CurrentCareSourcePolicy N/A

Epidural Steroid Injections (ESIs) — AR PASSE

Criteria, limitations, and coverage policy for epidural steroid injections for chronic spinal/radicular pain for members under CareSource Arkansas PASSE.

Policy Summary

PayerCareSource

PolicyEpidural Steroid Injections (ESIs) — AR PASSE

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization documenting all medical necessity criteria including pain ≥6/10, at least 6 weeks of conservative therapy, and required imaging when indicated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6max injections /12 months

6 wksmin conservative therapy

50%min pain/function improvement

≤3procedures per region /12 wks

≤2vertebral levels /TF ESI

Coverage Criteria for Epidural Steroid Injections

Policy Summary

PayerCareSource

PolicyEpidural Steroid Injections (ESIs) — AR PASSE

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization documenting all medical necessity criteria including pain ≥6/10, at least 6 weeks of conservative therapy, and required imaging when indicated.

SourceLink

On This Page

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inv-01: Initial (Diagnostic) Injection

Covered when ALL of the following are met

Initial (Diagnostic) ESI criteria: 1) Pain located in cervical, thoracic, or lumbar spine and predominantly radiating/shooting in nature; 2) Functional disability with pain ≥ 6 on a 0–10 scale; 3) Signs or symptoms consistent with radiculopathy (eg, paresthesia, numbness, sensory change, weakness in a dermatomal distribution, positive Spurling test, positive femoral nerve stretch test, positive straight leg raise); 4) Documentation 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) Documentation of at least 6 weeks of inactive conservative therapy within the past 6 months; 6) If imaging (eg, CT, MRI, X-ray) was performed, it demonstrates no condition that would preclude safe performance of the procedure.

Maximum of 2 initial diagnostic injections allowed; diagnostic injection counts toward total.

inv-02: Subsequent (Therapeutic) Injections

Therapeutic injections covered when ALL of the following are met

Therapeutic ESI continuation criteria: 1) Prior diagnostic or therapeutic injection for the current episode provided significant functional pain relief of at least 50% (eg, decreased pain level, reduced analgesic use, and/or increased physical function); 2) Member continues to have ongoing functional disability (≥ 6 on a 0–10 scale); 3) No more than 3 procedures per region in a 12-week period; 4) At least 3 weeks have passed since the prior injection to allow pharmacodynamic effect; 5) Patient continues to engage in conservative therapy.

Maximum of 6 epidural injections per member in any 12-month period.

Epidural steroid injections performed for labor and delivery or for post-surgical pain are exempt from medical necessity review and do not require prior authorization evaluation under this policy. When these injections occur in the peripartum or immediate post-operative setting, standard documentation for the procedure should be maintained in the medical record but a separate medical necessity review is not required. If monitored anesthesia is proposed in these contexts, see the policy stance on monitored anesthesia below.

Use of monitored anesthesia (monitored anesthesia care) for epidural steroid injections is considered not medically necessary. The policy treats monitored anesthesia as an excluded component of epidural injection services; conscious sedation, when required for co-morbidities or clinician/patient preference, is considered part of the procedure and is not separately reimbursable.

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required — all medical necessity criteria must be met

Prior authorization is required and will be approved only when ALL medical necessity criteria are met and fully documented in the medical record. Incomplete or missing documentation may result in denial of the request.

Prior authorization required — submit complete clinical documentation with request
Missing required documentation (see below) may lead to denial

Denial Risk

Documentation deficiencies risk denial

Documentation deficiencies increase the risk of denial. Ensure the medical record and prior authorization submission include: pain severity (numeric scale), evidence of functional disability, detailed history and physical exam findings supporting radiculopathy, imaging reports if obtained, documentation of conservative therapy (active and inactive) with dates and response, and notes describing prior injections and outcomes.

Pain severity documented (≥6/10 when indicated)
Functional disability described and quantified
Imaging reports (CT, MRI, X‑ray) if performed included
Record of response to prior diagnostic/therapeutic injections

Documentation Required

Device documentation — implanted stimulators or pumps

If the patient has an indwelling implanted spinal cord stimulator or intrathecal pump, include a device interrogation report and interpretation with the prior authorization request. If the device is malfunctioning, document evaluation and any device-related management or recommendations.

Include device interrogation report and clinician interpretation
Document device function status and any escalation or device management when applicable

Background

Epidural steroid injections (ESIs) — delivered via translaminar, transforaminal, or caudal approaches — are minimally invasive interventional procedures intended to provide diagnostic or short-term therapeutic relief for chronic spinal and radicular pain when conservative management has not produced adequate benefit. ESIs may reduce pain and improve function for some patients in the short term; however, long-term efficacy is variable. Candidates for ESIs should have documentation of pain location, severity, associated neurologic signs or radicular symptoms, engagement in conservative therapies, and any imaging performed that would affect procedural safety.

Definitions

inv-13: Conservative Therapy

DefinitionConservative Therapy: a multimodal plan including active therapies (physical therapy, occupational therapy, physician‑supervised HEP, chiropractic care) and inactive therapies (rest, ice/heat, TENS, pharmacotherapy)

Active therapy examplesPhysical therapy, occupational therapy, physician‑supervised home exercise program (HEP), chiropractic care

Inactive therapy examplesRest, ice/heat, medical devices, TENS, prescription or over‑the‑counter pharmacotherapy (eg, NSAIDs, acetaminophen)

inv-14: HEP

HEP definitionA 6‑week home exercise program requiring an exercise prescription/plan and a documented follow‑up in the medical record after completion

Documentation of inability to completeIf unable to complete HEP due to physical reasons (increased pain, inability to perform exercises), documentation of the reason must be in the record; patient inconvenience or unexplained noncompliance is not acceptable

Role in conservative therapy requirementHEP counts as active conservative therapy and must be documented within the past 6 months for initial ESI prior authorization

inv-15: Epidural Steroid Injection

Epidural Steroid Injection (general)Administration of steroids via a needle inserted in the epidural space (between the ligamentum flavum and the dura) using translaminar, transforaminal, or caudal approaches

Translaminar approachNeedle placed between the ligamentum flavum and dura in the midline/interlaminar space to deliver steroid into the posterior epidural space

Transforaminal approachNeedle directed into the neural foramen to place steroid adjacent to the affected nerve root (selective nerve root block / transforaminal ESI)

Caudal approachNeedle introduced via the sacral hiatus to access the epidural space from a caudal entry point

Conservative Treatment Requirements

inv-16: Required prior to initial epidural steroid injection unless documented contraindication or inability to complete — 6 weeks

Conservative therapy prerequisite before initial ESI: At least 6 weeks of active conservative therapy (eg, physical therapy, occupational therapy, physician‑supervised home exercise program [HEP]) within the past 6 months AND at least 6 weeks of inactive conservative therapy within the past 6 months unless there is a documented contraindication or documented inability to complete active therapy due to increased pain, physical inability, or intolerance.6 weeks

Required prior to initial epidural steroid injection unless documented contraindication or inability to complete.

Frequency and Quantity Limits

inv-17: epidural steroid injections

12‑week regional limitNo more than 3 epidural steroid injection procedures in a 12‑week period per region

Applies toLimit applies per anatomic region (eg, cervical, thoracic, lumbar) as specified in therapeutic continuation criteria

Therapeutic injection conditionTherapeutic injections must also meet other continuation criteria (eg, ≥50% functional pain relief from prior injection, ≥3 weeks since prior injection)

inv-18: all epidural injections

12‑month member maximumMaximum of 6 epidural injections per member in any 12‑month period regardless of number of levels treated

Counts all epidural approachesIncludes interlaminar, transforaminal, and caudal injections toward the 6‑injection limit

Enforced on prior authorizationThis maximum is a hard limit noted in limitations and exclusions and used in medical necessity review

inv-19: transforaminal epidural/selective nerve root block

Per‑date vertebral level limitTransforaminal epidurals or selective nerve root blocks: no more than 2 vertebral levels per treatment date (unilateral or bilateral)

ScopeLimit applies whether performing unilateral or bilateral procedures on the treatment date

Counts toward total limitsEach level treated counts toward overall injection frequency limits for the member

inv-20: interlaminar or caudal epidural injections

Per‑date interlaminar/caudal limitFor interlaminar or caudal epidural injections, no more than 1 epidural injection per treatment date should be performed

Applies toThis restriction is specific to interlaminar (interlaminar/translaminar) and caudal approaches per treatment date

Inclusion in paymentReal‑time image guidance and any injection of contrast are inclusive components of the epidural injection procedure and not billed separately

Imaging Requirements

Note

Obtain imaging when red flags or progressive neurologic deficits present

Obtain imaging of the symptomatic region when severe or progressive neurologic deficits or suspected serious underlying conditions are present; any imaging performed must not demonstrate a condition that would preclude safe performance of the procedure.

Imaging is recommended to evaluate specific causes (eg, herniated disc, stenosis, fracture, tumor) or when red flags/progressive deficits are present.
If imaging is performed, it must show no contraindication to safely perform the ESI.

Billing Rule

Use real-time fluoroscopy/DSA for cervical transforaminal ESIs

For cervical transforaminal ESIs, inject contrast under real-time fluoroscopy and/or digital subtraction angiography (DSA) in the frontal plane prior to injecting any potentially hazardous substance; particulate steroids must not be used for cervical TF injections.

Use real-time fluoroscopy/DSA to visualize contrast before injecting.
Do not use particulate steroids for cervical transforaminal injections.

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