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Epidural steroid injections (ESI) for low back pain - Effective 7/1/2015

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative process

Prior authorization is not required for epidural steroid injections. Providers must comply with decision support requirements when ordering epidural steroid injections. Approved decision support solutions will utilize criteria to determine the appropriateness of any epidural steroid injection ordered for HealthPartners members. Please see related content at right for a link to the Epidural Steroid Injection Decision Support on the HealthPartners Provider portal.

Sacroiliac joint injections are outside the scope of this policy. See Related content for policy detailing prior authorization and coverage information.

Lumbar epidural steroid injections are covered subject to the indications listed below, and per your plan documents.

Cervical and thoracic epidural steroid injections are covered subject to your plan documents.

Indications that are covered

Epidural steroid injections are covered when they are part of a comprehensive treatment plan and all of the following criteria are met:

Initial injection:
  1. The patient has lumbar radicular pain with demonstrable correlation on physical exam and/or imaging; AND
  2. Evaluation has ruled out tumor or other masses as a cause of the pain; AND
  3. The pain has been present for at least 6 weeks; AND
  4. The patient has failed conservative therapy;

    Conservative therapy must include physical therapy (PT) and may include activity modification, weight loss, and drug therapy. Documentation must correspond to the current episode of pain (within 6 months).

    Formal physical therapy, including active muscle conditioning is REQUIRED, OR there must be an explicit statement in the clinical documents that explains why such physical therapy is contraindicated. Documentation of formal physical therapy would be the therapist’s notes,
    -OR-

  5. Has acute radicular pain with demonstrable correlation on physical exam and/or imaging that precludes physical therapy (there must be an explicit statement in the clinical documents that explains why such physical therapy is contraindicated); AND
  6. The procedure is performed by an experienced clinician using real-time fluoroscopy monitoring of contrast material with hard copy or digital documentation of images
Repeat injection:
  1. Requires documentation of 50% pain and/or symptom relief as demonstrated on a Visual Analog Scale at 4 weeks post-primary ESI. A pre and post Visual Analog Scale must be submitted.
  2. Requires a minimum of 6 weeks between injections;
  3. Are limited to a total of 4 injections per 12 consecutive months.
  4. Requires documentation of member having tried and failed physical therapy during this episode. 

Indications that are not covered

Epidural steroid injections are not considered medically necessary and are not covered:

  1. For non-radicular back pain
  2. Without guidance by real-time fluoroscopic imaging

Lumbar radicular pain refers to low back pain that radiates to the leg in a radicular pattern consistent with imaging findings.

Epidural steroid injections may be delivered by the transforaminal, caudal or interlaminar approach.

Episode is defined as a 6 month consecutive time period corresponding with the member's pain.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

CodeDescription
64483Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level
64484Injection(s), anesthetic agent 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)
62311Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal)
62319Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal)
77003Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid)
Code(s)Description
M47.20Other spondylosis with radiculopathy, site unspecified
M47.819Spondylosis without myelopathy or radiculopathy, site unspecified
M47.899Other spondylosis, site unspecified
M47.9Spondylosis, unspecified
M48.00Spinal stenosis, site unspecified
M48.05Spinal stenosis, thoracolumbar region
M48.06Spinal stenosis, lumbar region
M48.07Spinal stenosis, lumbosacral region
M48.08Spinal stenosis, sacral and sacrococcygeal region
M48.50XA-M48.58XSCollapsed vertebra, not elsewhere classified
M51.15-M51.17Intervertebral disc disorders with radiculopathy, thoracolumbar, lumbar & lumbosacral regions
M51.26, M51.27Other intervertebral disc displacement, lumbar & lumbosacral regions
M51.36, M51.37Other intervertebral disc degeneration, lumbar & lumbosacral regions
M54.15-M54.17Radiculopathy, thoracolumbar, lumbar & lumbosacral regions
M54.30-M54.32Sciatica
M54.40-M54.42Lumbago with sciatica
M54.5Lumbago
M54.89Other dorsalgia
M54.9Dorsalgia, unspecified
M80.08XA-M80.08XSAge-related osteoporosis with current pathological fracture, vertebra(e)
M80.88XA-M80.88XSOther osteoporosis with current pathological fracture, vertebra(e)
M84.48XA-M84.48XSPathological fracture, other site
M84.58XA-M84.58XSPathological fracture in neoplastic disease, other specified site
M84.68XA-M84.68XSPathological fracture in other disease, other site
M99.21-M99.23Subluxation stenosis of neural canal of cervical, thoracic & lumbar regions
M99.31-M99.33Osseous stenosis of neural canal of cervical, thoracic & lumbar regions
M99.41-M99.43Connective tissue stenosis of neural canal of cervical, thoracic & lumbar regions
M99.51-M99.53Intervertebral disc stenosis of neural canal of cervical, thoracic & lumbar regions
M99.61-M99.63Osseous and subluxation stenosis of intervertebral foramina of cervical, thoracic & lumbar regions
M99.71-M99.73Connective tissue and disc stenosis of intervertebral foramina of cervical, thoracic & lumbar regions

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Bibliography:

  1. Epidural Steroids, Etanercept, or Saline in Subacute Sciatica. A multicenter, Randomized Trial, Annals of Internal Medicine, Volume 156, Number 8, April 17, 2012.
  2. Washington Health Technology Assessment: Spinal Injections Final Report (12-14-2010). Accessed April 2013.
  3. ECRI Hotline, ESI Lumbar Radicular Pain, December 2012
  4. Epidural Steroid Injections for Low Back Pain and Sciatica, Hayes; January 30, 2013

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.