ModifiedUnitedHealthcarePolicy 2025T0616L

Epidural Steroid Injections for Spinal Pain

Defines medical necessity, limitations, coding, and documentation expectations for epidural steroid injections (ESI) to manage radicular spinal pain for UnitedHealthcare members.

Policy Summary

PayerUnitedHealthcare

PolicyEpidural Steroid Injections for Spinal Pain

Policy CodePolicy 2025T0616L

Change TypeRevised coverage criteria and updated references

Effective Date07/01/2025

Next Review Date

Key ActionObtain and document ≥4 weeks of conservative therapy and imaging or electrodiagnostic evidence of nerve root involvement before authorizing ESI.

SourceLink

POLICY UPDATE CHANGES

Replaced requirement stating evidence of nerve root involvement by imaging or electromyography (EMG) with evidence by imaging or electrodiagnostic studies.

Updated Clinical Evidence and References sections to reflect most current information and archived prior policy version 2025T0616K.

4max ESI sessions / region / year

≥4wmin conservative tx before ESI

Fluoro/CTimaging guidance required

≥50%ASIPP repeat criterion

Coverage Criteria for Epidural Steroid Injections

Initial ESI medical necessity criteria

Covered when ALL of the following are met

Primary indication: Injection is intended for management of Radicular Pain as evidenced by history and physical exam

Conservative therapy: Radicular pain is unresponsive to conservative treatment for >= 4 weeks (eg, pharmacotherapy such as NSAIDs or acetaminophen; activity modification; physical therapy or home exercise)>= 4 weeks

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

Replaces prior wording specifying electromyography (EMG)

Imaging guidance: Injection is performed under fluoroscopic or CT guidance

Ultrasound guidance is considered unproven/not medically necessary

Continuation and frequency criteria

Limitations and continuation criteria

Session limit: A maximum of four (4) ESI sessions per region per year (region = cervical, thoracic, lumbosacral); a session is one date of service4 per region per 12 months

Year defined as 12-month period starting from first approved injection

Subsequent ESI authorization

Criterion 1: Previous injection resulted in <= 50% pain relief or functional improvement for less than 3 months with reassessment of individual and injection site/technique<= 50% relief < 3 months
Reassessment required
Criterion 2: Previous injection resulted in >= 50% pain relief or functional improvement for 3 or more months as measured by validated tools

Coverage criteria and clinical guidance

Coverage stance and clinical indication summary

Primary indications with evidence of short-term benefit: ESIs may be considered for radicular lumbosacral pain (eg, radiculopathy from disc herniation) where evidence shows short- to intermediate-term pain relief and improved outcomes compared with placebo or conservative careshort-term (1-3 months); intermediate (3-6 months)

Systematic reviews and RCTs demonstrate short- to intermediate-term benefit

Limited or no benefit indications: ESIs have insufficient evidence for long-term relief of chronic axial back pain in the absence of radiculopathy; evidence for cervical radiculopathy versus anesthetic alone is limitedlong-term (>6 months)

Guideline reviews note lack of sustained long-term benefit

Technique and safety considerations: Fluoroscopic guidance is commonly used; ultrasound guidance has limited evidence and is considered technically challenging; transforaminal injections have been associated with rare but serious neurologic complications and particulate vs nonparticulate steroid choice may affect safety

Coverage Rationale — evidence requirement

Revised coverage criteria highlights

Required evidence for ESI: There is evidence of structural and/or functional nerve root involvement by imaging or electrodiagnostic studies

Replaces prior wording that specified electromyography (EMG)

Epidural steroid injections (ESIs) are covered when all of the following are met: the procedure is intended to manage radicular pain documented by history and physical examination; there has been a documented trial of conservative therapy for ≥ 4 weeks (for example, NSAIDs or acetaminophen, activity modification, or physical therapy/home exercise); there is objective evidence of structural and/or functional nerve root involvement by imaging or electrodiagnostic studies; and the injection is performed under fluoroscopic or CT guidance. Conditions that contraindicate ESIs include but are not limited to spinal neoplasm, rapidly progressing neurological deficit, and epidural abscess.

For low back pain without radicular symptoms the policy follows guideline recommendations that ESIs are not recommended. ACOEM and other guideline statements indicate ESIs are typically considered for acute or subacute radicular pain after a trial of NSAIDs and waiting at least ~3 weeks; in the absence of significant radicular findings, ESIs for low back pain are not supported.

Systematic reviews and specialty society guidance indicate limited or insufficient evidence that ESIs provide long-term relief for chronic axial back pain when radiculopathy is absent. AANS/CNS and NASS summarize that lumbar epidural injections are not supported for sustained long-term benefit in chronic back pain without nerve-root involvement, although short-term benefit may be seen in selected patients.

The use of ultrasound guidance for ESIs is considered unproven and not medically necessary due to insufficient evidence of efficacy and technical limitations cited in the literature; fluoroscopy or CT remain the required guidance methods for covered ESIs.

Routine use of ESIs to achieve long-term improvement in pain or function is not recommended. AAN and other reviews note that while ESIs may provide short-term benefit (weeks to a few months) for radicular lumbosacral pain, they generally do not demonstrate sustained improvement beyond 3 months and should not be used routinely for long-term management.

Published guideline updates from surgical specialty societies state that the literature does not support the use of lumbar epidural injections for long-term relief of chronic back pain when radiculopathy is absent; such injections have limited support and are not recommended as a routine long-term therapy in these cases.

Applicable Codes and Limits

Applicable 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).
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 ICD-10 CodesICD-10

M47.20	Other spondylosis with radiculopathy, site unspecified.
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.
M47.24	Other spondylosis with radiculopathy, thoracic region.
M47.25	Other spondylosis with radiculopathy, thoracolumbar region.
M47.26	Other spondylosis with radiculopathy, lumbar region.
M47.27	Other spondylosis with radiculopathy, lumbosacral region.
M47.28	Other spondylosis with radiculopathy, sacral and sacrococcygeal region.
M50.10	Cervical disc disorder with radiculopathy, unspecified cervical region.

1–10 of 48

1/5

Applicable Codes (as listed)ICD-10

root of sacral spine, initial encounter

text listed under Applicable Codes

Maximum ESI sessions — summary

Maximum sessions4 per region per 12 months (region = cervical, thoracic, lumbosacral); a session = one date of service

Definition of year12-month period starting from the date of service of the first approved injection

ScopeLimit applies regardless of level, location, or side

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization and Code List

Prior Authorization Required: Prior authorization may be required for Epidural Steroid Injections (ESI) depending on the member-specific benefit plan. Verify prior authorization requirements and submit requests with supporting documentation per payer processes.

Affected codes include CPT 62320–62323, 64479–64484 (see Applicable Codes)
A session = one date of service in which ESI injection(s) are performed
Limit: maximum of 4 ESI sessions per region per 12-month period starting from the date of the first approved injection

Prior Authorization

Frequency / Prior Authorization Consideration

Frequency and timing considerations: Therapeutic-phase guidance recommends spacing injections approximately 2½ to 3 months or longer between injections when >50% relief is obtained for 2½–3 months, and not exceeding four injections per region per year.

Conservative Therapy Requirements Before ESI

Documented trial of conservative therapy (>= 4 weeks)

Documented conservative therapy must be present before ESI

Conservative therapy components: Documented trial must include at least one of: pharmacotherapy (eg, NSAIDs or acetaminophen), activity modification, or physical therapy/home exercise

See validated documentation in medical record

Duration requirement: Conservative therapy trial duration must be >= 4 weeks prior to ESI>= 4 weeks

Per policy definitions and prerequisites

Trial of NSAIDs prior to ESI for acute/subacute radicular pain (at least 3 weeks)

For acute or subacute radicular pain

Frequency Limits and Therapeutic-Phase Guidance

Epidural steroid injections (all approaches) — frequency limit

Policy limitMaximum of four (4) ESI sessions per region per 12-month period

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

Region definitionRegion defined as cervical, thoracic, or lumbosacral

Epidural steroid injections (therapeutic phase)

Therapeutic-phase annual limitNot exceeding 4 injections per year per region

Repeat-injection conditionConsider repeat only when prior injection provided >50% relief for 2½–3 months (therapeutic phase guidance)

Imaging and Diagnostic Requirements

Billing Rule

Fluoroscopy or CT guidance required for covered ESIs

ESIs must be performed under fluoroscopic or CT guidance for coverage; ultrasound guidance is considered unproven and not medically necessary.

Policy criterion: injection is performed under fluoroscopic or CT guidance.
Ultrasound guidance is listed as unproven/not medically necessary.

Note

Fluoroscopy commonly used; ultrasound an alternative with limited evidence

Fluoroscopy is the conventional imaging guidance for spine injections; ultrasound is noted as a possible alternative but evidence is limited and it remains technically challenging.

Limited peer-reviewed evidence supporting ultrasound versus fluoroscopy/CT.
Ultrasound-guided injections may be reasonable in select settings but are technically challenging and require careful patient selection.

Services Not Covered / Considered Not Medically Necessary

Use of ultrasound guidance for ESIs is listed as not covered / not medically necessary because current evidence is insufficient to demonstrate overall health benefit compared with fluoroscopic or CT guidance; the policy requires fluoroscopic or CT guidance for covered ESIs.

Ultrasound-guided ESIs and other ESI indications not listed as covered in this policy are considered not medically necessary. Providers should use fluoroscopy or CT guidance for procedures that meet coverage criteria.

ESI for low back pain without significant radicular symptoms is not covered/not recommended. ACOEM and AAN guidance classify ESIs as not recommended for treatment of low back pain in the absence of objective radicular findings.

Ultrasound guidance for ESIs and use of ESIs for non-radicular indications are considered not covered given the policy's limitation to radicular indications and requirement for fluoroscopic or CT guidance.

Definitions

Epidural Steroid Injections (ESI) — definition

DefinitionInjection of corticosteroid and/or anesthetic into the epidural space to relieve radicular pain and improve function

ApproachesInterlaminar (ILESI), transforaminal (TFESI), or caudal approaches

PurposeNonsurgical treatment for radiculopathy caused by disc herniation or degenerative vertebral changes

Conservative Therapy — definition

Core componentsCombination of medication (eg, NSAIDs, analgesics) plus physical therapy, spinal manipulation, CBT, or other interventions tailored to the individual

Minimum duration prior to ESI>= 4 weeks (documented trial) as required by policy

Background

Spine pain is common, affecting up to 90% of Americans at some point in life and often self-limiting. Epidural steroid injections (ESIs) are a nonsurgical option intended to relieve radicular pain (for example from disc herniation or degenerative changes) by delivering corticosteroid and often local anesthetic into the epidural space via interlaminar, transforaminal, or caudal approaches. ESIs may provide short- to intermediate-term pain relief for selected patients with radiculopathy, but are subject to the conservative therapy, imaging, and guidance requirements in this policy.

Policy Summary

PayerUnitedHealthcare

PolicyEpidural Steroid Injections for Spinal Pain

Policy CodePolicy 2025T0616L

Change TypeRevised coverage criteria and updated references

Effective Date07/01/2025

Next Review Date

Key ActionObtain and document ≥4 weeks of conservative therapy and imaging or electrodiagnostic evidence of nerve root involvement before authorizing ESI.

SourceLink

On This Page

>= 50% relief >= 3 months

Validated measurement tools required

Documented in systematic reviews, HTAs, and guideline statements

Guideline-based timing and prior treatment: For acute/subacute radicular pain, consider ESI after trial of NSAIDs and waiting at least ~3 weeks; in the therapeutic phase, repeat injections generally only if >50% relief persists for 2½–3 months, with intervals of 2½–3 months or longer and not exceeding 4 per year per region>50% relief lasting 2.5–3 months to repeat

ACOEM and ASIPP recommendations

Do not exceed 4 injections per region in a 12‑month period
Therapeutic-phase interval: ~2.5–3 months if clinically effective (>50% relief)

Note

Prior Authorization Note — Check Member-Specific Benefits

Prior Authorization Note: Always check the member-specific benefit plan and any applicable federal or state mandates before providing services. Member plan language governs coverage; prior authorization or additional documentation requirements may vary.

Member-specific benefit plan governs coverage in event of conflict with this policy
Medicare Advantage: check for applicable NCD/LCD or MAO guidance

Documentation Required

Conservative Therapy Prerequisite

Conservative therapy prerequisite: Epidural Steroid Injections are considered medically necessary for radicular pain only after an adequate trial (≥4 weeks) of conservative therapy unless clinical circumstances justify earlier intervention.

Conservative therapy includes medication (e.g., NSAIDs, analgesics) plus PT, spinal manipulation, CBT, activity modification or other interventions tailored to the individual
Trial duration: ≥ 4 weeks prior to ESI for radicular pain (unless clinical urgency)

Documentation Required

Conservative Therapy Prior to ESI

Conservative therapy before ESI: Follow guideline-recommended conservative care prior to ESI. ACOEM recommends NSAID treatment and waiting at least 3 weeks for acute/subacute radicular pain; WFNS recommends at least 3 weeks of therapeutic exercise for lumbar spinal stenosis and generally discourages repeat injections if relief <3 months.

ACOEM: consider ESI after NSAID trial and ~3 weeks for select acute/subacute radicular syndromes
WFNS: non-severe lumbar spinal stenosis — consider ≥3 weeks of therapeutic exercise; avoid repeat injections if relief <3 months

Prior Authorization

Conservative Treatment Before Repeat Injections

Conservative treatment before repeat injections: Repeat ESIs may be provided only when radicular pain has returned or function has deteriorated and when prior response meets one of the following: previous injection provided ≤50% relief (or improvement) for <3 months after reassessment; or provided ≥50% relief for ≥3 months.

Repeat injection criteria: return of symptoms or functional decline plus documented prior response
Documented prior response thresholds: ≤50% relief for <3 months OR ≥50% relief for ≥3 months

Denial Risk

Triggers for Denial

Triggers for denial: Requests may be denied if required clinical criteria are missing, conservative therapy is insufficient or not documented, or there is lack of imaging/electrodiagnostic evidence of structural or functional nerve root involvement.

Missing documentation of ≥4-week conservative therapy trial (when indicated)
No evidence of structural/functional nerve root involvement on imaging or electrodiagnostic studies
Exceeding 4 ESI sessions per region within a 12‑month period

Denial Risk

Frequency-Related Denial Risk

Frequency-related denial risk: Requests exceeding the policy limits (more than four ESI sessions per region in a 12‑month period) or without documentation supporting therapeutic-phase intervals and prior response may be denied.

More than 4 ESI sessions per region per 12 months is not supported
Lack of documentation that previous injections met response and interval criteria increases denial risk

Documentation Required

Safety and Risk Documentation

Safety and Risk Documentation: Document discussion of benefits and risks with the patient, including FDA safety communications noting rare but serious adverse events (loss of vision, stroke, paralysis, death) associated with epidural corticosteroid injections and that corticosteroids are not FDA-approved for epidural administration.

Record informed consent discussion including FDA safety warning and alternative options
Document choice of steroid, route, and rationale; if sedation or anesthesia is used, document indication and monitoring

Documentation Required

Required Documentation Elements

Required documentation elements: Submit medical records that demonstrate the indication, the injection approach, details of prior conservative therapy and response, objective measures of pain/function, and timing/response to prior injections when applicable.

Indication: history and physical consistent with radicular pain
Injection approach: interlaminar, transforaminal, or caudal and use of imaging guidance (fluoroscopy or CT)
Conservative therapy: types, durations (≥4 weeks when indicated), and response
Objective measures: validated pain/function scores and documentation of % relief and duration after prior injections
Timing: dates of prior injections and reassessment findings

Documentation Required

Required Clinical Documentation — Structural/Functional Nerve Root Involvement

Required Clinical Documentation — Evidence of nerve root involvement: Provide imaging or electrodiagnostic evidence of structural and/or functional nerve root involvement (e.g., MRI/CT showing nerve root compression, or electrodiagnostic studies consistent with radiculopathy) to support ESI for radicular pain.

Imaging: MRI or CT demonstrating concordant nerve root compression when available
Electrodiagnostic studies: EMG/nerve conduction studies or other electrodiagnostic testing showing functional nerve root involvement
If imaging/electrodiagnostics are unavailable, provide clinical justification and documentation of objective findings

NSAID trial: Trial of NSAID therapy is recommended prior to considering ESI for acute or subacute radicular painat least 3 weeks

Per ACOEM guidance to wait ~3 weeks after NSAID treatment

Attempt conservative care prior to surgery; consider further injections only if relief >= 3 months (therapeutic exercise)

Before surgery and when considering repeat injections for lumbar spinal stenosis

Attempt conservative care before surgery: Attempt conservative care (eg, multimodal physical therapy and at least 3 weeks of therapeutic exercise) prior to surgical consideration for lumbar spinal stenosis>= 3 weeks (therapeutic exercise)

Surgery considered if no clinical change after 3 months

Further injections consideration: Consider further epidural injections only if prior injection provided >= 3 months of meaningful relief; if relief < 3 months, further injections are not recommended>= 3 months relief

WFNS and ASIPP guidance

ASIPP therapeutic-phase recommendation referenced for timing and frequency

Interventional epidural injections — recommended interval

Suggested interval between injections2½ to 3 months or longer between injections in the therapeutic phase

Condition for intervalInterval applies provided >50% relief is obtained for 2½–3 months

Annual cap tie-inPart of ASIPP guidance that also suggests not exceeding 4 injections per year per region

Epidural Steroid Injections — ASIPP frequency suggestion

ASIPP recommendationDo not exceed 4 injections per year per region

Therapeutic-phase caveatRepeat injections considered when >50% relief persists for 2½–3 months

ApplicabilityRecommendation applies per region (cervical, thoracic, lumbosacral)

Prior Authorization

Imaging or electrodiagnostic confirmation required for coverage

Coverage requires objective confirmation of nerve root involvement by imaging or electrodiagnostic studies as part of the clinical criteria for ESI.

Policy explicitly requires evidence of structural and/or functional nerve root involvement by imaging or electrodiagnostic studies.
This requirement is part of the revised coverage criteria effective 07/01/2025.

ExamplesMedication, activity modification, PT or home exercise

Radicular Back Pain — definition

Clinical descriptionPain radiating from the spine into the extremity along a spinal nerve root dermatomal distribution

Supporting evidenceShould be consistent with clinical findings and the dermatome of the irritated nerve root

Contrast to non-radicular painRadiates along a dermatome versus non-radicular pain which does not

Non-Radicular Back Pain — definition

Clinical descriptionSpinal pain that does not radiate along a dermatome and lacks clinical or imaging evidence of nerve root compression

Imaging correlationAppropriate imaging does not reveal signs of spinal nerve root compression

Policy implicationESIs are not recommended for low back pain in the absence of significant radicular symptoms

Epidural Steroid Injection (ESI) — alternate definition

Alternate phrasingInjection of corticosteroid (and often local anesthetic) into the epidural space for treatment of spinal radicular pain

Procedure contextPerformed as a nonsurgical modality to treat low back or neck radicular pain

Sedation noteGenerally requires local anesthetic only; moderate/conscious sedation or MAC may be used in some patients

Epidural Steroid Injection (ESI) — procedure description

Procedure descriptionInjection of corticosteroid and/or anesthetic into the epidural space via interlaminar, transforaminal, or caudal approaches under imaging guidance

Guidance and safetyTypically performed under fluoroscopic or CT guidance; choice of steroid (particulate vs nonparticulate) and approach affects safety considerations

Regulatory noteProcedure is not FDA-regulated; corticosteroids are not FDA-approved for epidural administration and FDA has warned of rare but serious neurologic adverse events

Therapeutic phase frequency (ASIPP) — definition

ASIPP therapeutic-phase frequencySuggested interval of 2½ to 3 months or longer between injections in the therapeutic phase if >50% relief is obtained

Annual limit restatedASIPP states not exceeding 4 injections per year per region

Condition for repeat>50% relief maintained for the interval (2½–3 months) to justify repeat injection