CurrentCareSource GeorgiaPolicy MEDICAL POLICY STATEMENT Marketplace = Date Effective. Epidural Steroid Injections-MP-MM-1359, MEDICAL POLICY STATEMENT Marketplace = 03/01/2026. Policy Type MEDICAL, MEDICAL POLICY STATEMENT Marketplace = Policy Type MEDICAL

Epidural Steroid Injections

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Medical necessity and coverage criteria for epidural steroid injections (ESIs) for members covered by CareSource Georgia Marketplace plans, including initial diagnostic and subsequent therapeutic injections and limitations on frequency and technique.

Policy Summary

PayerCareSource Georgia

PolicyEpidural Steroid Injections

Policy CodePolicy MEDICAL POLICY STATEMENT Marketplace = Date Effective. Epidural Steroid Injections-MP-MM-1359, MEDICAL POLICY STATEMENT Marketplace = 03/01/2026. Policy Type MEDICAL, MEDICAL POLICY STATEMENT Marketplace = Policy Type MEDICAL

Change TypeNo material changes

Effective DateMar 1, 2026

Last ReviewMar 15, 2023

Next Review Date

Key ActionPrior authorization is required for epidural steroid injections (except labor/delivery or post-surgical pain) and must include clinical documentation demonstrating criteria for initial or subsequent injections.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6max per 12 months

3max per 12 weeks/region

6 weeksactive conservative therapy

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Epidural Steroid Injections

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Sign up for CareSource Georgia Policy MEDICAL POLICY STATEMENT Marketplace = Date Effective. Epidural Steroid Injections-MP-MM-1359, MEDICAL POLICY STATEMENT Marketplace = 03/01/2026. Policy Type MEDICAL, MEDICAL POLICY STATEMENT Marketplace = Policy Type MEDICAL alerts

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Policy Summary

PayerCareSource Georgia

PolicyEpidural Steroid Injections

Change TypeNo material changes

Effective DateMar 1, 2026

Last ReviewMar 15, 2023

Next Review Date

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6max per 12 months

3max per 12 weeks/region

6 weeksactive conservative therapy

50%required functional relief

Coverage Criteria for Epidural Steroid Injections

Initial (Diagnostic) Injection

Covered when ALL of the following are met:

Initial Injection Criteria: A) Pain located in the cervical, thoracic, or lumbar spine and predominantly radiating/shooting in nature; B) Pain causes functional disability (at least 6 on a 0–10 scale); C) Signs or symptoms consistent with radiculopathy evidenced by at least one of: diminished or absent deep tendon reflexes; paresthesia, numbness, sensory change, or weakness in a dermatomal distribution; positive femoral nerve stretch test; positive Spurling test; or positive straight leg raising test; D) Conservative therapy has failed, demonstrated by BOTH: 1) documentation of at least 6 weeks of active conservative therapy within the past 6 months OR documentation of inability to complete active conservative therapy due to contraindication, increased pain, or intolerance, AND 2) documentation of at least 6 weeks of inactive conservative therapy within the past 6 months; E) Imaging (if performed) demonstrates no condition that would preclude safe performance of the procedure.

Maximum of 2 diagnostic injections allowed.

Subsequent (Therapeutic) Injection

Covered when ALL of the following are met:

Therapeutic Injection Criteria: A) The diagnostic or most recent therapeutic injection for the current episode provided significant functional pain relief of at least 50% (measured by decreased pain level, decreased pain medication use, and/or increased physical function); B) The member continues to have ongoing pain or documented functional disability (at least a 6 on a 0–10 scale); C) At least 3 weeks have passed since the prior injection; D) No more than 3 procedures in a 12‑week period per region; E) The member continues to engage in conservative therapy.

Limitations

Coverage limitations and exclusions:

Limits: A) Maximum of all epidural injections is 6 in any 12‑month period regardless of number of levels; B) For interlaminar or caudal epidurals: no more than 1 epidural injection per treatment date; C) For transforaminal epidurals or selective nerve root blocks (SNRBs): no more than 2 vertebral levels per treatment date (unilateral or bilateral); D) Real‑time image guidance and injection of contrast are inclusive components of the procedure and are not separately reimbursed or unbundled for coverage.

Monitored anesthesia is explicitly designated as not medically necessary for epidural steroid injections. If conscious sedation is provided for co‑morbidities or provider/patient preference, it is considered an inclusive component of the procedure and is not eligible for separate reimbursement when administered by a second provider.

The evidence for long‑term efficacy of epidural steroid injections is inconclusive; therefore, continuation of epidural injections beyond 1 year may be subject to medical necessity review. Providers should be prepared to document ongoing clinical justification, response to prior injections, and continued engagement in conservative therapies when seeking authorization for treatments extending past one year.

Coding and Thresholds

Prior authorization affected codesmixed

affected codes

Placeholder — policy references prior authorization and affected codes but does not list CPT/HCPCS codes explicitly.

inv-07: Pain severity threshold

Pain severity thresholdPain causing functional disability of at least 6 on a 0–10 scale (≥6/10)

inv-08: Functional relief threshold

Functional relief thresholdDiagnostic or prior therapeutic injection must provide at least 50% functional pain relief

Provider Actions, Documentation, and Prior Authorization

Prior Authorization

Prior authorization required for ESIs (excludes L&D and post‑surgical pain)

Prior authorization is required for epidural steroid injections except for labor and delivery or post‑surgical pain. PA requests must include clinical documentation demonstrating that the criteria for initial or subsequent injections are met; include device interrogation and interpretation when applicable for members with implanted neuromodulation devices.

Step Therapy

Require 6 weeks active + 6 weeks inactive conservative therapy before initial ESI

Document a trial of both active and inactive conservative therapies prior to an initial ESI, consisting of at least 6 weeks of active conservative therapy and at least 6 weeks of inactive conservative therapy within the past 6 months, unless there is documentation of inability to complete active therapy due to contraindication, increased pain, or intolerance.

Active therapy examples: PT, OT, physician‑supervised HEP (6‑week program) or chiropractic care.
Inactive therapy examples: rest, ice/heat, medical devices, TENS, pharmacotherapy.

Definitions

inv-17: Conservative Therapy

DefinitionConservative Therapy: a multimodality plan of care including both active (e.g., physical therapy, supervised home exercise program) and inactive (e.g., rest, heat, TENS, pharmacotherapy) modalities.

Active therapies examplePhysical therapy, supervised home exercise program (HEP), chiropractic care

Inactive therapies exampleRest, heat/ice, TENS, medical devices, pharmacotherapy (OTC and prescription)

inv-18: HEP

DurationHome exercise program (HEP) of 6 weeks requiring an exercise prescription/plan and documented follow-up after completion

Documentation alternativeOr documented inability to complete HEP due to physical reasons (e.g., increased pain, inability to perform exercises)

Conservative Treatment Requirements Prior to Initial ESI

Documentation of 6 weeks active conservative therapy (or documented inability) and 6 weeks inactive conservative therapy within past 6 months

Documentation requirement (prerequisite for initial injections):

Conservative Therapy Documentation: Document at least 6 weeks of active conservative therapy within the past 6 months (active therapies include physical therapy, physician‑supervised home exercise program [HEP] with exercise prescription and follow‑up, chiropractic care, etc.) OR document inability to complete active therapy due to contraindication, increased pain, or intolerance; AND document at least 6 weeks of inactive conservative therapy within the past 6 months (eg, rest, heat, TENS, pharmacotherapy).6 weeks

Patient inconvenience or unexplained noncompliance does not constitute inability to complete active therapy. HEP requires an exercise prescription and follow‑up documentation or documented physical inability to complete.

Frequency and Quantity Limits

inv-21: Therapeutic epidural steroid injections

Per-region 12‑week limitTherapeutic epidural steroid injections: no more than 3 procedures in a 12‑week period per region

Applies toTherapeutic injections for the current episode of pain as defined in criteria

Rationale noteAllows spacing to reach pharmacodynamic effect (minimum 3 weeks between injections)

inv-22: All epidural injections

12‑month combined limitMaximum of 6 epidural injections in any 12‑month period (all epidural injections combined)

Applies regardless of levelsLimit applies regardless of number of vertebral levels involved

Imaging Requirements and Procedural Guidance

Note

Obtain imaging only when indicated or to confirm safety

Imaging of the symptomatic region is conditional — perform when indicated to evaluate specific causes, to assess safety, or when severe/progressive neurologic deficits or red flags are suspected; routine imaging for nonspecific back pain is not supported.

Documentation Required

Cervical transforaminal ESI requires realtime fluoroscopy/DSA with contrast

When performing cervical transforaminal ESIs, use realtime fluoroscopy and/or digital subtraction angiography (DSA) with contrast in the frontal plane and inject contrast before any potentially hazardous substance; particulate steroids should not be used for cervical TF injections.

Not Covered / Not Medically Necessary

Not covered items and exclusions include: (1) Monitored anesthesia — considered not medically necessary and not separately reimbursable; (2) use of particulate steroids for cervical transforaminal injections is contraindicated due to rare but catastrophic neurovascular risks, so particulate steroids are not covered for these procedures; and (3) long‑term continuation beyond one year may be subject to medical necessity review because the literature is inconclusive regarding sustained long‑term benefit.

Background

Epidural steroid injections (translaminar/interlaminar, transforaminal, or caudal) are described as a minimally invasive nonsurgical option for axial and radicular back pain. They are intended to provide short‑term reduction in pain and may be reasonable when conservative management has failed. Imaging is not routinely required for nonspecific back pain but is appropriate when evaluating specific causes or red flags; for cervical transforaminal procedures, realtime fluoroscopy/DSA with contrast is recommended and particulate steroids should not be used for safety reasons.

Revision History

2026-03-01effective_dateLatest

Policy effective date published as 03/01/2026 for the Epidural Steroid Injections medical policy statement (MP-MM-1359).

2023-03-15review

Annual review: reorganized criteria, simplified conservative therapy, added provocation tests, and added pain scale to diagnostic injection criteria; approved by Committee.

2024-01-31review

Policy Summary

PayerCareSource Georgia

PolicyEpidural Steroid Injections

Change TypeNo material changes

Effective DateMar 1, 2026

Last ReviewMar 15, 2023

Next Review Date

SourceLink

On This Page

Document start/end dates, prescriptions/plans, and follow‑up in the medical record.

Documentation Required

Submit device interrogation and interpretation for implanted devices

When the member has an implanted spinal cord stimulator or pain pump, submit a device interrogation report and an interpretation with the medical records as part of the prior authorization request.

If the device is not functioning properly, document evaluation/management of the implanted device.

Documentation Required

Clinical documentation required for initial (diagnostic) injection

For initial (diagnostic) injections include documentation of pain location, pain severity of at least 6/10 causing functional disability, signs or symptoms consistent with radiculopathy (eg, diminished/absent DTRs; paresthesia/numbness/weakness in a dermatomal distribution; positive femoral nerve stretch, Spurling, or straight leg raising tests), prior conservative therapies, and imaging if performed showing no contraindicating conditions.

Specify spine region (cervical, thoracic, or lumbar) and that pain is predominantly radiating/shooting.
Record objective provocation or neurologic findings supporting radiculopathy.
If imaging was performed (x‑ray, CT, MRI), include results confirming safety for the procedure.

Documentation Required

Document ≥50% functional relief from prior injection and continued benefit for therapeutic ESIs

For therapeutic injections document that the diagnostic or prior therapeutic injection provided significant functional pain relief of at least 50% and that the member continues to have ongoing pain or functional disability (≥6/10); also document continued engagement in conservative therapy.

Measure relief by decreased pain level, decreased pain medications, and/or increased physical function.
Note the date and outcome of the diagnostic or last therapeutic injection used to establish ≥50% benefit.

Denial Risk

Adhere to frequency and per‑date limits (3/12‑weeks; 6/12‑months; per‑date level limits)

Do not exceed frequency and per‑date limits: no more than 3 therapeutic procedures in any 12‑week period per region, maximum of 6 epidural injections in 12 months total, and per‑date limits of 1 interlaminar/caudal injection per treatment date or no more than 2 vertebral levels for transforaminal/SNRB per treatment date; exceeding these limits may result in noncoverage or review.

Therapeutic injections must be at least 3 weeks apart to allow pharmacodynamic effect.
Maximum of 2 diagnostic injections allowed for initial evaluation.

Denial Risk

Monitored anesthesia is not medically necessary and not separately reimbursed

Monitored anesthesia is considered not medically necessary; conscious sedation is considered part of the procedure and is not eligible for separate reimbursement when provided as part of the ESI.

Services provided by a second provider for conscious sedation will not be eligible for additional reimbursement.

Follow-up requirementFollow-up must be documented in the medical record after completion of the HEP

inv-19: Epidural Steroid Injection

DefinitionEpidural Steroid Injection: administration of steroids into the epidural space via translaminar (interlaminar), transforaminal, or caudal approaches

Approach — translaminar/interlaminarNeedle inserted between ligamentum flavum and dura to deliver steroid into the epidural space via translaminar approach

Approach — transforaminalInjection delivered via the foraminal route targeting the affected nerve root (transforaminal)

Approach — caudalInjection administered via the sacral hiatus into the caudal epidural space (caudal approach)

Exceeding this limit may result in noncoverage

inv-23: Interlaminar/caudal/transforaminal per-date limits

Interlaminar/caudal per-date limitInterlaminar or caudal: no more than 1 epidural injection per treatment date

Transforaminal/SNRB per-date limitTransforaminal epidurals or selective nerve root blocks (SNRBs): no more than 2 vertebral levels per treatment date (unilateral or bilateral)

Imaging and contrastReal-time image guidance and injection of contrast are inclusive components and not separately reimbursed

Annual review: updated references and approved by Committee.

2022-12-14issue

Original policy issued (new policy).