Currentmeridian_health_plan_of_michiganPolicy MI.CP.MP.165

Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections

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Clinical medical necessity criteria, procedural requirements, and coding guidance for selective nerve root blocks (SNRB) and transforaminal epidural steroid injections (TFESI) for members of Meridian Health Plan of Michigan.

Policy Summary

Payermeridian_health_plan_of_michigan

PolicySelective Nerve Root Blocks and Transforaminal Epidural Steroid Injections

Policy CodePolicy MI.CP.MP.165

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization and document trials of conservative therapy, pain duration, nerve root distribution, and imaging when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3SNRBs same area (6 months)

≤1.4Required INR (warfarin)

6Max TFESI per site (12 mo)

≥50%Required relief for recurrence

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Currentmeridian_health_plan_of_michiganPolicy MI.CP.MP.165

Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections

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Policy Summary

Payermeridian_health_plan_of_michigan

PolicySelective Nerve Root Blocks and Transforaminal Epidural Steroid Injections

Policy CodePolicy MI.CP.MP.165

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization and document trials of conservative therapy, pain duration, nerve root distribution, and imaging when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3SNRBs same area (6 months)

≤1.4Required INR (warfarin)

6Max TFESI per site (12 mo)

≥50%Required relief for recurrence

Centene-ownedpolicy ownership

Coverage Criteria for SNRB and TFESI

inv-01: SNRB — Acute Pain (medically necessary when ALL met)

Covered when ALL of the following are met

SNRB acute criteria: 1. There is severe radicular pain in a specific nerve root distribution that interferes substantially with activities of daily living (ADLs); 2. Severe pain persists after treatment with NSAIDs and/or opiate (both ≥ three days or contraindicated/not tolerated); 3. Cannot tolerate chiropractic or physical therapy, and the injection is intended as a bridge to therapy; 4. Member is not currently being treated with full anticoagulation therapy. For patients on warfarin, international normalized ratio (INR) should be ≤ 1.4 prior to the procedure.

inv-02: SNRB — Chronic Pain Diagnostic/Therapeutic (medically necessary when ALL met)

Covered when ALL of the following are met

SNRB chronic criteria: 1. Request is for an SNRB with a local anesthetic at a single nerve root; 2. Persistent radicular pain in a defined nerve root level, and the diagnosis remains uncertain after standard evaluation (neurologic examination, radiological studies and electrodiagnostic studies); 3. Pain interferes with ADLs and has lasted for at least three months; 4. Member is not currently being treated with full anticoagulation therapy. For patients on warfarin, INR should be ≤ 1.4 prior to the procedure; 5. Failure to respond to conservative therapy, including all of the following: (a) ≥ four weeks chiropractic, physical therapy or prescribed home exercise program; (b) NSAIDs ≥ three weeks or NSAID contraindicated or not tolerated; (c) ≥ four weeks activity modification.

inv-03: SNRB — Additional for Multilevel Pathology

Covered when ALL met

Additional SNRB for multilevel pathology: Multilevel pathology is suspected, and at least two weeks have passed since the prior injection.

inv-04: SNRB — Not Medically Necessary

SNRB not medically necessary: SNRBs are considered not medically necessary for any other indication because effectiveness has not been established.

inv-05: TFESI — Acute Pain (medically necessary when ALL met)

Covered when ALL of the following are met

TFESI acute criteria: 1. There is severe radicular pain in a specific nerve root distribution that interferes substantially with activities of daily living (ADLs); 2. If a cervical TFESI is requested, non-particulate steroid must be used and the procedure must be conducted with real-time imaging (e.g., fluoroscopy); 3. Severe pain persists after treatment with NSAIDs and/or opiate (both ≥ three days or contraindicated/not tolerated); 4. Cannot tolerate chiropractic or physical therapy, and the injection is intended as a bridge to therapy; 5. Member is not currently being treated with full anticoagulation therapy. For patients on warfarin, INR should be ≤ 1.4 prior to the procedure.

inv-06: TFESI — Chronic Pain (medically necessary when ALL met)

Covered when ALL of the following are met

TFESI chronic criteria: 1. TFESI is requested for a single level bilaterally or up to two levels unilaterally; 2. If a cervical TFESI is requested, non-particulate steroid must be used and the procedure must be conducted with real-time imaging (e.g., fluoroscopy); 3. Persistent radicular pain caused by disc herniation in a defined nerve root level, or spinal stenosis confirmed by physical exam and imaging; 4. Pain interferes with ADLs and has lasted for at least three months; 5. Member is not currently being treated with full anticoagulation therapy. For patients on warfarin, INR should be ≤ 1.4 prior to the procedure; 6. Failure to respond to conservative therapy including all of the following: (a) ≥ four weeks chiropractic, physical therapy or prescribed home exercise program; (b) NSAIDs ≥ three weeks or NSAID contraindicated or not tolerated; (c) ≥ four weeks activity modification.

inv-07: TFESI — Chronic Pain Not Improved from Prior Injection (medically necessary when ALL met)

Covered when ALL of the following are met

TFESI repeat if no improvement: 1. Request is for a TFESI at one level bilaterally or up to two levels unilaterally; 2. If a cervical TFESI is requested, non-particulate steroid must be used and the procedure must be conducted with real-time imaging (e.g., fluoroscopy); 3. At least two weeks have passed since the first TFESI; 4. Member is not currently being treated with full anticoagulation therapy. For patients on warfarin, INR should be ≤ 1.4 prior to the procedure.

inv-08: TFESI — Recurrence After Prior Improvement (medically necessary when ALL met)

Covered when ALL of the following are met

TFESI for recurrence after improvement: 1. Requested at a single level bilaterally or up to two levels unilaterally; 2. If a cervical TFESI is requested, non-particulate steroid must be used and the procedure must be conducted with real-time imaging (e.g., fluoroscopy); 3. Prior ≥ 50% relief and functional improvement for at least two months; 4. Member is not currently being treated with full anticoagulation therapy. For patients on warfarin, INR should be ≤ 1.4 prior to the procedure; 5. At least two months have passed since the last TFESI; 6. Less than six injections have been given at the same site within 12 months; 7. Less than 12 months have elapsed since the initial injection at the level requested.

inv-09: TFESI — Not Medically Necessary

TFESI limitations: Continuation of injections beyond 12 months or more than 6 therapeutic injections is considered not medically necessary because effectiveness and safety has not been established. TFESIs for any other indications are considered not medically necessary because effectiveness has not been established.

Consideration on case-by-case basis when definitive therapies cannot be tolerated or provided.

SNRBs and TFESIs performed for indications other than those explicitly described as medically necessary in this policy are considered not medically necessary. The policy states that procedures for any other indication are excluded because effectiveness has not been established.

This clinical policy is intended as a guide to medical necessity to assist in coverage determinations and benefit administration. It does not constitute a contract or guarantee of payment. Coverage decisions remain subject to the terms, conditions, exclusions and limitations of the member's coverage documents and applicable state or federal requirements.

SNRBs and TFESIs that exceed the policy's stated frequency, duration, or indication limits are not medically necessary. Examples include continuation of TFESI beyond 12 months or more than 6 therapeutic injections at the same site within 12 months, and SNRBs or TFESIs performed for indications not specified in this policy.

Required Conservative Treatments Before Chronic Procedures

Step Therapy

Conservative therapy trials required before chronic SNRB/TFESI

For chronic SNRB or TFESI requests, document and demonstrate failure to respond to specified conservative therapies before the procedure will be considered medically necessary. Required conservative therapy trials include: (a) ≥ 4 weeks of chiropractic care, physical therapy, or a prescribed home exercise program; (b) NSAIDs for ≥ 3 weeks or documentation that NSAIDs are contraindicated or not tolerated; and (c) ≥ 4 weeks of activity modification. For chronic indications the pain must have persisted for at least three months and conservative therapy trials must be clearly recorded in the medical record.

Document ≥ 4 weeks chiropractic, physical therapy, or prescribed home exercise program (per chronic criteria).
Document NSAIDs ≥ 3 weeks, or state NSAID contraindication/intolerance.
Document ≥ 4 weeks activity modification.
Confirm pain duration ≥ 3 months for chronic indications when applicable.

Must document trials of listed conservative therapies prior to chronic SNRB/TFESI.

Must document trials of the following conservative therapies prior to consideration of chronic Selective Nerve Root Block (SNRB) or Transforaminal Epidural Steroid Injection (TFESI).

Frequency and Quantity Limits

SNRB / TFESI frequency limits

SNRB frequency limitThree nerve blocks to the same area are covered within a six-month period without additional documentation; further treatment beyond this should be reviewed against applicable criteria.

TFESI per‑site limitNo more than six therapeutic TFESI injections at the same site within a 12‑month period; continuation beyond 12 months or >6 injections is considered not medically necessary (case‑by‑case exceptions possible when definitive therapies cannot be provided).

Interval for repeat TFESI after prior improvementAt least two months must have passed since the last TFESI for recurrence after prior improvement, and prior relief/functional improvement must have been ≥50% for at least two months.

Interval for repeat TFESI if no improvementAt least two weeks must have passed since the first TFESI before a repeat TFESI may be considered when prior injection did not produce improvement.

Anticoagulation considerationMember must not be on full anticoagulation therapy; if on warfarin, INR should be ≤ 1.4 prior to the procedure.

Imaging and Procedural Guidance

Prior Authorization

Require radiographic guidance — real-time imaging for cervical TFESI

Transforaminal epidural steroid injections must be performed with radiographic guidance; cervical TFESI specifically requires real-time imaging (e.g., fluoroscopy) and use of a non-particulate steroid.

Cervical TFESI — non-particulate steroid and real-time imaging (fluoroscopy) required
Procedures performed with fluoroscopy or CT imaging guidance

Denial Risk

Risk of denial for procedures without imaging or on full anticoagulation

Procedures performed without radiographic guidance or on members currently being treated with full anticoagulation may be denied; if on warfarin, INR should be ≤ 1.4 prior to the procedure.

Procedures without imaging guidance risk denial

Provider Responsibilities and Prior Authorization

Prior Authorization

Prior authorization expected and reference CPT coding

Prior authorization is expected for TFESI/SNRB procedures billed with the referenced CPT codes; providers should reference the most up-to-date professional coding guidance prior to claim submission.

Referenced CPT codes include 64479, 64480, 64483, 64484
Verify current coding guidance before submitting claims

Note

Policy is a medical necessity guide — prior auth per coverage documents

This clinical policy is a guide to medical necessity used to assist coverage decisions; actual prior authorization requirements are determined by the Health Plan and the member's coverage documents.

Policy guides medical necessity but does not guarantee payment
Prior authorization requirements may vary by Health Plan and coverage documents

Coding and Billing

Referenced CPT CodesCPT

64479	Injection(s), anesthetic agent(s) and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, single level.
64480	Injection(s), anesthetic agent(s) and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, each additional level (List separately in addition to code for primary procedure).
64483	Injection(s), anesthetic agent(s) and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level.
64484	Injection(s), anesthetic agent(s) and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level (List separately in addition to code for primary procedure).

Definitions

Selective Nerve Root Block (SNRB)

DefinitionInjection of a small amount of local anesthetic adjacent to a spinal nerve root, most often used diagnostically; steroids may be added when used therapeutically.

Typical usePrimarily used to identify the specific source of radicular nerve root pain; therapeutic SNRBs (with steroid) are used less commonly for short‑term pain relief.

Procedure contextSNRBs share safety considerations and anatomical benchmarks with TFESIs and are an alternative to interlaminar epidural steroid injections.

Transforaminal Epidural Steroid Injection (TFESI)

DefinitionInjection of local anesthetic and/or corticosteroid into the intervertebral foramen (transforaminal approach) to target nerve roots causing radicular pain; injectate may spread to multiple nerves.

Typical use

Background

Selective nerve root blocks (SNRBs) are small-volume injections of local anesthetic placed adjacent to a spinal nerve root, most often used as a diagnostic procedure; corticosteroid may be added if intended therapeutically. Transforaminal epidural steroid injections (TFESIs) deliver local anesthetic and/or corticosteroid into the intervertebral foramen to target the affected nerve root and treat radicular pain. TFESIs typically involve larger volumes and require radiographic guidance; for cervical TFESI the policy requires use of a non-particulate steroid and real-time imaging (e.g., fluoroscopy). Candidates are usually patients with radicular symptoms who have failed appropriate conservative measures.

Not Covered / Exclusions

SNRBs and TFESIs for indications other than those specified in this policy are not covered because effectiveness has not been established. Requests for these procedures outside the defined acute or chronic radicular indications, or that do not meet the policy criteria (including imaging, diagnostic workup and conservative therapy requirements), should be considered noncovered.

Policy Summary

Payermeridian_health_plan_of_michigan

PolicySelective Nerve Root Blocks and Transforaminal Epidural Steroid Injections

Policy CodePolicy MI.CP.MP.165

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization and document trials of conservative therapy, pain duration, nerve root distribution, and imaging when applicable.

SourceLink

On This Page

Conservative therapy documentation requirement

≥ 4 weeks of chiropractic care, physical therapy, or a prescribed home exercise program (document dates, providers, and response).
NSAID therapy for ≥ 3 weeks, or documentation that NSAIDs are contraindicated or not tolerated (document agent, dose, dates, and reason for intolerance/contraindication).
≥ 4 weeks of activity modification (document prescribed activity restrictions or modifications and duration).

Additional frequency limit notes

Documentation after initial SNRB limit reachedOnce three nerve blocks to the same area within six months have been reached, additional procedures require review using the relevant medical necessity criteria.

Maximum injections time windowThe six‑injection limit for TFESI applies to injections at the same site within a 12‑month period; less than 12 months must have elapsed since the initial injection for some repeat-coverage scenarios.

Case‑by‑case exceptionsContinuation beyond stated frequency/duration limits may be considered on a case‑by‑case basis when definitive therapies cannot be tolerated or provided.

Members on full anticoagulation risk denial; warfarin users require INR ≤ 1.4 prior to procedure

Note

Imaging guidance — fluoroscopy or CT required

All procedures must be performed with appropriate imaging guidance; the policy specifies fluoroscopy or CT for guidance and reiterates the real-time imaging requirement for cervical TFESI.

Use fluoroscopy or CT for imaging guidance
Confirm real-time imaging for cervical procedures

Documentation Required

Document duration, conservative therapy trials, nerve root distribution, and supporting exams

Medical record documentation must support symptom duration, prior conservative therapies (including inability to tolerate them), nerve root distribution, and when applicable, imaging and physical exam findings confirming pathology.

Duration of pain (acute vs chronic) and interference with ADLs
Details of conservative therapy trials and reasons for intolerance
Nerve root distribution and corroborating imaging/physical exam

Note

Provider responsibility to follow policy and retain clinical judgment

Providers must follow the Health Plan's clinical policy and applicable coverage documents and retain professional responsibility for medical judgment and treatment of members.

Exercise professional medical judgment in treatment decisions
Providers are independent and responsible for care

Denial Risk

Coverage determinations subject to member's coverage documents and limitations

Coverage decisions are subject to all terms, conditions, exclusions and limitations of the member's coverage documents; this policy does not constitute a contract or guarantee of payment.

Verify member-specific benefits and any state/federal requirements
State Medicaid provisions take precedence when conflicts exist

Billing Rule

Provider must use physician-performed, image-guided technique and confirm prior auth/coding

Ensure procedures are performed by a physician with appropriate radiographic guidance and that providers reference current coding guidance; providers should confirm prior authorization requirements before claims submission.

Physician must perform procedure with imaging guidance (fluoroscopy/CT)
Confirm prior authorization and coding (CPT 64479–64484) before submission
Maintain documentation supporting medical necessity

Used to treat radicular pain as an alternative to interlaminar epidural steroid injections; may provide short‑term pain improvement but long‑term benefit is unvalidated.

Special procedural considerationsCervical TFESI requires use of a non‑particulate steroid and real‑time imaging (e.g., fluoroscopy) due to safety concerns; radiographic guidance is required for TFESI procedures.