ModifiedUnitedHealthcarePolicy CS039PA.Y

Epidural Steroid Injections for Spinal Pain (for Pennsylvania Only)

Policy governing medical necessity, coding, limitations, and requirements for epidural steroid injections (ESI) 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 criteria and CPT description updates

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionDocument ≥4 weeks of conservative therapy and provide imaging or electrodiagnostic evidence of nerve root involvement when requesting ESI.

SourceLink

POLICY UPDATE CHANGES

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

Revised description 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 wksmin conservative tx

≥50%sufficient pain relief threshold

≤50%

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insufficient pain relief threshold

Pennsylvaniaapplicable state

4CPT descriptions revised

Coverage Criteria for Epidural Steroid Injections

Medical necessity criteria

Covered when ALL of the following are met

Indication: Injection is intended for management of radicular pain as evidenced by history and physical exam

Supported by policy Coverage Rationale

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

Definitions and Coverage Rationale

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

Coverage Rationale and revised criterion

Imaging guidance: Injection is performed under fluoroscopic or CT guidance

Coverage Rationale

Continuation / frequency criteria

Subsequent ESIs within a 12-month period are governed by the following

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

Epidural Steroid Injection Limitations

Clinical trigger for repeat injections: Subsequent ESIs may be provided only if radicular pain has returned and/or deterioration in function has occurred

Epidural Steroid Injection Limitations

Response-based criteria: One of the following must be met: (1) prior injection resulted in ≤ 50% pain relief or functional improvement for < 3 months after reassessment of the individual and injection site/technique; OR (2) prior injection resulted in ≥ 50% pain relief or functional improvement for ≥ 3 months50% pain relief; 3 months

Unproven / Not medically necessary indications

Unproven: Use of ultrasound guidance for ESIs

Listed as unproven and not medically necessary

Unproven: ESI for spine indications other than radicular pain meeting the policy criteria

Listed as unproven and not medically necessary

Coverage by clinical indication and frequency

Coverage supported with criteria for select indications where short- to intermediate-term benefit is demonstrated; limited or not supported for other indications.

Lumbar radicular pain due to disc herniation: ESI is supported for short-term (up to 3 months) pain relief and may provide intermediate-term (3–6 months) benefit in lumbosacral radicular pain from disc herniation; multiple RCTs and meta-analyses demonstrate benefit versus placebo or conservative care for short/intermediate term.timeframe: short- to intermediate-term benefit

Verheijen et al.; Yang et al.; NASS; ASIPP

Other radicular indications: For indications such as spinal stenosis, post-surgery syndrome, or cervical/thoracic radiculopathy the evidence is mixed: some guidelines (ASIPP) give moderate-to-strong recommendations for fluoroscopically guided interventions, while other assessments (AHRQ, Hayes, NASS) find limited or variable long-term benefit; apply individualized decision-making with documented conservative therapy and imaging as applicable.variable by indication

ASIPP; AHRQ; NASS; guideline statements

Revised coverage criterion — nerve root involvement

Coverage criteria revised — specific language on required evidence of nerve root involvement updated.

Evidence of nerve root involvement: There must be evidence of structural and/or functional nerve root involvement by imaging or electrodiagnostic studies.

Revision replaced prior EMG-specific wording with broader 'electrodiagnostic studies'

Conditions that contraindicate epidural steroid injections (ESIs) are noted in the coverage rationale and must be documented on the record. Contraindications include known or suspected spinal neoplasm, a rapidly progressing neurological deficit, and evidence of an epidural abscess. Procedures performed in the presence of these conditions are not consistent with the stated medical necessity criteria and may be denied.

Guideline bodies cited in the policy advise against routine ESI for purely axial low back pain without clear radicular features. The ACOEM guidance states ESIs are Not Recommended for acute, subacute, or chronic low back pain in the absence of significant radicular symptoms, and the AAN concluded that routine use for radicular lumbosacral pain beyond the short term is not recommended. These recommendations support restricting ESI coverage to patients with demonstrable radicular symptoms and objective evidence of nerve root involvement.

This policy is intended to interpret UnitedHealthcare standard benefit plans but does not replace the member's federal, state, or contractual benefit terms. When a conflict exists between this policy and applicable federal, state, or contractual requirements, the federal, state, or contractual requirements govern. Providers should verify and cite benefit-specific terms when requesting coverage, as this policy is informational and may be superseded by plan-specific provisions.

The policy classifies the use of ultrasound guidance for ESIs as unproven and not medically necessary due to insufficient evidence of efficacy compared with fluoroscopic or CT guidance. In addition, the policy designates ESIs for indications not specified in the radicular pain criteria as unproven/not medically necessary. When seeking coverage, documented use of the required imaging guidance (fluoroscopy or CT) and adherence to the specified indication criteria are expected.

Systematic reviews and guideline assessments indicate that while ESIs may provide short-term relief for radicular pain, evidence does not support sustained long-term effectiveness for nonradicular axial low back pain. The AHRQ assessment and AAN statement report small, transient benefits for radiculopathy and conclude there is no demonstrated long-term improvement in function or prevention of surgery for nonradicular conditions. As a result, routine use of ESIs for nonradicular low back pain is considered not supported and is treated as not medically necessary under this policy.

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 ICD-10 diagnosis codes (selected excerpts)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.
M54.11	Radiculopathy, occipito-atlanto-axial region.
M54.12	Radiculopathy, cervical region.
M54.13	Radiculopathy, cervicothoracic region.
M54.14	Radiculopathy, thoracic region.

1–10 of 20

1/2

Applicable CPT codes with revised descriptionsCPT

64479	Revised description for CPT code 64479 (as updated in policy)
64480	Revised description for CPT code 64480 (as updated in policy)
64483	Revised description for CPT code 64483 (as updated in policy)
64484	Revised description for CPT code 64484 (as updated in policy)

ESI sessions per region

LimitMaximum 4 ESI sessions per region per 12-month period (a year is defined as 12 months from the date of the first approved injection)

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

Region definitionRegion defined as cervical, thoracic, or lumbosacral

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization and Coverage Considerations

Prior Authorization Required: Prior authorization (PA) is required for epidural steroid injections (ESI). PA requests must document that the requested service and CPT code(s) meet the policy criteria, including conservative therapy trial, clinical history/exam demonstrating radicular pain, and supporting imaging or electrodiagnostic evidence of nerve-root involvement. When applicable, reference federal/state/contractual benefit terms; those govern in the event of conflict.

Affected CPTs include ESI procedure codes (see Applicable Codes section) and specific transforaminal/interlaminar codes with imaging guidance (e.g., 62321, 62323, 64479, 64480, 64483, 64484).
PA must include documentation of prior conservative therapy and response (see documentation requirements).
Ultrasound-guided ESI is considered unproven/not medically necessary and may be denied.
PA decisions may reference third-party utilization criteria (e.g., InterQual®) as applicable.

Prior Authorization

Frequency Limits and Repeat Injection Criteria

Frequency limits and clinical response documentation govern repeat injections. Limit frequency to approximately 2½–3 months between therapeutic injections when relief >50% is achieved, and do not exceed four ESI sessions per anatomic region in any 12‑month period starting from the first approved injection date. Additional injections within the year require documentation of recurrence of radicular pain and either limited duration of prior benefit (≤50% relief or benefit <3 months) or sustained benefit (≥50% relief for ≥3 months) with reassessment of site and technique.

Required Conservative Care Before ESI

Documentation of attempted conservative measures required prior to ESI

Documentation of attempted conservative measures is required prior to ESI.

Minimum duration: Documentation of a trial of conservative therapy for ≥ 4 weeks prior to ESI>= 4 weeks

Coverage Rationale and Definitions

Examples of conservative measures: Conservative therapy may include pharmacotherapy (e.g., NSAIDs or acetaminophen), activity modification, and physical therapy or home exercise

Definitions section

Document prior conservative therapy and response when seeking ESI

Document prior conservative therapy and response when requesting ESI.

Imaging and Electrodiagnostic Requirements

Documentation Required

Use fluoroscopic or CT guidance for ESIs and document it

For any ESI, plan and perform the procedure using fluoroscopic or CT guidance and document the modality used; the policy requires fluoroscopy or CT guidance for ESI.

Record that the injection was performed under fluoroscopic or CT guidance as required for coverage.
Ultrasound alone should not be used where fluoroscopy/CT is required per policy.

Documentation Required

Confirm and document fluoroscopic/CT guidance for transforaminal and interlaminar ESI

For transforaminal and interlaminar approaches, perform and document fluoroscopic or CT guidance and confirmation of needle placement and contrast spread as part of the procedural record.

Describe approach (transforaminal or interlaminar), imaging modality used, and how needle position and contrast spread were confirmed.
Include these details in the PA request and operative/procedure note.

Limits on Number and Timing of Injections

Epidural steroid injection (all approaches) — Maximum sessions

Overall limitEpidural steroid injection (all approaches): maximum 4 sessions per region per 12 months

ScopeLimit applies regardless of level, location, or side

Year definitionA year is the 12-month period starting from the date of service of the first approved injection

Epidural steroid injections (therapeutic phase)

Therapeutic-phase annual capNot to exceed 4 injections per region per 12-month period

Suggested intervalASIPP suggests 2.5–3 months or longer between injections in the therapeutic phase if >50% relief is obtained

Key Definitions

Conservative Therapy — definition

DefinitionConservative Therapy consists of an appropriate combination of medication (e.g., NSAIDs, analgesics), physical therapy, spinal manipulation, cognitive behavioral therapy (CBT), or other individualized interventions

Duration requirementAt least 4 weeks of conservative therapy is required prior to ESI (documentation of attempted conservative measures required)

Examples of componentsMedication (NSAIDs/acetaminophen), activity modification, physical therapy/home exercise; may include spinal manipulation or CBT

Epidural Steroid Injections (ESI) — definition

DefinitionEpidural Steroid Injections (ESI): percutaneous injection of corticosteroid and/or local anesthetic into the epidural space to manage radiculopathy, intended to relieve pain and improve function

Purpose

Services Not Covered

Not covered: Ultrasound-guided ESIs are considered unproven and not medically necessary. Additionally, ESIs performed for axial low back pain without radiculopathy (i.e., absence of significant radicular symptoms) are not covered in accordance with guideline recommendations that do not support these indications.

Not covered (emphasis): The policy explicitly treats Ultrasound-guided ESIs and ESIs for axial low back pain without radiculopathy as not medically necessary because current evidence and guideline statements do not demonstrate benefit for these uses.

Not covered: Any procedure or indication that is excluded by the member's federal, state, or contractual benefit plan is not covered under this policy. Providers must reconcile requests with the applicable benefit terms; where plan-specific requirements differ, those requirements govern coverage decisions.

Background and Clinical Context

Background: Epidural steroid injections (ESI) are a nonsurgical interventional option intended to treat radiculopathy arising from disc herniation or degenerative vertebral changes. ESIs may be delivered via interlaminar, transforaminal, or caudal approaches and are intended to relieve pain and improve function. The policy highlights that evidence supports short-term benefit for radicular pain but is insufficient for durable long-term outcomes in many nonradicular indications, and that appropriate patient selection, conservative therapy trials, and imaging or electrodiagnostic confirmation of nerve root involvement are required for coverage.

Policy Summary

PayerUnitedHealthcare

PolicyEpidural Steroid Injections for Spinal Pain (for Pennsylvania Only)

Policy CodePolicy CS039PA.Y

Change TypeRevised criteria and CPT description updates

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionDocument ≥4 weeks of conservative therapy and provide imaging or electrodiagnostic evidence of nerve root involvement when requesting ESI.

SourceLink

On This Page

Epidural Steroid Injection Limitations

Nonradicular axial low back pain: Routine use of ESI for axial low back pain without radiculopathy is not recommended; ACOEM and AAN advise against use in the absence of significant radicular symptoms.no radicular symptoms

Frequency and response: Repeat injections may be considered if ≥ 50% relief is achieved lasting roughly 2.5–3 months; suggested maximum is four injections per region per year in the therapeutic phase.>=50% relief for ~2.5–3 months; max 4/year/region

ASIPP; therapeutic phase guidance

Maximum: 4 ESI sessions per region per 12-month period (a session = one date of service in which ESI injection(s) are performed).
Suggested interval between injections: 2.5–3 months or longer when >50% relief is obtained and persists for that interval.
For repeated injections, document validated measures of pain/functional improvement and clinical reassessment.

Prior Authorization

Prior Authorization for Listed ESI CPT Codes

CPT code-specific PA: Certain ESI CPT codes have revised descriptions and require that procedure documentation demonstrate imaging guidance and technique consistent with policy. Ensure PA includes the specific CPT code, indication, level(s), and that imaging (fluoroscopy or CT) was used to confirm needle position/contrast flow when applicable.

Codes with revised descriptions include (but are not limited to) 64479, 64480, 64483, 64484 — confirm updated code descriptors when submitting PA.
Document whether interlaminar or transforaminal approach was used and the anatomic region (cervical, thoracic, lumbosacral).
If contrast was used, document periradicular/epidural contrast spread to confirm correct placement.

Note

Safety and Demonstrated Effectiveness Concerns

Safety, effectiveness, and regulatory context: The FDA notes that injectable corticosteroids are not approved for epidural use and has issued warnings about rare but serious neurologic adverse events. PA requests should weigh these safety concerns and include informed consent documentation when appropriate.

FDA: effectiveness and safety of corticosteroids for epidural administration have not been established; label changes warn of rare serious neurologic events (e.g., stroke, paralysis, vision loss, death).
Include documentation of risk/benefit discussion and any patient-specific safety considerations in the medical record submission.

Documentation Required

Required Documentation for Prior Authorization and Medical Record Submission

Required Documentation: PA and medical records must include all of the following to support medical necessity for ESI: clinical history and focused exam demonstrating radicular pain; documentation of ≥4 weeks of conservative therapy (medication, activity modification, PT/home exercise, spinal manipulation, CBT, or appropriate combination); imaging or electrodiagnostic evidence of structural/functional nerve root involvement; prior response to ESI if applicable; and informed consent/risk discussion.

History and exam: symptoms consistent with radicular pain following a dermatomal pattern, focal neurologic findings when present.
Conservative therapy: record types, start/end dates, adherence, and objective response — trial should be ≥4 weeks before initial ESI.
Imaging/electrodiagnostics: MRI, CT, or electrodiagnostic study report demonstrating nerve root compromise or concordant findings.
If prior ESI given: document percent pain relief and duration using validated measures; date(s) of prior injections and injection site/technique.
If ultrasound guidance was used, note that ultrasound-guided ESI is considered unproven and may not meet medical necessity criteria.

Guideline-recommended trial duration: Many guideline bodies recommend at least a trial of conservative care (commonly >= 3 weeks for some indications) before ESI; document duration and responsecommonly >=3 weeks (varies by guideline)

ACOEM; WFNS recommendations

Document response: Document the patient's response to conservative measures (symptom change, functional status) to support clinical decision-making for ESI

WFNS and guideline rationale

Follow guideline-recommended conservative care where the benefit requires it

Follow guideline-based conservative care: Follow guideline-recommended conservative treatment when the benefit requires it; use referenced guideline approaches for lumbar spinal stenosis and other conditions where conservative care is preferred before invasive procedures.

References and guideline-based expectations

Documentation Required

Provide imaging or electrodiagnostic evidence of nerve‑root involvement

When seeking coverage, include imaging or electrodiagnostic study results that demonstrate structural or functional nerve‑root involvement, as the revised policy requires objective evidence by imaging or electrodiagnostic studies.

Attach MRI/CT reports or electrodiagnostic study (EMG/nerve conduction/electrodiagnostic) results showing nerve‑root involvement.
Document correlation between imaging/EDX findings and the patient’s symptoms and exam.

Response-based repeat criteriaRepeat injections only if radicular pain returned and/or function deteriorated, and prior relief/duration criteria are met

Epidural steroid injections — general frequency limits

General frequency limitMaximum of four (4) ESI sessions per region per 12 months

Repeat triggersSubsequent ESIs may be given only if pain returned/functional deterioration and previous injection met the documented relief/duration criteria

Pain relief thresholdsConsider prior injection insufficient if ≤50% relief for <3 months; sufficient if ≥50% relief for ≥3 months

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

Drugs noteInjectable corticosteroids used include methylprednisolone, triamcinolone, betamethasone, dexamethasone (not FDA‑approved specifically for epidural use)

Radicular Back Pain — definition

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

Clinical correlateShould correspond to the dermatome of the affected nerve root identified on exam or imaging

Implication for coverageRadicular pattern is required for ESI per the policy's medical necessity criteria

Non-Radicular Back Pain — definition

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

Coverage stanceRoutine use of ESI for axial non‑radicular low back pain is not recommended (ACOEM, AAN) and is considered not medically necessary

AssessmentAppropriate imaging does not reveal nerve root compression

Epidural steroid injection (ESI) — drugs and approaches

Drugs usedInjectable corticosteroids commonly used include methylprednisolone, triamcinolone, betamethasone, dexamethasone

ApproachesESIs can be performed via interlaminar, transforaminal, or caudal approaches with imaging guidance (fluoroscopy or CT)

Regulatory noteFDA has not approved corticosteroids specifically for epidural administration; safety and effectiveness for epidural use have not been established

Therapeutic phase / frequency guidance (ASIPP)

ASIPP interval guidanceASIPP suggests intervals of 2.5–3 months or longer between injections in the therapeutic phase if >50% relief is obtained for that duration

Maximum frequencyDo not exceed four injections per year per region in the therapeutic phase

Response criterionRepeat injections should be based on documented pain relief (>50%) and duration (approximately 2.5–3 months) or on insufficient/short-lived benefit criteria

Electrodiagnostic studies — definition and note

DefinitionElectrodiagnostic studies: diagnostic tests (expanded terminology replacing 'EMG') used to demonstrate functional nerve root involvement

Policy changePolicy language broadened from 'electromyography (EMG)' to 'electrodiagnostic studies' to capture a wider range of diagnostic modalities

Use in criteriaEvidence of structural and/or functional nerve root involvement by imaging or electrodiagnostic studies is required for coverage