Centene SNRB TFESI Coverage Update

Medical Necessity Criteria for SNRB and TFESI

General procedural prerequisites

Procedures are medically necessary when performed by a physician with radiographic guidance and only one procedure per visit; anticoagulation management is a clinical decision (note).

ALL of the following

Procedure performed by a physician
Radiographic guidance is used (e.g., fluoroscopy or CT)
Only one procedure is performed per visit

Selective Nerve Root Block (SNRB) — Acute management (one SNRB)

One SNRB for acute management (pain lasting less than three months) is considered medically necessary when ALL of the following are met:

ALL of the following

Severe radicular pain in a specific nerve root distribution that interferes substantially with activities of daily living (ADLs)
Pain lasting less than three months (acute)
Severe pain persists after treatment with NSAIDs and/or opioids for at least three days, or NSAID/opioid is contraindicated or not tolerated
Cannot tolerate chiropractic or physical therapy, and the injection is intended as a bridge to therapy

Selective Nerve Root Block (SNRB) — Chronic management (diagnostic / therapeutic)

One SNRB for chronic pain to establish diagnosis and confirm response is medically necessary when ALL of the following are met:

ALL of the following

Persistent radicular pain in a defined nerve root level
Diagnosis remains uncertain after standard evaluation (neurologic exam, radiologic studies, and electrodiagnostic studies)
Request is for an SNRB with a local anesthetic at a single nerve root
Pain interferes with ADLs and has lasted for at least three months
ALL of the following

Selective Nerve Root Block (SNRB) — Additional SNRB

A second SNRB for chronic pain is considered medically necessary when ALL of the following are met:

ALL of the following

Multilevel pathology is suspected
At least two weeks have passed since the prior SNRB

Selective Nerve Root Block (SNRB) — Not covered

SNRBs are considered not medically necessary when effectiveness has not been established for other indications.

ANY of the following

Any indication not specifically supported by the above criteria

Transforaminal Epidural Steroid Injection (TFESI) — Acute management (one TFESI)

One TFESI for acute management (pain lasting less than three months) is considered medically necessary when ALL of the following are met:

ALL of the following

Severe radicular pain in a specific nerve root distribution that interferes substantially with activities of daily living (ADLs)
Pain lasting less than three months (acute)
Severe pain persists after treatment with NSAIDs and/or opioids for at least three days, or NSAID/opioid is contraindicated or not tolerated
Cannot tolerate chiropractic or physical therapy, and the injection is intended as a bridge to therapy
If cervical TFESI is requested, a non-particulate steroid must be used and the procedure must be conducted with real-time imaging (e.g., fluoroscopy)

Transforaminal Epidural Steroid Injection (TFESI) — Chronic management (one TFESI)

One TFESI for chronic pain is considered medically necessary when ALL of the following are met:

ALL of the following

Request is for TFESI at a single level bilaterally or up to two levels unilaterally
Persistent radicular pain caused by disc herniation in a defined nerve root level or spinal stenosis confirmed by physical exam and imaging
Pain interferes with ADLs and has lasted for at least three months
ALL of the following
- At least four weeks of chiropractic, physical therapy, or prescribed home exercise program

Transforaminal Epidural Steroid Injection (TFESI) — Second TFESI after non-response

A second TFESI for chronic pain that did not improve after the initial injection is considered medically necessary when ALL of the following are met:

ALL of the following

Request is for TFESI at one level bilaterally or up to two levels unilaterally
At least two weeks have passed since the first TFESI
If cervical TFESI is requested, a non-particulate steroid must be used and the procedure must be conducted with real-time imaging (e.g., fluoroscopy)

Transforaminal Epidural Steroid Injection (TFESI) — Subsequent injections for recurrence after improvement

Subsequent TFESIs for recurrence of chronic pain that had improved from the first or second TFESI are considered medically necessary when ALL of the following are met:

ALL of the following

TFESI is requested at a single level bilaterally or up to two levels unilaterally
There was ≥ 50% relief and functional improvement for at least three months since the last injection
Less than four injections have been given at the same site within 12 months
Less than 12 months have elapsed since the initial injection at the level requested
If cervical TFESI is requested, a non-particulate steroid must be used and the procedure must be conducted with real-time imaging (e.g., fluoroscopy)

Transforaminal Epidural Steroid Injection (TFESI) — Not covered / Limits

The following are considered not medically necessary:

ANY of the following

TFESIs for any indication other than those supported by the criteria because effectiveness has not been established
Continuation of injections beyond 12 months or more than therapeutic injections (beyond stated limits) because effectiveness/safety not established; exceptions considered case-by-case when definitive therapies cannot be tolerated or provided

Numeric and Clinical Thresholds

Policy Thresholds

Conservative therapy duration4 weeks (e.g., chiropractic/physical therapy/prescribed home exercise and activity modification) and NSAIDs ≥ 3 weeks unless contraindicated

Pain duration to qualify as chronicAt least 3 months

Relief requirement for recurrence continuation≥ 50% relief and functional improvement for at least 3 months

Maximum injections at same siteLess than 4 injections within 12 months

1 per visitOnly one procedure allowed per visit

<=4Maximum injections at same site in 12 months

CPT Codes and Coding Notes

Transforaminal epidural injection CPT codesCPTCovered

64479	Injection(s), anesthetic agent(s) and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, single level
64480	Injection(s), anesthetic agent(s) and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, each additional level (List separately in addition to code for primary procedure)
64483	Injection(s), anesthetic agent(s) and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level
64484	Injection(s), anesthetic agent(s) and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level (List separately in addition to code for primary procedure)

What Providers Must Do

Prior Authorization

Document conservative therapy and diagnostic evaluation

Providers must document that conservative therapy was tried and standard diagnostic evaluation performed to support medical necessity prior to authorization for TFESI/SNRB (examples: four weeks of chiropractic/physical therapy/prescribed home exercise and activity modification; NSAIDs for ≥3 weeks unless contraindicated) and include neurologic exam, imaging, and electrodiagnostic studies as applicable.

Affected codes: 64479, 64480, 64483, 64484

Documentation Required

Injection details and relief documentation for repeat injections

When requesting subsequent injections for recurrence, document the exact level(s) treated, use of radiographic guidance, steroid type (non-particulate is required for cervical TFESI), dates of prior injections, and objective documentation that there was ≥50% relief and functional improvement for at least three months.

Clinical Background and Rationale

Epidural steroid injections—including caudal, interlaminar, and transforaminal approaches—and selective nerve root blocks (SNRBs) are procedures used to manage radiculopathy and spinal stenosis when conservative measures fail. These procedures are intended for patients with significant radicular symptoms or neurogenic claudication that substantially impair activities of daily living and who have not achieved adequate relief with standard, noninvasive treatments. (See related policy CP.MP.164 for caudal and interlaminar injections.)

Randomized trials and systematic reviews report that epidural steroid injections can provide short-term benefit up to three months, but long-term efficacy is inconsistent and not validated. SNRBs consist primarily of a small amount of local anesthetic injected adjacent to a spinal nerve root and are primarily diagnostic—used to identify the specific symptomatic nerve root. When the procedure is performed with therapeutic intent, a corticosteroid is added to the injectate (commonly called a selective transforaminal epidural steroid injection).

Procedural safety and technique considerations require performance by an appropriately trained physician with radiographic guidance, and steroid selection (for example, avoiding particulate formulations for cervical TFESI) is part of the clinical approach to reduce risk.

Defined Terms

Definitions — Steroid formulations

Particulate steroidSteroid formulations containing particles that may aggregate (examples: methylprednisolone acetate, triamcinolone acetonide, betamethasone acetate brands listed in Table 1).

Non-particulate steroidSteroid formulations with smaller particle size considered lower embolic risk (examples listed in Table 1; required for cervical TFESI). Note: Table 1 in policy lists examples of particulate and non-particulate steroids and the distinction is based on particle aggregation size relative to a red blood cell.

Policy Changes

07/25revisedLatest

Annual review: Added note in Description regarding caudal or interlaminar epidural steroid injections; removed anticoagulation therapy requirement from criteria and added anticoagulation as a clinical note; updated criteria regarding relief and functional improvement from two months to three months; removed a criterion regarding length of time since last TFESI. (Revision noted in policy header as Date of Last Revision 07/25).

07/24revised

Revision: Duration requirement for conservative therapy changed from six weeks to four weeks and Table 1 was added to provide examples of particulate and non-particulate steroids; references reviewed and updated (Revision Date = 07/24).

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Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections

Medical Necessity Criteria for SNRB and TFESI

Numeric and Clinical Thresholds

CPT Codes and Coding Notes

What Providers Must Do

Clinical Background and Rationale

Defined Terms

Policy Changes

Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections

Medical Necessity Criteria for SNRB and TFESI

Numeric and Clinical Thresholds

CPT Codes and Coding Notes

What Providers Must Do

Clinical Background and Rationale

Defined Terms

Policies to Read With This One

Policy Changes