CurrentColorado Rocky Mountain Health PlansPolicy 2026T0616N

Epidural Steroid Injections for Spinal Pain (ESIs)

Defines UnitedHealthcare Commercial and Individual Exchange medical policy coverage criteria, limits, contraindications, coding references, and evidence summary for epidural steroid injections (ESIs) for radicular spinal pain.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyEpidural Steroid Injections for Spinal Pain (ESIs)

Policy CodePolicy 2026T0616N

Change TypeNo material change

Effective DateJun 1, 2026

Next Review Date

Key ActionDocument history/physical exam evidence of radicular pain, prior conservative therapies ≥4 weeks, imaging or electrodiagnostic confirmation of nerve root involvement, and validated outcome measures when requesting coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes.

4Max ESI sessions per region per year

>=4 wksRequired conservative trial

50%Pain/function threshold for subsequent injection

Coverage Summary

Epidural Steroid Injections (ESIs) are a nonsurgical treatment option for radiculopathy caused by disc herniation or degenerative changes, intended to relieve pain and improve function. Evidence supports short-term benefit for radicular (radicular back) pain, while there is insufficient evidence for effectiveness in nonradicular back pain. Coverage requires documentation of nerve root involvement by imaging or electrodiagnostic studies, and the procedure must be performed with fluoroscopic or computed tomography (CT) guidance. Scope: Defines UnitedHealthcare Commercial and Individual Exchange coverage criteria, limits, contraindications, coding references, and evidence summary for ESIs for radicular spinal pain.

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Not Medically Necessary / Unproven

The following are unproven and not medically necessary due to insufficient evidence of efficacy:

ANY of the following

The use of ultrasound guidance for ESIs
ESIs for all other indications of the spine not included above (i.e., nonradicular back pain and other non-specified indications)

Denial Risk

Ultrasound guidance not acceptable

ESI performed under ultrasound guidance is considered unproven and not medically necessary due to insufficient evidence of efficacy and may be denied.

Ultrasound guidance not acceptable

Limitations on Frequency / Subsequent Injections

Billing Rule

Session and region counting

Count one ESI session per date of service. Regions are defined as cervical, thoracic, or lumbosacral. A maximum of four sessions is allowed per region in a 12‑month period beginning with the date of the first approved injection.

Session and region counting

Documentation Required

Validated measurement tools for outcome assessment

Use validated measurement tools to document percent pain relief or functional improvement to determine eligibility for subsequent injections. Record whether prior injection response met thresholds (≤50% relief <3 months or ≥50% relief ≥3 months) as measured by validated instruments.

Validated measurement tools for outcome assessment

Coding

Imaging-guided epidural injection CPT codes (referenced)CPTCovered

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 (i.e., 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 (i.e., fluoroscopy or CT)
64479	Injection(s), transforaminal epidural, with imaging guidance; cervical or thoracic, single level
64480	Injection(s), transforaminal epidural, with imaging guidance; cervical or thoracic, each additional level
64483	Injection(s), transforaminal epidural, with imaging guidance; lumbar or sacral, single level
64484	Injection(s), transforaminal epidural, with imaging guidance; lumbar or sacral, each additional level

Diagnosis codes associated with radiculopathy / indications (referenced)ICD-10

M47.20	Other spondylosis with radiculopathy, site unspecified
M47.21	Other spondylosis with radiculopathy, occipito-atlanto-axial region
M47.22	Other spondylosis with radiculopathy, cervical region
M47.23	Other spondylosis with radiculopathy, cervicothoracic region
M47.24	Other spondylosis with radiculopathy, thoracic region
M47.25	Other spondylosis with radiculopathy, thoracolumbar region
M47.26	Other spondylosis with radiculopathy, lumbar region
M47.27	Other spondylosis with radiculopathy, lumbosacral region
M47.28	Other spondylosis with radiculopathy, sacral and sacrococcygeal region
M50.10	Cervical disc disorder with radiculopathy, unspecified cervical region

1–10 of 49

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Provider Actions

Prior Authorization

Documentation to support medical necessity

Medical records documentation may be required to support medical necessity. Required documentation should include: history and physical demonstrating radicular back pain; record of prior conservative therapies and duration (≥4 weeks); imaging or electrodiagnostic evidence of structural or functional nerve root involvement; and validated outcome measures showing response to prior injections when applicable.

Billing Rule

Session and region counting

Count one ESI session per date of service. Regions are defined as cervical, thoracic, or lumbosacral. A maximum of four ESI sessions per region is allowed in a 12‑month period beginning with the date of the first approved injection.

Documentation Required

Validated measurement tools for outcome assessment

Document percent pain relief and functional improvement using validated measurement tools to support decisions about subsequent ESIs. Specifically record whether prior injections produced ≤50% relief for <3 months or ≥50% relief for ≥3 months, as these thresholds guide repeat injection eligibility.

Denial Risk

Ultrasound guidance not acceptable

Epidural steroid injections performed under ultrasound guidance are listed as unproven and not medically necessary due to insufficient evidence compared with fluoroscopy or CT guidance and may be denied.

Background, Evidence, and Definitions

Indication and context: ESIs are indicated for management of Radicular Back Pain (pain radiating along a dermatomal distribution from spine to extremity) when supported by history and physical examination and when the pain is refractory to conservative therapy for at least ≥ 4 weeks. Conservative therapy may include pharmacotherapy (e.g., NSAIDs or acetaminophen), activity modification, and physical therapy or home exercise.

Required diagnostic confirmation and technique: Coverage requires evidence of structural and/or functional nerve root involvement by imaging or electrodiagnostic studies. ESIs must be performed under fluoroscopic or computed tomography (CT) guidance; the use of ultrasound guidance is considered unproven and not medically necessary due to insufficient evidence.

Evidence summary:

- AHRQ (2015): ESIs for radiculopathy were associated with immediate improvements in pain and might provide short-term functional improvement, but benefits were small and not sustained; limited evidence does not support effectiveness for spinal stenosis or nonradicular back pain (AHRQ 2015).

- Systematic reviews and RCTs: Multiple systematic reviews and RCTs show mixed but consistent evidence of short-term pain relief for radicular pain (including meta-analyses showing benefit at 1–3 months), while long-term benefit (≥ 6 months) and effectiveness for nonradicular axial back pain are insufficient or not demonstrated.

Term	Definition
Conservative Therapy	Consists of an appropriate combination of medication (for example, nonsteroidal antiinflammatory drugs, analgesics, etc.) in addition to physical therapy, spinal manipulation therapy, cognitive behavior therapy, or other interventions, based on the individual's specific presentation, physical findings, and imaging results.
Radicular Back Pain	Pain that radiates from the spine into the extremity along the course of the spinal nerve root. The pain should follow the pattern of a dermatome associated with the irritated nerve root identified.
Nonradicular Back Pain	Pain that does not radiate along a dermatome (sensory distribution of a single root). Appropriate imaging does not reveal signs of spinal nerve root compression, and there is no evidence of spinal nerve root compression seen on clinical examination.
Session	One date of service in which ESIs are performed.
Region	Either the cervical, thoracic, or lumbosacral region of the spine.