UnitedHealthcare Epidural Steroid Injection Coverage Update

Coverage Criteria for Epidural Steroid Injections (ESI)

Initial ESI medical necessity criteria

Covered when ALL of the following are met

Indication: Injection intended for management of Radicular Pain as evidenced by history and physical exam

Conservative therapy trial: Radicular Pain is unresponsive to conservative treatment for >= 4 weeks (pharmacotherapy such as NSAIDs or acetaminophen OR activity modification OR physical therapy/home exercise)>= 4 weeks

Conservative Therapy defined in policy

Objective evidence: Evidence of structural and/or functional nerve root involvement by imaging or electrodiagnostic studies

Guidance requirement: Injection is performed under fluoroscopic or CT guidance

Use of ultrasound guidance is considered unproven/not medically necessary

Subsequent ESI continuation criteria

Continuation or subsequent ESI sessions allowed only when

Return or deterioration: Radicular Pain has returned and/or deterioration in function has occurred

Prior response criteria: Either the previous injection resulted in <= 50% pain relief or functional improvement for < 3 months (with reassessment of the individual and injection site/technique) OR the previous injection resulted in >= 50% pain relief or functional improvement for >= 3 months as measured by validated tools50%; 3 months

Session counting and reassessment required

Guideline-supported indications and practice parameters

Evidence and guideline-derived conditions where ESIs have demonstrated benefit or recommended use

Short/intermediate-term benefit for radicular pain: Multiple systematic reviews and meta-analyses report ESI provides short-term (up to 3 months) and in some analyses intermediate-term (3-6 months) pain relief for lumbosacral radicular pain and disc herniation; functional benefits are less consistent and long-term benefit is not demonstrated.

Sources: Verheijen et al., Yang et al., AHRQ, others

Disc herniation: Evidence supports fluoroscopically guided ESIs (including transforaminal approaches) for radicular pain due to disc herniation with reported treatment success at 1–12 months in multiple studies.

Smith et al.; NASS; ASIPP

Spinal stenosis and other indications: Evidence for ESIs in spinal stenosis and non-radicular low back pain is limited or suggests only short-term benefit; guidelines recommend conservative treatment first and note limited long-term efficacy.

ACOEM, AHRQ, WFNS

Revised coverage criterion (nerve root involvement evidence)

Coverage criteria for Epidural Steroid Injections (ESI) were revised

Revised nerve root involvement criterion: There is evidence of structural and/or functional nerve root involvement by imaging or electrodiagnostic studies

Replaces prior wording that specified electromyography (EMG)

Contraindications for epidural steroid injections include conditions that place the patient at unacceptable risk or where injection is unlikely to be appropriate. Examples listed in the policy are spinal neoplasm, rapidly progressing neurological deficit, and epidural abscess.

The policy also states that ultrasound guidance for ESIs is considered unproven and not medically necessary due to insufficient evidence; providers should therefore use approved imaging guidance per the coverage criteria (fluoroscopy or CT) when requesting authorization.

The policy does not support routine use of ESIs for axial low back pain without clear radicular symptoms. Guideline summaries referenced (ACOEM, AHRQ, AAN) recommend conservative care first and indicate ESIs are not recommended or have limited benefit for non-radicular low back pain and for spinal stenosis in many cases.

For select acute or subacute radicular pain syndromes, some guidelines (ACOEM) note ESIs may be an option after initial conservative therapy (e.g., NSAID and about 3 weeks of treatment), but the general evidence shows only small, short-term improvements and limited long-term benefit (AHRQ; AAN).

This policy is a guide to UnitedHealthcare standard benefit plans; applicable federal, state, or contractual benefit plan requirements must be checked first. In any conflict, the terms of the governing benefit contract take precedence over this policy.

UnitedHealthcare may modify policies and may use third-party tools (for example, InterQual®) to assist in administering benefits; the policy is informational and does not replace the independent professional medical judgment of the treating clinician.

The policy requires image guidance for ESIs and identifies fluoroscopic or CT guidance as the recommended techniques for needle placement and confirmation of contrast spread. By contrast, use of ultrasound guidance for ESIs is listed as unproven and not medically necessary because evidence is insufficient to support its efficacy for these procedures.

High-quality studies and society guidance cited in the policy generally report outcomes using fluoroscopic or CT image guidance; documentation of image guidance and confirmation of needle/contrast position is expected when seeking authorization.

The evidence base summarized in the policy indicates limited or inconsistent benefit of ESIs for spinal stenosis and for non-radicular back pain. The AHRQ assessment concluded ESIs may provide immediate, small improvements in pain for radiculopathy but did not demonstrate sustained long-term benefit, and it found limited evidence of effectiveness for stenosis and non-radicular pain.

ACOEM guidance similarly rates ESIs as moderately not recommended for spinal stenosis and not recommended for low back pain without significant radicular symptoms, reinforcing the policy position that ESIs should be reserved for appropriately selected radicular presentations.

When applying this coverage policy, providers must verify specific member benefit language and any federal or state mandates that may alter coverage determinations. UnitedHealthcare policies are informational and may be superseded by contractual or regulatory requirements governing the member’s plan.

Providers should reference the applicable benefit contract and document how the requested ESI meets the plan’s medical necessity requirements before proceeding with authorization requests.

Conservative Therapy Requirements Before ESI

Documented trial and failure of conservative measures

Conservative therapy trial: Documented trial and failure of conservative therapy including pharmacotherapy (e.g., NSAIDs or acetaminophen), activity modification, or physical therapy/home exercise for >= 4 weeks prior to ESI>= 4 weeks

Record must document therapies tried and duration

Attempt conservative therapy prior to ESI in non-severe conditions

Conservative first for LSS: For non-severe lumbar spinal stenosis, attempt a conservative approach including at least ~3 weeks of therapeutic exercise or medical therapy prior to considering ESI; if conservative care is chosen, consider surgery only if clinical condition does not improve after approximately 3 months

Limits on Number and Interval of ESI Sessions

Epidural steroid injection (all approaches) — session limit

LimitMaximum of four (4) ESI sessions per region per 12-month period (a year defined from date of first approved injection)

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

Region definitionRegion = cervical, thoracic, or lumbosacral

Counting rulesLimit applies regardless of level, location, or side

Epidural steroid injection (therapeutic phase) — frequency

Therapeutic-phase frequencySuggested interval 2.5–3 months or longer between injections during therapeutic phase

Imaging and Diagnostic Requirements for ESI

Prior Authorization

Prior Authorization Required

Prior authorization is required for epidural steroid injections (ESI) performed under fluoroscopic or CT guidance. Submit appropriate CPT/HCPCS codes and documentation showing medical necessity. For multiple or repeat procedures, include procedure dates, levels treated, and prior authorization response. Coding must reflect image guidance modifiers when applicable.

Affected codes: CPT codes for ESI and image guidance (as billed)
Include image guidance documentation (fluoroscopy or CT) and electrodiagnostic or imaging evidence of nerve root involvement

Prior Authorization

Prior Authorization — Frequency and Response

Prior authorization requests must indicate the proposed frequency and include prior authorization response history if prior ESIs were authorized. Requests for repeat injections that exceed the allowed or usual frequency must include clinical rationale and outcome from prior injections. Expect a prior authorization decision within the payer’s standard response timeframe; failure to obtain prior authorization may result in denial.

CPT and Diagnosis Codes

Covered CPT Codes - part 1CPT

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 (i.e., fluoroscopy or CT)
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 (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)

Covered CPT Codes - part 2CPT

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 Codes (examples)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
G54.4	Lumbosacral root disorders, not elsewhere classified

ESI session limit

Maximum sessionsMaximum of four (4) ESI sessions per region per 12-month period

Start of 12-month period12-month period starts from date of service of the first approved injection

Applies per regionLimit applies per cervical, thoracic, or lumbosacral region

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior authorization required; session counting and limits apply

Obtain prior authorization when submitting ESI CPT codes (e.g., 62320–62323, 64479–64480, 64483–64484). Count one 'session' per date of service and apply the 4-session-per-region-per-12-month limit starting from the first approved injection.

Applicable CPT codes listed in the policy (62320–62323, 64479–64480, 64483–64484).
A session = one date of service; maximum of four ESI sessions per region per 12-month period.

Step Therapy

Limit injection frequency to ~2.5–3 months; ≤4/year per region

Follow recommended therapeutic-phase frequency: space therapeutic injections about 2.5 to 3 months or longer apart and do not exceed four injections per region per year when >50% relief is obtained for the interval.

Definitions and Terms

Conservative Therapy — definition and examples

DefinitionConservative Therapy consists of medication (e.g., NSAIDs, analgesics), physical therapy, spinal manipulation, cognitive behavioral therapy, or other interventions tailored to the individual's presentation

ExamplesMedications (NSAIDs, analgesics), physical therapy/home exercise, activity modification, spinal manipulation, CBT

Prerequisite durationDocumented trial and failure of conservative measures for ≥ 4 weeks is required before ESI in many cases

ESI definition — Epidural Steroid Injections (ESI)

DefinitionEpidural Steroid Injections (ESI) are a nonsurgical treatment delivering corticosteroids into the epidural space to manage radiculopathy from disc herniation or degenerative changes

Purpose

Background and Evidence Summary

Spine pain is a common clinical problem and is often self-limiting; however, when nerve root irritation from disc herniation or degenerative changes produces radicular pain, targeted interventions may be considered. Epidural steroid injections (ESIs) are a nonsurgical, image-guided therapy intended to reduce inflammation around the affected nerve root(s) and provide short- to intermediate-term pain relief and functional improvement in selected patients with documented radicular symptoms.

The policy emphasizes that ESIs are indicated for documented radicular pain unresponsive to a trial of conservative therapy (at least 4 weeks) and when there is objective evidence of nerve root involvement by imaging or electrodiagnostic studies, with procedures performed under fluoroscopic or CT guidance.

Not Covered / Experimental Indications

Ultrasound-guided epidural steroid injections are listed in the policy as unproven and not medically necessary due to insufficient evidence of efficacy. Providers should request ESI authorization using fluoroscopic or CT-guided approaches that are supported by the clinical literature and policy requirements.

Additionally, the policy identifies ESI use for spinal indications not explicitly included in the coverage criteria (for example, non-radicular low back pain or other unproven indications) as not medically necessary; such uses will be denied when they do not meet the policy’s defined indications.

The policy clarifies that procedures or techniques lacking sufficient supporting evidence—such as ultrasound-guided ESIs—are considered unproven and will not meet medical necessity criteria. Providers should document adherence to covered indications and required imaging modalities when submitting for authorization.

Requests for ESIs outside the defined indications should include compelling justification and supporting evidence; absent that, the policy regards these applications as not medically necessary.

Practices and technologies that have not demonstrated efficacy in the literature summarized by the policy are excluded from coverage. When evidence is lacking or conflicting for a specific procedure or indication, the policy treats it as not covered unless subsequent authoritative guidance or contract provisions state otherwise.

Providers are encouraged to refer to the policy’s cited clinical reviews and society guidance when considering procedures that fall outside standard, evidence-supported ESI indications.

The excerpt does not list additional explicit not-covered procedures beyond ultrasound guidance and non-radicular indications, but it states that explicit not-covered items may be specified elsewhere in the full policy. Providers should review the complete medical policy and benefit terms for any additional exclusions.

OpenPayer

Epidural Steroid Injections for Spinal Pain (for New Mexico Only)

Coverage Criteria for Epidural Steroid Injections (ESI)

Conservative Therapy Requirements Before ESI

Limits on Number and Interval of ESI Sessions

Imaging and Diagnostic Requirements for ESI

CPT and Diagnosis Codes

Provider Actions, Prior Authorization, and Documentation

Definitions and Terms

Background and Evidence Summary

Not Covered / Experimental Indications