CurrentmhnPolicy CP.MP.165

Selective Nerve Root Blocks and Transforaminal Epidural Injections (PDF)

Defines medical necessity criteria, limitations, and coding guidance for selective nerve root blocks (SNRB) and transforaminal epidural steroid injections (TFESI) for acute and chronic radicular pain, including procedural limits, steroid particulate requirements for cervical procedures, and diagnostic/therapeutic indications.

Policy Summary

Payermhn

PolicySelective Nerve Root Blocks and Transforaminal Epidural Injections (PDF)

Policy CodePolicy CP.MP.165

Change TypeRevisions & Additions

Effective Date

Next Review Date

Key ActionDocument conservative therapy attempts/durations and ensure procedures are single-per-visit with radiographic guidance; for cervical TFESI use and document a non-particulate steroid and real-time imaging.

SourceLink

POLICY UPDATE CHANGES

In I.B.4.a. and c. and II.B.5.a. and c. changed duration from six weeks to four weeks.

Added Table 1 to give examples of particulate and non-particulate steroids.

Updated Criteria II.D.3. from two months to three months regarding relief and functional improvement.

Removed anticoagulation therapy requirement in Criteria and added anticoagulation therapy as a note in Criteria.

Removed option for procedures without radiographic guidance; radiographic guidance required.

4Maximum therapeutic injections per site in 12 months

50%Minimum relief threshold for repeat TFESI

2wMinimum interval between injections (repeat)

3mMinimum duration of benefit required for repeat TFESI

Coverage Summary

Defines medical necessity criteria, limits, and coding guidance for Selective Nerve Root Blocks (SNRB) and Transforaminal Epidural Steroid Injections (TFESI). SNRBs are described as primarily diagnostic using a small amount of local anesthetic, while TFESIs involve a larger amount of local anesthetic or corticosteroid and may be therapeutic. The policy requires that invasive pain management procedures be performed by a physician, that only one procedure be performed per visit, and that procedures be performed with radiographic guidance.

Thresholds / Values

Acute duration threshold< 3 months

Chronic duration threshold>= 3 months

NSAID/opiate trial>= 3 days (acute) or >= 3 weeks (chronic NSAID trial)

Conservative therapy durations>= 4 weeks chiropractic/physical therapy/prescribed home exercise; >= 4 weeks activity modification

Interval between injections>= 2 weeks (second SNRB or second TFESI if no improvement)

Relief requirement for repeat TFESI>= 50% relief and functional improvement for at least 3 months

Maximum injections per site< 4 injections within 12 months

Maximum duration for continuation<= 12 months

Medical-Necessity Criteria — Selective Nerve Root Blocks (SNRB)

General policy

Invasive pain management procedures performed by a physician are medically necessary when relevant criteria are met and only one procedure is performed per visit, with radiographic guidance.

Physician and procedure limits: Procedure performed by a physician
Single procedure per visit: Only one procedure performed per visit
Radiographic guidance: Procedure performed with radiographic guidance

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Medical-Necessity Criteria — Transforaminal Epidural Steroid Injections (TFESI)

II. Transforaminal Epidural Steroid Injections (TFESI) - A. One TFESI for acute pain

Considered medically necessary when ALL of the following are met:

One TFESI for acute pain

Acute radicular pain: Pain is acute (< three months) and there is severe radicular pain in a specific nerve root distribution that interferes substantially with activities of daily living (ADLs)< three months
Cervical steroid and imaging: If cervical TFESI is requested, non-particulate steroid must be used (see Table 1), and procedure must be conducted with real-time imaging (e.g., fluoroscopy)
Analgesic trial: Severe pain persists after treatment with NSAID and/or opiate (both ≥ three days or contraindicated/not tolerated)

Coding

Relevant CPT codes describedCPT

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)

Provider Actions / Billing & Documentation

Prior Authorization

Single procedure per visit and radiographic guidance required

Only one invasive pain management procedure is allowed per visit and all procedures must be performed with radiographic guidance. Claims may be reviewed for adherence to the single-procedure-per-visit and imaging guidance requirement.

Affected codes: 64479, 64480, 64483, 64484
Claims may be reviewed for adherence to one procedure per visit and use of radiographic guidance

Documentation Required

Conservative therapy documentation

For chronic indications, document prior attempts and durations of conservative therapy before SNRB/TFESI are considered medically necessary.

Background & Evidence

Background and evidence note that SNRBs are primarily diagnostic (local anesthetic) and when steroid is added they become therapeutic (transforaminal). Randomized trials and meta-analyses report significant short-term pain improvement up to three months after epidural injections, but longer-term outcomes are inconsistent across studies and techniques, with some trials showing similar efficacy among approaches and mixed superiority findings at 12 months.

Study / Source	Key finding
Meta-analysis (2015)
Epidural injections of local anesthetic with or without steroids have beneficial but similar short-term effects for chronic low back and lower extremity pain.

Definitions

SNRBsmall amount of local anesthetic injected adjacent to a spinal nerve root often used diagnostically.

TFESIlarger amount of local anesthetic or corticosteroid injected into the intervertebral foramen targeting nerve roots.

Particulate vs Non-particulate steroidParticulate steroids contain particles that may aggregate; non-particulate steroids have smaller particles and are required for cervical TFESI.

Medicare Determinations

Name	Number	Type	Effective Date
Epidural steroid injections for pain management
L39240
LCD

Revision History

07/24revised

Conservative therapy duration thresholds reduced from 6 to 4 weeks (effective 07/24).

07/24added

Provides examples and clarifies requirement for non-particulate steroid in cervical TFESI.

07/25revisedLatest

Now requires ≥50% relief and functional improvement for at least three months since last injection for repeat TFESI.

Policy Summary

Payermhn

PolicySelective Nerve Root Blocks and Transforaminal Epidural Injections (PDF)

Policy CodePolicy CP.MP.165

Change TypeRevisions & Additions

Effective Date

Next Review Date

SourceLink

On This Page

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I. Selective Nerve Root Blocks (SNRB) - A. One SNRB for acute pain

Considered medically necessary when ALL of the following are met:

One SNRB for acute pain

Acute radicular pain: Pain is acute (< three months) and there is severe radicular pain in a specific nerve root distribution that interferes substantially with activities of daily living (ADLs)< three months
Analgesic trial: Severe pain persists after treatment with NSAIDs and/or opiate (both ≥ three days or contraindicated/not tolerated)NSAIDs and/or opiate ≥ three days
Unable to tolerate therapy: Cannot tolerate chiropractic or physical therapy, and the injection is intended as a bridge to therapy

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I. Selective Nerve Root Blocks (SNRB) - B. One SNRB for chronic pain (diagnostic)

Considered medically necessary to establish a diagnosis and confirm beneficial response when ALL of the following are met:

One SNRB for chronic pain (diagnostic)

Single-root SNRB: Request is for an SNRB with a local anesthetic at a single nerve root
Persistent radicular pain and uncertain diagnosis: Persistent radicular pain in a defined nerve root level, and diagnosis remains uncertain after standard evaluation (neurologic examination, radiological studies and electrodiagnostic studies)
Chronic duration: Pain interferes with ADLs and has lasted for at least three monthsduration ≥ 3 months
Failure of conservative therapy
- Chiropractic/PT/exercise: ≥ four weeks chiropractic, physical therapy or prescribed home exercise program≥ 4 weeks
- NSAID trial: NSAIDs ≥ three weeks or NSAID contraindicated or not toleratedNSAIDs ≥ 3 weeks
- Activity modification: ≥ four weeks activity modification≥ 4 weeks

I. Selective Nerve Root Blocks (SNRB) - C. Second SNRB for chronic pain

Considered medically necessary when:

Second SNRB for chronic pain

Multilevel pathology suspected: Multilevel pathology is suspected
Interval since prior injection: At least two weeks have passed since the prior injection≥ 2 weeks

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I. Selective Nerve Root Blocks (SNRB) - D. Not medically necessary

SNRBs are considered not medically necessary:

Not medically necessary - other indications: For any indication other than those specified because effectiveness has not been established

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NSAID and/or opiate ≥ 3 days

Unable to tolerate therapy: Cannot tolerate chiropractic or physical therapy, and the injection is intended as a bridge to therapy

II. Transforaminal Epidural Steroid Injections (TFESI) - B. One TFESI for chronic pain

Considered medically necessary when ALL of the following are met:

One TFESI for chronic pain

Levels requested: TFESI requested for a single level bilaterally or up to two levels unilaterally
Cervical steroid and imaging: If cervical TFESI is requested, non-particulate steroid must be used (see Table 1), and procedure must be conducted with real-time imaging (e.g., fluoroscopy)
Confirmed cause: Persistent radicular pain caused by disc herniation in a defined nerve root level, or spinal stenosis confirmed by physical exam and imaging
Chronic duration: Pain interferes with ADLs and has lasted for at least three monthsduration ≥ 3 months
Failure of conservative therapy
- Chiropractic/PT/exercise: ≥ four weeks chiropractic, physical therapy or prescribed home exercise program≥ 4 weeks
- NSAID trial: NSAID ≥ three weeks or NSAID contraindicated or not toleratedNSAID ≥ 3 weeks
- Activity modification: ≥ four weeks activity modification≥ 4 weeks

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II. Transforaminal Epidural Steroid Injections (TFESI) - C. Second TFESI for chronic pain (no initial improvement)

Considered medically necessary when ALL of the following are met:

Second TFESI for chronic pain (no initial improvement)

Levels requested: Request is for a TFESI at one level bilaterally or up to two levels unilaterally
Cervical steroid and imaging: If a cervical TFESI is requested, non-particulate steroid must be used and procedure must be conducted with real-time imaging (e.g., fluoroscopy)
Interval since first TFESI: At least two weeks have passed since the first TFESI≥ 2 weeks

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II. Transforaminal Epidural Steroid Injections (TFESI) - D. Subsequent TFESIs for recurrence of chronic pain that had improved

Considered medically necessary when ALL of the following are met:

Subsequent TFESIs for recurrence

Levels requested: TFESI requested at a single level bilaterally or up to two levels unilaterally
Cervical steroid and imaging: If a cervical TFESI is requested, non-particulate steroid must be used and procedure must be conducted with real-time imaging (e.g., fluoroscopy)
Relief and duration: There was ≥ 50% relief and functional improvement for at least three months since the last injection≥ 50% relief for ≥ 3 months
Injection count limit: Less than four injections have been given at the same site within 12 months< 4 injections per site per 12 months
Time since initial injection: Less than 12 months have elapsed since the initial injection at the level requested< 12 months since initial injection at level

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II. Transforaminal Epidural Steroid Injections (TFESI) - E. Continuation limits

Considered not medically necessary:

Continuation limits: Continuation of injections beyond 12 months or more than 4 therapeutic injections because effectiveness and safety have not been established

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II. Transforaminal Epidural Steroid Injections (TFESI) - F. Not medically necessary

TFESIs are considered not medically necessary:

Not medically necessary - other indications: For any indication other than those specified because effectiveness has not been established

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≥ 4 weeks chiropractic, physical therapy, or prescribed home exercise program

NSAIDs ≥ 3 weeks or documentation of NSAID contraindication or intolerance

≥ 4 weeks activity modification

Documentation Required

Diagnostic evaluation documentation for SNRB

For diagnostic SNRB requests, document that the diagnosis remains uncertain after standard evaluation and include neurologic exam findings, radiological studies, and electrodiagnostic studies demonstrating single-root localization.

Neurologic examination documenting focal nerve root signs or localization
Relevant radiological studies (e.g., MRI/CT) indicating levels of interest
Electrodiagnostic studies supporting single-root localization

Billing Rule

Cervical TFESI steroid selection and imaging

For cervical transforaminal epidural steroid injections, a non-particulate steroid must be used and the procedure must be performed with real-time imaging (for example, fluoroscopy). Document the steroid type used and the imaging modality employed.

Use non-particulate steroid for cervical TFESI (see Table 1 examples)
Document steroid type (non-particulate) in the chart
Document real-time imaging modality used (e.g., fluoroscopy)

Denial Risk

Limit on continuation/number of injections

Continuation of injections beyond 12 months or more than four therapeutic injections at the same site within 12 months is considered not medically necessary and is at risk for denial unless exceptional, case-by-case justification is provided.

Referenced codes: 64479, 64483

Documentation Required

Interval since prior injection

Document timing and clinical response for repeat injections. For second injections, note that at least 2 weeks have passed since the prior injection; for repeat-injection criteria, document prior clinical response consistent with policy requirements.

At least 2 weeks since prior injection for second SNRB/TFESI
Document prior clinical response when applying repeat-injection criteria

07/25removedLatest

Anticoagulation discontinuation is now a clinical decision noted rather than a strict criterion.

08/21revised

Procedures must be performed with radiographic guidance; removed allowance for non-image-guided procedures (08/21).