Overview
This article outlines the clinical background, requirements, and limitations for epidural steroid injections (ESIs), particularly in the lumbar spine, emphasizing the two common types: interlaminar and transforaminal. It details medical necessity criteria, contraindications, and authorization guidelines for both initial and continued treatment.
Clinical Background
Steroid injections can happen in any section of the spine; however, they are most common in the lumbar region, which is in the low back. Each bone within the spine is known as a vertebra.
There are two types of epidural steroid injections that are most common and require pre-authorization through Cohere: interlaminar and transforaminal.
Interlaminar injection: Delivered into the space between two vertebrae. Since this injection is not targeted to one specific nerve, the steroid will travel throughout the entire lumbar region, meaning it will have a more widespread effect on pain.
Transforaminal injection: Targeted to a specific nerve or nerves. Before a patient receives a transforaminal injection, it is common for the patient to have an MRI prior to the injection, so the nerve causing pain can be identified. This injection both helps pain, as well as confirms which nerve is the cause of pain.
Limitations and contraindications
The following are limitations and contraindications to epidural steroid injections and should not be performed when any of the following criteria are met:
Request is NOT for a continuation of ESI injections over 12 months; OR
The request is for continuation of ESI injections over twelve (12) months and ALL of the following are TRUE:
Pain is severe enough to cause a significant degree of functional disability or vocational disability; AND
ESI provides at least 50% sustained improvement of pain and/or 50% objective improvement in function (using same scale as baseline); AND
Rationale for the continuation of ESIs including but not limited to patient who are high-risk surgical candidates, the patient does not desire surgery, and/or recurrence of pain in the same location relieved with ESIs for at least three (3) months; AND
The primary care provider must be notified regarding continuation of procedures and prolonged repeat steroid use.
Injections performed without image guidance or by ultrasound, except in cases of documented contraindication to contrast media (e.g., allergy, pregnancy);
Performing multiple blocks (ESI, sympathetic blocks, facet blocks, trigger point injections etc.) during the same session as ESIs, with the exception of a facet synovial cyst and ESI performed in the same session;
Use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care (MAC)
ESIs to treat non-specific low back pain (LBP), axial spine pain, complex regional pain syndrome, widespread diffuse pain, pain from neuropathy from other causes, cervicogenic headaches are considered investigational;
More than four (4) sessions per spinal region in a rolling twelve (12) month period;
More than one spinal region injected in the same session
Performing transforaminal epidural steroid injections (TFESIs) at more than two (2) nerve root levels during the same session OR at more than two (2) levels in one spinal region
Performing caudal epidural steroid injections (CESIs) or interlaminar epidural steroid injections (ILESIs) at more than one (1) level during the same session or bilaterally
Epidural steroid injections should not be performed when contraindicated, including but not limited to ANY of the following
Suspected or active localized spinal infection; OR
Significant systemic infection; OR
Compressive lesions of the spinal cord, conus medullaris or cauda equina; OR
Suspicion or major risk factors for cancer
What to include with your request
Initial requests | Subsequent requests |
The request must meet the following criteria: |
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