ModifiedUnitedHealthcarePolicy CS039NM.C

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

Medical policy governing coverage and medical necessity criteria for epidural steroid injections (ESI) for spinal pain for members in New Mexico; applies to providers delivering interventional spinal injections and payers adjudicating benefits.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS039NM.C

Change TypeRevised clinical criterion (EMG → electrodiagnostic studies) and updated references

Effective DateAug 1, 2025

Next Review Date

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

SourceLink

POLICY UPDATE CHANGES

Replaced criterion requiring 'there is evidence of structural and/or functional nerve root involvement by imaging or electromyography (EMG)' with 'there is evidence of structural and/or functional nerve root involvement by imaging or electrodiagnostic studies'.

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

4max ESI sessions / region / year

≥4 wksmin conservative therapy

Fluoro/CTrequired image guidance

rare

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

New Mexicogeographic applicability

1material revision count

Coverage Criteria for Epidural Steroid Injections

inv-01: Initial medical necessity criteria

ESIs are proven and medically necessary 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 treatment: Radicular pain is unresponsive to conservative treatment for ≥ 4 weeks (examples: 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 documented by imaging or electrodiagnostic studies

Image guidance: Injection is performed under fluoroscopic or CT guidance

inv-02: Continuation / frequency criteria

Limits and criteria for subsequent/continued ESIs:

Frequency limit: Maximum of four (4) ESI sessions per region per 12-month period starting from date of first approved injection4 per 12 months

A session is one date of service; region = cervical, thoracic, or lumbosacral

Return of symptoms requirement: Subsequent ESIs may be provided only if radicular pain has returned and/or deterioration in function has occurred

Response-based allowance for subsequent ESIs: One of the following must be met to allow repeat injection: (1) previous injection resulted in ≤ 50% pain relief or functional improvement for less than 3 months despite reassessment of the individual and injection site/technique; OR (2) previous injection resulted in ≥ 50% pain relief or functional improvement for 3 or more months as measured by validated tools50%

inv-03: Unproven / Not medically necessary indications

Unproven / Not medically necessary

Unproven technique: Use of ultrasound guidance for ESIs

Not covered indications: ESI for spine indications not explicitly included in the covered criteria (i.e., non‑radicular spinal pain or other indications without meeting criteria)

inv-04: General coverage considerations for ESI

Covered when supported by guideline-based indications and documentation of prior conservative therapy; effectiveness and recommendations vary by anatomic indication:

Lumbar radicular pain (disc herniation): Evidence (including RCTs and systematic reviews) supports short- to intermediate-term pain relief from ESIs, with particularly strong evidence for lumbar transforaminal injections for radicular pain due to disc herniation; coverage appropriate when clinical diagnosis and imaging correlate and conservative therapy attempted.evidence-based

Spinal stenosis and other indications: Evidence is mixed: short- to intermediate-term benefits may occur for symptomatic lumbar spinal stenosis but long-term efficacy is limited; selective coverage may be allowed with documentation of symptom severity, prior conservative management, and expected goals.selective

Cervical and thoracic ESIs: Evidence for cervical radiculopathy is inconclusive/inadequate to recommend routine use; thoracic data are limited—consider selective coverage with image guidance and careful risk-benefit assessment.

Contraindications to performing an epidural steroid injection (ESI) include, but are not limited to, the presence of a spinal neoplasm, a rapidly progressing neurological deficit, or an epidural abscess. These conditions should be identified and managed appropriately prior to consideration of ESI.

Major guideline bodies advise against routine use of ESIs for patients with non‑radicular low back pain (i.e., absence of clinically significant radicular symptoms). ACOEM specifically lists treatment of low back pain without radiculopathy as Not Recommended, and systematic assessments (AHRQ, AAN) report limited or no sustained benefit for non‑radicular axial low back pain, supporting a stance that ESIs are not recommended for these presentations.

This policy is an interpretive guide for UnitedHealthcare standard benefit plans in New Mexico and is intended to assist decision‑making about coverage for ESIs. Federal, state, or contractual benefit plan terms may differ and will govern in the event of a conflict; users should verify applicable plan documents and any prior authorization requirements. UnitedHealthcare may also use external decision tools (e.g., InterQual®) to support authorization determinations.

Use of ultrasound guidance for ESIs is considered unproven and not medically necessary due to insufficient evidence of efficacy; the policy requires image guidance with fluoroscopy or CT for covered ESIs and emphasizes documentation of the guidance technique used when requesting coverage.

The routine use of ESIs for chronic low back pain in the absence of radicular symptoms is generally considered not medically necessary. Evidence syntheses and guideline statements show limited or no long‑term benefit for axial low back pain without nerve root involvement, and several organizations explicitly recommend against ESI for non‑radicular presentations.

Conservative Therapy Requirements Before ESI

inv-34: Must be unresponsive to conservative therapy for at least 4 weeks prior to ESI

Conservative therapy must be documented and unsuccessful prior to ESI:

Minimum duration: Must be unresponsive to conservative therapy for at least 4 weeks prior to ESI>= 4 weeks

Conservative therapy includes medication (e.g., NSAIDs, acetaminophen), activity modification, and PT/home exercise; may include spinal manipulation or CBT

inv-35: Document prior conservative therapies and duration

Document prior conservative therapies and duration — recommended trial lengths and expectations before proceeding to ESI or surgery:

Document therapies: Document prior conservative therapies (for example: NSAIDs or acetaminophen, activity modification, physical therapy or home exercise, spinal manipulation, cognitive behavioral therapy) and the duration of each trial

Frequency Limits and Therapeutic Phase Guidance

inv-36: Epidural Steroid Injection (any approach) — maximum sessions per region per year

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

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

Region definitionCervical, thoracic, or lumbosacral region

12‑month periodStarts from date of service of the first approved injection

Condition for subsequent ESIsAllowed only if radicular pain has returned and/or deterioration in function has occurred and additional criteria met

inv-37: Epidural steroid injections (per region)

Imaging and Procedural Guidance Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Epidural steroid injections (ESIs) that meet coverage criteria may still require prior authorization. Submit clinical documentation supporting medical necessity, including conservative therapy attempts, imaging or electrodiagnostic evidence of nerve root involvement, and planned procedural guidance. Failure to obtain prior authorization when required may result in claim denial.

Affected CPT: 62321, 62323, 64479-64480, 64483-64484
Frequency limits: prior authorization required for multiple/serial ESIs per member — document clinical response and justification for repeat injections
Decision aids: provide relevant decision support documentation or prior authorization forms per payer processes

Documentation Required

Documentation & Safety Requirements

Documentation and Safety Requirements: Document pre-procedure conservative therapy (≥4 weeks) and response, indication of radicular pain from history and physical exam, and objective evidence of nerve root involvement by imaging (MRI/CT) or electrodiagnostic studies (EMG/NCS). Procedure notes must include imaging modality used (fluoroscopy or CT), needle placement confirmation (contrast spread or equivalent), level(s) treated, medications and doses administered, and any immediate complications or adverse events. Lack of required documentation or omission of imaging-guidance details increases denial risk.

Coding and Billing

Applicable CPT — selected list (part 1)CPT

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)

Applicable CPT — selected list (part 2)CPT

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 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
M54.30	Sciatica, unspecified side
M54.31	Sciatica, right side

1–10 of 11

1/2

inv-13: Maximum ESI sessions — 4 per region per 12 months (coding/limit summary)

Maximum per region per 12 months4 ESI sessions per region per 12 months (counted from first approved injection date)

Procedure coding noteApplicable imaging‑guided CPT codes include transforaminal and interlaminar codes (see policy CPT list) for authorization considerations

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

Provider Actions, Documentation, and Prior Authorization

Prior Authorization

Obtain prior authorization consistent with utilization limits and applicable CPT codes

Prior authorization is expected for ESI use consistent with utilization limits; consider the listed CPT codes when submitting authorization requests.

Prior authorization expectation tied to limits: maximum 4 sessions per region per 12 months
Codes to consider when requesting auth: 62321, 62323, 64479, 64480, 64483, 64484, 62320, 62322

Billing Rule

Adhere to frequency limits and response thresholds for repeat ESIs

Frequency limits: a maximum of four ESI sessions per region per 12 months; subsequent injections allowed only if radicular pain returns/deterioration occurs and prior response meets the policy thresholds (≤50% relief <3 months or ≥50% relief ≥3 months).

Limit: ≤4 injections per region per 12 months

Definitions

inv-27: Conservative Therapy — definition and examples

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

Medication examplesNSAIDs, acetaminophen, other analgesics

Non‑pharmacologic examplesPhysical therapy, spinal manipulation therapy, home exercise programs, cognitive behavioral therapy (CBT)

PurposeInitial management to attempt symptom relief and functional improvement before ESI

inv-28: Epidural Steroid Injections (ESI) — definition and approaches

DefinitionEpidural Steroid Injections (ESI) are a nonsurgical treatment that injects corticosteroid (often with or without local anesthetic) into the epidural space to relieve radiculopathy and improve function

Not Covered / Unproven Services

Not covered under this policy are (1) ultrasound‑guided ESIs, which are listed as unproven and not medically necessary, and (2) ESIs provided for non‑radicular low back pain (absence of significant radicular symptoms), consistent with ACOEM and AAN recommendations. In addition, ESIs for spinal indications not explicitly included in the covered criteria are considered not medically necessary due to insufficient evidence. See the Policy History for updates to criteria and references.

Policy Revision History and Summary of Changes

2025-08-01material_revisionLatest

Revised coverage criteria to replace requirement for evidence of nerve root involvement by imaging or electromyography (EMG) with imaging or electrodiagnostic studies; archived prior policy version CS039NM.B.

This version includes updates to the Clinical Evidence and References sections to reflect current literature and guideline statements. The coverage criteria were revised (see Summary of Changes) to replace the term 'EMG' with the broader phrase 'electrodiagnostic studies,' and the prior policy version CS039NM.B has been archived.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS039NM.C

Change TypeRevised clinical criterion (EMG → electrodiagnostic studies) and updated references

Effective DateAug 1, 2025

Next Review Date

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

SourceLink

On This Page

Recommended minimum trial: For non-severe cases, a minimum conservative period of approximately 3 weeks is commonly recommended prior to ESI; for lumbar spinal stenosis consider at least 3 weeks of therapeutic exercise and reassess up to 3 months before surgery~3 weeks (minimum); up to 3 months before surgery consideration

Annual frequency limitDo not exceed four (4) injections per region per year

Suggested therapeutic intervalApproximately 2.5–3 months between injections when >50% relief is achieved (ASIPP guidance)

Condition for repeat injectionRepeat only if radicular pain returns and/or function worsens and documented prior response meets criteria

Response thresholdsPrevious injection ≤50% relief for <3 months, or ≥50% relief for ≥3 months (as measured by validated tools)

inv-02 (cross-reference): Continuation / frequency criteria

Operational rules linking response thresholds to dosing/interval decisions for subsequent injections:

Frequency cap: Do not exceed four (4) injections per region per 12 months (period starts at first approved injection)4 per 12 months

Interval guidance when effective: When a prior injection produced ≥ 50% pain relief or functional improvement, consider spacing therapeutic-phase injections approximately 2.5–3 months apart; continuation beyond four injections still requires meeting repeat-injection criteria and prior authorization when applicable>= 50%

Short-lived response: If prior injection produced ≤ 50% relief and benefit lasted for less than 3 months despite reassessment, repeat injections may be considered per clinical judgment but remain subject to the maximum annual limit<= 50%

Required clinical documentation: history and physical exam showing radicular pain, conservative therapy attempts and dates, imaging or electrodiagnostic reports demonstrating nerve root involvement
Procedure and safety documentation: fluoroscopic/CT guidance confirmation, contrast flow when used, needle depth/location, levels treated, agent(s) and dose, informed consent, and post-procedure observations
Documentation expectations: retain imaging/report copies in the medical record; include dates and interpreting clinician
Safety risk / documentation concern: without confirmation of imaging or electrodiagnostic evidence and imaging-guided technique, procedure may be considered not medically necessary or high denial risk

Step Therapy

Conservative Therapy & Frequency Limits

Conservative Therapy & Frequency Expectations: A trial of conservative therapy for ≥4 weeks is required prior to initial ESI (examples: NSAIDs/acetaminophen, activity modification, physical therapy or home exercise). For repeat injections, document clinical improvement from prior injection(s) and the rationale for additional procedures. Use decision aids/prior authorization processes to confirm spacing and number of injections consistent with medical necessity.

Conservative therapy before ESI: pharmacotherapy (NSAIDs/acetaminophen), activity modification, and physical therapy/home exercise for at least 4 weeks prior to initial ESI
Provider action — Frequency limits and prior authorization: document objective improvement and medical necessity for repeat ESIs; follow payer-specific limits and obtain prior authorization when required
Provider action — Prior authorization and decision aids: include prior authorization forms and any required decision-support tools with submitted documentation

Repeat injection criteria: pain returned/deterioration and either ≤50% relief <3 months or ≥50% relief ≥3 months

ASIPP suggested interval in therapeutic phase: ~2.5–3 months when >50% relief obtained

Prior Authorization

Check benefit plan PA requirements; InterQual may be used

Verify applicable benefit plan prior authorization requirements and note UnitedHealthcare may use InterQual criteria to assist authorization decisions.

Check federal/state/contractual plan terms for PA obligations
UnitedHealthcare may use third‑party tools (e.g., InterQual) to assist authorization

Step Therapy

Document ≥4 weeks of conservative therapy before ESI

Demonstrate at least 4 weeks of appropriate conservative therapy before ESI, consisting of medication (e.g., NSAIDs), activity modification, and physical therapy or home exercise; other modalities (spinal manipulation, CBT) may be included as clinically indicated.

Minimum conservative therapy duration: ≥4 weeks
Components: pharmacotherapy (NSAIDs/acetaminophen), activity modification, PT/home exercise; may include spinal manipulation or CBT

Step Therapy

Follow guideline-recommended conservative therapy timelines before ESI

Guideline bodies recommend trials of conservative care (NSAIDs, therapeutic exercise, multimodal physical therapy) with a minimum period (often ~3 weeks) before ESI in non‑severe cases; for lumbar stenosis consider at least 3 weeks of therapeutic exercise and reassess up to 3 months before surgery.

ACOEM: wait at least 3 weeks after NSAID trial for acute/subacute radicular pain
WFNS: ≥3 weeks therapeutic exercise for non‑severe lumbar spinal stenosis; reassess up to 3 months before surgery

Note

Refer to updated references and the policy revision history

See updated Clinical Evidence and References sections for supporting guidance; policy revisions replaced 'EMG' with 'electrodiagnostic studies' and updated references as noted in the policy history.

Policy history: 08/01/2025 summary of changes and updated references
Replaced wording: 'electromyography (EMG)' → 'electrodiagnostic studies'

Documentation Required

Include history, objective evidence, conservative therapy, and prior injection response in documentation

Clinical documentation must demonstrate radicular pain by history and physical, evidence of structural/functional nerve root involvement by imaging or electrodiagnostic studies, prior conservative treatment for ≥4 weeks, and details of prior injection response (pain/function percentage and duration) when requesting subsequent ESIs.

History and physical documenting radicular pain
Objective evidence: imaging or electrodiagnostic studies
Conservative therapy: documentation of ≥4 weeks and modalities tried
For repeats: prior injection pain/function % and duration using validated tools

Documentation Required

Record image‑guided procedure details and safety discussion in the operative note

Document procedure details including image guidance used (fluoroscopy/CT), needle position and contrast spread/flow confirmation, target region, indication, prior conservative therapies tried, and discussion of FDA safety warnings.

Procedure notes: image guidance modality and fluoroscopic/contrast confirmation of needle/flow
Safety: list potential complications and reference FDA safety communication
Include target region and clinical indication (e.g., radiculopathy due to disc herniation)

Documentation Required

Ensure documentation conforms with applicable plan terms and revised criteria

Follow federal, state, and contractual benefit plan terms; documentation should support conformity with the revised clinical criteria and current references when deciding coverage.

Check and follow federal/state/contractual plan terms which govern in a conflict
Ensure documentation aligns with revised criteria and current references

Denial Risk

Avoid denials by meeting radicular indication, conservative therapy, objective evidence, and imaging guidance requirements

Claims may be denied if criteria are not met, including non‑radicular indications, failure to try ≥4 weeks of conservative therapy, absence of imaging or electrodiagnostic evidence of nerve root involvement, lack of fluoroscopic/CT guidance, or presence of contraindications (e.g., spinal neoplasm, rapidly progressing neurologic deficit, epidural abscess).

Non‑radicular low back pain without radicular symptoms is not covered
No documentation of ≥4 weeks conservative therapy may lead to denial
Lack of imaging/electrodiagnostic evidence or image guidance may trigger denial
Contraindications (spinal neoplasm, rapidly progressing neuro deficit, epidural abscess) are exclusionary

Documentation Required

Document informed consent discussing FDA‑noted rare but serious neurologic risks

The FDA has warned that epidural corticosteroid injections may result in rare but serious neurologic adverse events (loss of vision, stroke, paralysis, death); document informed discussion of these risks and benefits with the patient.

FDA safety communication: rare serious neurologic events after epidural corticosteroid injections
Document that benefits/risks were discussed with the patient

Denial Risk

Risk of denial if documentation lacks imaging or electrodiagnostic evidence of nerve root involvement

Denials may occur if documentation does not show evidence of structural and/or functional nerve root involvement as required by the revised criteria (documented by imaging or electrodiagnostic studies).

Policy revision: requirement for imaging or electrodiagnostic studies to demonstrate nerve root involvement
Ensure documentation explicitly cites imaging or electrodiagnostic results

Note

Background on ESIs and their role in managing radicular pain

Epidural steroid injections are a nonsurgical intervention to manage radicular pain by injecting corticosteroids into the epidural space; evidence supports short‑term benefit for radicular pain but limited long‑term effect and variable evidence by indication.

ESI goal: relieve pain, improve function and quality of life by epidural steroid injection
Evidence: short‑ to intermediate‑term relief demonstrated in meta‑analyses and guidelines; limited long‑term benefit

IndicationsPrimarily used for radicular back pain due to disc herniation or degenerative changes when conservative therapy has failed

Evidence summaryRCTs and meta-analyses show short‑ to intermediate‑term pain relief for radicular pain but limited long‑term benefit

inv-29: 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 dermatomal pattern associated with an irritated nerve root

Clinical correlationRequires history and physical exam consistent with radiculopathy and, when indicated, imaging or electrodiagnostic corroboration

Distinguishing featureRadiation along a dermatome versus axial or non‑radicular pain

inv-30: Non-Radicular Back Pain — definition

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

Evidence for ESILimited evidence supports use of ESIs for non‑radicular low back pain; professional bodies generally do not recommend routine ESI for axial low back pain

Clinical implicationESI is generally not covered for non‑radicular low back pain per policy guidance

inv-31: Epidural steroid injection (ESI) — procedural definition (interlaminar, transforaminal, caudal)

Procedural definitionAn ESI is a percutaneous injection of corticosteroid (often with or without local anesthetic) into the epidural space delivered via interlaminar, transforaminal, or caudal approaches

Interlaminar approachInjection into the posterior epidural space between the laminae, often used for multilevel or central epidural delivery

Transforaminal approachTargeted injection into the neuroforamen adjacent to the affected nerve root; evidence supports efficacy for lumbar disc herniation radiculopathy

Caudal approachInjection through the sacral hiatus to deliver medication to the epidural space, used when other approaches are not feasible

inv-32: Therapeutic phase — definition and ASIPP spacing guidance

DefinitionTherapeutic phase: the period after the diagnostic phase during which injections are given for symptom relief

ASIPP spacing guidanceSuggested spacing of injections is 2.5–3 months or longer between injections during the therapeutic phase provided >50% relief is obtained for that period

Frequency capDo not exceed four (4) injections per region per year during the therapeutic phase

inv-33: electrodiagnostic studies — definition and note that wording replaces 'EMG' in updated criteria

Definition changeElectrodiagnostic studies: term replaces ‘electromyography (EMG)’ in coverage criteria to indicate broader electrodiagnostic testing modalities

PurposeUsed as evidence of functional nerve root involvement alongside imaging when documenting objective findings for ESI coverage

Documentation notePolicy revision (08/01/2025) updated wording from EMG to electrodiagnostic studies in coverage criteria