UnitedHealthcare Epidural Steroid Injection Coverage

Coverage and Medical Necessity Criteria

Medical necessity criteria for ESI

Covered when ALL of the following are met:

Primary coverage criteria: 1) Symptoms are radicular pain intended to be managed by the injection as evidenced by history and physical exam; 2) Documented trial of conservative therapy (combination of pharmacotherapy and non‑pharmacologic therapy such as PT/home exercise and activity modification) for 2–4 weeks prior to ESI; 3) Objective evidence of structural and/or functional nerve root involvement by imaging or electromyography (EMG); 4) Injection performed under fluoroscopic or CT guidance; 5) No contraindicating condition (for example spinal neoplasm, epidural abscess, or rapidly progressing neurological deficit).

Criteria for subsequent ESIs

Continuation / repeat injection criteria (subsequent ESIs may be provided only if):

Subsequent injection allowed if: A) The previous injection resulted in < 50% relief or functional improvement for less than three months as measured by validated tools and there has been reassessment of the individual and the injection site/technique; OR B) Radicular pain has returned and/or deterioration in function has occurred; OR C) The previous injection resulted in ≥ 50% relief or functional improvement for three or more months as measured by validated tools.

Indication-specific coverage considerations

Coverage considerations vary by indication and strength of evidence. Summarized guidance from referenced societies:

Radicular pain due to disc herniation: Multiple randomized controlled trials and NASS guidance support short‑term effectiveness of lumbar ESIs for radicular pain from disc herniation; ASIPP and NASS provide moderate‑to‑strong recommendations for fluoroscopically‑guided ESIs for herniation‑related radiculopathy.

Benefit often observed up to ~1 month and short term; limited long‑term functional improvement beyond 3 months

Spinal stenosis: Evidence is mixed; ACOEM and AHRQ indicate limited or no consistent long‑term benefit for spinal stenosis. ASIPP and WFNS note short‑ to intermediate‑term symptomatic relief with fluoroscopically‑guided injections, but further injections are not routinely recommended if relief < 3 months.

If relief < 3 months, further injections not routinely recommended

Axial nonradicular low back pain: Guidelines (AAN, ACOEM, AHRQ) do not support routine use of ESIs for axial low back pain without radicular symptoms; evidence shows no sustained long‑term functional benefit.

Epidural steroid injections (ESIs) not explicitly included in the policy’s stated coverage criteria are considered unproven and not medically necessary. The policy identifies ESIs for spine indications outside the enumerated radicular pain criteria as lacking sufficient evidence of efficacy and therefore noncovered. The document also states that the use of ultrasound guidance for ESIs is considered unproven and not medically necessary given limited comparative evidence versus fluoroscopy or CT guidance.

Routine use of ESIs for chronic low back pain in the absence of clear radicular symptoms is not recommended and may be noncovered. Guideline reviews and technology assessments (for example AAN and AHRQ) report limited or no sustained long-term functional benefit of ESIs for axial, nonradicular low back pain, and identify a lack of consistent evidence to support routine repeated injections for this indication.

Epidural steroid injections for spinal indications not included in the coverage criteria and ESIs performed using ultrasound guidance are identified as unproven and not medically necessary. The policy cites insufficient evidence for efficacy of ESIs outside the covered radicular indications and notes that the peer-reviewed literature provides limited evidence that ultrasound guidance confers overall health benefit compared with fluoroscopic or CT guidance.

Professional society guidance generally does not support routine ESIs for low back pain without significant radicular features. The AAN and other guideline summaries conclude that ESIs show limited short-term benefit for some radicular presentations but do not support routine use for axial, nonradicular low back pain, and therefore recommend against routine application of ESIs when significant radicular symptoms are absent.

Applicable Codes and Coding Notes

Applicable CPT codes for ESIsCPT

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 (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 (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
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

Applicable ICD-10 diagnosis codes (selected examples shown in document)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	Radiculopathy, site unspecified (cervical/thoracic listing group)
G54.3	Cervical root disorders, not elsewhere classified
G54.4	Lumbosacral root disorders, not elsewhere classified
M51.16	Intervertebral disc disorders with radiculopathy, lumbar region
M51.17	Intervertebral disc disorders with radiculopathy, lumbosacral region

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Prior injection response threshold — >= 50% relief or functional improvement for three or more months

Threshold>= 50% relief or functional improvement

DurationThree or more months of sustained benefit

MeasurementAs measured by validated measurement tools (documented in record)

Maximum sessions — 4 sessions per region per 12 months

Maximum sessionsMaximum 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

Provider Requirements and Documentation

Prior Authorization

Prior Authorization and Session Definition

Prior authorization is required per payer process. A session is defined as one date of service in which epidural steroid injection(s) are performed. Frequency limits apply as stated in policy (e.g., maximum sessions per region per year and ASIPP-referenced timing between therapeutic-phase injections).

Session = one date of service
Prior authorization required per UnitedHealthcare process
Frequency limits and therapeutic-phase timing referenced

Prior Authorization

Prior Authorization for Repeat Injections

Repeat injections should follow guideline-recommended timing: after the diagnostic phase, therapeutic-phase injections are generally spaced about 2–3 months or longer provided the patient achieved >50% relief; additional injections are appropriate only with documented recurrence of radicular pain or decreased function and when prior benefit and duration are documented.

Follow ASIPP suggested frequency in therapeutic phase (~2–3 months or longer)

Background and Context

Epidural steroid injection (ESI) is a nonsurgical, image-guided procedure that delivers corticosteroid — often combined with a local anesthetic — into the epidural space via interlaminar, transforaminal (periradicular), or caudal approaches. ESIs are intended to relieve radicular pain associated with nerve-root compression or inflammation; evidence supports short- and intermediate-term pain relief for radicular pain from disc herniation, while long-term functional benefit is variable. Because ESIs carry risks (including infection and rare but serious neurologic events), procedures are expected to be performed with appropriate imaging guidance and documented technique.

Key Definitions

Conservative Therapy definition

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

Typical componentsPharmacotherapy (NSAIDs/analgesics) and structured physical therapy or home exercise

Behavioral componentCognitive behavioral therapy or other psychosocial interventions when indicated

CustomizationInterventions based on individual presentation, physical findings, and imaging results

Epidural Steroid Injection (ESI) definition

DefinitionInjection of corticosteroid and/or anesthetic into the epidural space to relieve radiculopathy caused by disc herniation or degenerative vertebral changes

Conservative Treatment Before ESI

Documented trial required — 2–4 weeks

Documented trial required:

Required conservative therapy before ESI: Documented trial of conservative therapy consisting of pharmacotherapy (for example NSAIDs or acetaminophen), plus physical therapy or home exercise and activity modification (and other appropriate noninvasive modalities) for 2–4 weeks prior to ESI.2–4 weeks

Document duration and components of conservative care in the record.

Documented trial of conservative treatment prior to ESI is recommended — approximately 3 weeks or multimodal PT per WFNS

Documented trial recommended (guideline-aligned):

Recommended conservative therapy before ESI: Guideline‑based conservative management is recommended prior to ESI — for example NSAIDs and at least approximately 3 weeks of conservative therapy or a multimodal physical therapy course as described by WFNS for lumbar spinal stenosis and related radicular conditions.

Session Limits and Timing

Epidural steroid injection (per region: cervical, thoracic, lumbosacral) — Maximum of four (4) ESI sessions per region per 12-month period

Frequency limitMaximum of four (4) ESI sessions per region (cervical, thoracic, lumbosacral) per 12-month period

Region specificationLimit applies per region regardless of level, location, or side

12‑month periodYear defined as 12 months starting from date of service of the first approved injection

Epidural steroid injections (therapeutic phase repeat injections) — Every 2-3 months or longer between therapeutic-phase injections

Recommended spacingTherapeutic-phase repeat injections should be spaced every 2–3 months or longer

Condition for repeatsRepeat injections should be provided consistent with documented clinical benefit (>50% relief or functional improvement when applicable)

Imaging Guidance Requirements

Billing Rule

Fluoroscopy or CT required for all covered ESIs

All covered epidural steroid injections must be performed under fluoroscopic or CT guidance; policy requires imaging guidance for covered ESIs despite codes existing for with or without guidance.

Fluoroscopy or CT required for covered ESIs
Codes exist for both with and without imaging guidance, but coverage requires imaging guidance

Documentation Required

Perform TF, interlaminar, and caudal ESIs with fluoroscopic (or CT) guidance

Transforaminal, interlaminar, and caudal ESIs should be performed with fluoroscopic guidance (or CT guidance as noted by some society statements); document image guidance and needle/contrast confirmation per society recommendations.

Services Considered Not Medically Necessary

The following are specifically identified as not covered: the use of ultrasound guidance for ESIs (considered unproven and not medically necessary) and epidural steroid injections for spine indications that are not included in the policy’s coverage criteria. The source notes limited comparative evidence supporting ultrasound guidance versus fluoroscopy or CT and therefore classifies ultrasound-guided ESIs as unproven for the purposes of coverage.

OpenPayer

Epidural Steroid Injections for Spinal Pain (for Idaho Only)