ModifiedUnitedHealthcarePolicy CS039PA.Y

Epidural Steroid Injections for Spinal Pain (for Pennsylvania Only)

Policy governs medical necessity and coverage parameters for epidural steroid injections for radicular spinal pain for UnitedHealthcare members in Pennsylvania.

Policy Summary

PayerUnitedHealthcare

PolicyEpidural Steroid Injections for Spinal Pain (for Pennsylvania Only)

Policy CodePolicy CS039PA.Y

Change TypeRevised diagnostic requirementCPT code description updatesevidence refresh

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and provide documentation of ≥4 weeks of conservative therapy plus imaging or electrodiagnostic evidence of nerve root involvement.

SourceLink

POLICY UPDATE CHANGES

Revised coverage criteria to replace requirement for EMG with 'electrodiagnostic studies' to demonstrate structural and/or functional nerve root involvement.

Revised descriptions for CPT codes 64479, 64480, 64483, and 64484.

Updated Clinical Evidence and References sections to reflect the most current information.

4max ESI sessions/region/yr

≥4 wksconservative tx min duration

≤50%prior relief threshold

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required imaging guidance

Coverage Criteria for Epidural Steroid Injections (ESI)

Therapeutic ESI for Radicular Pain

Covered when ALL of the following are met:

Primary coverage criteria: Injection is intended for management of Radicular Pain as evidenced by history and physical exam; AND Radicular Pain is unresponsive to conservative treatment for ≥ 4 weeks (for example, pharmacotherapy such as NSAIDs or acetaminophen; activity modification; or physical therapy/home exercise); AND there is evidence of structural and/or functional nerve root involvement by imaging or electrodiagnostic studies; AND the injection is performed under fluoroscopic or CT guidance.

From Coverage Rationale (policy)

Criteria for subsequent ESIs

Subsequent ESI sessions within the year allowed only when:

Subsequent injection criteria: Radicular pain has returned and/or deterioration in function has occurred; AND one of the following: (a) the previous injection resulted in ≤ 50% pain relief or functional improvement for less than three months as measured by validated measurement tools and there has been reassessment of the individual and the injection site/technique; OR (b) the previous injection resulted in ≥ 50% pain relief or functional improvement for three or more months as measured by validated measurement tools.≤50% or ≥50% with time conditions

From Epidural Steroid Injection Limitations

Evidence-informed coverage considerations

Summarized evidence and guideline-based considerations relevant to coverage decisions

Short-term efficacy for radicular pain: Randomized trials and meta-analyses demonstrate that ESIs provide short-term (approximately 1–3 months) and sometimes intermediate-term (3–6 months) pain relief for lumbosacral radicular pain compared with placebo or conservative care; long-term benefit beyond 6 months is not consistently demonstrated.

Supported by Verheijen 2021 and Yang 2020

Indications with stronger evidence: Evidence most consistently supports use of ESIs for radiculitis due to disc herniation and select radicular syndromes; guideline bodies (e.g., ASIPP, NASS) provide recommendations for fluoroscopically guided epidural approaches in these settings.

Supported by ASIPP and NASS guidance

Imaging and technique expectations: Fluoroscopic or CT guidance with contrast confirmation is recommended for transforaminal injections to confirm needle position and reduce risk; variability in technique affects interpretation of evidence.

Supported by procedure-specific guidance and technique reviews

Diagnostic evidence requirement

Coverage criteria updated:

Revised diagnostic requirement: There is evidence of structural and/or functional nerve root involvement by imaging or electrodiagnostic studies (this replaces prior wording that specified electromyography [EMG]).

Operationally replaces EMG-specific requirement with broader 'electrodiagnostic studies' per policy revision

ESIs are contraindicated in patients with known or suspected spinal neoplasm, rapidly progressing neurological deficit, or epidural abscess. These conditions should be identified on history, exam, or imaging prior to planning an injection and preclude ESI.

The policy considers the use of ultrasound guidance for ESIs to be unproven and not medically necessary due to insufficient evidence of efficacy; fluoroscopic or CT guidance is required for covered injections per the coverage criteria.

Guideline and systematic-review evidence does not support routine ESI use for nonradicular axial low back pain. ACOEM (2021) and AHRQ (2015) note limited or absent benefit for spinal stenosis and low back pain without radiculopathy, and neurosurgical society guidance states there is insufficient evidence to support lumbar epidural injections for long‑term relief of chronic back pain without radiculopathy.

For non-severe presentations without clear radicular findings, guidelines recommend an initial trial of conservative care (for example, NSAIDs and therapeutic exercise for approximately ~3 weeks per some guidance) before considering injections.

When applying this policy, always consult the member's federal, state, or contractual benefit terms. If those benefit terms conflict with this policy, the federal, state, or contractual requirements govern and may supersede the coverage guidance contained here.

The policy classifies ESI performed solely with ultrasound guidance as unproven and not medically necessary because current evidence is insufficient to demonstrate efficacy for this technique; covered ESIs must be performed with fluoroscopic or CT guidance as specified in the coverage criteria.

Additionally, ESI for spinal indications not expressly included in the coverage rationale (for example, non-radicular indications) are considered unproven and not medically necessary.

Multiple guideline bodies and systematic reviews find that ESIs may offer short-term relief for radicular syndromes but do not support routine use for chronic axial low back pain without radiculopathy. AHRQ (2015) concluded benefits are small and not sustained; ACOEM (2021) and the neurosurgical societies state ESIs are not recommended or have limited support for low back pain without significant radicular symptoms.

Applicable Procedure and Diagnosis Codes

Applicable CPT Procedure 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).
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).

Applicable Diagnosis Codes (examples listed)ICD-10

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
M51.15	Intervertebral disc disorders with radiculopathy, thoracolumbar region
M54.10	Radiculopathy, site unspecified
M51.A0	Intervertebral annulus fibrosus defect, lumbar region, unspecified size
M51.16	Intervertebral disc disorders with radiculopathy, lumbar region
M54.16	Radiculopathy, lumbar region
M54.30	Sciatica, unspecified side

1–10 of 12

1/2

Applicable CPT codes (revised descriptions)CPT

64479	Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar
64480	Injection, anesthetic agent and/or steroid, transforaminal epidural; each additional level, lumbar
64483	Injection(s), anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic
64484	Injection(s), anesthetic agent and/or steroid, transforaminal epidural; each additional level, cervical or thoracic

Maximum ESI sessions — limit

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

Region definitionRegion defined as cervical, thoracic, or lumbosacral

Session definitionOne date of service in which ESI injection(s) are performed

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Prior authorization is required for Epidural Steroid Injections (ESI) per plan rules. Requests must reference the procedure codes being requested and include documentation that the coverage criteria are met.

Include applicable CPT/CPT-like codes (e.g., 62320-62323, 64479, 64480, 64483, 64484) on the authorization request.
Obtain prior authorization before service unless plan rules allow retrospective review.

Billing Rule

Frequency Limits and Justification

Frequency limits apply and must be justified in the clinical record. A maximum of four (4) ESI sessions per anatomical region (cervical, thoracic, lumbosacral) are allowed in any 12-month period beginning with the date of the first approved injection. Providers should document response to prior injections and rationale for additional injections.

Key Definitions

Conservative Therapy — definition and required trial

Core componentsConservative therapy consists of an appropriate combination of medication (e.g., NSAIDs, acetaminophen/analgesics), physical therapy, spinal manipulation, cognitive behavioral therapy, or other individualized interventions.

Examples of medicationNSAIDs and other analgesics as part of multimodal pharmacotherapy

Activity and exerciseActivity modification and structured home or supervised exercise/physical therapy programs

Duration requirement (actionable)Trial of conservative therapy for ≥ 4 weeks is required prior to initial ESI

Epidural Steroid Injections (ESI) — definition

DefinitionEpidural Steroid Injections (ESI): injection of corticosteroid and/or anesthetic into the epidural space to relieve radiculopathy-related pain and improve function.

Conservative Treatment Before ESI

Required prior to initial ESI — trial of conservative therapy ≥ 4 weeks

Required prior to initial ESI:

Conservative therapy trial: Trial of conservative therapy for at least 4 weeks including pharmacotherapy (e.g., NSAIDs or acetaminophen), activity modification, or physical therapy/home exercise is required prior to initial ESI.>= 4 weeks

From Coverage Rationale and Definitions

Documented trial for non-severe/non-radicular presentations — guideline referenced ~3 weeks

Documented trial for non-severe or non-radicular presentations:

Guideline-referenced conservative trial: For non-severe clinical presentations (for example in lumbar spinal stenosis or non-radicular low back pain), guidelines recommend a conservative approach based on therapeutic exercise and multimodal care; some bodies reference approximately a 3-week trial of therapeutic exercise before interventional procedures are considered.

Limits on Number and Timing of Epidural Steroid Injections

Epidural Steroid Injections — numeric limit

Numeric limit4

UnitPer region per 12 months

Applies toEpidural Steroid Injections (all approaches) regardless of level, location, or side

Therapeutic ESI frequency guidance

Annual frequency capDo not exceed 4 injections per region per year (therapeutic phase)

Inter-injection interval guidanceSuggested interval approximately 2.5–3 months between injections when >50% relief is obtained for that duration

Criteria for repeat

Imaging and Guidance Requirements

Documentation Required

Require imaging/electrodiagnostic confirmation and fluoroscopic/CT guidance

Obtain imaging or electrodiagnostic studies demonstrating nerve root involvement before ESI and ensure the procedure is performed with fluoroscopic or CT guidance for covered ESIs.

Imaging or electrodiagnostic confirmation of structural/functional nerve root involvement is required.
Fluoroscopy or CT guidance is required for covered ESIs.

Note

Use fluoroscopy or CT guidance for transforaminal and thoracic ESIs; document confirmation

For transforaminal and thoracic (and other higher‑risk) ESIs, use fluoroscopic or CT guidance and document confirmation of needle position and contrast spread as recommended.

Transforaminal injections should be performed with image guidance to confirm needle position and contrast flow.
Fluoroscopic guidance reduces risk in thoracic approaches and should be documented.

Services Considered Not Medically Necessary or Excluded

Not covered: ESI guided solely by ultrasound is considered unproven and not medically necessary due to insufficient evidence of efficacy. Requests for ESIs that rely only on ultrasound guidance will not meet the imaging/technique requirement of fluoroscopic or CT guidance for covered therapy.

Also not covered: ESI for non-radicular spinal pain indications (for example, axial low back pain without radiculopathy) where guideline evidence does not support routine benefit.

Duplicate not-covered entry: ESI guided solely by ultrasound and ESI for non‑radicular indications are listed as unproven and not medically necessary because available evidence does not demonstrate sufficient efficacy for these uses.

Duplicate not-covered entry: the policy repeats that ultrasound-only guidance for ESIs and injections for non‑radicular spinal pain are considered unproven and therefore not covered under medical necessity criteria.

Not covered: Any services that are expressly excluded by the member's federal, state, or contractual benefit terms remain excluded even if this policy would otherwise permit them; benefit terms take precedence.

Background and Clinical Context

Background: Epidural steroid injections (ESIs) are a nonsurgical treatment option intended to relieve radicular pain from disc herniation or degenerative spinal changes. ESIs can be delivered via transforaminal, interlaminar, or caudal approaches and are intended to provide short‑term pain relief and functional improvement in selected patients with confirmed nerve‑root involvement; proper imaging guidance (fluoroscopy or CT) and appropriate patient selection are emphasized in the coverage rationale.

Policy Summary

PayerUnitedHealthcare

PolicyEpidural Steroid Injections for Spinal Pain (for Pennsylvania Only)

Policy CodePolicy CS039PA.Y

Change TypeRevised diagnostic requirementCPT code description updatesevidence refresh

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and provide documentation of ≥4 weeks of conservative therapy plus imaging or electrodiagnostic evidence of nerve root involvement.

SourceLink

On This Page

Conservative management prior to ESI: Guidelines suggest a trial of conservative care (NSAIDs, therapeutic exercise, multimodal physical therapy) typically for a defined period (for some recommendations at least ~3 weeks) before ESI for non-severe cases; ESIs have limited or no demonstrated benefit for nonradicular low back pain or spinal stenosis in many circumstances.~3 weeks for some guideline recommendations

Supported by ACOEM 2021 and WFNS 2020

Frequency and repeat injection criteria: In the therapeutic phase, recommended interval between injections is approximately 2.5–3 months if >50% relief is obtained for that duration, and injections should not exceed about four per region per year.>50% relief for 2.5–3 months; ≤4 per year

From ASIPP guidance and policy frequency limits

Safety and informed consent: Providers should counsel patients about rare but serious neurologic and vascular adverse events described by FDA and the literature, document risks and benefits, and use image guidance as appropriate to mitigate risks.

Supported by FDA safety communications and case series

A session = one date of service with one or more ESI injections.
ASIPP suggests spacing therapeutic injections approximately 2½ to 3 months apart when >50% relief is achieved; do not exceed 4 injections per region per year.
Subsequent injections beyond initial course allowed only if radicular pain recurs or function deteriorates and either: prior injection provided ≤50% relief for <3 months, or ≥50% relief lasted ≥3 months, documented with validated measures.

Billing Rule

Prior Authorization and Code Updates

Code and authorization updates: Providers should obtain prior authorization per plan rules and submit the correct, current code descriptions. Code descriptors for CPT codes (including 64479, 64480, 64483, 64484) were revised in the 03/01/2026 policy update.

Use the most current CPT codes and descriptions on all requests and claims.
Authorization requests must reference specific procedure codes and laterality/level as applicable.

Documentation Required

Safety Counseling/Document Informed Discussion

Safety Counseling and Documentation: Counsel the individual about rare but serious risks associated with epidural corticosteroid injections (including loss of vision, stroke, paralysis, infection, bleeding, and death) and document that the discussion occurred.

Document informed consent discussion including risks, benefits, and alternatives.
Include documentation of adherence to safety practices (e.g., use of imaging guidance, contrast confirmation when performed).

Note

Benefit Terms Govern

Benefit Terms Govern: Coverage determination is subject to the member's federal, state, or contractual benefit plan terms. When plan or statutory requirements conflict with this policy, the applicable benefit terms take precedence.

Verify member benefits and any state or contractual mandates before proceeding.
This policy is informational; it does not override specific benefit plan language.

Documentation Required

Required Documentation

Required Documentation: Prior authorization and claims must include documentation to support radicular pain, prior conservative therapy, duration of therapies, and rationale for ESI.

History and physical exam documenting radicular pain consistent with a dermatomal pattern.
Documentation of trial of conservative therapy for ≥4 weeks (e.g., NSAIDs, activity modification, physical therapy, home exercise) unless contraindicated or in cases of rapidly progressing neurologic deficit.
Record of prior treatments, dates, and objective measures of response (pain and function) using validated tools.

Documentation Required

Procedure and Safety Documentation

Procedure and Safety Documentation: Providers must document procedural details and monitor for complications. Include imaging guidance used and any safety-related observations.

Procedure note with date of service, clinician performing procedure, approach/technique, levels treated, medications and doses administered, and use of fluoroscopy or CT guidance.
Documentation of contrast flow or needle placement confirmation if performed, and immediate post-procedure status and instructions.
Report and document any adverse events (e.g., hematoma, paraplegia, meningitis, epidural abscess) per facility and regulatory requirements.

Documentation Required

Required Supporting Documentation

Required Supporting Documentation: Imaging or electrodiagnostic evidence must be provided to demonstrate structural and/or functional nerve root involvement when required by coverage criteria.

Recent relevant imaging (MRI, CT) showing nerve root compression or concordant pathology, or electrodiagnostic studies demonstrating nerve root dysfunction.
If imaging is inconclusive but clinical exam strongly supports radiculopathy, provide rationale and supporting clinical findings.
Include prior imaging/study dates and reports with the authorization request.

Step Therapy

Conservative Therapy Prerequisite

Conservative Therapy Prerequisite: For non-emergent radicular pain, document an adequate trial of conservative therapy prior to ESI unless contraindicated or in rapidly progressing neurologic deficits.

Conservative therapy should generally include an appropriate combination of medications (e.g., NSAIDs or acetaminophen) and active measures (physical therapy, home exercise, activity modification) for at least 4 weeks prior to authorization.
For lumbar spinal stenosis or other scenarios with guideline-specified timelines, follow specialty recommendations (e.g., WFNS suggests at least 3 weeks of therapeutic exercise for non-severe cases before escalating).
Document reasons if conservative therapy was not attempted or was contraindicated.

Denial Risk

Denial Risk and Common Reasons for Denial

Denial Triggers and Administrative Notes: Requests lacking required documentation, not meeting conservative therapy duration, or submitted for non-radicular indications are at high risk for denial.

Absent evidence of radicular pain (history/physical) or absent imaging/electrodiagnostic support.
No documentation of ≥4 weeks of conservative therapy when required.
Requests exceeding frequency limits without documented justification of prior response and clinical change.

PurposeNonsurgical treatment for radiculopathy from disc herniation or degenerative spinal changes

Approaches notedCan be delivered via interlaminar, transforaminal, or caudal approaches

Radicular Back Pain — definition

DefinitionRadicular Back Pain: pain radiating from the spine into the extremity along the course of a spinal nerve root following a dermatome pattern associated with the irritated nerve root.

Clinical implicationShould be supported by history and exam consistent with nerve root involvement

Relevance to coverageESIs are intended to manage radicular (not non-radicular) pain per policy criteria

Non-Radicular Back Pain — definition

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

Evidence stanceGuidelines and reviews state ESIs have limited or no demonstrated long-term benefit for non-radicular axial low back pain

Coverage implicationESI for non-radicular indications is generally considered not medically necessary or unproven

Transforaminal / Interlaminar / Caudal ESI — procedural approach definitions

TransforaminalTransforaminal ESI: targets the nerve root via the neural foramen to deliver steroid adjacent to the irritated nerve root (often used for radicular pain).

InterlaminarInterlaminar ESI: deposits medication between the laminae into the posterior epidural space, useful for broader epidural spread.

CaudalCaudal ESI: accesses the epidural space via the sacral hiatus to deliver steroid into the caudal epidural space; approach and evidence vary by indication.

Electrodiagnostic studies — definition and policy note

Term replacedElectrodiagnostic studies (broader term) now replaces prior explicit EMG requirement to demonstrate functional nerve root involvement.

PurposeUsed as supporting evidence of structural or functional nerve root involvement when imaging is inconclusive or complementary to imaging.

DocumentationPolicy requires imaging or electrodiagnostic studies as part of evidence of nerve root involvement for coverage decisions.

Based on ACOEM 2021 and WFNS 2020 recommendations

Subsequent injections allowed when radicular pain returns and prior relief/functional improvement meets specified duration and magnitude criteria (≤50% for <3 months or ≥50% for ≥3 months)

Frequency limits — summary (placeholder)

PlaceholderNo additional frequency limits specified in this slot — see policy frequency statements for details.

ContextPolicy references guideline-based limits (e.g., ASIPP) and documentation requirements for repeat injections.

ActionRefer to 'Epidural Steroid Injection Limitations' and prior authorization requirements when requesting additional injections.

Documentation Required

Affirm imaging or electrodiagnostic requirement for ESI coverage

The policy affirms that epidural steroid injections require supporting imaging or electrodiagnostic studies to demonstrate nerve root involvement as part of coverage criteria.

Imaging or electrodiagnostic studies are required to meet the diagnostic evidence criterion.
This replaces prior EMG‑specific wording with broader 'electrodiagnostic studies.'