Epidural Steroid Injections and Selective Nerve Root Blocks
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Coverage criteria and prior authorization guidance for diagnostic selective nerve root blocks (SNRBs) and therapeutic epidural steroid injections (interlaminar, transforaminal, caudal) for musculoskeletal spine indications under Cigna-administered plans.
No material clinical or coverage changes in this revision.
Coverage Criteria for SNRB and ESI
inv-01: Diagnostic SNRB - Initial Level
Covered when ALL of the following are met:
See chunk 11 for list of clinical scenarios.
inv-02: Diagnostic SNRB - Additional Levels
Covered when ALL of the following are met:
Chunk 12
inv-03: Initial ESI (ILESI, CESI, TFESI)
An initial ESI is considered medically necessary for ANY of the listed conditions when ALL associated criteria are met.
See chunks 13-17 for individual indication criteria.
Chunk 14
Chunk 15
Chunk 16
Chunk 17
inv-04: Repeat ESI
Covered when ALL of the following are met:
Chunk 18
inv-05: Repeat Interlaminar, Caudal, or Transforaminal ESI
Covered when ALL of the following are met:
All elements must be met
inv-06: Selective Nerve Root Block (SNRB) - Not Medically Necessary Conditions
Not medically necessary when ANY of the following apply:
Any listed condition makes the procedure not medically necessary
inv-07: Epidural Steroid Injection (ESI) - Not Medically Necessary Conditions
An ESI is considered not medically necessary when performed without meeting Definitions, General Guidelines, and Indications. ALL of the following are specified not medically necessary scenarios:
Any listed condition makes the procedure not medically necessary
Epidural injections administered for obstetrical or surgical epidural anesthesia, for perioperative pain management, or for epidural catheter placement for trial of an implantable pump are considered out of scope for this guideline and may be redirected to the health plan for review. The guideline applies to SNRBs and ESIs for the indications listed in the policy, and determinations of medical necessity are made on a case-by-case basis.
This guideline applies only to injections of an anesthetic, corticosteroid, and/or contrast agent. Procedures using biologic injectates (for example, platelet rich plasma, stem cells, or amniotic fluid) administered alone or in combination are out of scope and explicitly listed as not covered under the policy.
Image guidance for SNRBs and ESIs is required to be fluoroscopic or CT with contrast except in contraindicated emergent situations; procedures performed with ultrasound guidance are explicitly described as not medically necessary. Likewise, use of injectates other than anesthetic, corticosteroid, and/or contrast (including biologics) is not within the scope of this guideline.
The References section provides citations supporting clinical context and comparative effectiveness but does not contain explicit coverage exclusion statements or implementation rules; coverage exclusions and non-indications are specified elsewhere in the policy.
Examples of Selective Nerve Root Blocks that would be considered not medically necessary include: performing a diagnostic SNRB when the policy's Definitions, General Guidelines, and Indications are not met; using ultrasound guidance instead of fluoroscopy/CT with contrast; or using injectates other than anesthetic/corticosteroid/contrast (for example, biologics).
Examples of scenarios where an SNRB or ESI would be not medically necessary include: treatment for non-indicated conditions such as post-herpetic neuralgia or axial spinal pain without radiculopathy; performing ESIs or SNRBs with ultrasound guidance; or using nonstandard injectates (e.g., biologics). Additionally, diagnostic or therapeutic injections that do not meet the policy's required documentation and indication criteria are subject to denial.
The excerpted references list contains bibliographic citations and evidence summaries but does not itself include explicit 'not medically necessary' statements; those non-coverage statements are presented in the policy's Non-Indications/General Guidelines sections.
Procedure Codes, Limits, and Timing
Prior Authorization, Documentation, and Billing Notes
Prior authorization and image-guidance requirement
Prior authorization applies to selective nerve root blocks (SNRBs) and epidural steroid injections (ESIs). Procedures must be performed with fluoroscopic- or CT-guidance and the injection of contrast, except in emergent situations when fluoroscopy, CT, or contrast is contraindicated (e.g., pregnancy).
Code list and prior authorization note
The codes listed for ESIs and related injections may require prior authorization per the applicable health plan; inclusion of a code in the codes table does not itself imply management or guarantee payment — refer to the member’s Certificate of Coverage or Evidence of Coverage.
Prior authorization (references-only)
There are no additional prior authorization rules or requirements stated in the References section of this policy excerpt.
Conservative therapy prerequisite
Document at least four (4) weeks of failed conservative treatment (e.g., exercise, physical therapy, chiropractic care, or medications including NSAIDs/analgesics) and that the individual is participating in a comprehensive pain management program (physical therapy, patient education, psychosocial support, and oral medications) when seeking initial ESI.
Clinical step requirement for repeat ESI
Before performing a repeat ESI, document that the prior ESI produced ≥50% relief of radicular pain for two or more weeks and that it has been at least 14 days since the prior injection; additionally document either increased function/physical activity or reduced use of pain medication and/or additional medical services.
- Repeat ESI requires ≥50% pain relief for ≥2 weeks.
- Minimum interval since prior ESI: ≥14 days.
- Also require increase in function or reduction in medication/services.
Step therapy (references-only)
No step therapy requirements are described in the References section of this policy excerpt.
Required supporting clinical documentation
For suspected radiculopathy, include documentation of a detailed neurologic examination within the prior three (3) months demonstrating loss of strength, altered sensation, or diminished/absent/asymmetric reflexes and/or a concordant MRI/CT interpretation or electrodiagnostic (EMG/NCV) study within the prior 24 months.
Conservative treatment and imaging documentation
When requesting ESI or SNRB, document failure of at least four (4) weeks of conservative treatment and participation in a comprehensive pain management program; for cervical/thoracic interlaminar and transforaminal ESIs, advanced diagnostic imaging within 24 months is required.
Required documentation for repeat ESI
For a repeat ESI, include the date of the prior injection to confirm at least a 14‑day interval and objective documentation showing ≥50% relief of radicular pain for two or more weeks plus either improved function or reduced use of pain medication and/or additional services. Advanced diagnostic imaging within 24 months is required for cervical/thoracic interlaminar and transforaminal ESIs.
- Record prior ESI date to confirm ≥14 days since prior injection.
- Document objective ≥50% radicular pain relief for ≥2 weeks.
- Document increased function or reduced medication/use of services.
Documentation (references-only)
This References section excerpt contains only bibliography and does not specify additional provider documentation requirements.
Denial risk for nonconforming SNRB
Selective nerve root blocks (SNRBs) performed without meeting the Definitions, General Guidelines, and Indications criteria are considered not medically necessary and may be denied.
Denial risk for unmet criteria
Requests for diagnostic SNRB or ESI that do not meet the Definitions, General Guidelines, and Indications sections are considered not medically necessary and may be denied.
Authorization/denial (references-only)
No authorization or denial requirements are stated in the References-only section of this policy excerpt.
Definitions
Background and Scope
Epidural steroid injections (interlaminar, transforaminal, caudal) and selective nerve root blocks are image-guided spinal procedures intended to diagnose or treat radicular pain, radiculitis, radiculopathy, or neurogenic claudication. SNRBs are diagnostic procedures using local anesthetic (with contrast) targeted to a single nerve root under fluoroscopic or CT guidance, while ESIs are therapeutic injections of corticosteroid (with or without local anesthetic and contrast) into the epidural space via interlaminar, transforaminal, or caudal approaches. The policy scope covers these procedures when performed for the listed spine indications and following the documented imaging, conservative-therapy, and timing requirements.
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