ModifiedColorado Rocky Mountain Health PlansPolicy CS039.AA

Epidural Steroid Injections for Spinal Pain

Policy governing medical necessity, coverage criteria, limits, and coding for epidural steroid injections (ESI) for radicular spinal pain for Colorado Rocky Mountain Health Plans membership; excludes several listed states with state-specific policies.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyEpidural Steroid Injections for Spinal Pain

Policy CodePolicy CS039.AA

Change TypeRevised coverage criteriaadded documentation requirementhousekeeping updates

Effective DateAug 1, 2025

Next Review Date

Key ActionObtain prior authorization and document ≥4 weeks of conservative therapy, imaging or electrodiagnostic evidence of nerve root involvement, and use of fluoroscopic or CT guidance.

SourceLink

POLICY UPDATE CHANGES

Revised coverage criteria for Epidural Steroid Injections (ESI) replacing 'imaging or electromyography (EMG)' with 'imaging or electrodiagnostic studies'.

Added language that medical records documentation may be required to assess whether the member meets clinical criteria for coverage.

Removed content/language pertaining to the state of Louisiana.

Removed reference link to state-specific policy version (retired Feb. 1, 2026).

Updated Clinical Evidence and References sections to reflect the most current information.

4max ESI sessions/region/year

>=4 wksmin conservative therapy

≤50%

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.

pain relief threshold for reauth

fluoroscopy/CTrequired imaging guidance

ultrasoundmethod labeled NMN

Coverage Criteria for Epidural Steroid Injections (ESI)

Repeat/Continuation Criteria — Covered when ALL of the following are met:

ALL of the following

There is prior documentation of a clinically meaningful response (pain reduction and/or functional improvement) to a prior epidural steroid injection in the same anatomic region for the same clinical indication; and
The interval since the prior epidural steroid injection is appropriate per specialty guideline recommendations and individualized response (examples: ≥2½ to 3 months between injections if >50% relief was obtained for 2½ to 3 months; do not exceed 4 injections per region per year unless clinically justified).
References: ASIPP 2021; WFNS 2020
There is documentation that conservative therapy was continued or optimized between injections as clinically appropriate (for example pharmacotherapy, activity modification, physical therapy, or home exercise programs).
The current injection is being provided for the same radicular pain indication supported by prior imaging or electrodiagnostic evidence of nerve root involvement, or new objective findings supporting ongoing radiculopathy.
There is clinician documentation describing the clinical benefit observed from previous injections (magnitude and duration of pain relief, functional gains) and the rationale for repeat injection.
Medical records documentation may be required to assess whether the member meets the clinical criteria for continuation therapy.

Conservative Care and Trial Requirements Before ESI

inv-35: Must document failure of conservative therapy prior to ESI

Must document failure of conservative therapy prior to ESI:

Minimum duration: Documented failure of an adequate trial of conservative therapy for at least 4 weeks prior to ESI>= 4 weeks

Conservative Therapy includes medication (e.g., NSAIDs), activity modification, and physical therapy/home exercise as described in definitions

Conservative modalities: Conservative therapy should include pharmacotherapy (e.g., NSAIDs or acetaminophen), activity modification, or physical therapy/home exercise unless documented as inappropriate or contraindicated

Definition of Conservative Therapy (AHRQ, Qassem, Summers)

inv-36: documented trial of conservative therapy or rationale for earlier intervention

Documented trial of conservative therapy or rationale for earlier intervention:

Limits on Number and Frequency of Epidural Steroid Injections

Epidural Steroid Injection (per region) — Maximum 4 ESI sessions

LimitMaximum 4 ESI sessions per region (per 12 months)

Session definitionOne date of service in which ESI injection(s) are performed

Region definitionCervical, thoracic, or lumbosacral region

Year definition12-month period starting from the date of service of the first approved injection

therapeutic epidural steroid injections (per region) — not to exceed 4 injections per year per region

Annual frequency capTherapeutic epidural steroid injections not to exceed 4 injections per year per region

Imaging and Electrodiagnostic Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for epidural steroid injections (ESI). Check the member’s Plan/Contract and obtain authorization before scheduling the procedure. Failure to obtain prior authorization may result in claim denial or nonpayment.

Prior authorization required for ESI — verify member-specific benefits and obtain authorization prior to service.
Check Plan/Contract for Authorization — benefit coverage is governed by federal, state, and contractual requirements; medical record submission does not guarantee coverage.

Billing Rule

Frequency Limits (ASIPP Guidance)

Frequency limits follow ASIPP guidance: in the therapeutic phase, if >50% pain relief is obtained and sustained for 2½ to 3 months, repeat injections may be considered but do not exceed 4 injections per region per year. Long‑term repeated use is limited by diminishing benefit and safety concerns.

Applicable Codes and Coding Rules

Applicable CPT CodesCPT

62320	Injection(s), interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance.
62321	Injection(s), interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (fluoroscopy or CT).
62322	Injection(s), interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance.
62323	Injection(s), interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (fluoroscopy or CT).
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), transforaminal epidural, with imaging guidance; cervical or thoracic, each additional level.
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), transforaminal epidural, with imaging guidance; lumbar or sacral, each additional level.

Applicable ICD-10 Codes (selected list)ICD-10

M47.20	Other spondylosis with radiculopathy, site unspecified.
M47.25	Other spondylosis with radiculopathy, thoracolumbar region.
M51.15	Intervertebral disc disorders with radiculopathy, thoracolumbar region.
M54.10	Radiculopathy, site unspecified.
M96.1	Postlaminectomy syndrome, not elsewhere classified.
G54.2	Cervical root disorders, not elsewhere classified.
G54.3	Thoracic root disorders, not elsewhere classified.
M50.10	Cervical disc disorder with radiculopathy, unspecified cervical region.
M50.121	Cervical disc disorder at C4-C5 level with radiculopathy.
M51.16	Intervertebral disc disorders with radiculopathy, lumbar region.

1–10 of 16

1/2

FDA and drugs mentionedmixed

No codes listed

ESI session limit — Maximum 4 sessions per region per 12 months (year defined from date of first approved injection)

Maximum sessions per region per 12 monthsMaximum 4 sessions per region per 12 months (year defined from date of first approved injection)

Session definitionOne date of service in which ESI injection(s) are performed

Region definitionCervical, thoracic, or lumbosacral region

N/A

StatusN/A

NotePolicy history contains state-specific application and template updates; refer to policy history for details

Provider Requirements and Actions

Prior Authorization

Prior authorization required for ESI requests

Obtain prior authorization when requesting ESIs to confirm all coverage criteria are met, including radicular indication, ≥4 weeks of conservative therapy, imaging/electrodiagnostic evidence, and use of fluoroscopic or CT guidance.

Prior authorization is used to verify indication, conservative therapy trial, objective evidence, and appropriate imaging guidance.
Applicable 'with imaging guidance' CPT codes are listed in the policy.

Step Therapy

Adhere to ASIPP frequency guidance and policy limits

Follow ASIPP guidance when considering frequency of therapeutic ESIs: space injections approximately 2½–3 months apart and generally do not exceed four injections per year per region when >50% relief is obtained.

ASIPP suggests 2½–3 months between injections during the therapeutic phase.
Policy limits a maximum of 4 ESI sessions per region per 12 months (year starts with first approved injection).

Definitions and Key Terms

Conservative Therapy

DefinitionConservative Therapy consists of an appropriate combination of medication (for example, NSAIDs, analgesics) plus physical therapy, spinal manipulation, cognitive behavioral therapy, or other interventions tailored to the individual

Required duration prior to ESIMust document failure of conservative therapy for ≥ 4 weeks before ESI in most cases

Examples of componentsMedication, activity modification, structured physical therapy/home exercise, spinal manipulation, CBT

Epidural Steroid Injections (ESI)

DefinitionEpidural Steroid Injections (ESI) are injections of corticosteroid and/or local anesthetic into the epidural space to relieve radiculopathy from disc herniation or degenerative changes

Approaches

Background and Evidence Summary

Epidural steroid injections (ESIs) are a nonsurgical interventional therapy intended to relieve radicular pain related to disc herniation or degenerative spinal changes by delivering corticosteroid, often with local anesthetic, into the epidural space via interlaminar, transforaminal, or caudal approaches. Clinical studies and guideline reviews indicate ESIs can provide short-term improvement (commonly up to 1–3 months) for selected patients with radiculopathy, and certain techniques (e.g., lumbar transforaminal injections for disc herniation) have stronger supporting evidence. Image guidance (fluoroscopy or CT) and careful patient selection are emphasized in guidance documents.

Services Not Covered / Considered Not Medically Necessary

Not covered items highlighted in the policy include: the use of ultrasound guidance for epidural steroid injections, which the policy lists as unproven/not medically necessary given limited evidence of benefit over fluoroscopy/CT; and ESI for non‑radicular low back pain, which guideline statements and evidence reviews do not support. Requests lacking documentation of radicular symptoms, appropriate conservative therapy, or required imaging/electrodiagnostic evidence may be denied.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyEpidural Steroid Injections for Spinal Pain

Policy CodePolicy CS039.AA

Change TypeRevised coverage criteriaadded documentation requirementhousekeeping updates

Effective DateAug 1, 2025

Next Review Date

Key ActionObtain prior authorization and document ≥4 weeks of conservative therapy, imaging or electrodiagnostic evidence of nerve root involvement, and use of fluoroscopic or CT guidance.

SourceLink

On This Page

Guideline-recommended waiting period: For acute or subacute radicular pain, consider attempting conservative management (e.g., NSAIDs, therapeutic exercise) and waiting approximately 3 weeks before ESI unless clinical circumstances justify earlier interventionduration ~3 weeks

ACOEM (2021) recommends waiting at least 3 weeks for select acute/subacute radicular pain; WFNS recommends at least 3 weeks of therapeutic exercise for lumbar spinal stenosis in non-severe cases

Rationale for earlier ESI: If earlier ESI is performed, the medical record should document the clinical rationale (for example, severe neurologic deficit, intolerable pain despite initial conservative measures, or progressive neurologic decline)

Guideline recommendations allow immediate intervention in select severe cases; documentation required to justify deviation from usual waiting period

ASIPP therapeutic phase guidanceSpace injections approximately 2½–3 months apart when >50% relief is obtained

Condition for additional injectionsSubsequent injections allowed when radicular pain returns and functional deterioration occurs

epidural injections for lumbar spinal stenosis — Do not repeat injections if symptomatic relief lasted <3 months

Repeat injections guidance for LSSDo not repeat injections if symptomatic relief lasted <3 months

Role of steroids in LSSInclusion of steroids does not confer benefit compared with local anesthetic alone for LSS

Conservative-first recommendationFor non-severe lumbar spinal stenosis, at least 3 weeks of therapeutic exercise is recommended as initial approach

Epidural steroid injection — (additional frequency note)

Reauthorization pain thresholdPrevious injection response tracked using ≥ or ≤ 50% pain relief/functional improvement to guide further injections

Timing between injectionsSuggested spacing ~2½–3 months in therapeutic phase when >50% relief obtained

Requirement for reassessmentIf prior relief ≤ 50% for <3 months, reassessment of individual and technique is required before repeating injection

Frequency limit — generally not more than 4 ESIs per region per 12 months.
ASIPP recommendation — interval of 2½ to 3 months (or longer) between injections when >50% relief is achieved.

Denial Risk

Triggers for Denial and Safety Considerations

ESI may be denied if documentation does not support radicular pain, failure of required conservative therapy, lack of evidence of structural/functional nerve root involvement on imaging or electrodiagnostic studies, or absence of appropriate image guidance documentation. Also consider denial when indications reflect primarily axial (nonspecific) low back pain without radicular features.

Triggers for denial: no prior authorization when required; insufficient conservative therapy prior to ESI; no evidence of nerve root involvement on imaging/electrodiagnostics; lack of fluoroscopic/CT guidance documentation.
Safety & limited long-term benefit — repetitive long-term ESIs have limited proven long-term benefit and carry safety risks.

Effective dateSee Policy History for revision dates and details

Note

Check plan/contract requirements before authorization

Verify federal, state, and contractual benefit plan requirements and prior authorization processes before submitting ESI requests; this policy is informational for standard benefit plans and may not govern all plans.

In the event of conflict, federal, state, or contractual requirements govern coverage.
Check plan-specific authorization rules as terms may differ from the standard policy.

Step Therapy

Document ≥4 weeks of conservative therapy before ESI

Document at least 4 weeks of conservative therapy (e.g., NSAIDs/acetaminophen, activity modification, or physical therapy/home exercise) prior to ESI unless a documented rationale for earlier intervention is provided.

Conservative Therapy includes medication plus PT, spinal manipulation, CBT, or other individualized interventions.
Policy requires radicular pain unresponsive to conservative treatment for ≥4 weeks for coverage.

Step Therapy

Attempt guideline-recommended conservative treatment duration before ESI

When guidelines recommend, attempt conservative measures (e.g., NSAIDs, therapeutic exercise) and consider waiting a period (commonly ~3 weeks for acute/subacute radicular pain) before ESI; for lumbar spinal stenosis consider at least 3 weeks of therapeutic exercise.

ACOEM recommends waiting at least 3 weeks for acute/subacute radicular pain before ESI.
WFNS recommends ≥3 weeks of therapeutic exercise in non-severe lumbar spinal stenosis prior to surgery and cautions about repeating injections if relief <3 months.

Documentation Required

Include required documentation with authorization request

Provide medical records documenting history and physical exam consistent with radicular pain, documentation of ≥4 weeks of conservative therapy (or rationale for earlier intervention), imaging or electrodiagnostic evidence of nerve root involvement, and documentation that the procedure will use fluoroscopic or CT guidance.

Medical records may be required to assess whether the member meets clinical criteria, and documentation does not guarantee coverage.
Include objective evidence that clinical presentation correlates with imaging/electrodiagnostic findings.

Documentation Required

Document image guidance and target confirmation

Document fluoroscopic or CT guidance and confirmation of needle position/contrast flow in the procedural record to support correct placement and safety.

Multiple studies and guideline statements describe fluoroscopic confirmation and contrast spread as important for ensuring correct needle placement.
Provide procedure note details showing image guidance and target confirmation.

Documentation Required

Provide medical records for review when requested

Be prepared to supply medical records to demonstrate the member meets the policy's clinical criteria; submission of records is sometimes required for review but does not guarantee coverage.

Benefit coverage is determined by federal, state, or contractual requirements; policy-added language notes that medical records may be required to assess clinical criteria.
Medical records documentation used for reviews should follow the referenced guidelines.

Denial Risk

Avoid common triggers for denial

Requests lacking documentation of radicular pain, lacking ≥4 weeks of conservative therapy (or rationale for earlier intervention), lacking imaging or electrodiagnostic evidence of nerve root involvement, or using ultrasound guidance may be denied.

Ultrasound guidance for ESIs is listed as unproven and not medically necessary.
Absence of required clinical or objective documentation are common triggers for denial.

Denial Risk

Discuss FDA safety warnings and obtain informed consent

Discuss risks and benefits with patients before ESI; be aware the FDA warns of rare but serious adverse events (e.g., stroke, paralysis, death) and that corticosteroids are not FDA‑approved for epidural use.

FDA notes injectable corticosteroids are approved drugs but their epidural administration effectiveness and safety have not been established and added label warnings in 2014.
Rare but serious neurologic events have been reported; document informed consent discussion.

Billing Rule

Follow plan- and jurisdiction-specific documentation and coverage rules

Ensure coverage decisions and documentation follow applicable federal, state, and contractual benefit plan requirements; failure to meet plan-specific documentation or contractual rules may result in denial.

Policy history notes added language that medical records documentation may be required and that coverage is subject to federal/state/contractual requirements.
In event of conflict, federal/state/contractual requirements govern coverage.

Can be performed via interlaminar, transforaminal, or caudal approaches with image guidance

Safety noteCorticosteroids are not FDA‑approved for epidural use and FDA has warned of rare but serious adverse events (eg, stroke, paralysis, death); discuss risks and benefits with patients

Radicular Back Pain

DefinitionRadicular Back Pain radiates from the spine into the extremity along the course of a spinal nerve root and follows a dermatome pattern

Clinical correlationPresentation should correlate with imaging and exam findings to support nerve root involvement

DistinctionNon-radicular back pain does not follow a dermatome and lacks imaging or exam evidence of nerve root compression

Epidural steroid injection

DefinitionEpidural steroid injection: injection of corticosteroid, often with local anesthetic, into the epidural space via interlaminar, transforaminal, or caudal approaches

Image guidanceImage guidance (fluoroscopy or CT) is recommended to ensure correct needle placement and confirm contrast spread

EvidenceTransforaminal injections for radicular pain due to disc herniation have Level I evidence supporting efficacy for short to intermediate term pain and function improvement

Epidural corticosteroids

Regulatory statusFDA has not approved corticosteroids specifically for epidural use

Common agentsInjectable corticosteroids commonly used include methylprednisolone, hydrocortisone, triamcinolone, betamethasone, and dexamethasone

FDA safety communicationFDA warned (April 2014) of rare but serious neurologic adverse events and requires label warnings for injectable corticosteroids

Electrodiagnostic studies

DefinitionElectrodiagnostic studies: tests such as EMG and nerve conduction studies used to demonstrate functional nerve root involvement

Role in coverageEvidence of structural and/or functional nerve root involvement may be demonstrated by imaging or electrodiagnostic studies for coverage consideration

DocumentationElectrodiagnostic studies may be required when imaging is inconclusive to support radicular pathology