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) 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
No nationwide Part B prior authorization. EXCEPTION - WISeR model (from Jan 2026, NJ/OH/OK/TX/AZ/WA): epidural steroid injections for pain management are a WISeR service category (Novitas JL LCDs L39015 / L39240 / L36920 referenced for NJ - verify current versions) - in those states submit prior authorization or the claim faces 100% pre-payment medical review. Not on the hospital-OPD PA list. Documentation: radicular pain diagnosis, imaging correlation, failed conservative care, and response to any prior injections per the applicable LCD. [NEEDS CLINICAL SPOT-CHECK]
Commonly required documentation
- Clinical documentation per the applicable NCD/LCD: diagnosis, conservative-care history, imaging correlation, and (for repeat procedures) documented response.
How to submit
- Method: Office/professional claims: no PA to submit outside WISeR states. HOPD claims for OPD-list services: hospital submits PA to the MAC.
Sources & verification
Sources: CMS WISeR model page (cms.gov/priorities/innovation/innovation-models/wiser, verified 2026-07-09); CMS hospital-OPD prior-authorization program (42 CFR 419.83); KFF WISeR analysis (kff.org). WISeR states: NJ, OH, OK, TX, AZ, WA; six-year model from Jan 1, 2026. Last verified 2026-07-09.
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)?
No nationwide Part B prior authorization. EXCEPTION - WISeR model (from Jan 2026, NJ/OH/OK/TX/AZ/WA): epidural steroid injections for pain management are a WISeR service category (Novitas JL LCDs L39015 / L39240 / L36920 referenced for NJ - verify current versions) - in those states submit prior authorization or the claim faces 100% pre-payment medical review. Not on the hospital-OPD PA list. Docu… 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.