CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Epidural Steroid Injection (ESI) Authorization Request

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This document is an authorization request form for epidural steroid injections for BlueCross BlueShield of Tennessee commercial members; it governs what information providers must submit to request prior authorization for ESIs.

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyEpidural Steroid Injection (ESI) Authorization Request

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the ESI authorization form with supporting medical records (imaging, office notes, conservative treatment documentation, and prior injection details).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Epidural Steroid Injection (ESI) Authorization Request

Customize your policy alerts

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

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the ESI authorization form with supporting medical records (imaging, office notes, conservative treatment documentation, and prior injection details).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Coverage and Authorization Criteria

Authorization submission criteria

Form fields indicate authorization is contingent on documentation of the following when applicable:

Basic submission requirements: Completed authorization form and relevant medical records (imaging, office visit notes, documentation of conservative treatments, dates and details of prior injections, and confirmation of radiculopathy findings when applicable) must be submitted.

Submit the completed authorization form with supporting records.

Indication for ESI: Chronic or acute cervical, thoracic, or lumbar pain, or other documented reason for ESI (select all that apply on the form).

Reason for ESI captured on form.

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

Form asks whether radiculopathy is documented by exam, imaging, or neuro-testing.

Conservative treatment attempt: Document conservative treatments attempted (NSAIDs, analgesics, other medications such as steroids/muscle relaxants/neuropathic agents, rest/activity modification, physical therapy, or 'None of the above') and select duration: Less than four (4) weeks OR Four (4) weeks or longer.

Form requires indication of which conservative treatments were tried and duration selection.

Procedure logistics: Indicate requested CPT code, modifier (LT/RT or 50 as applicable), quantity, spine level, primary and additional diagnosis codes, anticipated date of service, and whether the procedure will be performed with fluoroscopic guidance (Yes/No).

Form collects procedure code, modifiers, spine level, date, and fluoroscopy selection.

Contraindications and prior injections: Document presence of contraindications or relevant comorbidities (known allergy to injectate; insufficient epidural space from prior surgery/compression/congenital condition; bleeding disorder or anticoagulant use; infection systemic or at injection site; uncontrolled hypertension; diabetes; congestive heart failure) and whether the patient had more than two (2) prior ESI injections without relief within 2 to 6 weeks. Also indicate number and dates of previous injections (No previous, 1, 2, or 3+).

Form lists specific contraindications/comorbidities and captures prior injection count and dates.

The form asks providers to identify the presence of any contraindications or comorbidities that could affect procedural eligibility. Requested items include: known allergy to the injectate; insufficient epidural space (for example from prior surgery, compression, or congenital conditions); bleeding disorder or anticoagulant use; infection (systemic or at the injection site); uncontrolled hypertension; diabetes; congestive heart failure; and whether the patient has had more than two (2) previous ESI injections without relief of pain within 2 to 6 weeks. The form also provides a None of the above option and requests the number and dates of any prior injections.

CPT Codes and Modifiers

Covered CPT Codes (use this form)CPTCovered

62320
62321
62322
62323
62324
62325
62326
62327
64479
64480

1–10 of 12

1/2

Modifiers guidanceModifier

LT	Left side modifier
RT	Right side modifier
50	Bilateral modifier (form notes 64480 uses LT/RT not 50)

Required Provider Actions and Submission Requirements

Prior Authorization

Prior authorization required for listed CPT codes (commercial members)

Prior authorization is required for the listed CPT codes for BlueCross BlueShield of Tennessee commercial members; providers must complete and submit the ESI authorization request form with supporting records.

Use this form for CPT codes: 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 64479, 64480, 64483, 64484
Submit via the ESI authorization request form (paper or online through Availity)

Step Therapy

Document conservative therapies and select duration on the form

Indicate which conservative treatments were attempted and select the duration on the form; the form provides mutually exclusive duration options.

Select conservative treatments attempted (NSAIDs, analgesics, steroids/muscle relaxants/nerve pain meds, rest/activity modification, physical therapy, or None)

Conservative Treatment — Documented Attempts and Duration

Document attempted conservative treatments and duration on the form

Indicate how long conservative treatments were attempted by selecting one of the options below:

Conservative treatment duration: Less than four (4) weeks.

Select this option if conservative therapies have been attempted for under four weeks.

Conservative treatment duration: Four (4) weeks or longer.

Select this option if conservative therapies have been attempted for four weeks or longer.

Injection Frequency and Prior Injection History

inv-12: Prior ESI history and frequency threshold

Form field capturedHas a previous injection been performed? If so, how many? (No previous injection; 1 previous; 2 previous; 3 or more previous)

Threshold rule queriedMore than two (2) previous ESI injections without relief of pain within 2 to 6 weeks is specifically queried as a potential contraindication/comorbidity.

Dates requiredForm requests listing of all dates of previous injections in the submission.

Response options reflect frequencyForm collects prior injections count as: 0, 1, 2, or 3+.

Imaging and Diagnostic Evidence

Note

Provide imaging when used to confirm radiculopathy

If imaging is used to confirm radiculopathy, include the imaging study with the authorization request; the form explicitly asks whether imaging documents radiculopathy.

Select 'Imaging' under radiculopathy documentation if applicable and attach the imaging report/images with the form
Provide physical exam or neuro‑testing documentation if used to confirm radiculopathy

Key Definitions and Clinical Confirmation

inv-10: Radiculopathy confirmation (required documentation)

Form prompt for radiculopathyIs there documentation of confirmed radiculopathy by any of the following? Select all that apply.

Acceptable documentation typesPhysical exam findings; Imaging; Neuro-testing; or selection of 'No confirmed radiculopathy'.

Form behaviorProviders can select multiple documentation sources to confirm radiculopathy on the authorization form.

Clinical Background

Epidural steroid injections (ESIs) are requested for cervical, thoracic, or lumbar spinal pain. The authorization form captures the clinical indication and procedural details needed for review, including confirmation of prior injections (number and dates) and the presence or absence of relevant contraindications or comorbidities.