CurrentUnitedHealthcarePolicy CS039NE.AA

Epidural Steroid Injections for Spinal Pain (for Nebraska Only)

State-specific (Nebraska) medical policy defining medical necessity, limitations, contraindications, and evidence basis for epidural steroid injections (interlaminar, transforaminal, caudal) for radicular spinal pain; includes applicable CPT and ICD-10 codes and documentation guidance.

Policy Summary

PayerUnitedHealthcare

PolicyEpidural Steroid Injections for Spinal Pain (for Nebraska Only)

Policy CodePolicy CS039NE.AA

Change TypeCoverage criteria revised; state-specific version created

Effective DateAug 1, 2025

Next Review Date

Key ActionRecord history and physical demonstrating radicular pain, document ≥4 weeks of conservative therapy, and document imaging or electrodiagnostic evidence of nerve root involvement.

POLICY UPDATE CHANGES

Created state-specific policy version for the state of Nebraska.

Revised coverage criteria to require evidence of structural and/or functional nerve root involvement by imaging or electrodiagnostic studies.

Added language that medical records documentation may be required and that federal/state/contractual requirements govern coverage where applicable.

Archived previous policy version CS039.Z.

4Maximum sessions per region per year

>=4 wkMinimum conservative therapy duration before ESI

50%

Coverage Summary

This Nebraska-specific policy (Policy Number CS039NE.AA, effective August 1, 2025) addresses coverage of Epidural Steroid Injections (ESI) — interlaminar, transforaminal, and caudal — for radicular spinal pain. Coverage stance: covered with criteria. The policy defines medical necessity requirements (including documented radicular pain, ≥ 4 weeks of conservative therapy unless contraindicated, evidence of structural and/or functional nerve root involvement by imaging or electrodiagnostic studies, and use of fluoroscopic or CT guidance), contraindications and exclusions, and documentation expectations. Frequency is limited to a maximum of four (4) ESI sessions per region per 12-month period (regions = cervical, thoracic, lumbosacral).

Medical-Necessity Criteria

Contraindications, Exclusions, and Not Medically Necessary

Frequency & Session Limits

Unsupported block type: object

Provider Actions & Documentation Requirements

Documentation Required

Document radicular pain and conservative therapy trial

Document a history and physical demonstrating radicular pain (pain radiating along a dermatome consistent with nerve root irritation). Document at least ≥ 4 weeks of conservative therapy prior to ESI (examples: NSAIDs or acetaminophen, activity modification such as avoiding heavy lifting/bending/spinal torsion, or physical therapy/home exercise). Include imaging or electrodiagnostic evidence of structural and/or functional nerve root involvement to meet coverage criteria.

Documentation Required

Document prior injection response for repeat ESI

For repeat/subsequent ESIs, document the prior injection response including percentage relief and duration as measured by validated measurement tools. Document reassessment of the individual, the injection site, and the injection technique. For subsequent injections, also document return of radicular pain and/or deterioration in function to justify additional treatment.

Prior Authorization

Prior authorization / medical records review may be required

Medical records and relevant documentation may be requested for prior authorization or medical review. Submission of documentation does not guarantee coverage of the requested service. Refer to the guideline titled 'Medical Records Documentation Used for Reviews' for details; this documentation language was added in the 08/01/2025 revision.

Denial Risk

Denial risk for unproven indications or improper guidance

Claims for ESIs that do not meet guidance requirements may be denied. Specifically, claims for injections performed without fluoroscopic or CT guidance, claims using ultrasound guidance as the primary guidance technique (considered unproven/not medically necessary), or claims for non-radicular indications not included in the medically necessary criteria may be considered not medically necessary and denied.

Denial Risk

Risk of denial if criteria not met

Claims may be denied if documentation fails to demonstrate required evidence of nerve root involvement by imaging or electrodiagnostic studies or does not meet other stated coverage criteria (e.g., documented conservative therapy trial, fluoroscopic/CT guidance, or required prior injection response).

Coding

Covered/Relevant CPT Procedure Codes (reference list)CPTCovered

62320	Interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance
62321	Interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (fluoroscopy or CT)
62322	Interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance
62323	Interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (fluoroscopy or CT)
64479	Transforaminal epidural, with imaging guidance; cervical or thoracic, single level
64480	Transforaminal epidural, with imaging guidance; cervical or thoracic, each additional level
64483	Transforaminal epidural, with imaging guidance; lumbar or sacral, single level
64484	Transforaminal epidural, with imaging guidance; lumbar or sacral, each additional level

Relevant ICD-10 Diagnosis Codes (radiculopathy / spine conditions referenced)ICD-10

M47.20	Other spondylosis with radiculopathy, site unspecified
M47.25	Other spondylosis with radiculopathy, thoracolumbar region
M51.15	Intervertebral disc disorders with radiculopathy, thoracolumbar region
M54.10	Radiculopathy, site unspecified
M96.1	Postlaminectomy syndrome, not elsewhere classified
G54.2	Cervical root disorders, not elsewhere classified
G54.3	Thoracic root disorders, not elsewhere classified
M47.21	Other spondylosis with radiculopathy, occipito-atlanto-axial region
M47.22	Other spondylosis with radiculopathy, cervical region
M47.23	Other spondylosis with radiculopathy, cervicothoracic region

1–10 of 48

1/5

Procedure/CPT/HCPCS codes (document references procedures generally; specific codes not listed in this part)mixed

No codes listed

Background & Evidence Summary

Epidural steroid injections (interlaminar, transforaminal, caudal) are described as a nonsurgical option to manage radiculopathy from disc herniation or degenerative vertebral changes; multiple specialty society guidelines and evidence reviews (AAN, ASA, NASS, ASIPP, AHRQ, Hayes and others) are cited. Randomized trials and meta-analyses generally show short- and intermediate-term pain relief for radicular (particularly lumbosacral) pain but limited and inconsistent long-term benefit; evidence quality and effect vary by spinal region and injection technique. The policy also notes an April 2014 FDA safety communication that corticosteroids are not FDA-approved for epidural use and that rare but serious adverse events (loss of vision, stroke, paralysis, death) have been reported.

Definitions

Definitions:

Conservative Therapy — Combination of medication (e.g., NSAIDs, analgesics) plus physical therapy, spinal manipulation, cognitive behavioral therapy, or other interventions individualized to presentation and findings; used as a required initial trial (≥ 4 weeks) before ESI unless contraindicated.

Epidural Steroid Injections (ESI) — Nonsurgical treatment in which corticosteroids (with or without anesthetic) are injected into the epidural space (interlaminar, transforaminal, or caudal approaches) to relieve radiculopathy and improve function.

Functional Impairments — Limitations in social or occupational functioning attributable to illness or injury.

Radicular Back Pain — Pain radiating from the spine into an extremity along a dermatome consistent with nerve root irritation or compression.

Non-Radicular Back Pain — Back pain that does not follow a dermatomal distribution and lacks clinical or imaging evidence of nerve root compression.

Electrodiagnostic studies — Tests such as electromyography (EMG) and nerve conduction studies used to demonstrate functional nerve root involvement.

Revision History

2025-11-01material_revisionLatest

Created state-specific policy version for the state of Nebraska; noted no change to coverage guidelines.

2025-08-01material_revision

Revised coverage criteria to replace wording requiring 'imaging or electromyography (EMG)' with 'imaging or electrodiagnostic studies'; added medical records documentation language; updated clinical evidence and references.

2025-08-01non-material_revision