Aetna Epidural Steroid Injection (interlaminar / transforaminal) prior authorization requirements (2026)

Medical-necessity criteria Aetna generally applies

[NEEDS CLINICAL SPOT-CHECK] PRECERTIFICATION IS REQUIRED and is submitted to eviCore, but the BINDING CLINICAL CRITERIA are Aetna's own Clinical Policy Bulletins. Two CPBs split this procedure row: interlaminar epidural injections are governed by CPB 0016 "Back Pain - Invasive Procedures"; transforaminal epidural injections (64479, 64480, 64483, 64484) are governed by the separate CPB 0722 "Transforaminal Epidural Injections". Both fetched 2026-08-07. Note CPB 0016 states an overarching rule (verbatim): Aetna considers these injections medically necessary "provided that only one invasive modality or procedure will be considered medically necessary at a time." INTERLAMINAR EPIDURAL INJECTIONS — CPB 0016 (verbatim): medically necessary "In the outpatient setting for management of members with radiculopathy or sciatica when all of the following are met: Pain is radicular in nature (radicular signs may include, but are not limited to, a positive straight leg raise or a dermatomal pattern of sensory loss)... and Intraspinal tumor or other space-occupying lesion, or non-spinal origin for pain, has been ruled out as the cause of pain... Where indicated for evaluating lumbar, cervical or thoracic pain, advanced diagnostic imaging should be performed within 24 months prior to initiating intralaminar epidural injections; and Member has failed to improve after 4 or more weeks of conservative treatments (e.g., rest, systemic analgesics, physical therapy); and Interlaminar epidural injections are provided as part of a comprehensive pain management program, which includes physical therapy, patient education, psychosocial support, and oral medications, where appropriate." REPEAT / FREQUENCY (verbatim): additional interlaminar epidural injections are covered "if the initial injection resulted in at least two of the following for at least two weeks: A 50 % or greater relief in pain; and Increase in the level of function/physical activity (e.g., return to work); and Reduction in the use of pain medication and/or additional medical services such as physical therapy/chiropractic care". Also verbatim: "No more than one interlaminar epidural injection is considered medically necessary per session"; "Interlaminar epidural injection of more than one region per session is considered not medically necessary"; "Repeat epidural injections more frequently than every two weeks are not considered medically necessary"; and "A total of up to 3 interlaminar epidural injections per region, per episode of pain are considered medically necessary in 6 months, and up to four interlaminar epidural steroid injections per region (ie, cervical, thoracic, lumbar) per rolling 12-month period are considered medically necessary, only upon return of pain and/or deterioration in function and only when responsiveness to prior injections has occurred (ie, the individual should have at least a 50% reduction in pain and/or symptoms for two weeks)." Ultrasound guidance of epidural injections is experimental, investigational, or unproven. TRANSFORAMINAL EPIDURAL INJECTIONS — CPB 0722 (verbatim limits): "Aetna considers not medically necessary TFESIs at more than two (2) contiguous vertebral levels or more than four (4) TFESIs [i.e., more than two (2) bilateral TFESIs at two (2) contiguous vertebral levels in the same spinal region (cervical, thoracic or lumbar)] during a single session"; "Aetna considers not medically necessary more than three (3) TFESI sessions per episode of pain, per spinal region (cervical, thoracic or lumber) per six (6) months"; "Aetna considers medically necessary a maximum of twelve (12) TFESIs per spinal region (cervical, thoracic or lumbar), administered during a maximum of three (3) sessions, for an episode of pain lasting six (6) months"; "Aetna considers not medically necessary more than four (4) sessions of TFESIs per spinal region (cervical, thoracic or lumbar) per twelve (12) months"; and "Aetna considers not medically necessary TFESI sessions more frequently than every two (2) weeks for all spinal regions (cervical, thoracic or lumbar)." Ultrasound-guided TFESI is not covered. Diagnostic selective TFESIs are addressed separately in CPB 0722 for identifying the etiology of pain where the diagnosis remains uncertain after standard evaluation. PRECERTIFICATION SCOPE (from the Aetna participating-provider precertification list updated 2026-08-01): the "Pain management" entry lists 27096, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64510, 64520, 64633, 64634, 64635, 64636, 0213T-0218T, 0627T-0630T, G0259 and G0260 — every CPT code on this procedure row is in scope. Verbatim: "Precertification is required for all members with plans applicable to this precertification list unless services are emergent."

Commonly required documentation

• Documentation that pain is radicular in nature (e.g., positive straight leg raise or dermatomal sensory loss)
• documentation that intraspinal tumor or other space-occupying lesion and non-spinal causes have been ruled out
• advanced diagnostic imaging performed within 24 months prior to initiating the injection where indicated
• documentation of failure to improve after 4 or more weeks of conservative treatment
• evidence the injection is part of a comprehensive pain management program including physical therapy, patient education, psychosocial support and oral medications. For repeat injections: documentation of at least two of (>= 50% pain relief
• increased function/physical activity
• reduced pain medication or other medical services) sustained for at least two weeks.

How to submit

• Method: Precertification to eviCore healthcare: online at Evicore.com, by phone at 1-888-622-7329 (TTY: 711) between 7 AM and 8 PM ET, or by fax at 1-855-774-1319.
• Portal: eviCore healthcare (Aetna pain management precertification)

Sources & verification

• BindingSource — Clinical Policy Bulletin: Back Pain - Invasive Procedures (interlaminar epidural injections) (0016).View
• BindingSource — Clinical Policy Bulletin: Transforaminal Epidural Injections (0722).View
• BindingSource — Participating provider precertification list for Aetna, Updated August 1, 2026 — "Pain management" entry · effective 2026-08-01.View

Binding = the payer's own policy. Proxy = a public, evidence-based clinical guideline the payer mirrors. Portal-only = the binding criteria are confirmed in the administrator's portal. Always confirm against the payer for the member's specific plan. Last verified 2026-08-07.

Frequently asked questions

Other Aetna prior authorization requirements

Related guides