Centene TFESI SNRB Coverage Update

Coverage Criteria for SNRB and TFESI

inv-01: SNRB - Acute

One SNRB for acute pain management (pain < 3 months) is medically necessary when ALL of the following are met:

SNRB acute criteria: 1. Severe radicular pain in a specific nerve root distribution that interferes substantially with activities of daily living (ADLs).

SNRB acute criteria: 2. Severe pain persists after treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) and/or opiate (both ≥ three days or contraindicated/not tolerated).

SNRB acute criteria: 3. Cannot tolerate chiropractic or physical therapy, and the injection is intended as a bridge to therapy.

inv-02: SNRB - Chronic

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

SNRB chronic criteria: 1. Request is for an SNRB with a local anesthetic at a single nerve root.

SNRB chronic criteria: 2. Persistent radicular pain in a defined nerve root level, and the diagnosis remains uncertain after standard evaluation (neurologic examination, radiological studies and electrodiagnostic studies).

SNRB chronic criteria: 3. Pain interferes with activities of daily living (ADLs) and has lasted for at least three months.

SNRB chronic criteria: 4. Failure to respond to conservative therapy, including all of the following: a) ≥ 4 weeks chiropractic, physical therapy or prescribed home exercise program; b) NSAIDs ≥ 3 weeks or NSAID contraindicated/not tolerated; c) ≥ 4 weeks activity modification.

inv-03: SNRB - Second Injection

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

SNRB second: Multilevel pathology is suspected, and at least two weeks have passed since the prior injection.

inv-04: TFESI - Acute

One TFESI for acute pain management (pain < 3 months) is medically necessary when ALL of the following are met:

TFESI acute: 1. Severe radicular pain in a specific nerve root distribution that interferes substantially with activities of daily living (ADLs).

TFESI acute: 2. If a cervical TFESI is requested, non-particulate steroid must be used and the procedure must be conducted with real-time imaging (e.g., fluoroscopy).

TFESI acute: 3. Severe pain persists after treatment with NSAID and/or opiate (both ≥ three days or contraindicated/not tolerated).

TFESI acute: 4. Cannot tolerate chiropractic or physical therapy, and the injection is intended as a bridge to therapy.

inv-05: TFESI - Chronic Initial

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

TFESI chronic initial: 1. TFESI is requested for a single level bilaterally or up to two levels unilaterally.

TFESI chronic initial: 2. If a cervical TFESI is requested, non-particulate steroid must be used and the procedure must be conducted with real-time imaging (e.g., fluoroscopy).

TFESI chronic initial: 3. There is persistent radicular pain caused by disc herniation in a defined nerve root level, or spinal stenosis confirmed by physical exam and imaging.

TFESI chronic initial: 4. Pain interferes with activities of daily living (ADLs) and has lasted for at least three months.

inv-06: TFESI - Second (No improvement)

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

TFESI second: 1. Request is for a TFESI at one level bilaterally or up to two levels unilaterally.

TFESI second: 2. If a cervical TFESI is requested, non-particulate steroid must be used and the procedure must be conducted with real-time imaging (e.g., fluoroscopy).

TFESI second: 3. At least two weeks have passed since the first TFESI.

inv-07: TFESI - Subsequent After Improvement

Subsequent TFESIs for recurrence of chronic pain that had improved from prior TFESI(s) are medically necessary when ALL of the following are met:

TFESI subsequent: 1. TFESI requested at a single level bilaterally or up to two levels unilaterally.

TFESI subsequent: 2. If a cervical TFESI is requested, non-particulate steroid must be used and the procedure must be conducted with real-time imaging (e.g., fluoroscopy).

TFESI subsequent: 3. There was ≥ 50% relief and functional improvement for at least 3 months since the last injection.

TFESI subsequent: 4. Less than 4 injections have been given at the same site within 12 months.

inv-08: TFESI - Limits / Not Medically Necessary

Limits and exclusions:

TFESI limits: 1. Continuation of injections beyond 12 months is considered not medically necessary because effectiveness and safety have not been established; exceptions considered case-by-case when more definitive therapies cannot be tolerated or provided.

TFESI limits: 2. More than 4 therapeutic injections at the same site within 12 months is considered not medically necessary.

TFESI limits: 3. TFESIs (and SNRBs) for any indication other than those listed in this policy are considered not medically necessary because effectiveness has not been established.

SNRBs and TFESIs performed for indications other than those specifically listed in this policy are considered not medically necessary because effectiveness for other indications has not been established. This includes requests that do not meet the diagnostic or clinical criteria set forth for acute or chronic radicular pain in the Coverage Criteria sections.

This clinical policy is a coverage guideline and does not constitute medical advice or dictate clinical care. Providers retain full professional medical judgment and remain responsible for diagnosis and treatment decisions for their patients. The policy is intended to guide determinations of medical necessity and payment, not to replace individualized clinical decision-making.

Continuation of TFESIs beyond 12 months, or administering more than four therapeutic injections at the same site within a 12‑month period, is considered not medically necessary. These limits are administrative frequency/duration exclusions and may result in denial when exceeded.

Required Conservative Therapies Before Chronic Injections

Prior Authorization

Prior Authorization Required

Prior authorization is required for Transforaminal Epidural Steroid Injections (TFESI) and Selective Nerve Root Blocks (SNRB) CPT codes. Providers must document prior authorization approval before scheduling these procedures.

Affected procedures: TFESI and SNRB (all relevant CPT codes)
Obtain prior authorization before performing TFESI or SNRB

Frequency and Duration Limits

TFESI — Less than 4 therapeutic injections at the same site within 12 months

LimitLess than 4 therapeutic injections at the same site within 12 months

PeriodPer 12 months

Applies toTransforaminal Epidural Steroid Injection (TFESI) therapeutic injections

TFESI — Continuation beyond 12 months generally not covered

Coverage stanceContinuation of TFESIs beyond 12 months is generally not covered (not medically necessary)

Exception processWhen more definitive therapies cannot be tolerated or provided, consideration will be made on a case-by-case basis

Imaging and Procedure Requirements

Documentation Required

Obtain fluoroscopic or CT guidance (real-time for cervical)

Procedures must be performed with radiographic guidance; fluoroscopy or CT is required, and cervical TFESI must be conducted with real-time imaging (e.g., fluoroscopy).

Imaging guidance (fluoroscopy or CT) is required for SNRB and TFESI.
Cervical TFESI requires real-time imaging such as fluoroscopy.

Documentation Required

Document non-particulate steroid and real-time imaging for cervical TFESI

If requesting a cervical TFESI, document that a non-particulate steroid will be used and that the procedure will be performed with real-time imaging (for example, fluoroscopy).

Policy explicitly requires non-particulate steroid for cervical TFESI (see Table 1).
Document use of real-time imaging (e.g., fluoroscopy) for cervical procedures.

Coding and Therapeutic Thresholds

Referenced CPT CodesCPT

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).

Therapeutic response threshold for repeat TFESI — ≥ 50% relief and functional improvement for at least 3 months

Therapeutic threshold≥ 50% relief and functional improvement

Minimum duration of benefitSustained for at least 3 months since the last injection

Context for useRequired for eligibility for subsequent TFESI after prior improvement

Maximum therapeutic injections at same site — Less than 4 injections at same site within 12 months

Maximum per siteLess than 4 injections at the same site within 12 months

Counting ruleIncludes therapeutic TFESIs given at the same anatomic level/site

Provider Actions and Documentation Requirements

Prior Authorization

Obtain prior authorization and show medical necessity

Prior authorization is required for the referenced TFESI/SNRB CPT codes; authorization documentation must demonstrate that the member meets the medical necessity criteria specified in this policy.

Referenced CPT codes include 64479, 64480, 64483, 64484.
Documentation submitted with prior authorization must show the member meets all applicable criteria.

Prior Authorization

Verify Health Plan prior authorization and effective date

Verify the Health Plan's prior authorization requirements and effective date for this clinical policy before requesting services; plan-level administrative policies may apply.

The clinical policy is effective as determined by the Health Plan; the posting date may not be the effective date.
Confirm any plan-level notification or administrative requirements prior to scheduling.

Definitions

Selective Nerve Root Block (SNRB) — definition and typical diagnostic use

DefinitionInjection of a small amount of local anesthetic adjacent to a spinal nerve root primarily used diagnostically

Therapeutic variationSteroid may be added when used therapeutically (selective transforaminal epidural steroid injection)

Typical indicationUsed to help identify the specific nerve root causing radicular pain

Transforaminal Epidural Steroid Injection (TFESI) — definition and therapeutic intent

DefinitionInjection of local anesthetic and/or corticosteroid into the intervertebral foramen to target nerve roots

IntentUsed therapeutically to relieve radicular pain by delivering medication closer to affected nerve roots

Background

Selective nerve root blocks (SNRBs) and transforaminal epidural steroid injections (TFESIs) are targeted procedures used for radicular pain and may be used as alternatives to interlaminar or caudal epidural steroid injections. An SNRB typically places a small volume of local anesthetic adjacent to a specific spinal nerve root and is often used diagnostically; a TFESI delivers local anesthetic and/or corticosteroid into the intervertebral foramen to directly target the affected nerve root. Both procedures are performed under radiographic guidance (fluoroscopy or CT) to verify needle placement and optimize safety and accuracy.

Not Covered / Exclusions

TFESIs or SNRBs requested for indications not enumerated in this policy are not covered because clinical effectiveness has not been established. In addition, continuation of TFESIs beyond the stated administrative limits — specifically beyond 12 months or exceeding four therapeutic injections at the same site within 12 months — is not medically necessary and therefore not covered. Providers should verify plan-specific prior authorization requirements and applicable legal or state Medicaid provisions before proceeding.

Revision History

07/25Annual review / criteria revisionLatest

Added note in Description regarding caudal or interlaminar epidural steroid injections; removed anticoagulation therapy from formal criteria and added it as a note; updated subsequent TFESI sustained benefit requirement from two months to three months; removed prior requirement about length of time since last TFESI; coding and references reviewed.

07/24Annual review / approval

In I.B.4.a. and c. and II.B.5.a. and c. changed conservative therapy duration from six weeks to four weeks and added Table 1 with examples of particulate and non-particulate steroids; added description note about caudal or interlaminar epidural steroid injections; removed anticoagulation therapy requirement from Criteria and added anticoagulation as a note.

OpenPayer

Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections

Coverage Criteria for SNRB and TFESI

Required Conservative Therapies Before Chronic Injections

Frequency and Duration Limits

Imaging and Procedure Requirements

Coding and Therapeutic Thresholds

Provider Actions and Documentation Requirements

Definitions

Background

Not Covered / Exclusions

Revision History