RetiredUnitedHealthcarePolicy CS039LA1.F

Epidural Steroid Injections (for Louisiana Only)

Defines Louisiana Medicaid coverage rationale and applicable CPT procedure codes for epidural steroid injections (interlaminar and transforaminal) for radiculopathy, radicular pain, or neurogenic claudication; policy was retired effective April 1, 2026 and applied only to Louisiana.

Policy Summary

PayerUnitedHealthcare

PolicyEpidural Steroid Injections (for Louisiana Only)

Policy CodePolicy CS039LA1.F

Change TypeRetired / Coverage language removed

Effective DateSep 1, 2025

Next Review Date

Key ActionDocument history, exam, and concordant imaging showing radiculopathy/radicular pain or neurogenic claudication and that the condition is protracted and severely impacts function; verify state fee-schedule coverage for codes 64479 and 64480.

POLICY UPDATE CHANGES

Policy retired effective April 1, 2026; Louisiana plan membership disenrolled on Apr. 1, 2026.

09/01/2025 coverage rationale language removed that had allowed ESI for chronic intractable pain at provider discretion and various administrative statements about fee schedule and prior authorization.

References section updated to most current information; previous policy version archived (CS039LA1.E).

1State scope

RetiredPolicy status

8CPT codes referenced

This UnitedHealthcare Medical Policy (Policy No. CS039LA1.F) defined coverage rationale for epidural steroid injections (interlaminar and transforaminal) and applied only to Louisiana Medicaid. The policy referenced specific CPT procedure codes for interlaminar and transforaminal ESI and instructed that coverage decisions follow state requirements. The policy status is RETIRED; it was effective September 1, 2025 (effective date range shown as September 1, 2025 – March 31, 2026) and was retired with plan disenrollment effective April 1, 2026 (last review/retirement noted April 1, 2026).

Policy summary

State scope1 (Louisiana only)

Policy statusRetired

CPT codes referenced8

Policy numberCS039LA1.F

Effective dateSeptember 1, 2025

Last reviewApril 1, 2026

Medical-Necessity Criteria

Medical Necessity for Epidural Steroid Injection (ESI)

Covered when ALL of the following are met:

ALL of the following

History of illness
Physical examination
AND concordant diagnostic imaging supporting ONE of
- Radiculopathy
- Radicular pain
- Neurogenic claudication due to herniation, stenosis, and/or degenerative disease
Condition is protracted and severe enough to greatly impact quality of life or function

ref

CPT Procedure Codes

Referenced Procedure Codes (CPT) - Interlaminar and Transforaminal ESICPT

62320	Injection(s), of diagnostic or therapeutic substance(s), interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance
62321	Injection(s), of diagnostic or therapeutic substance(s), interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance
62322	Injection(s), of diagnostic or therapeutic substance(s), interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance
62323	Injection(s), of diagnostic or therapeutic substance(s), interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance
64479	Injection(s), anesthetic agent(s) and/or steroid, transforaminal epidural, with imaging guidance; cervical or thoracic, single level. Note: Code marked with asterisk in policy: not on State of Louisiana Medicaid Fee Schedule and therefore may not be covered
64480	Injection(s), anesthetic agent(s) and/or steroid, transforaminal epidural, with imaging guidance; cervical or thoracic, each additional level. Note: Code marked with asterisk in policy: not on State of Louisiana Medicaid Fee Schedule and therefore may not be covered
64483	Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance, lumbar or sacral, single level
64484	Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance, lumbar or sacral, each additional level

Provider Actions & Billing Notes

Documentation Required

Document clinical history, exam, and imaging concordance

Document the patient’s history of illness, relevant physical examination findings, and diagnostic imaging that is concordant with radiculopathy, radicular pain, or neurogenic claudication due to herniation, stenosis, or degenerative disease. Also document that the condition is protracted and severe enough to greatly impact the patient’s quality of life or function.

History of illness
Physical examination findings
Concordant diagnostic imaging supporting radiculopathy, radicular pain, or neurogenic claudication due to herniation, stenosis, and/or degenerative disease
Documentation that condition is protracted and severely impacts quality of life or function

Billing Rule

State fee schedule applicability

Codes marked with an asterisk (64479, 64480) are not on the State of Louisiana Medicaid Fee Schedule and therefore may not be covered by the State of Louisiana Medicaid Program; providers should verify reimbursement eligibility with the Louisiana fee schedule and their contract terms.

64479
64480
Codes labeled with an asterisk (*) are not on the State of Louisiana Medicaid Fee Schedule and therefore may not be covered by the State of Louisiana Medicaid Program.

Background

This policy applied exclusively to the state of Louisiana and described clinical criteria for epidural steroid injections: documentation of history of illness, physical examination, and concordant diagnostic imaging supporting radiculopathy, radicular pain, or neurogenic claudication due to herniation, stenosis, and/or degenerative disease that is protracted and severe enough to greatly impact quality of life or function.

The policy instructed that it should be interpreted in the context of federal, state, or contractual benefit requirements and applicable laws, and that those requirements govern in the event of a conflict. It also noted that CPT code listings are for reference and do not guarantee coverage or reimbursement.

The policy referenced Louisiana Department of Health guidance (Managed Care Organization Manual, Professional Services: Anesthesia. Pain Management) as an applicable resource and included instructions mandated by the Louisiana Department of Health.

Revision History

2026-04-01retirementLatest