Epidural Steroid Injections for Back Pain

Description of Procedure or Service

Back pain is an extremely common condition. Most episodes are self-limited and will resolve within 1 month, but a small percentage will persist and become chronic. Patients with chronic back pain may suffer from serious disability and may use a high volume of medical services. Despite high utilization, many patients with chronic back pain do not improve with available treatments, including surgical interventions. Therefore, there is a high unmet need to determine the efficacy of different treatments for chronic back pain and to determine which patient populations may benefit from specific interventions. In addition, in recent years there has been a proliferation of new technologies, combined with large increases in the number of patients treated and in the intensity of treatment. Therefore, there is a concern for overtreatment of patients who may not benefit from interventions for back pain.

Back pain can result from a variety of underlying causes. Radiculopathy is a subset of back pain that is associated with irritation of 1 or more spinal nerve roots. Symptoms of lumbar radiculopathy, which is sometimes known as sciatica, include pain that radiates down the leg to below the knee, numbness, muscle weakness, and lack of reflexes in a dermatomal distribution. Most patients with radiculopathy respond to conservative care with a resolution of their symptoms within several weeks to months following onset. In a subset of patients, symptoms and signs of progressive muscle weakness prompt a more aggressive intervention to prevent permanent dysfunction. In other patients, symptoms persist despite conservative management, without progression of neurologic signs, and further treatment options are sought for pain relief.

Spinal stenosis is another common source of back pain. Spinal stenosis is caused by narrowing of the spinal canal due to degenerative changes, leading to impingement of the spinal cord and the spinal nerve roots. Symptoms of spinal stenosis can include back pain, leg pain with exertion (neurogenic claudication), muscle weakness, and sensory deficits. Definitive treatment for spinal stenosis is surgery, which includes decompression of the spinal canal with or without spinal fusion. Epidural steroids may reduce inflammation from pressure on the spinal cord, and thus reduce symptoms of compression.

Nonspecific low back pain, sometimes called mechanical low back pain, is diagnosed when no specific etiology of pain can be identified. Although the etiology of nonspecific low back pain is uncertain, many experts feel that the pain is of discogenic origin or due to painful movement of the vertebrae. In these instances, epidural steroid injections may reduce swelling of the vertebral disc and/or surrounding structures, leading to pain relief.

Regardless of specific etiology, conservative management is the first-line treatment for most patients with back pain. Nonsteroidal anti-inflammatory drugs or other analgesics are used for symptom relief. These agents should be used for at least several weeks at a dose sufficient to induce a therapeutic response. Additionally, modification of activity in conjunction with some form of exercise therapy is frequently prescribed early in the course of symptoms and typically involves a physical therapist. For patients with persistent nonradicular back pain, current guidelines recommend interdisciplinary rehabilitation, which is defined as an integrated approach using physical rehabilitation in conjunction with a psychological or psychosocial intervention.

For patients who fail conservative therapy, there are a number of interventional therapies available, which range from minimally invasive procedures, such as injections, to major surgeries, such as spinal decompression with fusion. Injections can be given in different locations (e.g., soft tissues, intraspinal, sacroiliac joints) and can use different therapeutic agents (e.g., botulinum toxin, steroids, proteolytic enzymes). Other interventional techniques include radiofrequency ablation, prolotherapy, and chemonucleolysis. Most of these nonsurgical interventions do not have high-quality evidence demonstrating their efficacy. A number of surgical interventions are available, such as discectomy and spinal fusion, each of which can be performed by a variety of different techniques. The decision to undertake surgery is best made in the setting of shared decision-making between the patient and surgeon, with thorough consideration given to the risks and benefits of surgery.

Epidural Steroid Injections

Epidural injection therapy is one of several second-line therapies available for patients who fail conservative treatment and is one of the most common modalities used in this group of patients. Epidural steroid injections (ESIs) are performed by inserting a needle into the space between the dura and ligamentum flavum and injecting a steroid preparation. There is considerable variability in the technical aspects of epidural injections. Several different approaches may be used for entering the epidural space (translaminar, transforaminal, caudal). In addition, ESIs may be administered with or without fluoroscopic guidance. Some investigators have estimated that lack of correct needle position in the epidural space may occur in 25% or more of injections administered. Therefore, live fluoroscopic guidance is shown to be much more effective than still image fluorography in the epidural space. Variability of technique may also involve factors such as the depth of injection into the epidural space, volume of injectate, and the filling patterns of the injectate.

Treatment is generally given as 1 to 3 injections, each performed at least 1 month apart. Some experts recommend no more than 3 injections in a 12-month period, owing to concerns about the adverse events of chronic steroid administration, both locally and systemically. However, other experts believe that up to 6 injections per year is safe.

Regulatory Status

Steroids are not approved by the U.S. Food and Drug Administration (FDA) for use as epidural injections; such use represents off-label use of an FDA-approved medication. The specific preparations used for epidural injections are steroids added to a sterile saline solution, which are prepared by a compounding pharmacy.

Related Policies

Artificial Intervertebral Disc

Image-Guided Minimally Invasive Decompression (IG-MLD) for Spinal Stenosis

Interspinous Fixation (Fusion) Devices

Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)

Lumbar Spine Fusion Surgery

Maximum Units of Service

***Note: This Medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your physician.

Policy

BCBSNC will provide coverage for epidural steroid injections for back pain when it is determined to be medically necessary because the medical criteria and guidelines noted below are met.

Benefits Application

This medical policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore, member benefit language should be reviewed before applying the terms of this medical policy. 

When epidural steroid injections are covered

Epidural steroid injections performed with live fluoroscopic guidance (video type x-ray pictures of the epidural space) may be considered medically necessary for the treatment of back pain when the following criteria are met:

• Lumbar or cervical radiculopathy (sciatica) that is not responsive to at least 4 weeks of conservative management (see Policy Guidelines section); AND
• Persistent pain is present of at least moderate-severe intensity (i.e. documented limits in day-to-day activities and/or walking); AND
• Short-term relief of pain is the anticipated outcome.

Repeat treatment of persistent pain due to radiculopathy/sciatica may be considered medically necessary under the following conditions:

• Previous epidural steroid injections were successful at relieving pain; AND
• At least 30 days have elapsed since the prior injection

No more than 6 injections given over a 12-month period regardless of spine level treated or procedural approach.

Simultaneous treatment of 2 vertebral levels may be considered medically necessary if criteria are met at each level not to exceed a total of 6 injections over a 12-month period regardless of procedural approach.

When epidural steroid injections are not covered

Repeat treatment is considered not medically necessary if the initial treatment did not result in substantial pain relief (i.e., at least 50% reduction of pain with overall improvement of activities of daily living and/or walking).

Simultaneous treatment of more than 2 vertebral levels is considered not medically necessary.

Epidural steroid injections are considered investigational in all other situations, including but not limited to treatment of spinal stenosis and nonspecific low back pain.

The use of still image fluorography (snapshot x-ray pictures of the epidural space) as a component of epidural steroid injections is considered investigational.

The use of CompuFlo® for epidural spinal needle placement is considered investigational.

Policy Guidelines

The diagnosis of lumbar radiculopathy is typically made by a combination of suggestive signs and symptoms in conjunction with imaging that demonstrates compression of a spinal nerve root. Symptoms are due to irritation of the spinal nerve root at L4, L5, or S1, and may include posterior leg pain that extends past the knee, a loss of sensation in a dermatomal pattern, and/or loss of deep tendon reflexes. However, all of these symptoms may not be present. On exam, provocative tests such as the straight leg maneuver are positive. Magnetic resonance imaging is the most useful imaging modality and can confirm or exclude the presence of nerve root compression, most commonly due to herniated disc.

Conservative nonsurgical therapy for at least 4 weeks should include the following:

• Use of prescription-strength analgesics for several weeks at a dose sufficient to induce therapeutic response
  • Analgesics should include anti-inflammatory medications if not contraindicated, with or without adjunctive medications such as nerve membrane stabilizers or muscle relaxants AND
• Participation in at least 4 weeks of physical therapy (including active exercise) or documentation of why the patient could not tolerate physical therapy, AND
• Evaluation and appropriate management of associated cognitive and behavioral issues

For individuals who have lumbar or cervical radiculopathy who receive ESIs, the evidence includes randomized controlled trials (RCTs) and a number of systematic reviews and metaanalyses of these RCTs. Relevant outcomes are symptoms, functional outcomes, health status measures, quality of life, medication use, and treatment-related morbidity. The evidence base lacks large-scale, high-quality trials and has a high degree of variability among the available trials in terms of patient populations, epidural injection techniques, and comparison treatments. The results of individual trials are mixed, with some reporting significant benefits for the ESI group and others reporting no benefit. Meta-analyses have found reduced pain in the short- and intermediate-term (up to 6 months) with ESI compared with conventional therapy. None of the analyses reported long-term benefits for treatment with ESIs. Adverse events were generally mild but not well reported in these trials. Serious adverse events can occur, but their rate is unknown. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have spinal stenosis who receive ESIs, the evidence includes a moderately large RCT and systematic reviews of RCTs. Relevant outcomes include symptoms, functional outcomes, health status measures, quality of life, medication use, and treatment-related morbidity. The largest RCT and the majority of smaller trials in the systematic reviews did not report a benefit for ESIs. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have nonspecific low back pain who receive ESIs, the evidence includes systematic reviews of RCTs and nonrandomized studies. Relevant outcomes include symptoms, functional outcomes, health status measures, quality of life, medication use, and treatment-related morbidity. Most trials were of low quality and did not report a benefit for ESIs. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

The American Society of Interventional Pain Physicians (2021) updated its guidelines on interventional techniques in chronic spinal pain.

For patients with disc herniation, the following recommendations were made:

• Based on relevant, high-quality trials of fluoroscopically guided epidural injections, with or without steroids and results of previous systematic reviews, “the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness.”
• “For thoracic disc herniation, based on one relevant, high-quality RCT of thoracic epidural with fluoroscopic guidance, with or without steroids, the evidence is Level II with moderate to strong recommendation for long-term effectiveness.” 

For patients with spinal stenosis, the following recommendations were made: “based on one high quality RCT in each category the evidence is Level III to II for caudal epidural injections with moderate to strong recommendation and Level II for lumbar and cervical interlaminar epidural injections with moderate to strong recommendation for long-term effectiveness. The evidence for lumbar transforaminal epidural injections is Level IV to III with moderate recommendation for long-term improvement.

For patients with axial discogenic pain, “The evidence for axial discogenic pain without fact joint pain or sacroiliac joint pain in the lumbar and cervical spine with fluoroscopically guided caudal, lumbar and cervical interlaminar epidural injections, based on one relevant high quality RCT in each category in Level II with moderate to strong recommendation for long-term improvement, with or without steroids.

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable codes: 62320, 62321, 62322, 62323, 64479, 64480, 64483, 64484, 0777T

BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included. 

Scientific Background and Reference Sources

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.94, 11/12/2015

Specialty Matched Consultant Advisory Panel 10/2016

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.94, 11/9/2017

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.94, 11/8/2018

Specialty Matched Consultant Advisory Panel 04/2020

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.94, 11/14/2019

Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician. Apr 2013;16(2 Suppl):S49-283. PMID 23615883 

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.94, 11/12/2020

Specialty Matched Consultant Advisory Panel 04/2021

Medical Director review 4/2021

Manchikanti L, Knezevic NN, Navani A, et al. Epidural Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Comprehensive Evidence-Based Guidelines. Pain Physician. Jan 2021; 24(S1): S27-S208. PMID 33492918

Specialty Matched Consultant Advisory Panel 04/2022

Medical Director review 4/2022

Medical Director review 11/2022

Pinto RZ, Maher CG, Ferreira ML, et al. Epidural corticosteroid injections in the management of sciatica: a systematic review and meta-analysis. Ann Intern Med. Dec 18 2012; 157(12): 865-77. PMID 23362516

Specialty Matched Consultant Advisory Panel 04/2023

Medical Director review 4/2023

Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine (Phila Pa 1976). May 01 2009; 34(10): 1066-77. PMID 19363457

Benyamin RM, Manchikanti L, Parr AT, et al. The effectiveness of lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain. Pain Physician. 2012; 15(4): E363-404. PMID 22828691

Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. Apr 04 2017; 166(7): 514-530. PMID 28192789

Chou R, Atlas SJ, Stanos SP, et al. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976). May 01 2009; 34(10): 1078-93. PMID 19363456

Manchikanti L, Buenaventura RM, Manchikanti KN, et al. Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Physician. 2012; 15(3): E199-245. PMID 22622912

Specialty Matched Consultant Advisory Panel 04/2024

Medical Director review 4/2024

Policy Implementation/Update Information

2/29/16 New policy created. Epidural steroid injections are medically necessary for treatment of lumbar sciatica/radiculopathy when criteria are met, not medically necessary if previous epidural injections were not successful, and investigational for all other situations. Notification given 2/29/2016 for policy effective date 5/31/2016. (sk)

11/22/16 Specialty Matched Consultant Advisory Panel review 10/26/2016. (sk)

12/30/16 Codes 62310 and 62311 deleted from Billing/Coding section. Codes 62320 and 62322 added to Billing/Coding section. (sk)

6/30/17 Specialty Matched Consultant Advisory Panel review 4/26/2017. No change to policy statement. (an)

6/8/18 Minor change to Policy Guidelines section. Reference added. Specialty Matched Consultant Advisory Panel review 5/23/2018. No change to policy statement. (an)

4/30/19 Reference added. Specialty Matched Consultant Advisory Panel review 4/17/2019. No change to policy statement. (an)

4/28/20 References added. Societal guidelines added to Policy guidelines section. Clarification of fluoroscopic guidance as “live” and “(video type x-ray pictures of the epidural space)” added to When covered section. Clarification of fluorography as “still image” and “(snapshot x-ray pictures of the epidural space)“ added to When not covered section. Added clarification for substantial relief to When not covered section “(i.e. at least 50% reduction of pain with overall improvement of activities of daily living and/or walking).” Clarification added to When covered section injection limits “regardless of spine level treated or procedural approach.” When covered statement for persistent pain clarified with “(i.e. documented limits in day to day activities and/or walking).” Specialty Matched Consultant Advisory Panel review 4/15/2020. No change to policy statement. (eel)

3/9/21 Codes 62321 and 62323 added to Billing/Coding section. (bb)

6/1/21 Policy guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 4/2021. Medical Director review 4/2021. No change to policy statement. (bb)

5/3/22 Policy guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 4/2022. Medical Director review 4/2022. No change to policy statement. (tt)

5/31/22 The following reimbursement policy was added to Related Policies section: Maximum Units of Service. (tt)

12/30/22 Added the following statement to When Not Covered section, “The use of CompuFlo® for epidural spinal needle placement is considered investigational.” Updated Billing/Coding section to add 0777T, effective 1/1/2023. Medical Director review 11/2022. (tt)

5/2/23 Description and policy guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 4/2023. Medical Director review 4/2023. No change to policy statement. (tt)

5/1/24 References added. Specialty Matched Consultant Advisory Panel review 4/2024. Medical Director review 4/2024. No change to policy statement. (tt)