Epidural Steroid Injections
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Coverage policy for epidural steroid injections (ESIs) and selective nerve root blocks (SNRBs) for specified indications; applies to health benefit plans administered by Cigna and used by eviCore for medical necessity and prior-authorization determinations.
No material clinical or coverage changes in this revision.
Coverage Criteria for SNRB and ESI
Covered with criteria
Epidural steroid injections and selective nerve root blocks are considered medically necessary when the following general requirements and limits are met:
See Image Guidance and Injectates requirements.
See Frequency & Number of Injections/Procedures.
See Levels section for details.
Selective Nerve Root Block (SNRB) - Initial Level
Initial diagnostic SNRB is considered medically necessary when ALL of the following are met:
Document neurologic exam and imaging/electrodiagnostic studies per Indications.
Selective Nerve Root Block (SNRB) - Other Than the Initial Level
Diagnostic SNRB at a level other than the initial level is considered medically necessary when ALL of the following are met:
Meets criteria for subsequent diagnostic level evaluation.
Initial Interlaminar, Transforaminal, or Caudal Epidural Steroid Injection (ESI)
Initial interlaminar, transforaminal, or caudal epidural steroid injection (ESI) is considered medically necessary for ANY of the following clinical scenarios when ALL associated criteria are met:
Each indication below contains ALL criteria.
See Treatment of Presumed Radiculitis or Radicular Pain.
See Treatment of Presumed Radiculopathy.
See Neurogenic Claudication Trial.
TFESI with synovial cyst aspiration allowed as exception for same-day procedures.
Repeat Interlaminar, Transforaminal, or Caudal ESI
Repeat interlaminar, transforaminal, or caudal ESI is considered medically necessary when ALL of the following are met:
Document sustained benefit and functional improvement prior to repeat ESI.
Frequency & Same-day Modality Limits
Session and same-day procedure constraints:
Also see Levels limits for per-session level constraints.
SNRB — Not Medically Necessary
Selective Nerve Root Block (SNRB) is considered not medically necessary when any of the following apply:
Directly from SNRB Not Medically Necessary statements.
ESI — Not Medically Necessary
Epidural Steroid Injection (ESI) is considered not medically necessary when any of the following apply:
Directly from ESI Not Medically Necessary statements.
This guideline applies only to selective nerve root blocks (SNRBs) and epidural steroid injections (ESIs) for the indications listed in the Indications section. Procedures that are outside the scope of management and may be redirected to the health plan include epidural injections administered for obstetrical or surgical epidural anesthesia, epidural injections for perioperative pain management, and epidural catheter placement for implantable intrathecal or epidural drug pump trials when no delegation exists for those pump codes.
The document contains a Non‑Indications / Not Medically Necessary section. Specific items and detailed NMN conditions are enumerated elsewhere in the guideline; the provided excerpt indicates the presence of NMN listings but does not include the full set of excluded conditions in this window.
Use of ultrasound guidance for either SNRB or ESI is explicitly listed as not medically necessary in the policy; the guideline requires CT- or fluoroscopic-guidance when criteria are met (except for emergent contraindications).
Within the chunks provided there are no additional explicit exclusion conditions beyond the out‑of‑scope contexts and NMN lists referenced elsewhere; the excerpted material does not present further standalone exclusion rules.
The policy states that therapeutic SNRBs (repeat SNRB at the same level) have insufficient evidence to support clinical utility and are therefore treated as not medically necessary for repeat therapeutic use.
A Not Medically Necessary section is present in the guideline; specific NMN items for ESIs are detailed elsewhere in the full document and are not included in the excerpted chunks here.
Diagnostic and therapeutic SNRBs performed outside the Definitions, General Guidelines, and Indications sections (including use of non‑approved injectates, ultrasound guidance, or scheduling as a preplanned "series‑of‑three") are listed as not medically necessary.
The policy lists conditions under which ESIs are considered not medically necessary, including procedures performed without meeting Definitions/General Guidelines/Indications, use of ultrasound guidance, use of injectates other than anesthetic/corticosteroid/contrast, and scheduling as a preplanned 'series‑of‑three' without evaluation of response.
No explicit standalone "not medically necessary" statements beyond the NMN lists and references are present in the provided chunks; the document portion supplied contains literature citations and NMN headings but not a separate exhaustive NMN narrative in this excerpt.
Coding and Session Limits
| CPT (general) | CPT codes referenced; specific code list appears in Codes section (not in this chunk set). |
| 62320 | Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance. |
| 62321 | Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (i.e., fluoroscopy or CT). |
| 62322 | Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance. |
| 62323 | Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (i.e., fluoroscopy or CT). |
| 62324 | Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar (cervical or thoracic) without imaging guidance (per Codes section). |
| 62325 | Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance. |
| 62326 | Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance. |
| 62327 | Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (i.e., fluoroscopy or CT). |
| 64479 | Injection(s), anesthetic agent and/or steroid, transforaminal epidural; with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level. |
| +64480 | Injection(s), anesthetic agent and/or steroid, transforaminal epidural; with imaging guidance; cervical or thoracic, each additional level (add-on). |
| No codes listed |
Provider Requirements, Authorization, and Documentation
Prior authorization required for SNRB and ESI
Prior authorization is required for SNRBs and ESIs when used for conditions listed in the Indications section; procedures must be performed with CT- or fluoroscopic-guidance and use anesthetic, corticosteroid, and/or contrast agent when criteria are met.
Prior authorization & same-day procedure rule
Prior authorization is required for requests that trigger the policy's frequency and interval rules; only one invasive modality/procedure per date of service is considered medically necessary (exception: TFESI with synovial cyst aspiration).
Codes listed — refer to health plan for PA
The policy lists CPT procedure codes for epidural and transforaminal injections, but inclusion does not itself indicate plan-level prior authorization — refer to the member's applicable health plan for authorization requirements.
- Document lists ESI/TFESI codes (see Codes section) and notes plan-level management may differ.
Evidence & guideline references inform PA
Guideline and evidence references (including North American Spine Society Appropriate Use Criteria and coverage recommendations) are cited as sources that inform prior authorization and documentation expectations.
- NASS Appropriate Use Criteria and NASS coverage recommendations are referenced (see policy bibliography).
Procedure frequency limits (3 per 6 months; 4 per 12 months)
Frequency limits apply: up to 3 sessions per episode per region within six months and up to 4 sessions during a rolling 12-month period when criteria are met.
Document ≥4 weeks conservative therapy and active rehab
Providers must document failure of at least four (4) weeks of conservative therapy and participation in an active rehabilitation/home exercise or functional restoration program prior to initial ESI or when indicated.
- Examples of conservative therapy include exercise, physical therapy, chiropractic care, or medications (NSAIDs or analgesics).
Do not schedule pre-planned 'series-of-three' injections
Scheduling injections as a pre-planned 'series-of-three' without evaluating the patient's response to a prior injection is considered not medically necessary.
No step therapy requirements specified
No step therapy (prior authorization step requirements) are specified within these document chunks.
Include neurologic exam (≤3 months) or confirmatory testing for radiculopathy/SNRB
For radiculopathy or SNRB requests, include a detailed neurologic examination within the prior three (3) months demonstrating at least one concordant finding (motor weakness, sensory change, or reflex change) or confirmatory advanced imaging or electrodiagnostic testing as specified.
- Acceptable concordant findings: loss of strength in specific myotomal distribution, altered sensation, or diminished/absent/asymmetric reflexes.
- Alternatively, concordant radiologist interpretation of advanced imaging within 24 months or EMG/NCV within 24 months may be used.
Documentation must show failed conservative care, active rehab, and required imaging
Required clinical documentation for authorization must show prior conservative treatment failure (≥4 weeks), participation in an active rehabilitation/home exercise/functional restoration program, and when indicated, advanced imaging within the past 24 months (particularly for cervical/thoracic injections and synovial cyst cases).
- For cervical/thoracic interlaminar and transforaminal injections, advanced imaging within 24 months is required.
- For TFESI with synovial cyst aspiration, imaging within 24 months must confirm compression/displacement of the nerve root.
Codes listed do not guarantee PA or payment — check health plan
The inclusion of procedure codes in the policy's Codes table does not imply that the codes are under eviCore code management or require prior authorization; refer to the applicable health plan's Certificate of Coverage or Evidence of Coverage for authorization and payment terms.
Policy cites literature and guidelines to support documentation
The policy contains extensive literature and guideline references (including randomized trials, systematic reviews, and NASS documents) that support documentation practices and clinical indications; cite these references as needed in complex cases.
- Bibliography includes trials and NASS guidance relevant to ESI/SNRB indications and documentation.
Out-of-scope requests may be redirected to the health plan
Some prior authorization requests may be redirected to the member's health plan when the procedure is out of scope for this guideline (examples: epidural anesthesia for obstetrics or surgery, perioperative pain management, or epidural/pump trial codes without delegation).
Frequency/interval exceedance may lead to denial
Requests that exceed frequency limits (more than four sessions in a rolling 12‑month period, more than three sessions per region in six months) or repeat injections performed before the required interval (less than 14 days since prior ESI) risk denial.
- Minimum interval for repeat ESI: at least 14 days since prior injection.
- Frequency caps: 3 sessions per episode per region in six months; up to 4 sessions in a rolling 12-month period.
SNRB performed without meeting criteria may be denied
Diagnostic SNRB performed without meeting the Definitions, General Guidelines, and Indications sections (including guidance on imaging, exam findings, and conservative therapy) is considered not medically necessary and may be denied.
ESI performed without meeting criteria may be denied
An ESI (interlaminar, transforaminal, or caudal) performed without meeting the Definitions, General Guidelines, and Indications sections (including required imaging, conservative therapy, and imaging guidance) is considered not medically necessary and may be denied.
Conservative Therapy and Pre-procedure Requirements
Applicability statement
Applicability statement:
See Application of Guideline for out-of-scope examples.
Documented failure and active rehab participation
Documented failure and active rehabilitation participation requirement:
Required for initial and repeat ESI indications.
Procedures must meet Definitions, General Guidelines, and Indications to be medically necessary
Procedures must meet Definitions, General Guidelines, and Indications to be medically necessary:
See Definitions, General Guidelines, and Indications sections.
Conservative treatment placeholders (additional nodes/references)
Examples of conservative treatments referenced in the Indications section (non-exhaustive):
At least 4 weeks' documented failure required before injections in most initial indications.
Session and Level Limits
Imaging and Guidance Required
Use fluoroscopy or CT for image‑guided procedures
When imaging guidance is required, proceed using fluoroscopy or computed tomography (CT) for SNRB and ESI per the policy's image‑guidance requirement.
Require MRI/CT/CT myelogram within 24 months for specified indications
Advanced imaging (MRI, CT, or CT myelogram) within the past 24 months is required for certain cervical/thoracic interlaminar and transforaminal injections, for evaluation of neurogenic claudication, and to confirm synovial cyst compression for TFESI with aspiration.
Align coding with fluoroscopic or CT guidance
Policy distinguishes procedure codes for imaging‑guided versus non‑imaging procedures; when performing imaging‑guided ESI or SNRB use fluoroscopy or CT as specified by the coded procedure.
Research citations support imaging/documentation expectations
Numerous research studies cited in the references (e.g., CT‑guided transforaminal injection outcome studies and systematic reviews) provide contextual support for imaging and documentation practices referenced in the policy.
Not Covered / Out of Scope Procedures
Examples of settings and uses that are out of scope for this guideline and that may be redirected to the health plan include epidural injections for obstetrical or surgical epidural anesthesia and epidural injections for perioperative pain management. These contexts are explicitly noted as not managed under the SNRB/ESI criteria in this policy.
The guideline reiterates out‑of‑scope contexts such as obstetrical/surgical anesthesia and perioperative pain uses of epidural injections; prior authorization requests for these scenarios may be redirected to the member's health plan for review.
The document contains placeholders and headings for additional not‑covered items and non‑indications; detailed not‑covered procedures and indications are enumerated elsewhere in the full guideline beyond the extracted excerpts.
Specific items listed as Not Medically Necessary are referenced in the guideline but the detailed exclusions for some procedures (for example, particular ESI NMN entries) are located outside the provided excerpt.
Sections labeled as not covered or not medically necessary appear repeatedly across the guideline; the excerpted material shows these headings and page references but not the complete lists in this window.
The guideline includes multiple not‑covered and NMN placeholders indicating that several specific exclusions exist in the full policy; those detailed entries are not included in the provided chunks.
Several repeated NMN headings in the excerpt signal multiple discrete NMN items across the policy; the excerpt does not list every individual not‑covered procedure.
The guideline structure includes recurring 'Not Medically Necessary' sections; the provided window contains references to those sections but not full text for each excluded scenario.
Within the provided excerpt there are no additional explicit 'not covered' procedure listings beyond the NMN headings and references to literature; comprehensive not‑covered lists reside in other sections of the full guideline.
Definitions and Terms
Epidural steroid injections introduce corticosteroid (and often local anesthetic and contrast) into the epidural space to treat radicular pain and related syndromes. Selective nerve root blocks are diagnostic injections of local anesthetic into a single named spinal nerve root to establish a diagnosis of radicular pain and are typically performed under fluoroscopic or CT guidance.
References, Evidence, and Guideline Citations
The guideline cites the North American Spine Society (NASS) Appropriate Use Criteria and Coverage Recommendations and related NASS evidence‑based clinical guidelines as referenced sources that inform coverage determinations for ESIs and SNRBs. It also references broader literature and guideline sources contained in the reference list.
The document contains an extensive literature reference list—including randomized trials, systematic reviews, and evidence syntheses—that is intended to support documentation of indication and rationale for SNRBs and ESIs in clinical decision‑making and prior authorization determinations.
Several cited studies and commentaries in the reference list address the frequency of epidural steroid injections and their outcomes; the guideline references this literature in context of its frequency and session limits but the excerpt does not replace the guideline's explicit numeric limits.
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