Medicare (CMS LCD/NCD) Epidural Steroid Injection (interlaminar / transforaminal) prior authorization requirements (2026)
What Medicare (CMS LCD/NCD) generally requires to approve Epidural Steroid Injection (interlaminar / transforaminal) (CPT 62321, 62323, 64479, 64480, 64483, 64484), for Medicare, Medicare (NJ WISeR), Medicare (NY) plans. Based on the cited policy, Medicare (CMS LCD/NCD) does not generally require prior authorization for Epidural Steroid Injection (interlaminar / transforaminal) (CPT 62321, 62323, 64479, 64480, 64483, 64484). Confirm with Medicare (CMS LCD/NCD), as this can vary by plan.
Medical-necessity criteria Medicare (CMS LCD/NCD) generally applies
Covered when ALL THREE are met: (1) history, exam, and CONCORDANT image-based testing supporting lumbar/cervical/thoracic radiculopathy, radicular pain or neurogenic claudication from disc herniation, osteophyte/osteophyte complex or severe DDD producing foraminal or central stenosis - OR post-laminectomy syndrome - OR acute herpes zoster pain; AND (2) severity great enough to materially impact function, with an objective pain or function scale recorded at BASELINE and the SAME scale repeated at every follow-up; AND (3) pain >= 4 weeks with documented failure of, or inability to tolerate, 4 weeks of noninvasive conservative care (herpes zoster refractory to conservative care is exempt from the 4-week wait). Must be performed under CT or fluoroscopic guidance WITH CONTRAST (ultrasound without contrast only for documented contrast allergy or pregnancy); an initial contrast injection confirming epidural placement is required. TFESI maximum 2 levels in one spinal region; CESI and ILESI maximum 1 level and NOT bilateral. Repeat requires >= 50% consistent pain improvement for >= 3 months, or >= 50% consistent functional/ADL improvement vs baseline on the same scale; a non-responder may be re-injected after 14 days using a different approach, level or medication with rationale documented. NOT COVERED: nonspecific low back or axial pain, CRPS, widespread diffuse pain, neuropathy of other cause, cervicogenic headache (all investigational); injections without image guidance; biologicals; a predetermined series of injections; more than one spinal region per session; and multiple block types (facet, sympathetic, trigger point) in the same session as an ESI, except a facet synovial cyst. Moderate/deep sedation, general anesthesia and MAC are not reasonable and necessary absent exceptional documented need. Therapy beyond 12 months requires ALL of: significant functional or vocational disability; >= 50% sustained pain or function improvement; documented rationale for continuing (e.g. high surgical risk, patient declines surgery, recurrence relieved >= 3 months); and notification of the primary care provider. [NEEDS CLINICAL SPOT-CHECK]
Commonly required documentation
- Baseline pain AND function scale with the identical scale at each follow-up
- concordant imaging report
- 4-week conservative-care record
- fluoroscopic/CT images documenting contrast confirmation of epidural placement
- operative note stating approach, level(s), laterality and agents
- for repeats, dated measurements evidencing duration of relief.
How to submit
- Method: No prior authorization in the office or ASC setting - bill Part B with documentation on file. If performed in a HOSPITAL OUTPATIENT DEPARTMENT, check the CMS OPD prior-authorization list for the specific code before the date of service.
Sources & verification
- BindingSource — LCD: Epidural Steroid Injections for Pain Management (L39036) · effective 2026-05-07.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 2026-08-10.
Frequently asked questions
Does Medicare (CMS LCD/NCD) require prior authorization for Epidural Steroid Injection (interlaminar / transforaminal)?
Based on the cited policy, Medicare (CMS LCD/NCD) does not generally require prior authorization for Epidural Steroid Injection (interlaminar / transforaminal) (CPT 62321, 62323, 64479, 64480, 64483, 64484). Confirm with Medicare (CMS LCD/NCD), as this can vary by plan.
What does Medicare (CMS LCD/NCD) require to approve Epidural Steroid Injection (interlaminar / transforaminal)?
Covered when ALL THREE are met: (1) history, exam, and CONCORDANT image-based testing supporting lumbar/cervical/thoracic radiculopathy, radicular pain or neurogenic claudication from disc herniation, osteophyte/osteophyte complex or severe DDD producing foraminal or central stenosis - OR post-laminectomy syndrome - OR acute herpes zoster pain; AND (2) severity great enough to materially impact fu… Always confirm against the current Medicare (CMS LCD/NCD) policy.
How long does a Medicare (CMS LCD/NCD) prior authorization take?
Turnaround varies by plan and submission method. Check the Medicare (CMS LCD/NCD) portal for current timeframes.
Submitting Epidural Steroid Injection (interlaminar / transforaminal) to Medicare (CMS LCD/NCD)?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.