CurrentCareSourcePolicy Epidural Steroid Injections-ARPASSE-MM1504

Epidural Steroid Injections-ARPASSE-MM1504

Policy governing medical necessity, limitations, and documentation requirements for epidural steroid injections (diagnostic and therapeutic) for chronic spinal pain for members covered under the Arkansas PASSE plan.

Policy Summary

PayerCareSource

PolicyEpidural Steroid Injections-ARPASSE-MM1504

Policy CodePolicy Epidural Steroid Injections-ARPASSE-MM1504

Change TypeNo material change

Effective DateMay 1, 2024

Next Review Date

Key ActionObtain prior authorization with documentation of >=6 weeks active conservative therapy, clinical findings, and device interrogation when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

max 2Initial (diagnostic) limit

≤3Therapeutic per region (12 wks)

max 6All epidurals (12 months)

≥6 wksRequired conservative therapy

≥3 wksMinimum interval repeat

Coverage Criteria for Epidural Steroid Injections

Policy Summary

PayerCareSource

PolicyEpidural Steroid Injections-ARPASSE-MM1504

Policy CodePolicy Epidural Steroid Injections-ARPASSE-MM1504

Change TypeNo material change

Effective DateMay 1, 2024

Next Review Date

Key ActionObtain prior authorization with documentation of >=6 weeks active conservative therapy, clinical findings, and device interrogation when applicable.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Initial (Diagnostic) Injection

CareSource considers an initial (diagnostic) epidural steroid injection (maximum of 2 injections) medically necessary when ALL of the following are met:

Initial Injection - All required: 1) Pain is located in the cervical, thoracic, or lumbar spine and is predominantly radiating or shooting in nature; 2) Pain causes functional disability (at least 6 on a scale of 0 to 10); 3) Signs or symptoms consistent with radiculopathy (eg, paresthesia, numbness, sensory change, weakness in a dermatomal distribution, diminished or absent deep tendon reflexes, positive Spurling, positive femoral nerve stretch test, or positive straight leg raise); 4) Documentation in the medical record of at least 6 weeks of active conservative therapy within the past 6 months OR documented inability to complete active conservative therapy due to contraindication, increased pain, or intolerance; 5) If imaging (eg, X-ray, CT, MRI) was performed, it demonstrates no condition that would preclude safe performance of the procedure.

Maximum of 2 initial injections

Subsequent (Therapeutic) Injections

CareSource considers therapeutic epidural steroid injections medically necessary when ALL of the following are met:

Therapeutic Injection - All required: 1) The diagnostic or most recent therapeutic injection for the current episode provided significant functional pain relief (at least 50%) as evidenced by decreased pain level, reduced pain medication use, and/or improved physical function; 2) The member continues to have ongoing pain or documented functional disability (at least 6 on a scale of 0 to 10); 3) At least 3 weeks have passed since the prior injection to allow pharmacodynamic effect; 4) The patient continues to engage in conservative therapy (active and/or inactive); 5) Frequency limits are observed (no more than 3 procedures in a 12-week period per region and overall limits below).>=50% relief for prior injection

Epidural steroid injections (ESIs) administered for labor and delivery or for immediate post-surgical pain do not require prior authorization and are excluded from the routine prior authorization requirement for chronic pain management. Ultrasound guidance for epidural injections is considered inappropriate and is not supported as a reimbursable separate service; real-time image guidance and injection of contrast are considered integral to the ESI procedure and are not separately billable.

Monitored anesthesia provided specifically as an added service for epidural injections is considered not medically necessary. If conscious sedation is required for patient comorbidity or per patient/physician preference, it is considered part of the procedure and not separately eligible for additional reimbursement when administered by a second provider. For members with implanted spinal cord stimulators or pain pumps, a device interrogation report and interpretation must be submitted with the authorization request; these device-related evaluations do not change the noncoverage stance for monitored anesthesia.

Use of particulate corticosteroid formulations for cervical transforaminal (TF) epidural injections is contraindicated per the FDA and is associated with rare but catastrophic neurovascular complications (eg, stroke or death). Cervical TF procedures carry higher arterial risk because of dense arterial anatomy near the intervertebral foramen; if a cervical TF injection is performed, inject contrast under real-time fluoroscopy and/or digital subtraction angiography (DSA) in a frontal plane before introducing any potentially hazardous substance, and avoid particulate steroids.

Provider Actions, Authorization & Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for epidural steroid injections (ESIs) except when performed for labor/delivery or for treatment of postoperative (post‑surgical) pain. Submit prior authorization requests before performing ESIs unless an exception applies. Authorization requests must include the clinical documentation elements described below.

Prior authorization required for all ESIs except labor/delivery and post‑surgical pain
Include full clinical documentation with the authorization request (see Documentation callout)
Requests for monitored anesthesia should follow limits below; monitored anesthesia is generally not considered medically necessary

Documentation Required

Conservative Therapy Requirement

Conservative, multidisciplinary management is required prior to authorization of ESIs unless there is a documented contraindication or inability to complete therapy. Conservative therapy includes both active and inactive modalities. An adequate trial typically consists of at least 6 weeks of active conservative therapy within the past 6 months (or documentation of inability to complete the prescribed home exercise program due to a valid clinical reason). In addition, inactive conservative therapies (eg, medication, heat/ice, TENS) should be documented. The member should also be actively engaged in ongoing conservative therapy when receiving subsequent therapeutic injections.

Document at least 6 weeks of active conservative therapy within the past 6 months OR a documented contraindication/intolerance that prevented completion
Document inactive conservative therapies and dates (eg, pharmacotherapy, TENS, modalities) during the prior authorization period
For subsequent/therapeutic injections, patient must continue to engage in conservative therapy

Billing Rule

Frequency, Limits & Monitored Anesthesia

Frequency limits apply to therapeutic and total epidural injections. No more than 3 procedures per anatomic region are considered medically necessary in any 12‑week period. A minimum interval of 3 weeks is required between injections to allow for pharmacodynamic effect. The maximum total number of epidural injections of any kind is 6 in a 12‑month period. Monitored anesthesia is generally not medically necessary; conscious sedation, if provided for comorbidity or physician/patient preference, is considered inclusive to the procedure and is not separately reimbursable.

Therapeutic injections: ≤3 procedures per region per 12 weeks
Minimum interval: ≥3 weeks between injections
12‑month maximum: ≤6 total epidural injections
Transforaminal/SNRB: ≤2 vertebral levels per treatment date
Interlaminar/caudal: ≤1 epidural injection per treatment date
Real‑time image guidance and contrast are inclusive; do not bill separately
Monitored anesthesia: generally not medically necessary; conscious sedation included in procedure payment

Conservative Treatment Prerequisites

Documented prior to initial injection; ongoing engagement required for therapeutic injections

Documentation of conservative therapy must be present prior to an initial injection and ongoing engagement is required for therapeutic injections:

Conservative Therapy Requirements: 1) Documentation in the medical record of at least 6 weeks of active conservative therapy (eg, physical therapy, occupational therapy, physician‑supervised home exercise program [HEP], chiropractic care) within the prior 6 months; 2) Inability to complete an active program must be due to a physical contraindication, increased pain, or intolerance (patient inconvenience or unexplained noncompliance is not acceptable); 3) Inactive conservative therapies (eg, TENS, medications, rest, heat/ice) may be documented as part of conservative care; 4) For therapeutic injections, continued engagement in conservative therapy must be documented during the treatment course.

Frequency and Quantity Limits

inv-16: Therapeutic epidural injections

LimitNo more than 3 therapeutic epidural procedures per anatomical region in a 12‑week period

Applies toTherapeutic (subsequent) epidural steroid injections when meeting criteria for ongoing injections

Rationale in policyFrequency limit stated under Subsequent (Therapeutic) Injections and Limitations

inv-17: All epidural injections

LimitMaximum of 6 epidural injections per member in any 12‑month period

ScopeIncludes all epidural approaches (transforaminal, interlaminar, caudal) regardless of levels

ConsequenceRequests exceeding this annual maximum may be denied

inv-18: Transforaminal epidurals / selective nerve root blocks

Limit per treatment dateFor transforaminal epidurals or selective nerve root blocks (SNRBs), perform no more than 2 vertebral levels per treatment date (unilateral or bilateral)

Applies toTransforaminal approach / selective nerve root blocks only

DocumentationLevels treated should be documented in the medical record for authorization and review

inv-19: Interlaminar or caudal epidural injections

Limit per treatment dateFor interlaminar or caudal epidural injections, no more than 1 epidural injection per treatment date

Applies toInterlaminar and caudal epidural approaches

Bundling noteReal-time image guidance and injection of contrast are inclusive components and not separately reimbursed

Imaging Guidance and Related Requirements

Note

Fluoroscopy/DSA required for cervical TF; imaging only for red flags

Real‑time fluoroscopy (and use of contrast/DSA when indicated) is required as part of epidural injections; for cervical transforaminal injections, inject contrast under real‑time fluoroscopy and/or DSA in the frontal plane before any potentially hazardous substance is administered. Routine imaging is otherwise reserved for red‑flag concerns.

Real‑time image guidance and any injection of contrast are inclusive components of epidural injections and are not separately reimbursed
Cervical transforaminal ESIs: perform contrast injection under real‑time fluoroscopy and/or DSA (frontal plane) before injecting therapeutic agent
Imaging (eg, X‑ray, CT, MRI) is recommended when red flags or suspected serious conditions are present, not routinely for nonspecific low back pain

Background on Epidural Steroid Injections

Epidural steroid injections (ESIs) are minimally invasive procedures that deliver corticosteroid into the epidural space to provide short-term regional pain reduction. Common approaches include the translaminar (interlaminar), transforaminal (TF), and caudal routes. ESIs are used as a trial intervention when conservative multidisciplinary management has not provided adequate relief; evidence for long-term efficacy is inconclusive, so ESIs are typically offered to achieve short-term functional improvement and symptom control while other therapies continue.

Real-time image guidance (fluoroscopy or digital subtraction angiography) and use of contrast are integral to the safe performance of ESIs, particularly for cervical TF injections where arterial anatomy increases risk. Imaging is otherwise reserved for patients with red-flag features (eg, suspected infection, malignancy, or acute neurologic compromise) or when targeted evaluation of the painful region is clinically indicated.

Definitions and Terminology

inv-12: Active Conservative Therapies

DefinitionActive Conservative Therapies: activities that strengthen muscle groups and target key spinal structures, including physical therapy, occupational therapy, physician‑supervised home exercise program (HEP), and/or chiropractic care

IncludesBoth active therapies (PT, OT, supervised HEP, chiropractic) and documented use of TENS as part of conservative care when recorded

Role in policyA documented trial of active conservative therapies is required prior to initial injection and continued engagement is required for therapeutic injections

Inactive therapiesPassive modalities (rest, ice/heat), medical devices, and pharmacotherapy are considered inactive conservative therapies and may be documented as part of the multimodal plan

inv-13: HEP (Home Exercise Program)

DefinitionHome Exercise Program (HEP): a physician‑supervised 6‑week program with an exercise prescription/plan and documented follow‑up in the medical record after completion

Alternative documentationIf the member cannot complete HEP due to a stated physical reason (eg, increased pain or inability to physically perform exercises), documentation of that inability is required; patient inconvenience or unexplained noncompliance does not qualify

TimingHEP must be documented within the past 6 months as part of the required conservative therapy prior to initial injection

inv-14: Epidural Steroid Injection (ESI)

DefinitionEpidural Steroid Injection (ESI): administration of steroids via a needle into the epidural space using translaminar, transforaminal, or caudal approaches intended for short‑term regional pain reduction

ApproachesSpecifically includes translaminar (interlaminar), transforaminal, and caudal approaches

Imaging and techniqueReal‑time image guidance and any injection of contrast are considered inclusive components of the procedure

OpenPayer