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Epidural Steroid Injections / Selective Nerve Root Block (SNRB)
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Defines medical necessity, investigational uses, and appropriateness criteria for diagnostic and therapeutic selective nerve root blocks for radicular pain/radiculopathy.
No material clinical or coverage changes in this revision.
Coverage Criteria for SNRB and ESI
Initial diagnostic SNRB (medically appropriate)
Covered when ALL of the following are met
Diagnostic SNRB at a spinal level other than the initial level (medically appropriate)
Covered when ALL of the following are met
Initial Epidural Steroid Injection for presumed radiculopathy
Covered when ALL of the following are met:
Detailed neurologic exam requirement applies as specified, and advanced imaging within 24 months is required for cervical/thoracic interlaminar and transforaminal ESI.
Initial ESI for neurogenic claudication
Covered as an initial trial when ALL of the following are met:
TFESI with intra-articular facet joint injection and synovial cyst aspiration
Considered medically appropriate when ALL of the following are met:
TFESI with intra-articular facet injection and synovial cyst aspiration — Medically Appropriate
Covered when ALL of the following are met:
Refer to Policy Guidelines for the exception allowing TFESI on the same day as intra-articular facet injection with synovial cyst aspiration.
Repeat ESI — Medically Appropriate
Covered when ALL of the following are met:
See Policy Statement XI and Policy Guidelines for session limits.
Image Guidance
Covered when ALL of the following are met
Exception allowed for emergent situations or contraindications to fluoroscopy/CT/contrast (e.g., pregnancy).
Frequency & Same-Day Procedure Limits
Covered when ALL of the following are met
Exception: TFESI with synovial cyst aspiration may be performed on the same date as intra-articular facet injection with aspiration.
Level Limits
Covered when ALL of the following are met
Injectates
Covered only for specified injectates
Other policies or programs may govern these agents.
Efficacy summary and indications
Covered when evidence and clinical context support use (e.g., radicular pain after conservative therapy); supporting evidence and limitations summarized:
Oliveira et al 2020; Verheijen et al 2021
Schneider et al 2019
Celenlioglu et al 2022
Fujiwara 2018; Choi 2020; Chuang 2025
Guideline-supported Coverage Scenarios
Covered when supported by guideline-recommended indications and evidence levels
Level I evidence cited for many ESI approaches for disc herniation.
ASIPP/ASPN statements summarized.
AAN review
Biologic Injectates (PRP, MSC, ACS) Coverage Considerations
Injectates (biologics) coverage determined by current evidence level
ASPN and ASIPP evidence summaries.
ASPN consensus points and ASIPP guidance.
A diagnostic selective nerve root block (SNRB) performed for indications not specified in the medically appropriate criteria is considered not medically necessary. An explicit example in the policy is SNRB for post-herpetic neuralgia, which is listed as a non-covered indication.
Diagnostic SNRBs performed using injectates other than an anesthetic, corticosteroid, and/or contrast agent (administered alone or in combination) are considered investigational and are outside the scope of this policy. The policy applies only to anesthetic, corticosteroid, and/or contrast injectates and explicitly excludes other agents (for example, Spinraza, chemotherapy, neurolytic substances, antibiotics, antivirals, and biologics).
Therapeutic SNRB—defined in the policy as a repeat SNRB at the same spinal level performed for the purpose of treating pain—is considered investigational. The policy states there is insufficient evidence to support the clinical utility of therapeutic (repeat) SNRBs, and therefore such procedures are excluded from coverage.
Selective nerve root blocks performed using ultrasound guidance are considered investigational under this policy. The policy references the NASS (2020) finding that there is insufficient safety and efficacy data to support ultrasound guidance for any approach delivering an epidural steroid injection, and extends that stance to ultrasound-guided SNRBs.
Both therapeutic repeat SNRBs (repeat injection at the same level for pain) and SNRBs performed with ultrasound guidance are considered investigational and are excluded from coverage. The policy defines SNRBs primarily as diagnostic procedures and indicates there is insufficient evidence to support either therapeutic repeat SNRBs or ultrasound-guided SNRBs.
The policy lists multiple circumstances that are considered not medically necessary for epidural steroid injections (ESI) and related procedures. Examples include: ESI performed without imaging guidance (CT or fluoroscopy) except in emergent situations or when imaging/contrast is contraindicated; TFESI or caudal ESI performed at >2 contiguous foraminal levels in the same session; caudal ESI above L4‑L5; interlaminar or caudal ESI performed at >1 spinal level in the same session; ESI performed the same date as other invasive procedures (except TFESI combined with intra-articular facet injection for synovial cyst aspiration as specified); and exceeding session limits (more than 3 sessions per episode per region in 6 months or more than 4 sessions per region in a rolling 12 months). Scheduling a predefined “series-of-three” without evaluating response to the prior injection is also listed as not medically necessary.
The injectate restrictions described in this policy apply specifically to agents other than anesthetic, corticosteroid, and/or contrast. Exceptions in the document note that the policy does not apply to epidural injections given for obstetrical or surgical epidural anesthesia, peri‑operative pain management, or catheter/drug‑pump trial procedures when those services follow their own authorization pathways.
The policy emphasizes that SNRBs are defined primarily as diagnostic injections of contrast followed by local anesthetic into a single named spinal nerve root. It reiterates that therapeutic repeat SNRBs for pain management lack sufficient evidence to support clinical utility and are considered investigational; diagnostic and therapeutic SNRBs are thus distinguished explicitly in the policy.
The North American Spine Society (NASS, 2020) concluded there is insufficient safety and efficacy data to support the use of ultrasound guidance for any epidural steroid injection approach. This policy references that NASS finding and adopts a stance that limits coverage for ultrasound‑guided approaches accordingly.
Coverage under this policy is contract dependent. If a member’s product does not cover a given service, the medical policy criteria do not apply; providers must confirm product‑level benefit coverage when submitting services that may otherwise meet policy criteria.
Coding and Key Numeric Criteria
| No codes listed |
| 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) with imaging guidance (e.g., CT or fluoroscopy) |
| 62322 | Injection(s), interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance |
| 62323 | Injection(s) with imaging guidance (e.g., CT or fluoroscopy) including indwelling catheter placement, continuous infusion, or intermittent bolus, interlaminar epidural or subarachnoid, cervical or thoracic |
| 62325 | Injection(s) with imaging guidance (i.e., fluoroscopy or CT) including indwelling catheter placement, continuous infusion, or intermittent bolus, interlaminar epidural or subarachnoid, lumbar or sacral (caudal) with imaging guidance |
| 64479 | Injection(s), anesthetic agent, and/or steroid, transforaminal epidural |
| 64480 | Each additional level (transforaminal) — list separately in addition to code for primary procedure |
| 64483 | Injection(s), anesthetic agent, and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level |
| 64484 | Each additional level (transforaminal with imaging) — list separately in addition to code for primary procedure |
| No codes listed |
| Multiple Codes | ICD-10 diagnoses applicable to ESIs (specific codes not listed in this section) |
| HCPCS Codes | HCPCS codes listed in policy (detailed codes not included in this extract) |
| ICD10 Codes | ICD-10 diagnosis codes listed in policy (detailed codes not included in this extract) |
Provider Requirements, Authorization, and Documentation
Repeat diagnostic SNRB at a different level: pain relief & timing
Prior diagnostic SNRB at a different spinal level is allowed only if the prior diagnostic SNRB resulted in less than 80% pain relief from the injectate used and at least seven (7) days have passed since the prior diagnostic SNRB.
Document ≥4 weeks of conservative therapy before ESI
Document at least four (4) weeks of prior conservative therapy (for example, exercise, physical therapy, chiropractic care, or medications including NSAIDs or analgesics) before initial ESI.
Prior auth must verify interval and session limits for repeat ESI
Prior authorization for repeat ESI should confirm the interval since the prior ESI is at least 14 days and that session limits have not been exceeded (no more than 3 sessions per episode per region in 6 months; no more than 4 sessions per region in a rolling 12‑month period).
Use fluoroscopic or CT image guidance; note exceptions and frequency limits
When criteria are met, perform ESI and SNRB with fluoroscopic- or CT‑guidance; imaging guidance is required except in emergent situations or when fluoroscopy/CT/contrast is contraindicated. Frequency limits (see policy) still apply.
SNRBs are diagnostic; therapeutic repeat SNRBs are investigational
Recognize that selective nerve root blocks (SNRBs) are defined as diagnostic procedures; therapeutic (repeat at the same level) SNRBs lack sufficient evidence and are considered investigational — prior authorization may be required or coverage denied when billed as therapeutic.
Prior authorization may be required for repeated ESIs
Payers may require prior authorization for repeated ESIs because number and frequency of injections may be limited by insurance and payer rules; check prior‑auth requirements before scheduling repeat procedures.
Confirm product coverage and document applicability
Follow product‑specific benefit coverage: applicability of policy and any prior authorization requirements depends on the member’s product/contract and should be confirmed and documented when submitting requests.
Complete standard evaluation before initial diagnostic SNRB
Complete the standard evaluation (detailed neurologic exam and radiological and/or electrodiagnostic studies) and document that the diagnosis remains uncertain before performing an initial diagnostic SNRB.
Document participation in comprehensive pain management program
Document participation in a comprehensive pain management program (physical therapy, patient education, psychosocial support, and oral medications) when required by the indication, and ensure the patient is participating in the program when ESI is performed.
- Participation must include physical therapy, patient education, psychosocial support, and oral medications.
Require documented participation in comprehensive program for ESI
Ensure participation in the comprehensive program is documented and, when indicated, required before or concurrent with ESI; lack of program participation may render ESI not medically necessary.
Follow session limits before requesting additional ESI sessions
Adhere to session limits: do not exceed the allowed number of injections per episode/region before requesting additional sessions (see policy session limits).
- Up to 3 ESI sessions per episode per region in a 6‑month period.
- Up to 4 ESI sessions per region in a rolling 12‑month period.
Expect failure of conservative therapy before ESI; document response for repeats
ESIs are expected after failure of conservative therapy; routine series of injections without documented response are not supported and repeat injections should be justified by documented benefit.
Document trial of ESI prior to surgery when guideline‑recommended
When surgery is being considered for radicular pain, document that a trial of ESI was performed when guideline recommendations apply; conservative therapy expectations may vary by indication.
Document neurologic exam, imaging/EMG, and clinical justification
Include neurologic exam findings, relevant imaging and/or electrodiagnostic studies, and clinical justification demonstrating uncertainty after standard evaluation or the specific rationale (e.g., discordant imaging, multilevel pathology, prior surgery, or surgical planning) when submitting requests.
Provide advanced imaging within 24 months for specified ESI indications
For cervical/thoracic interlaminar and transforaminal ESI, TFESI with synovial cyst aspiration, and other specified indications, provide advanced imaging (MRI, CT, or CT myelogram) within the past 24 months to support the request.
Document ≥50% pain relief + functional or medication/service improvement for repeat ESI
When requesting repeat ESI, document that the prior injection produced at least 50% pain relief for at least two (2) weeks and either improved function or reduced use of pain medications/additional services.
- Document ≥50% pain relief for ≥2 weeks and (a) increased function or (b) reduced medication or service use.
Provide recent detailed neurologic exam and concordant imaging/EMG for radiculopathy
Support radiculopathy with a detailed neurologic exam within the prior 3 months or concordant advanced imaging/electrodiagnostic studies within required timeframes when radiculopathy criteria are required.
- Detailed neurologic exam within prior 3 months showing strength loss, altered sensation, or diminished/asymmetric reflexes.
- Concordant MRI/CT or EMG/NCV within past 24 months confirming nerve root compression.
Document diagnosis, prior conservative care, and measurable response for repeats
Include clinical justification documenting the diagnosis (radicular pain or spinal stenosis), prior conservative management when indicated, and measurable treatment response when requesting repeat ESIs.
Do not use diagnostic SNRB for non‑specified indications (NMN)
Diagnostic SNRB for indications not listed in the medically appropriate criteria (for example, post‑herpetic neuralgia) is considered not medically necessary and may be denied.
Investigational techniques/injectates: repeat SNRB, ultrasound, non‑specified injectates
Therapeutic (repeat at the same level) SNRBs, SNRBs performed with ultrasound guidance, or use of injectates other than anesthetic, corticosteroid, and/or contrast are considered investigational or outside policy and may be denied.
- Therapeutic repeat SNRB at same level is investigational.
- SNRB with ultrasound guidance is investigational.
- Injectates other than anesthetic/corticosteroid/contrast are not covered under this policy.
Series‑of‑three scheduling without response evaluation is NMN
Scheduling a diagnostic SNRB as part of a 'series‑of‑three' without evaluating response to the prior injection is considered not medically necessary and may be denied.
Common denial triggers for ESI (imaging, levels, program participation, session limits, series scheduling)
ESI performed without imaging guidance (CT or fluoroscopy) except in emergent/contraindicated situations; TFESI/CESI at >2 contiguous foraminal levels in same session; ILESI/CESI at >1 spinal level in same session; ESI performed in isolation without comprehensive pain program participation; exceeding session limits; or scheduling a series‑of‑three without evaluating response are all denial triggers.
Ultrasound guidance and disallowed injectates are outside policy and may be denied
Do not perform ESI or SNRB using ultrasound guidance for any indication per policy statements and NASS findings; use of disallowed injectates (non‑anesthetic/corticosteroid/contrast) is also outside policy and may be denied.
Missing concordant imaging or recent neurologic exam may trigger denial for radiculopathy
For radiculopathy indications, absence of appropriate imaging confirmation of nerve root compression within the described timeframes or lack of a recent detailed neurologic exam concordant with compression may trigger denial.
Exceeding frequency/session limits may cause denial
Exceeding payer or contract frequency limits on the number and timing of repeated ESIs may lead to denial; verify limits before scheduling.
Coverage and prior‑auth requirements depend on the member’s product/contract
Services are contract dependent; if the member’s product does not cover a service, medical policy criteria do not apply. If covered, follow product‑specific rules and document coverage for the member.
Conservative Treatment and Program Participation Requirements
Complete standard evaluation prior to SNRB
Failure of at least four (4) weeks of conservative treatment prior to initial ESI
Participation in a comprehensive pain management program — physical therapy, patient education, psychosocial support, and oral medications
Must be participating in the program when ESI is performed
Failure of conservative therapy expected prior to ESI in typical practice (contextual expectation)
Document prior conservative therapies when applicable; exceptions exist for acute disabling conditions per guideline.
(placeholder) — additional conservative treatment nodes (no specific chunks provided)
Placeholder; follow product-specific guidance.
Frequency, Session and Level Limits
Imaging and Guidance Requirements
Definitions and Procedural Terms
Background and Evidence Summary
Selective nerve root block (SNRB) is described as a diagnostic injection of contrast (if not allergic) followed by local anesthetic to anesthetize a single named spinal nerve root. The procedure is performed via the neuroforamen under fluoroscopic or CT guidance and is used to help establish the nerve root as the source of radicular pain or radiculopathy when standard evaluation (neurologic exam and radiological and/or electrodiagnostic studies) is inconclusive.
Evidence summaries cited in the policy report that epidural steroid injections provide small, short‑term reductions in leg pain and disability for lumbosacral radicular pain (e.g., Oliveira et al. 2020 meta‑analysis of 25 RCTs). Systematic reviews note limited evidence to establish guidelines for frequency and timing of repeat injections and that routine series of injections are not supported by available data; some randomized trials and reviews show positive short‑term results but mixed or absent long‑term benefits.
The policy states that therapeutic repeat SNRBs for pain lack sufficient evidence to support clinical utility and are therefore considered investigational. The document defines therapeutic SNRBs as repeat injections at the same level intended to treat pain rather than to diagnostically localize a nerve root.
The policy references NASS (2020) regarding ultrasound guidance, noting that NASS found insufficient evidence to support ultrasound guidance for any epidural steroid injection approach. Based on that guidance, the policy does not support routine use of ultrasound guidance for ESI or SNRB and treats ultrasound‑guided procedures as investigational in coverage determinations.
The policy highlights that the literature does not support routine series of injections without demonstrated response. Systematic reviews and guideline analyses indicate limited evidence to define an appropriate partial response that should trigger repeat injection; therefore repeat procedures should be based on documented clinical response rather than automatic scheduling.
Guideline reviews and society statements summarized in the policy note limited or mixed evidence regarding imaging modalities. While some meta‑analyses compare ultrasound versus fluoroscopy/CT guidance, the policy aligns with guideline panels (including NASS) that cite insufficient evidence to broadly endorse ultrasound guidance for ESI approaches; fluoroscopy or CT guidance remains the established imaging standard when criteria are met.
Not Covered or Experimental / Investigational
Diagnostic SNRBs performed for indications not listed in the medically appropriate criteria (for example, post‑herpetic neuralgia), diagnostic SNRBs using injectates other than anesthetic/corticosteroid/contrast, therapeutic (repeat at the same level) SNRBs, and SNRBs performed with ultrasound guidance are listed in the policy as not covered / investigational. Providers should not expect coverage for these services under this policy unless product‑specific benefit language indicates otherwise.
Policy Revision History
Policy effective date set to 2026-10-15.
Annual review completed; policy intent unchanged.
Annual review completed; conservative treatment criteria revised.
New policy created by splitting content from CMP#7.01.87 into CMP#7.01.115 and CMP#7.01.116; no change to original policy criteria.
Summary-of-changes tracking implemented.
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