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Epidural steroid injections (ESI) for low back pain

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 required for each lumbar epidural steroid injection (ESI).

Each individual epidural steroid injection (ESI) requires prior authorization except as described below.

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

Prior authorization is not required for:

  1. Please see related content at the right for link to HealthPartners Preferred Spine Injection Therapy Network providers. All members must meet the criteria for coverage regardless of where the service is provided.

  2. Cervical and thoracic epidural steroid injections.

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 it is 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
  3. By clinicians other than physicians

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.

64483 - Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance
(fluoroscopy or CT); lumbar or sacral, single level
64484 - Injection(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) 
62311- Injection(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)
62319 - Injection(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) 
77003 - Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous
diagnostic or therapeutic injection procedures (epidural or subarachnoid)
721.90 – Spondylosis of unspecified site, without mention of myelopathy
722.10 - Lumbar intervertebral disc without myelopathy
722.51 – Degeneration of thoracic or thoracolumbar intervertebral disc
722.52 – Degeneration of lumbar or lumbosacral intervertebral disc
724.00 – Spinal stenosis, unspecified region other than cervical
724.01 – Spinal stenosis of thoracic region
724.02 – Spinal stenosis of lumbar region, without neurogenic claudication
724.03 – Spinal stenosis of lumbar region, with neurogenic claudication
724.09 – Spinal stenosis, other region other than cervical
724.2 – Lumbago
724.3 – Sciatica
724.4 - Thoracic or lumbosacral neuritis or radiculitis, unspecified
724.5 - Unspecified backache
733.13 – Vertebral compression fracture

Please see the Related content section at the right to see a list of ICD-10-CM codes associated with this policy.

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.