Caudal or Interlaminar Epidural Steroid Injections (PDF)

Coverage Summary

Background: Epidural steroid injections (caudal/interlaminar) are non‑surgical procedures delivering a glucocorticoid and/or anesthetic into the epidural space and are used to treat radiculopathy, spinal stenosis, and degenerative spinal conditions. Evidence for long‑term benefit is inconsistent and heterogeneous across trials; some studies report significant short‑term pain improvement (for example, around three months) while systematic reviews and meta‑analyses show mixed results regarding sustained pain and functional benefit.

Scope summary: This policy defines medical necessity criteria, limits, and exclusions for caudal or interlaminar epidural steroid injections for acute (< 3 months) and chronic (≥ 3 months) radicular or spinal pain for health plans affiliated with Centene Corporation. It requires documentation of diagnosis by physical exam and imaging, trials of conservative therapy per specified durations, limits on number and frequency of injections (e.g., < 4 injections per 12 months, continuation beyond 12 months considered not medically necessary), and imaging guidance for procedures except in rare documented exceptions.

Quick Facts / Policy Thresholds

Procedure allowed per visit1 procedure per visit (only one invasive pain management procedure)

Maximum therapeutic injections per 12 monthsLess than 4 injections within 12 months (policy considers more than four therapeutic injections not medically necessary)

Minimum interval when no improvementAt least 2 weeks since the prior ESI for a second ESI when the first did not improve

Minimum interval after improvementAt least 2 months since the last ESI for subsequent injections after initial improvement

Pain relief threshold for repeatInitial injection(s) must have produced ≥ 50% pain relief and functional improvement for at least 2 months to qualify for recurrence-based repeat

Maximum duration of therapyContinuation of injections beyond 12 months is considered not medically necessary (≤ 12 months)

Medical-Necessity Criteria

Medically Necessary

Caudal or interlaminar ESIs are medically necessary when the relevant criteria are met, only one procedure per visit, and with imaging guidance (except rare instances with documented justification).

ANY of the following

A. One caudal or interlaminar ESI for acute pain management (pain < 3 months)
- Severe radicular pain that interferes substantially with activities of daily living (ADLs)
- Severe pain persists after treatment with NSAIDs and/or opiates (both ≥ three days or contraindicated/not tolerated)
- Member/enrollee cannot tolerate chiropractic or physical therapy, and the injection is intended as a bridge to therapy
B. Initial ESI for chronic pain

Not Medically Necessary / Exclusions

Caudal or interlaminar ESIs are not medically necessary in the following circumstances:

ANY of the following

A third or subsequent caudal or interlaminar ESI for chronic pain that did not improve from the first two ESIs (effectiveness not established)
Continuation of injections beyond 12 months or more than four therapeutic injections is considered not medically necessary (effectiveness and safety not established); consideration on a case-by-case basis when more definitive therapies cannot be tolerated or provided
Caudal or interlaminar ESI for any other indication or location (effectiveness not established)

Coding

Referenced CPT codes (informational)CPT

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
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
62324	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, interlaminar epidural or subarachnoid, cervical or thoracic (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 (text in source overlaps with 62324/62325 descriptions)
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

Provider Actions

Prior Authorization

One procedure per visit and imaging guidance required

Only one invasive pain management procedure is allowed per visit. Imaging guidance (fluoroscopy or CT) is required for caudal or interlaminar ESIs, except in rare instances when a documented justification for no imaging is provided.

Documentation Required

Document conservative therapy trials and imaging

Document duration and failure or intolerance of conservative therapies: NSAID trial ≥ 3 weeks; ≥ 4 weeks of chiropractic, physical therapy, or prescribed home exercise program; and ≥ 4 weeks of activity modification. Also document confirmation of diagnosis by physical exam and imaging, and the functional impact on activities of daily living (ADLs).

Background & Evidence

Epidural steroid injections are indicated for patients with severe radicular pain or neurogenic claudication from causes such as disc herniation, spinal stenosis, or degenerative vertebral changes, particularly when pain substantially interferes with activities of daily living (ADLs) and conservative measures have failed or are not tolerated. The evidence base shows inconsistent long‑term benefit: randomized trials and meta‑analyses report short‑term improvements (for example at three months) but do not consistently demonstrate sustained long‑term efficacy. The policy therefore aligns use of ESIs with documented trials of conservative therapy and requires clinical and imaging correlation to confirm the anatomical source of radicular pain. Imaging guidance (fluoroscopy or CT) is required for procedures except in rare instances with documented justification, and only one invasive pain management procedure is allowed per visit.

Study	Summary
Meta-analysis (Zhai et al. 2015)
Epidural injections with or without steroids have beneficial but similar effects for chronic low back and lower extremity pain.
Manchikanti et al. 2015
Caudal, interlaminar and transforaminal techniques showed similar efficacy; some superiority of steroids at 3-6 months.

ADLs = Activities of daily living.

NSAID = Nonsteroidal anti‑inflammatory drug.

ESI = Epidural steroid injection.

Imaging guidance = Fluoroscopy or computed tomography (CT) used to provide guidance and anatomic detail during administration.

Conservative therapy trials = Examples include ≥ 4 weeks of physical therapy/chiropractic/home exercise, ≥ 3 weeks of NSAID therapy (or NSAID contraindicated/not tolerated), and ≥ 4 weeks of activity modification.

Medicare Determinations

Name	Number	Effective Date	Type
Epidural Steroid Injections for Pain Management
L39015
2021-12-05
LCD

Revision History

2025-05-25revisionLatest

05/25 annual review: Removed anticoagulation/INR language from criteria ('and the member/enrollee is not currently being treated with full anticoagulation therapy. If on warfarin, international normalized ratio (INR) should be ≤ 1.4 prior to the procedure'). Updated week requirement language in criteria I.B.4.a.-c; description and background updated with no clinical significance. Coding and references reviewed; internal and external specialists reviewed.

2024-06revision

06/24 annual review: Updated week requirement criteria I.B.4.a.-c. Removed anticoagulation/INR requirement from criteria. Description and background updated with no clinical significance. Coding and references reviewed; specialists reviewed.

2021-07