Epidural steroid injections (ESIs) are a treatment for back pain that has not responded to conservative measures. Local steroid injections may improve pain by reducing inflammation, thus relieving pressure on nerve roots or other structures that may be the origin of pain. ESIs are performed by inserting a needle into the space between the dura and ligamentum flavum and injecting a steroid preparation. Several different approaches may be used for entering the epidural space (translaminar, transforaminal, caudal). The techniques are most accurately performed using fluoroscopy visualization for needle placement. The procedure may be safely performed in the outpatient setting.
Epidural steroid injections are considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Epidural steroid injection is considered medically appropriate if ALL of the following are met:
For the treatment of acute and chronic cervical, thoracic or lumbar pain
Documentation of radiculopathy (by exam, imaging, or neuro-testing)
Pain has been unresponsive to a minimum of four weeks conservative treatment (e.g., oral medications, rest/limited activity, and/or physical therapy)
Performed with fluoroscopic guidance
No contraindications including ABSENCE of ALL of the following:
Allergy to the medication to be administered
A significantly altered or eliminated epidural space (e.g., congenital anatomic anomalies or previous surgery)
Localized infection in the region to be injected
Other co-morbidities which could be exacerbated by steroid usage (e.g., poorly controlled hypertension, severe congestive heart failure, diabetes, etc.)
More than 2 (two) epidural steroid injections have been given without significant relief of back pain within 2 to 6 weeks
Does not exceed 3 (three) injection sessions within a 6-month period
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
Limiting the injections to three within a six month period minimizes the risks associated with large doses of steroids. It is not appropriate to repeat a procedure a third time without improvement from the two prior injections.
Contrast-enhanced fluoroscopy is recommended to guide epidural steroid injections to improve the accuracy of medication delivery.
Agency for Healthcare Research and Quality. (March, 2015). Technology Assessment: Pain management injection therapies for low back pain. Retrieved August 18, 2015 fromthe Agency for Healthcare Research and Quality.
American Society of Anesthesiologists Task Force on Chronic Pain Management and American Society of Regional Anesthesia and Pain Medicine. (2010). Practice guidelines for chronic pain management: An updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology, 112 (4), 810-833.
Benyamin, R., Manchikanti, L., Parr, A., Diwan, S., Singh, V., & Falco, F. (2012). The effectiveness of lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain. Pain Physician, 15, E363-E404. (Level 1 evidence)
BlueCross BlueShield Association. Evidence Positioning System. (11:2018). Epidural steroid injections for neck or back pain (2.01.94). Retrieved January 10, 2019 from https://www.evidencepositioningsystem.com/. (31 articles and/or guidelines reviewed)
Friedly, J. L., Comstock, B.A., Turner, J.A., Heagerty, P.J., Deyo, R. A., Sullivan, S. D., et al. (2014). A randomized trial of epidural glucocorticoid injections for spinal stenosis. The New England Journal of Medicine, 371 (1), 11-31. (Level 1 evidence)
Institute for Clinical Systems Improvement. (2012). Adult acute and subacute low back pain. Retrieved February 21, 2014 from https://www.icsi.org.
Liu, K., Liu, P., Liu, R., Wu, X., & Cai, M. (2015). Steroid for epidural injection in spinal stenosis: a systematic review and meta-analysis. Drug Design, Development and Therapy, 2015 (9), 707-716. (Level 1 evidence)
Manchikanti, L., Abdi, S., Atluri, S., Benyamin, R. M., Boswell, M. V., Buenaventura, R. M., et al. (2013). An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: Guidance and recommendations. Pain Physician, 16 (2 Suppl.), S49-S283. (Level 1 evidence)
Manchikanti, L., Buenaventura, R. M., Manchikanti, K. N., Ruan, X., Gupta, S., Smith, H. S., et al. (2012). Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Physician, 15 (3), E199-E245. (Level 1 evidence)
Manchikanti, L., Kaye, A.D., Manchikanti, K., Boswell, M., Pampati, V., & Hirsch, J. (2015). Efficacy of epidural injections in the treatment of lumbar central spinal stenosis: a systematic review. Anesthesiology and Pain Medicine, 5 (1), e23139. (Level 1 evidence)
National Institute for Health and Care Excellence. (2016). Low back pain and sciatica in over 16s: assessment and management. Retrieved January 10, 2019 from www.nice.org.
North American Spine Society. (2010). Evidence-based clinical guidelines for multidisciplinary spine care: diagnosis and treatment of cervical radiculopathy from degenerative disorders. Retrieved April 12, 2016 from https://www.spine.org.
North American Spine Society. (2011). Cervical epidural steroid injections: Review & recommendation statement. Retrieved April 11, 2016 from https://www.spine.org.
North American Spine Society. (2011). Evidence-based clinical guidelines for multidisciplinary spine care: diagnosis and treatment of degenerative lumbar spinal stenosis. Retrieved August 18, 2015 from https://www.spine.org.
North American Spine Society. (2012). Evidence-based clinical guidelines for multidisciplinary spine care: clinical guidelines for diagnosis and treatment of lumbar disc herniation with radiculopathy. Retrieved August 18, 2015 fromhttps://www.spine.org.
Ökmen, K., & Ökmen, B. (2017). The efficacy of interlaminar epidural steroid administration in multilevel intervertebral disc disease with chronic low back pain: a randomized, blinded, prospective study. Spine Journal, 17 (2), 168-174. Abstract retrieved March 15, 2017 from PubMed database.
Sharma, A.K., Vorobeychik, Y., Wasserman, R., Jameson, J., Moradian, M., Duszynski, B., et al. (2017). The effectiveness and risks of fluoroscopically guided lumbar interlaminar epidural steroid injections: a systematic review with comprehensive analysis of the published data. Pain Med, 18 (2), 239-251. Abstract retrieved January 14, 2019 from PubMed database.
Wylde, V., Dennis, J., Beswick, A.D., Bruce, J., Eccleston, C., Howells, N., et al. (2017). Systematic review of management of chronic pain after surgery. British Journal of Surgery, 104 (10), 1293-1306. (Level 2 evidence)
Zhai, J., Zhang, L., Li, M., Tian, Y., Zheng, W., Chen, J., et al. (2015). Epidural injection with or without steroid in managing chronic low back and lower extremity pain: a meta-analysis of ten randomized controlled trials. International Journal of Clinical and Experimental Medicine, 15 (8), 8304-8316. Abstract retrieved April 14, 2016 from PubMed database.
ORIGINAL EFFECTIVE DATE: 4/1999
MOST RECENT REVIEW DATE: 2/14/2019
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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