RetiredUnitedHealthcarePolicy CS039LA1.F

Epidural Steroid Injections (for Louisiana Only)

Defines Louisiana Medicaid medical necessity criteria and applicable procedure codes for epidural steroid injections; applies to providers and members in Louisiana Medicaid.

Policy Summary

PayerUnitedHealthcare

PolicyEpidural Steroid Injections (for Louisiana Only)

Policy CodePolicy CS039LA1.F

Change TypeRetired / revised

Effective DateSep 1, 2025

Next Review Date

Key ActionConfirm applicable Louisiana Medicaid prior authorization and coverage status with the state Professional Services Fee Schedule.

SourceLink

POLICY UPDATE CHANGES

Retired policy; Louisiana plan membership disenrolled on Apr. 1, 2026.

Coverage Rationale: removed language allowing provider-determined ESI for chronic intractable pain and other payer-specific coverage statements.

Effective date range specified as September 1, 2025 - March 31, 2026 in the policy header.

LAstate-specific

62320-23,64479-84CPT codes listed

04/01/2026retirement

09/01/2025

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Coverage / Medical Necessity Criteria

Medical necessity for ESI

Covered when ALL of the following are met

History of illness documenting symptoms consistent with radiculopathy, radicular pain, or neurogenic claudication

Physical Examination: Physical examination findings consistent with the suspected radicular condition

Imaging: 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 previously included specific language allowing provider-determined use of epidural steroid injections (ESI) for chronic intractable pain and statements tying coverage definitions to the Louisiana Professional Services Fee Schedule. That language was removed in the revision history; the policy no longer contains provisions that authorize ESI based solely on a provider’s determination for chronic intractable pain, nor language stating that the Fee Schedule alone defines covered treatments. The revision also removed prior references that epidurals administered for acute perioperative or obstetric pain were covered by the Professional Services Program for that purpose only. Confirm current applicability of any of those prior provisions with the state Fee Schedule and Medicaid contract.

Listing of procedure or diagnosis codes in this policy is for reference only and does not imply that the service described by a code is a covered or non-covered health service. Benefit coverage is determined by federal, state, or contractual requirements and applicable law; inclusion of a code does not guarantee reimbursement or payment. Providers should consult the applicable Louisiana Medicaid Fee Schedule and contract terms to determine coverage and payment for specific services.

Applicable Procedure Codes

Applicable interlaminar ESI CPT 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).

Applicable transforaminal ESI CPT codesCPT

64479	Injection(s), anesthetic agent(s) and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level. (asterisked—not on LA Medicaid fee schedule)
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).

Provider Requirements and Billing Notes

Prior Authorization

Prior Authorization Required

Certain Medicaid procedures and services may require prior authorization per the state Professional Services Fee Schedule. Verify PA requirements and obtain authorization before performing services when applicable to avoid claim denials or delayed payment.

Check the Louisiana Professional Services Fee Schedule for CPT codes requiring PA
Obtain prior authorization when required before rendering services

Billing Rule

Coding listing note

Listing of a code in this policy does not imply that the service described by the code is a covered or non‑covered health service. Benefit coverage is determined by federal, state, contractual requirements and applicable laws; inclusion of a code does not guarantee reimbursement or claim payment. Confirm beneficiary benefit details and other applicable policies before billing.

Clinical Background

Epidural steroid injections (ESI) are used diagnostically and therapeutically for patients with symptoms of radicular pain, radiculopathy, or neurogenic claudication associated with herniation, spinal stenosis, or degenerative disease. Medical necessity for ESI requires documentation of a compatible history, physical examination findings consistent with the suspected radicular condition, and concordant diagnostic imaging demonstrating the anatomic pathology that is materially contributing to significant impairment of quality of life or function.

Key Definitions

Concordant diagnostic imaging — definition supporting radiculopathy/radicular pain/neurogenic claudication

DefinitionConcordant diagnostic imaging supporting radiculopathy, radicular pain, or neurogenic claudication due to herniation, stenosis, and/or degenerative disease.

Clinical requirementImaging must demonstrate pathology that is protracted and severe enough to greatly impact quality of life or function.

Context of useRequired as part of medical necessity determination along with history of illness and physical examination for ESI.

Associated diagnosesRadiculopathy, radicular pain, or neurogenic claudication related to herniation, spinal stenosis, or degenerative disease.

Conservative Therapy / Prior Treatment

Imaging & Frequency Guidance

Imaging guidance (fluoroscopy or CT) — applicability and frequency limits

Imaging guidance specifiedCertain CPT codes explicitly require imaging guidance (fluoroscopy or CT), e.g., 62323; 64479, 64480, 64483, 64484.

Mode of guidanceFluoroscopy or CT are the specified imaging guidance modalities for the listed codes.

Code examples (interlaminar)62323 — interlaminar epidural (lumbar or sacral/caudal) with imaging guidance (fluoroscopy or CT).

Code examples (transforaminal)64479/64480 (cervical/thoracic) and 64483/64484 (lumbar/sacral) — transforaminal epidural with imaging guidance (fluoroscopy or CT).

Frequency limitsNo numeric frequency limits or timing intervals are provided in this policy for procedures using imaging guidance.

Imaging Requirements

Billing Rule

Perform procedures with required imaging guidance and concordant imaging

For interlaminar and transforaminal epidural injections that require imaging guidance, use fluoroscopy or CT and ensure concordant diagnostic imaging supports the procedure.

Use fluoroscopy or CT for CPT codes identified as 'with imaging guidance' (e.g., 62321, 62323, 64479, 64480, 64483, 64484).
Maintain imaging documentation demonstrating concordance with the clinical diagnosis.

Non-Covered Services

The policy does not explicitly list procedures or conditions under a standalone “Not Covered” section. Instead, the document was retired effective 04/01/2026 for Louisiana membership, and the summary of changes directs readers to confirm current coverage status with the State of Louisiana Medicaid Fee Schedule and contract. For Medicaid members in Louisiana, verify coverage and any exclusionary determinations with the state Fee Schedule and applicable Medicaid program guidance.