Epidural Steroid Injection for Pain Management (ESI)
Billing, coding, and reimbursement guidelines for epidural steroid injections (ESI) applied to Priority Health commercial, Medicare, and Medicaid lines of business; describes allowed codes, frequency limits, modifier use, documentation and place-of-service expectations.
No material clinical or coverage changes in this revision.
Coverage Criteria and Billable Conditions
Coverage criteria and billing rules
Coverage is permitted when billing follows the policy's code, frequency, modifier, place-of-service and documentation requirements. Specific Medicare PSOD and authorization requirements may apply.
ALL of the following
ALL of the following
- Spinal region: Only one spinal region may be treated per date of service.
ALL of the following
- No more than 4 epidural injection sessions per spinal region in any 12-month period regardless of number of levels involved.
ALL of the following
ALL of the following
- Modifiers must follow CMS NCCI guidance and be supported by documentation; incorrect modifier use may result in denials (examples: 50, KX, LT, RT).
- Complete and thorough documentation to substantiate the performed procedure is required; failure to document can result in denial or recoupment.
ALL of the following
- For Medicare indications that do not meet NCD, local LCD, or specific medical policy, a Pre-Service Organization Determination (PSOD) is required.
- Coverage is considered when services are furnished in an appropriate setting to the patient’s medical needs; authorization may be required based on place of service.
Allowed Procedure Codes, Levels, and Frequency Limits
| 64479 | Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level |
| 64480 | Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, each additional level (list separately in addition to code for primary procedure) |
| 64483 | Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level |
| 64484 | Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, each additional level (list separately in addition to code for primary procedure) |
| 62321 | Injection, of diagnostic or therapeutic substance (e.g., anesthetic, antispasmodic) not including neurolytic substances, with or without contrast, with catheter, epidural, cervical/thoracic; single level |
| 62323 | Injection, of diagnostic or therapeutic substance ... epidural, lumbar/sacral; single level |
Prior Authorization, Documentation, and Modifier Use
Pre-Service Organization Determination (Medicare)
For Medicare: When indications do not meet an NCD, local LCD, or a specific medical policy, a Pre-Service Organization Determination (PSOD) is required. See the Provider Manual for PSOD details and submission instructions.
Modifier documentation and denial risk
Modifiers must be applied per CMS NCCI and Priority Health billing guidance and supported by documentation. Incorrect or unsupported modifier use can result in claim denials, payment recovery, or request for additional information. Providers should only append modifiers when the clinical record clearly justifies their use and follow any specific modifier instructions in applicable medical policies.
- Common modifiers include but are not limited to: 50 (bilateral procedures), KX (policy-specific requirements met), LT (left side), RT (right side).
- Modifier use must be documented in the medical record and match the service performed — unsupported modifiers risk denial or recoupment.
Documentation requirements
Complete, accurate, and thorough documentation to substantiate the performed procedure is the provider's responsibility. Documentation must support the procedure, the reason for any modifiers, place of service, and medical necessity. Failure to document appropriately will result in denial, payment recoupment, or audit. Consult the Provider Manual and any applicable medical policy for additional documentation requirements.
Key Terms
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.