Currentsierra health and lifePolicy 2026T0616M

Epidural Steroid Injections for Spinal Pain

Clinical coverage criteria and coding guidance for epidural steroid injections (ESI) for radicular spinal pain applicable to UnitedHealthcare Commercial and Individual Exchange plans.

Policy Summary

Payersierra health and life

PolicyEpidural Steroid Injections for Spinal Pain

Policy CodePolicy 2026T0616M

Change TypeTemplate update — no material clinical changes

Effective DateJan 1, 2026

Next Review Date

Key ActionDocument at least 4 weeks of prior conservative therapy and confirm radicular pain with imaging or electrodiagnostic evidence before requesting authorization for ESI.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≤4max ESI sessions per region per 12 months

≥4 wkminimum conservative therapy before ESI

≥50%threshold for adequate prior relief

fluoro/CTimaging guidance required

ultrasoundnot medically necessary

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FDA serious AE warning

Coverage Criteria for Epidural Steroid Injections (ESI)

Medically necessary indications for ESI

Epidural Steroid Injections (ESI) are medically necessary when ALL of the following are met:

Primary coverage criteria: Injection is intended for management of radicular pain documented by history and physical exam.

Document radicular distribution and correlating exam findings.

Conservative therapy: Radicular pain is unresponsive to at least 4 weeks of conservative treatment (eg, pharmacotherapy such as NSAIDs or acetaminophen; activity modification; or physical therapy/home exercise).>= 4 weeks

Document specific therapies and duration in the medical record.

Objective evidence of nerve involvement: There is evidence of structural and/or functional nerve root involvement demonstrated by imaging (eg, MRI/CT) or electrodiagnostic studies.

Provide imaging or electrodiagnostic reports.

Image guidance: Injection will be performed under fluoroscopic or CT guidance.

Document imaging guidance used on the procedure note.

Frequency limits and criteria for additional injections

Limitations and reauthorization logic:

Frequency limits: Maximum of four (4) ESI sessions per region per 12-month period. A session is one date of service in which ESI injection(s) are performed; a region is cervical, thoracic, or lumbosacral; a year is the 12 months starting from the date of the first approved injection.4 per region per 12 months

Track region and date of first approved injection.

Criteria for subsequent injections: Subsequent ESIs may be provided only if radicular pain has returned and/or function has deteriorated AND one of the following is met:

Provider must document return of symptoms and prior response.

Previous injection response — short or long: (a) Previous injection resulted in ≤ 50% pain relief or functional improvement for < 3 months despite reassessment of patient and technique; OR (b) Previous injection resulted in ≥ 50% pain relief or functional improvement for ≥ 3 months.

Covered indications and operational criteria

Covered when clinical evidence and guideline-based indications are met:

Appropriate indications: ESIs are appropriate for selected patients with radicular pain, particularly radiculopathy due to disc herniation where randomized trials support short-term benefit; they are used as part of an active therapy program to relieve pain and improve function.short- to intermediate-term benefit

Support from multiple systematic reviews and RCTs (eg, Level I evidence for transforaminal in disc herniation).

Imaging and technique recommendations: Image guidance (fluoroscopy or CT) is recommended to confirm needle position and contrast spread for transforaminal and many epidural approaches; ultrasound is emerging but evidence is limited and operator-dependent.

Prefer fluoroscopy/CT for coverage; ultrasound considered unproven in many contexts.

Conservative care prior to ESI: Conservative treatments (eg, NSAIDs, therapeutic exercise, multimodal physical therapy) are typically attempted first for an appropriate interval (guidelines commonly cite approximately 3 weeks for some conditions) unless clinical circumstances justify earlier intervention.

WFNS and FDA guidance related to ESIs

Guidance and evidence-based recommendations present in this section:

Conservative care before surgery for lumbar spinal stenosis (LSS): In non-severe LSS, begin with a conservative approach including at least 3 weeks of therapeutic exercise; prefer medical/interventional treatment over surgery for mild symptoms; consider surgery if no clinical change after 3 months.3 weeks; 3 months

WFNS Spine Committee recommendations.

Efficacy of ESIs for LSS: Literature supports short- to intermediate-term symptomatic benefit from epidural injections for LSS; inclusion of steroids does not necessarily add benefit compared with local anesthetic alone.short- to intermediate-term

WFNS statement.

Limit further injections when relief is short-lived: Do not proceed with further epidural injections for patients whose symptomatic relief after an injection lasts less than 3 months.

Epidural steroid injections (ESIs) are contraindicated in patients with active conditions that increase procedural risk. Examples include known or suspected spinal neoplasm, a rapidly progressing neurological deficit, or an epidural abscess. Coverage for ESIs as medically necessary requires that all primary indications be documented: the procedure is intended to treat radicular pain demonstrated by history and physical exam, the radicular pain has been unresponsive to ≥ 4 weeks of conservative therapy (eg, pharmacotherapy, activity modification, or PT/home exercise), there is evidence of nerve‑root involvement on imaging or electrodiagnostic testing, and the injection is performed with fluoroscopic or CT guidance.

The evidence base does not support routine use of ESIs for back pain that lacks radicular features. Systematic reviews and guideline statements note that ESIs may offer short‑term symptomatic improvement for selected patients with radiculopathy but there is insufficient evidence to demonstrate effectiveness for back pain in the absence of nerve‑root compression. Major guideline bodies (eg, ACOEM, AHRQ, AAN) and technology assessments consistently find ESIs are not recommended or provide limited utility for non‑radicular low back pain.

Regulatory information is provided for clinician awareness and informed consent but does not by itself determine coverage. The FDA notes that corticosteroids themselves are approved drugs but are not FDA‑approved for epidural administration, and in April 2014 issued a safety communication warning of rare but serious neurologic adverse events (including vision loss, stroke, paralysis, and death) associated with epidural corticosteroid injections. Providers should discuss these risks with patients as part of shared decision‑making.

The use of ultrasound guidance for epidural steroid injections is considered unproven and not medically necessary due to limited and inconsistent evidence demonstrating clinical benefit compared with fluoroscopy or CT. Peer‑reviewed literature and the policy identify insufficient data to support routine ultrasound‑guided ESIs; fluoroscopic or CT guidance remains the required imaging standard for covered procedures.

For non‑radicular back pain (pain without radicular radiation or objective evidence of nerve‑root involvement), the literature does not support ESIs as an effective treatment. Comparative effectiveness reviews and professional society guidelines conclude that ESIs offer limited or no durable benefit for non‑radicular low back pain, and routine use for these indications is not supported by current evidence.

Numerous guideline statements recommend against epidural steroid injections for patients with acute, subacute, or chronic low back pain when significant radicular symptoms are absent. Where guidance exists, ESIs are typically reserved for radiculopathy (eg, disc herniation) and are not recommended as first‑line therapy for non‑radicular low back pain.

The World Federation of Neurosurgical Societies (WFNS) recommends that clinicians should not proceed with additional epidural injections for patients whose symptomatic relief after a prior injection lasted less than 3 months. This recommendation supports limiting repeat therapeutic injections when clinical benefit is short‑lived.

Coding and Billing Guidance

Interlaminar cervical/thoracic CPT codesCPT

62320	Injection(s), of diagnostic or therapeutic substance(s) (e.g., 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) (e.g., 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).

Interlaminar lumbar/caudal and transforaminal CPT codesCPT

62322	Injection(s), of diagnostic or therapeutic substance(s) (e.g., 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) (e.g., 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).
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).

Diagnosis ICD-10 codes (radiculopathy and nerve root injury)ICD-10

M47.20	Other spondylosis with radiculopathy, site unspecified.
M50.121	Cervical disc disorder at C4-C5 level with radiculopathy.
M51.16	Intervertebral disc disorders with radiculopathy, lumbar region.
M54.16	Radiculopathy, lumbar region.
S14.2XXA	Injury of nerve root of cervical spine, initial encounter.
S34.21XA	Injury of nerve root of lumbar spine, initial encounter.

inv-15: Maximum ESI sessions — 4 per region per 12 months

Maximum sessions4 ESI sessions per region per 12 months (a session = one date of service)

Region definitionRegion = cervical, thoracic, or lumbosacral

Year definition12-month period starting from the date of service of the first approved injection

Provider Actions, Prior Authorization & Documentation

Prior Authorization

Verify Member Benefit & Prior Authorization

Verify member benefits and prior authorization requirements before scheduling or performing an epidural steroid injection (ESI). Benefit coverage is determined by the member-specific plan document and applicable laws; prior authorization may be required and coverage is not guaranteed by documentation alone.

Check member-specific benefit plan and prior authorization rules
Confirm any plan-mandated prior authorization timeframes and submission portals
Document PA approval or denial in the medical record prior to service

Documentation Required

Documentation & Indication Risks

ESI is medically necessary for radicular pain only after an adequate trial of conservative therapy and when documentation supports radicular etiology, structural or electrodiagnostic evidence of nerve root involvement, and use of image guidance. Absence of required documentation or treatment prerequisites may lead to denial.

Key Definitions

inv-29: Conservative Therapy definition

DefinitionConservative Therapy consists of an appropriate combination of medication (for example, NSAIDs, analgesics, etc.) plus physical therapy, spinal manipulation therapy, cognitive behavioral therapy (CBT) or other interventions based on the individual's presentation, physical findings, and imaging results.

Common componentsMedication (NSAIDs, analgesics), physical therapy/home exercise, activity modification

PurposeReduce pain and improve function prior to considering interventional procedures

inv-30: Epidural Steroid Injections (ESI) definition

DefinitionEpidural Steroid Injections (ESI): a nonsurgical treatment in which steroids are injected directly into the epidural space to relieve radiculopathy, improve function, and quality of life.

Typical agents

Conservative Care Requirements Before ESI

Document prior conservative therapies in medical record before approval (>= 4 weeks)

Document prior conservative therapies in the medical record before approval:

Minimum conservative therapy documented: At least 4 weeks of conservative therapy including pharmacotherapy (eg, NSAIDs or acetaminophen), activity modification, or physical therapy/home exercise must be documented prior to approval of ESI for radicular pain.>= 4 weeks

Record specific therapies, start/end dates, and patient response.

Content of conservative therapy: Conservative Therapy may include combinations of medication, physical therapy, spinal manipulation, cognitive behavioral therapy, or other individualized interventions based on presentation.

Provide description of modalities used and adherence.

Conservative care trial generally expected before ESI (~3 weeks)

Frequency Limits for Epidural Steroid Injections

inv-39: Epidural steroid injections (interlaminar, transforaminal, caudal) — maximum of four (4) ESI sessions per region

Policy limitEpidural steroid injections (interlaminar, transforaminal, caudal) — maximum of four (4) ESI sessions per region per 12 months

Session definitionA session is one date of service in which ESI injection(s) are performed

Region definitionRegion = cervical, thoracic, or lumbosacral

inv-40: Epidural injections (therapeutic phase) — not exceeding 4

Therapeutic phase limitTherapeutic epidural injections should generally be limited to no more than 4 procedures per region per year

Spacing guidanceSpace injections ~2.5–3 months provided >50% relief is obtained for that interval

Imaging Guidance for ESIs

Billing Rule

Use fluoroscopy or CT image guidance for ESIs

Covered epidural injections (interlaminar, transforaminal, caudal) must be performed under fluoroscopic or CT guidance; documentation should indicate which modality was used.

Policy states the injection must be performed under fluoroscopic or CT guidance for coverage.
Include imaging modality in procedure documentation.

Note

Prefer fluoroscopy/CT for transforaminal and interlaminar ESIs; ultrasound not established

Transforaminal and interlaminar epidural injections should be performed with fluoroscopy or CT to confirm needle position and contrast spread; ultrasound is noted as an emerging technique but evidence is limited and considered unproven for coverage.

ASIPP and ASA recommend image guidance for transforaminal injections.

Background

Epidural steroid injections (ESIs) are a nonsurgical interventional option for patients with radicular pain caused by disc herniation or degenerative spinal changes. ESIs can be delivered by interlaminar, transforaminal, or caudal approaches and are intended to provide short‑term pain relief and functional improvement as part of an active therapy program. Covered ESIs must be documented as treating radicular pain with prior conservative care (≥ 4 weeks unless otherwise clinically indicated), evidence of nerve‑root involvement on imaging or electrodiagnostics, and performed with fluoroscopic or CT guidance. Frequency limits apply: therapeutic injections are generally spaced about 2.5–3 months and limited to a maximum of 4 sessions per region per 12 months.

Not Covered / Not Medically Necessary

Ultrasound guidance for ESIs is specifically identified as not covered / not medically necessary because available studies are limited, operator dependent, and have not demonstrated overall health benefit compared with fluoroscopy or CT. Additionally, ESIs performed for non‑radicular indications (back pain without nerve‑root involvement) are not covered given insufficient evidence supporting effectiveness for those conditions.

Policy Summary

Payersierra health and life

PolicyEpidural Steroid Injections for Spinal Pain

Policy CodePolicy 2026T0616M

Change TypeTemplate update — no material clinical changes

Effective DateJan 1, 2026

Next Review Date

Key ActionDocument at least 4 weeks of prior conservative therapy and confirm radicular pain with imaging or electrodiagnostic evidence before requesting authorization for ESI.

SourceLink

On This Page

50% relief; 3 months

Use validated measurement tools to document percent relief and duration.

Document conservative measures and duration; WFNS and ACOEM guidance referenced.

Therapeutic-phase frequency and response: Repeat therapeutic injections should be spaced approximately 2.5–3 months and limited to no more than 4 per year per region, and typically continued only if the patient achieves >50% relief lasting the expected interval.>50% relief for 2.5–3 months

ASIPP and therapeutic phase guidance.

WFNS recommendation.

FDA safety communication: Providers should discuss and document benefits and risks because FDA warns of rare but serious adverse events (loss of vision, stroke, paralysis, death) associated with epidural corticosteroid injections; corticosteroids are not FDA‑approved for epidural administration.N/A

FDA safety communication (2014) and drug labeling guidance.

Required: history and physical exam consistent with radicular pain
Required: ≥ 4 weeks of conservative therapy for radicular pain (see conservative therapy block)
Required: imaging or electrodiagnostic evidence of nerve root involvement
Required: procedure performed under fluoroscopic or CT guidance
Missing documentation of the above increases risk of claim denial

Denial Risk

Denial Risk Drivers

Denials are commonly driven by requests for ESIs that do not meet radicular indications, lack required conservative therapy, insufficient imaging/electrodiagnostic evidence, lack of image guidance, or requests for ultrasound-guided ESIs (considered unproven).

ESI for nonradicular back pain or spinal stenosis without supporting evidence — likely not covered
Use of ultrasound guidance for ESI — considered unproven and may be denied
Insufficient clinical documentation tying symptoms to a specific nerve root or lacking objective testing
Failure to document conservative therapy trial (duration, modalities, response)

Denial Risk

Potential Denial Triggers & Safety Considerations

Potential denial triggers and safety considerations include repeating injections when prior benefit was short-lived (< 3 months) without reassessment, absence of informed consent discussing FDA safety communications, and failure to recognize contraindications (e.g., spinal neoplasm, rapidly progressive neurologic deficit, epidural abscess).

Do not repeat injections if prior relief was < 3 months unless there is documented reassessment and justification
Document informed consent that includes discussion of FDA safety warnings (rare but serious neurologic events)
Screen and document absence of contraindications prior to proceeding

Documentation Required

Required Clinical Documentation

Required clinical documentation to support ESI requests should be submitted with prior authorization and retained in the medical record for review.

Detailed history and physical exam documenting radicular pain and dermatomal distribution
Dates, modalities, and responses for conservative therapies (medications, PT/home exercise, activity modification, CBT, spinal manipulation) including duration (≥4 weeks unless specific guideline recommends ~3 weeks)
Imaging reports (MRI/CT) or electrodiagnostic study results demonstrating nerve root involvement
Pain and functional outcome measures (validated tools) documenting baseline and response to prior treatments
Procedure note indicating image guidance (fluoroscopy or CT), laterality/levels treated, drugs used (steroid agent), and injection technique

Billing Rule

Imaging & Frequency Documentation

Imaging guidance and frequency documentation expectations: ESIs should be performed with fluoroscopic or CT guidance and contrast/spread confirmation as appropriate. Frequency limits apply — generally no more than four ESI sessions per region per 12-month period, with recommended spacing of roughly 2.5–3 months between therapeutic injections when effective.

Image guidance: fluoroscopy or CT required; ultrasound guidance considered unproven
Document contrast use and needle position/contrast spread when applicable (e.g., transforaminal injections)
Frequency limit: maximum 4 sessions per region per 12-month period (year defined from date of first approved injection)
Spacing guidance: typically 2.5–3 months between injections if >50% relief is achieved for that interval; do not exceed 4/year
Define a session as one date of service with ESI(s) performed

Documentation Required

Informed Consent & Plan Documentation

Informed consent and treatment plan documentation must address benefits, alternatives, and the FDA communication about rare but serious neurologic risks associated with epidural corticosteroid injections. Include a plan for follow-up, objective reassessment, and criteria for repeating injections.

Document discussion of FDA safety communication (rare risks: vision loss, stroke, paralysis, death) and that corticosteroids are not FDA-approved specifically for epidural administration
Record the agreed treatment plan, expected benefit, alternatives (including continued conservative care and surgical options), and follow-up timing
Include objective measures and thresholds for repeating injections (pain relief percentage and duration, functional improvement)

Step Therapy

Conservative Therapy Prerequisite

Conservative therapy prerequisite: At minimum, a trial of conservative therapy is required prior to ESI for radicular pain — typically ≥ 4 weeks. Guidance from specialty societies supports approximately 3 weeks of therapeutic exercise as an initial conservative approach in some circumstances.

Minimum: ≥ 4 weeks of conservative therapy (medication, activity modification, PT/home exercise) documented with dates and response
ACOEM notes waiting at least ~3 weeks and treatment with NSAIDs prior to considering ESI in select acute/subacute radicular pain
WFNS recommends at least 3 weeks of therapeutic exercise as first-line for non-severe lumbar stenosis cases

Step Therapy

Conservative Therapy Prior to ESI

Conservative therapy prior to ESI should be individualized but commonly includes a combination of pharmacotherapy and therapeutic exercise for an interval (recommended ≈3–4 weeks) with documentation of modalities tried and clinical response.

Examples: NSAIDs or acetaminophen, activity modification, supervised physical therapy or structured home exercise programs, CBT or multimodal PT approaches
Document duration (~3–4 weeks), adherence, and objective/subjective response to each modality
If conservative measures fail or symptoms worsen (progressive neurologic deficit), consider earlier intervention per clinical judgment

Note

Conservative First-Line Recommendation

Conservative first-line recommendation: Prioritize noninvasive management (therapeutic exercise, medications, activity modification) as first-line therapy for radicular back pain and lumbar spinal stenosis when clinically appropriate, reserving ESIs for patients who fail to improve or have objective evidence of nerve root involvement.

Therapeutic exercise and multimodal physical therapy are first-line for non-severe cases
Medical/interventional therapies preferred over surgery for mild spinal stenosis when conservative measures are appropriate
Surgery considered if no improvement after an appropriate conservative period (commonly up to 3 months for LSS) or if severe/progressive deficits are present

Injectable corticosteroids (eg, methylprednisolone, triamcinolone, betamethasone, dexamethasone) and/or local anesthetic

Regulatory noteCorticosteroids are FDA-approved drugs but not specifically approved for epidural administration; safety and effectiveness for epidural use have not been established

inv-31: Radicular Back Pain definition

DefinitionRadicular Back Pain: pain that radiates from the spine into an extremity along the course of a spinal nerve root and follows a dermatomal pattern corresponding to the irritated nerve root.

CorrelationShould correspond to nerve root findings on clinical exam and imaging

Clinical implicationIndication for ESI when conservative therapy fails and nerve‑root involvement is demonstrated

inv-32: Non-Radicular Back Pain definition

DefinitionNon-Radicular Back Pain: back pain that does not radiate along a single dermatome and lacks imaging or clinical evidence of spinal nerve root compression.

Imaging/examAppropriate imaging does not reveal signs of nerve root compression and clinical exam lacks corresponding findings

Coverage implicationESI generally not supported for non-radicular back pain absent nerve‑root involvement

inv-33: Transforaminal ESI — definition and evidence level

DefinitionTransforaminal ESI: an epidural steroid injection delivered via the neural foramen targeted to the exiting nerve root.

Evidence levelMultiple RCTs provide Level I evidence supporting transforaminal injections for radicular pain due to disc herniation; evidence varies by indication for other conditions

Safety noteGenerally safe but associated with rare major neurological complications (eg, spinal cord infarction), prompting evaluation of injectate choice and technique

inv-34: Therapeutic phase (interventional) definition and suggested intervals

DefinitionTherapeutic phase (interventional): the period after diagnostic interventions when therapeutic injections are given.

Suggested intervalSuggested spacing of injections is approximately 2.5–3 months or longer between injections provided >50% relief is obtained for that interval

Frequency capTypically not to exceed 4 injections per year per region during the therapeutic phase

inv-35: Epidural Steroid Injection (ESI) — procedural substance examples

Examples of injectatesInjectable corticosteroids such as methylprednisolone, triamcinolone, betamethasone, and dexamethasone (often combined with local anesthetic)

Regulatory cautionFDA notes corticosteroids are not approved specifically for epidural use and safety/effectiveness for epidural administration have not been established

Alternative injectates evaluatedNonparticulate steroids and local anesthetic alone have been studied; no alternative injectate proven superior

Conservative care trial generally expected before ESI:

Expected conservative trial duration: Guidelines commonly recommend a trial of conservative management (eg, NSAIDs, therapeutic exercise, multimodal physical therapy) for approximately 3 weeks prior to ESI for many non-severe lumbar spinal stenosis and acute/subacute radicular presentations unless urgent indications exist.~3 weeks

Document reason if ESI is provided earlier (eg, severe neurologic deficit, progressive weakness).

Exception criteria: Earlier ESI may be appropriate when clinical circumstances justify urgent intervention (eg, progressive motor deficit, cauda equina syndrome), which should be documented.

Provide clinical justification in the record.

Conservative therapy recommended prior to surgical intervention; supports ESI as symptomatic treatment (3 weeks minimum; reassess at 3 months)

Conservative therapy recommended prior to surgical intervention; supports ESI as symptomatic treatment:

Initial approach for non-severe LSS: For non-severe lumbar spinal stenosis start with conservative management including at least 3 weeks of therapeutic exercise and multimodal physical therapy; medical/interventional options are preferred over surgery for mild symptoms.3 weeks minimum

WFNS recommends multimodal PT and therapeutic exercise.

Reassessment and surgical consideration: If conservative treatment is chosen, consider surgery when the clinical condition does not improve after 3 months; ESIs may be used as symptomatic relief during this interval.reassess at 3 months

Document functional outcomes and decision-making.

ApplicabilityApplies to therapeutic phase after diagnostic procedures are completed

inv-41: Epidural injections — do not repeat injections for patients whose symptomatic relief is < 3 months

Do not repeat when relief short-livedDo not proceed with further epidural injections for patients whose symptomatic relief after an injection lasts less than 3 months

Assessment requirementIf prior injection produced ≤50% relief or relief <3 months, reassess the individual, injection site, and technique before considering repeat injection per policy criteria

RationaleWFNS recommendation and policy frequency criteria cite limited utility and safety concerns when relief is short-lived

Ultrasound is emerging but listed as unproven/not medically necessary in the policy.

Note

Document FDA safety communications; no other specific imaging mandated here

The policy excerpt notes safety communications regarding epidural injections and that corticosteroids are not FDA‑approved specifically for epidural use; no additional imaging requirement beyond fluoroscopy/CT is specified in this excerpt.

FDA states corticosteroids are not approved for epidural administration and requires label warnings.
Safety communications detail rare but serious neurologic adverse events.