should consult the full policy and references for procedural details.

Policy cites ASIPP, ASA, systematic reviews, and CMS LCD for guidance

Definitions

Selective Nerve Root Block (SNRB)

DefinitionInjection of a small amount of local anesthetic adjacent to a spinal nerve root, most often used to diagnose the source of radicular pain

Therapeutic useSteroid may be added when used therapeutically (selective transforaminal epidural steroid injection)

PurposePrimarily diagnostic localization of symptomatic nerve root to guide treatment planning

Transforaminal Epidural Steroid Injection (TFESI)

DefinitionInjection of local anesthetic and/or corticosteroid into the intervertebral foramen to treat radicular pain, allowing injectate to spread to target multiple nerves

Technique requirementProcedure requires radiographic guidance (fluoroscopy or CT); cervical TFESI requires real-time imaging and non-particulate steroid

Background and Scope

Selective Nerve Root Blocks (SNRBs) involve injection of a small amount of local anesthetic adjacent to a spinal nerve root and are used primarily to localize the source of radicular pain; steroids may be added when used therapeutically. Transforaminal Epidural Steroid Injections (TFESIs) deliver local anesthetic and/or corticosteroid into the intervertebral foramen to target radicular pain and typically require radiographic guidance. These procedures are intended for patients with radicular pain that substantially interferes with activities of daily living and when conservative measures have failed or are not tolerated; benefits are generally short term and, per policy, repeat injections and specific technique (e.g., non‑particulate steroid for cervical TFESI and real‑time imaging) are required under defined circumstances.

Non-Covered Indications

SNRBs and TFESIs are not covered for indications other than those explicitly specified in the policy because their effectiveness for other uses has not been established. This includes continuation beyond policy frequency and duration limits and any therapeutic or diagnostic use not meeting the stated medical necessity criteria.

OpenPayer

Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections