Fidelis Care caudal/interlaminar ESI Policy Update

Medical Necessity and Coverage

Medical Necessity Criteria

Covered when ALL of the following are met for specified scenarios

General policy: Invasive pain management procedures performed by a physician are medically necessary when relevant criteria are met; only one procedure is performed per visit; and imaging guidance (fluoroscopy or CT) is used except in rare instances with documented justification.

Acute management (one caudal or interlaminar ESI): Severe radicular pain that interferes substantially with activities of daily living; severe pain persists after treatment with NSAIDs and/or opioids for >= 3 days or NSAID/opioid is contraindicated or not tolerated; the patient cannot tolerate chiropractic or physical therapy and the injection is intended as a bridge to therapy.

Initial ESI for chronic pain

Conservative therapy (all required)
- 4 weeks of chiropractic care, physical therapy, or prescribed home exercise program.
- 4 weeks of activity modification.
- 3 weeks of NSAID therapy, or NSAID contraindicated/not tolerated.

Second ESI for chronic pain not improved from first ESI: Request is for an ESI at one level in the cervical, thoracic, or lumbar region; at least 2 weeks have passed since the first ESI.

Subsequent ESI for recurrence after improvement: Initial injection(s) led to >= 50% relief and functional improvement for at least 2 months; fewer than 4 therapeutic injections have been administered within 12 months; and at least 2 months have passed since the last ESI.

It is the policy of health plans affiliated with Centene Corporation that caudal or interlaminar epidural steroid injections (ESIs) for any indication or location not specifically supported by this policy are considered not medically necessary because effectiveness has not been established.

Coverage determinations guided by this clinical policy are only one component of the Health Plan’s decision-making process. Coverage is subject to the terms, conditions, exclusions and limitations of the member’s coverage documents (for example, evidence of coverage, certificate of coverage, policy or contract of insurance) and this policy does not guarantee payment or results.

A third or subsequent caudal or interlaminar ESI for chronic pain that did not improve from the first two ESIs is considered not medically necessary. Requests for continuation of injections beyond 12 months or for more than four therapeutic injections per 12 months are also considered not medically necessary unless exceptional circumstances are documented and reviewed on a case‑by‑case basis.

Procedure Codes and Quantity Limits

Referenced CPT CodesCPT

62320	Injection(s), of diagnostic or therapeutic substance(s), interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance.
62321	Injection(s), of diagnostic or therapeutic substance(s), interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance.
62322	Injection(s), of diagnostic or therapeutic substance(s), interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance.
62323	Injection(s), of diagnostic or therapeutic substance(s), interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance.
62324	Injection(s), including indwelling catheter placement; continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s), interlaminar epidural or subarachnoid (description truncated in source).
62325	Injection(s), including indwelling catheter placement; continuous infusion or intermittent bolus, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance (and with imaging guidance for another variant described).
62326	Injection(s), including indwelling catheter placement; continuous infusion or intermittent bolus, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance.
62327	Injection(s), including indwelling catheter placement; continuous infusion or intermittent bolus, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance.

Number of therapeutic injections

Allowed therapeutic injectionsLess than or equal to 4 therapeutic injections per 12 months

Not medically necessary beyond limitContinuation of injections beyond 12 months or more than four therapeutic injections is considered not medically necessary

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

Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for caudal or interlaminar epidural steroid injections (ESIs). Requests must demonstrate the member meets medical necessity criteria in this policy and comply with plan-specific authorization processes.

One procedure per visit; imaging guidance required unless rare documented justification.
Authorization must reference clinical criteria in this policy and be obtained before scheduling the ESI when required by the Health Plan.
For Medicaid and Medicare members, applicable state Medicaid provisions and Medicare NCDs/LCDs take precedence; verify plan-level rules.
Coverage decisions are subject to the member’s coverage documents, applicable exclusions, limitations, and administrative policies.

Documentation Required

Documentation of Conservative Therapy and Clinical Findings

Providers must document that conservative therapies were attempted and failed or were not tolerated before initial ESI for chronic pain. Required clinical documentation must demonstrate severity, duration, and objective confirmation of pathology.

Noninvasive Treatment Trials Required Before ESI

Conservative Therapy Trials Required

Must document trials and failure or intolerance of conservative therapies prior to coverage for initial chronic pain ESI.

ALL of the following

4 weeks of chiropractic care, physical therapy, or a prescribed home exercise program.
4 weeks of activity modification.
3 weeks of NSAID therapy, or documentation that NSAIDs are contraindicated or not tolerated.

Documentation: Clinical record must include duration of conservative trials, response (or intolerance), and supporting imaging/physical exam findings demonstrating radicular etiology.

Limits on Number and Timing of Epidural Steroid Injections

Caudal or interlaminar ESI — Frequency limit

Frequency limit (caudal/interlaminar)Less than or equal to 4 therapeutic injections per 12 months

Not medically necessary if exceededContinuation of injections beyond 12 months or more than four therapeutic injections is considered not medically necessary

Procedure scopeApplies to caudal or interlaminar epidural steroid injections

Interval between subsequent injections (recurrence after improvement)

Minimum interval after improvementAt least 2 months must have passed since the last ESI for recurrence after improvement

Improvement threshold requiredInitial injection(s) must have led to ≥50% relief and functional improvement for at least two months

Imaging Guidance for Procedures

Billing Rule

Imaging guidance (fluoroscopy or CT) required for caudal/interlaminar ESI

Fluoroscopy or CT imaging guidance is required for caudal or interlaminar epidural steroid injections except in rare instances with documented justification.

If imaging guidance is not used, document the rare circumstance and justification in the medical record.

Billing Rule

Use CT or standard fluoroscopy for image-guided ESI

CT or standard fluoroscopy can be used during administration to provide guidance and anatomic detail for ESI procedures.

Select imaging modality (CT or fluoroscopy) based on clinical need and documentation.

Clinical Background and Scope

Epidural steroid injections (ESIs) are non‑surgical procedures that deliver a glucocorticoid and/or local anesthetic into the epidural space. Approaches include caudal, interlaminar, and transforaminal techniques. The goal of caudal and interlaminar ESIs is to reduce radicular pain and inflammation, provide short‑term analgesia, and, when effective, facilitate participation in rehabilitation or other definitive therapies.

Image guidance (standard fluoroscopy or CT) is typically used to assist needle placement and confirm anatomic location; the policy operationalizes the expectation that invasive pain management procedures be performed with imaging guidance except in rare instances with documented justification.

Definitions and Evidence Sources

Epidural steroid injection (ESI) — Definition

DefinitionEpidural steroid injections (ESIs) are non-surgical administration of glucocorticoid and/or anesthetic via a needle into the epidural space (between ligamentum flavum and dura)

ApproachesCommon approaches include caudal, interlaminar, and transforaminal

Imaging guidanceComputed tomography (CT) or standard fluoroscopy can be used during administration to provide guidance and anatomic detail

Evidence sources and guidelines

Systematic reviews and comparative studiesCited evidence includes systematic reviews and comparative studies (e.g., Vorobeychik et al. 2016; Chang-Chien et al. 2014)

UpToDate and clinical reviewsUpToDate topics on cervical radiculopathy and lumbosacral radiculopathy are referenced (Kothari; Levin et al.)

Procedures and Scenarios Considered Not Covered

Not covered: A third or subsequent caudal or interlaminar ESI for chronic pain that did not improve from the first two ESIs. Additionally, continuation of injections beyond 12 months or more than four therapeutic injections in a 12‑month period is considered not medically necessary; exceptions may be evaluated on a case‑by‑case basis when more definitive therapies cannot be tolerated or provided.

Not covered: Caudal or interlaminar ESIs for indications or anatomic locations not supported by established effectiveness evidence are considered not medically necessary.

Not covered: Continuation of caudal or interlaminar ESI beyond the limits specified in this policy — including duration and frequency thresholds — is considered not medically necessary absent compelling, documented justification.

No additional explicit procedural exclusions are listed in the cited evidence and guideline references; the policy does, however, reference the relevant literature and national guidance that inform appropriate use of ESIs.

Policy Changes and Governance

2024-06criteria_revision

Updated conservative therapy duration requirements (week-based elements revised for chiropractic/physical therapy/home exercise, activity modification, and NSAID trial).

2024-06language_revision

Policy language clarified to require imaging guidance for invasive pain management procedures except in rare instances with documented justification (one procedure per visit with imaging guidance).

2024-05criteria_revision

OpenPayer

Caudal or Interlaminar Epidural Steroid Injections