Modifiedpartners_health_managementPolicy CP.MP.164

Caudal or Interlaminar Epidural Steroid Injections

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Clinical coverage policy defining medical necessity criteria, limits, and coding guidance for caudal and interlaminar epidural steroid injections for members/enrollees of the health plan.

Policy Summary

Payerpartners_health_management

PolicyCaudal or Interlaminar Epidural Steroid Injections

Policy CodePolicy CP.MP.164

Change TypeMaterial — clinical criteria revised (imaging, conservative therapy durations, anticoagulation wording removed)

Effective Date

Next Review Date

Key ActionObtain prior authorization and document required conservative therapy trials, imaging confirmation, and pain relief from prior injections.

SourceLink

POLICY UPDATE CHANGES

In policy statement, changed 'with or without radiographic guidance' to 'with imaging, (except in rare instances, with documented justification).'

Updated week requirement criteria I.B.4.a.-c. (≥4 weeks PT/home exercise, ≥3 weeks NSAID, ≥4 weeks activity modification).

Removed anticoagulation/INR specific requirement from criteria.

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Modifiedpartners_health_managementPolicy CP.MP.164

Caudal or Interlaminar Epidural Steroid Injections

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Clinical coverage policy defining medical necessity criteria, limits, and coding guidance for caudal and interlaminar epidural steroid injections for members/enrollees of the health plan.

Policy Summary

Payerpartners_health_management

PolicyCaudal or Interlaminar Epidural Steroid Injections

Policy CodePolicy CP.MP.164

Change TypeMaterial — clinical criteria revised (imaging, conservative therapy durations, anticoagulation wording removed)

Effective Date

Next Review Date

Key ActionObtain prior authorization and document required conservative therapy trials, imaging confirmation, and pain relief from prior injections.

SourceLink

POLICY UPDATE CHANGES

In policy statement, changed 'with or without radiographic guidance' to 'with imaging, (except in rare instances, with documented justification).'

Updated week requirement criteria I.B.4.a.-c. (≥4 weeks PT/home exercise, ≥3 weeks NSAID, ≥4 weeks activity modification).

Removed anticoagulation/INR specific requirement from criteria.

≤4Max injections/12 mo

≥50%Required improvement

≥4 wksPT/home exercise

Coverage Criteria

COVERAGE CRITERIA

Covered when ALL of the following are met

Acute pain ESI (single caudal or interlaminar)

Symptoms: There is severe radicular pain that interferes substantially with activities of daily living (ADLs).
Medication trial: Severe pain persists after treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) and/or opiates (both ≥ 3 days) OR NSAID/opiate contraindicated or not tolerated.
Therapy tolerance: Member/enrollee cannot tolerate chiropractic or physical therapy, and the injection is intended as a bridge to therapy.

COVERAGE CRITERIA

Covered when ALL of the following are met

Initial chronic ESI (one level)

Diagnosis: Persistent radicular pain caused by spinal stenosis, disc herniation or degenerative changes in the vertebrae, confirmed by physical exam and imaging.
Duration: Pain interferes with activities of daily living (ADLs) and has lasted for at least 3 months.
Conservative therapy
- PT/Exercise: ≥ 4 weeks of chiropractic, physical therapy or prescribed home exercise program.
- NSAID trial: NSAID for ≥ 3 weeks OR NSAID contraindicated or not tolerated.

COVERAGE CRITERIA

Covered when ALL of the following are met

Second ESI after nonresponse: Request is for a caudal or interlaminar ESI at one level in the cervical, thoracic or lumbar region; at least 2 weeks have passed since the first ESI.

COVERAGE CRITERIA

Covered when ALL of the following are met

Subsequent ESI after prior improvement: Initial injection(s) led to ≥ 50% pain relief and functional improvement for at least 2 months; at least 2 months have passed since the last ESI; fewer than 4 injections have been administered within 12 months; and less than 12 months have elapsed since the initial injection at the level requested.

Caudal or interlaminar epidural steroid injections (ESI) for indications or locations not specified in the coverage criteria are considered not medically necessary because effectiveness has not been established. Specifically, a third or subsequent caudal or interlaminar ESI for chronic pain that did not improve from the first two ESIs is not medically necessary. Continuation of injections beyond 12 months or more than four therapeutic injections in a 12‑month period is also not medically necessary, except that consideration may be given on a case‑by‑case basis when more definitive therapies cannot be tolerated or provided.

When state Medicaid program coverage provisions conflict with this clinical policy, the state Medicaid requirements take precedence. Refer to the applicable state Medicaid manual and the member's plan documents for the controlling coverage rules and any plan‑level administrative policies.

Conservative Treatment Requirements

inv-24: Documented trials of noninvasive therapies — required durations

Documented trials of noninvasive therapies — required durations

Physical therapy / chiropractic / home exercise: Documented trial of ≥ four weeks of chiropractic care, physical therapy, or a prescribed home exercise program.

NSAID trial: Documented trial of NSAID therapy for ≥ three weeks, unless NSAID is contraindicated or not tolerated.

Activity modification: Documented trial of ≥ four weeks of activity modification.

Imaging Requirements

Prior Authorization

Imaging guidance required (fluoroscopy or CT)

Fluoroscopy or computed tomography (CT) imaging guidance is required during administration of caudal or interlaminar epidural steroid injections, except in rare instances when a lack of imaging is documented and justified.

Imaging guidance provides anatomic detail and procedural guidance (CT or standard fluoroscopy).

Documentation Required

Diagnostic imaging required for initial chronic ESI

For an initial chronic caudal or interlaminar ESI, diagnostic imaging confirming the causative pathology (spinal stenosis, disc herniation, or degenerative vertebral changes) must be documented along with physical exam findings.

Imaging confirmation is part of the coverage criteria for initial chronic ESI.
Documentation must show imaging supports the diagnosis causing persistent radicular pain.

Frequency Limits and Timing

inv-26: caudal or interlaminar ESI — maximum therapeutic injections (≤ 4 in 12 months)

Maximum therapeutic injections≤ 4 therapeutic caudal or interlaminar ESIs in any 12-month period.

Applies toCaudal or interlaminar epidural steroid injections (all levels).

Consequence of exceeding limitContinuation beyond four therapeutic injections in 12 months is considered not medically necessary.

inv-27: second ESI timing — at least 2 weeks between first and second ESI when first was nonresponsive

Minimum intervalAt least 2 weeks must have passed between the first and second caudal or interlaminar ESI when the first was nonresponsive.

Applies toSecond ESI for chronic radicular pain that did not improve after the first ESI.

Provider Actions and Documentation Requirements

Prior Authorization

Submit prior authorization showing indication, conservative therapy, and imaging

Obtain prior authorization that documents the indication, required conservative therapy trials and durations, and imaging confirmation (for chronic cases) to show medical necessity before performing caudal or interlaminar ESIs.

Prior authorization must demonstrate the indication and that conservative therapy trials/durations were met. [[chunk 2]]
For chronic cases, imaging confirmation of pathology is required as part of medical necessity. [[chunk 4]]

Note

Prior authorization requirements determined by the plan

Follow the Health Plan's prior authorization requirements and plan documents; this clinical policy is a medical necessity guide but prior authorization rules are determined by the plan.

The clinical policy provides guidance; prior authorization requirements are determined by the Health Plan and plan documents. [[chunk 21]]

Coding and Billing Guidance

Referenced CPT CodesCPT

62320	Injection(s), of diagnostic or therapeutic substance(s) (eg, 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) (eg, 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) (eg, 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) (eg, 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, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance.
62325	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (i.e., fluoroscopy or CT).
62327	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (i.e., fluoroscopy or CT).

Referenced LCDmixed

L39015

Local coverage determination: Epidural Steroid Injections for Pain Management (CMS LCD L39015)

inv-10: Number of therapeutic injections — quantity limit (<= 4 in 12 months)

Quantity limit≤ 4 therapeutic injections in any 12-month period.

ScopeApplies to therapeutic caudal or interlaminar epidural steroid injections.

Denial policyMore than four therapeutic injections in 12 months is considered not medically necessary.

Not Medically Necessary / Not Covered

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. In addition, continuation of injections beyond 12 months or administration of more than four therapeutic injections within a 12‑month period is considered not medically necessary because effectiveness and safety have not been established; exceptions may be considered on a case‑by‑case basis when more definitive therapies cannot be tolerated or provided.

No additional explicit procedures or indications are listed as not covered beyond those specified in the policy. Coverage decisions remain subject to the health plan’s terms, conditions, exclusions and limitations as described in plan documents.

Definitions

inv-21: ESI definition — Epidural steroid injections (ESIs) definition entry

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

PurposeUsed as a non-surgical treatment for radicular pain or neurogenic claudication to provide short-term pain relief and functional improvement.

Approaches notedPerformed via caudal, interlaminar, or transforaminal approaches (policy covers caudal and interlaminar).

inv-22: Caudal or interlaminar approach definition — approaches covered by this policy

Covered approachesCaudal and interlaminar approaches to lumbar epidural injections are covered by this policy.

Other approaches

Background

Epidural steroid injections (ESIs) deliver a glucocorticoid, often combined with local anesthetic, into the epidural space to reduce inflammation and radicular pain. Approaches include the caudal approach (via the sacral hiatus), the interlaminar approach (midline entry between laminae), and the transforaminal approach; this policy addresses the caudal and interlaminar approaches. Imaging guidance such as fluoroscopy or CT is generally required to provide anatomic detail and needle placement confirmation, except in rare instances with documented justification. Candidates for ESIs are typically patients with radiculopathy or neurogenic claudication who have significant functional impairment and have failed appropriate conservative therapies.

Policy Summary

Payerpartners_health_management

PolicyCaudal or Interlaminar Epidural Steroid Injections

Policy CodePolicy CP.MP.164

Change TypeMaterial — clinical criteria revised (imaging, conservative therapy durations, anticoagulation wording removed)

Effective Date

Next Review Date

Key ActionObtain prior authorization and document required conservative therapy trials, imaging confirmation, and pain relief from prior injections.

SourceLink

On This Page

Activity modification:

≥ 4 weeks activity modification.

Note

Referenced guidance (CMS LCD L39015 and NASS) and explicit imaging requirement

Policy references CMS Local Coverage Determination (L39015) and NASS coverage recommendations; imaging guidance expectations are aligned with these references and the policy’s explicit requirement that ESIs be performed with imaging except in rare documented cases.

CMS LCD L39015 and NASS recommendations are cited in the policy references.
The policy explicitly changed wording to require imaging except in rare instances with documented justification.

DocumentationRequest must specify timing since prior injection to demonstrate the 2-week interval has elapsed.

inv-28: subsequent ESI after prior improvement — at least 2 months since last ESI for recurrence after documented improvement

Minimum interval after improvementAt least 2 months must have passed since the last ESI for recurrence after documented improvement (initial injection(s) produced ≥50% pain relief and functional improvement for ≥2 months).

Other requirementsFewer than four injections administered within 12 months and less than 12 months have elapsed since the initial injection at the level requested.

Applies toSubsequent caudal or interlaminar ESI for recurrence after prior improvement.

inv-29: Additional frequency limits placeholder (inventory item with no explicit summary)

Placeholder itemInventory item reserved for additional frequency limits or references; no explicit summary provided in the policy extract.

Reference noteSee referenced literature and CMS LCD for supplementary guidance.

ActionConsult full policy text or plan documents for any additional frequency clarifications.

Step Therapy

Document trials of specified conservative therapy durations before initial chronic ESI

Before an initial chronic ESI, document tried and failed conservative therapies meeting specified durations: at least 4 weeks of chiropractic/physical therapy or prescribed home exercise, and at least 3 weeks of NSAID therapy (or documented contraindication/not tolerated).

Conservative therapy must include ≥ four weeks of chiropractic, physical therapy or prescribed home exercise. [[chunk 4]]
NSAID for ≥ three weeks or NSAID contraindicated/not tolerated is required. [[chunk 4]]
Policy lists these conservative therapy requirements as prerequisites for initial chronic ESI. [[chunk 2]]

Documentation Required

Provide clinical documentation: ADL impact, conservative therapy details, and imaging

Include clinical documentation of severity (interference with ADLs), prior conservative treatments with dates/durations, and imaging confirmation of radicular pathology when requesting chronic ESIs.

Policy requires documentation that pain interferes with ADLs and has lasted ≥ three months for chronic ESI. [[chunk 2]]
Document prior conservative therapy trials and imaging confirmation of spinal pathology. [[chunk 4]]

Denial Risk

Third/subsequent nonresponsive ESIs will be denied

Do not expect coverage for a third or subsequent caudal/interlaminar ESI for chronic pain if the member did not improve after the first two injections; such requests are considered not medically necessary and will be denied.

A third or subsequent ESI for chronic pain that did not improve from the first two ESIs is considered not medically necessary. [[chunk 4]]

Denial Risk

Do not continue injections beyond 12 months or >4 therapeutic injections

Requests for continuation of therapeutic injections beyond 12 months or for more than four therapeutic injections within 12 months will be considered not medically necessary and denied unless exceptional case review is granted.

Continuation of injections beyond 12 months or more than four therapeutic injections is considered not medically necessary. [[chunk 4]]
Consideration on a case-by-case basis may occur when more definitive therapies cannot be tolerated or provided. [[chunk 4]]

Billing Rule

Follow plan terms, exclusions, and applicable legal/regulatory requirements

When submitting claims and prior authorization requests, adhere to all applicable plan terms, conditions, exclusions, limitations, and state and federal requirements.

Coverage decisions and administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents and applicable state/federal requirements. [[chunk 21]]

Note

Coverage decisions are subject to all plan terms and limitations

Coverage determinations using this clinical policy are subject to the plan's benefit terms, conditions, exclusions and limitations; this policy does not guarantee coverage or payment.

The policy is a guide to medical necessity and does not constitute a contract or guarantee regarding payment. [[chunk 21]]

Note

Ensure complete, policy-conforming submissions to avoid denial

Provide all required documentation, meet the policy clinical criteria, and follow prior authorization and plan submission rules; incomplete or nonconforming submissions risk denial.

Procedures must be performed by a physician and with imaging guidance except in rare documented instances. [[chunk 2]]
Failure to document required conservative therapy, imaging, or exceed frequency/duration limits may result in denial per policy. [[chunk 4]]
Plan-level terms, conditions and administrative policies govern final coverage decisions. [[chunk 21]]

Transforaminal approach exists but is covered under a separate policy (CP.MP.165).

GuidanceImaging guidance (CT or fluoroscopy) may be used during administration to provide anatomic detail; policy requires imaging except in rare documented instances.

inv-23: Clinical policy definition — explains that clinical policy guides medical necessity and is not a contract or payment guarantee.

RoleA clinical policy provides guidance to assess medical necessity and assist coverage decisions and benefit administration.

Not a contractThis clinical policy does not constitute a contract or guarantee of payment or results.

Legal/administrative limitsCoverage decisions remain subject to all terms, conditions, exclusions and limitations of the coverage documents and applicable law.