CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Pain Management — Epidural Steroid Injection Authorization Request Form (Coverage Criteria)

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Form and requirements for prior authorization submission for epidural steroid injections for BlueCross BlueShield of Tennessee commercial members; applies to providers requesting authorization for specified CPT codes.

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyEpidural steroid injection (ESI) authorization request — coverage criteria and required documentation

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed authorization form with relevant medical records including imaging, office visit notes, and documentation of attempted conservative treatments.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Pain Management — Epidural Steroid Injection Authorization Request Form (Coverage Criteria)

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Sign up for all blue cross blue shield - tennessee policy alerts

Know when blue cross blue shield - tennessee releases new policies or updates existing guidance.

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Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyEpidural steroid injection (ESI) authorization request — coverage criteria and required documentation

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed authorization form with relevant medical records including imaging, office visit notes, and documentation of attempted conservative treatments.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Coverage Criteria and Clinical Documentation

Authorization documentation and clinical criteria

Authorization is supported when the request form documents the following patient- and procedure-specific information

Form and member details: Completed form with member information, provider and facility details, requested procedure code, modifiers, spine level, quantity, primary and additional diagnosis codes, anticipated date of service, and patient anthropometrics (height, weight, BMI).

Supported by form fields

Reason for procedure: Indication for epidural steroid injection selected (cervical, thoracic, or lumbar pain) and specific reason(s) for ESI as documented on the form.

Form asks 'What is the reason for epidural steroid injection (ESI)?'

Conservative treatment: Documentation of conservative treatments attempted (medications including NSAIDs, analgesics, other medications, rest/activity modification, physical therapy, or other) with selection of duration of attempts.

Form collects conservative treatment types and duration

Evidence of radiculopathy: Documentation of confirmed radiculopathy by physical exam findings, imaging, or neuro-testing, or explicit selection of 'No confirmed radiculopathy'.

Form asks to select applicable findings

Safety, comorbidities, and prior injection history: Assessment of contraindications and comorbidities (known allergy to injectate, insufficient epidural space, bleeding disorder/anticoagulant use, infection, uncontrolled hypertension, diabetes, congestive heart failure) and documentation of prior injection history including number and dates of previous ESIs and response to prior injections (including option noting more than two prior injections without relief within 2–6 weeks).

Form contains checkboxes for these items and a field to list dates of previous injections

Fluoroscopy: Indicate whether fluoroscopic guidance will be used (Yes/No).

Form contains this question

Attester and submission: Form completed by and dated, with confirmation that all pertinent clinical information has been provided for decision making.

Signature/date fields on form

The request form explicitly asks providers to identify active infectious conditions. Infection (either systemic or at the injection site) is listed among the checklist items and should be identified prior to scheduling or performing an epidural steroid injection. Presence of infection may preclude proceeding with the injection until the infection is resolved; document the finding on the form and include relevant clinical records.

Covered CPT and Procedure Codes

Covered CPT Codes (listed on form)CPT

62320
62321
62322
62323
62324
62325
62326
62327
64479
64480

1–10 of 12

1/2

Coding notesmixed

62321	Unilateral; does not require a modifier
62322	Unilateral; does not require a modifier
62323	Unilateral; does not require a modifier
64480	Use LT and/or RT modifier only; do not use modifier 50 (bilateral)

Prior Authorization and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for the listed CPT codes. Providers must submit a completed Pain Management Epidural Steroid Injection Authorization Request Form or submit requests via Availity. Call Utilization Management at 866-747-0586 or fax 423-800-5302 for assistance.

Affected CPT: 62320, 62321*, 62322*, 62323*, 62324, 62325, 62326, 62327, 64479, 64480**, 64483, 64484
*62321, 62322, 62323 are unilateral (no modifier required)
**64480 uses LT/RT only, not 50 (bilateral)

Documentation Required

Conservative Treatment Documentation

Document all conservative treatments attempted and the duration for each. The authorization request form collects specific conservative therapies (e.g., NSAIDs, analgesics, steroids, muscle relaxants, nerve pain medications, rest/activity modification, physical therapy, other) and asks how long treatments were tried (less than 4 weeks or 4 weeks or longer). Include whether any conservative treatments were not attempted.

Prior Conservative Care Documentation

Document prior conservative care and duration on form

Document prior conservative care and select duration on the form:

Duration of conservative care (select one): Less than four (4) weeks

Form provides this option

Duration of conservative care (select one): Four (4) weeks or longer

Form provides this option

Conservative treatments attempted (select all that apply): Medication (NSAIDs, analgesics, other medications such as steroids, muscle relaxants, nerve pain medications), rest or activity modification, physical therapy, other, or none of the above.

Form lists these treatment categories to be documented

Imaging and Confirmation of Radiculopathy

Note

Attach imaging when used to confirm radiculopathy

Provide imaging documentation when applicable to confirm radiculopathy; the form asks whether imaging supports radiculopathy and requests selection of imaging as supporting evidence.

Select 'Imaging' on the form if imaging confirms radiculopathy and attach the imaging reports/images

Epidural Steroid Injection Frequency

Epidural steroid injection — frequency/history query

Frequency query on prior ESIsForm specifically asks if there have been 'More than two (2) previous ESI injections without relief of pain within 2 to 6 weeks'.

Response options for prior injectionsForm lists number of prior injections: No previous injection, One, Two, Three or more; and requests listing all dates of previous injections.

Action required by providerDocument number and dates of prior ESIs and indicate response to those injections on the authorization form.

Coding Modifiers and Unilateral/Bilateral Definitions

Unilateral codes (62321, 62322, 62323)

Unilateral CPT codesCPT codes 62321, 62322, and 62323 are unilateral and do not require a modifier.

Context of listingThese unilateral codes are included among the covered CPT codes on the form for commercial members.

Implication for billingDo not append laterality or bilateral modifiers to 62321, 62322, or 62323 when submitting the authorization form.

Modifier use for CPT 64480

Modifier guidance for 64480Code 64480 uses LT and/or RT modifier only; do not use modifier 50 (bilateral).

Form modifier fieldThe form requests a modifier (LT, RT or 50) but notes in coding guidance that 64480 should only be reported with LT and/or RT.

Clinical Background

Epidural steroid injections (ESIs) are used for management of cervical, thoracic, or lumbar radicular pain. The authorization request form collects key documentation elements to support medical necessity, including patient and procedure details, history of prior injections and dates, clinical findings that confirm radiculopathy (physical exam, imaging, or neuro‑testing), and comorbidities or contraindications that affect safety. The form also asks providers to document conservative treatments attempted and the duration of conservative care, and whether fluoroscopic guidance will be used.