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

Medical-necessity criteria QualCare generally applies

[NEEDS CLINICAL SPOT-CHECK] COVERAGE ROUTE NOT CONFIRMED — DO NOT TREAT THIS ROW AS AUTHORITATIVE. WHAT PRAXIGEN CONFIRMED on 2026-08-07: eviCore by Evernorth publishes a Cigna-branded interventional-pain guideline set (CMM-200 Epidural Steroid Injections, V1.0.2026, effective 2026-08-04) and eviCore's Cigna provider-resources page lists Musculoskeletal among the solutions eviCore manages for Cigna. WHAT PRAXIGEN COULD NOT CONFIRM: no current published QualCare page, Cigna page, or eviCore page reviewed on 2026-08-07 names QualCare as being in scope for the Cigna/eviCore interventional-pain program. eviCore's Cigna provider-resources page does not mention QualCare at all. QualCare's ownership by Cigna is not, by itself, evidence that a QualCare member's epidural steroid injection is reviewed under the Cigna eviCore program or against CMM-200. IF the Cigna/eviCore interventional-pain program is confirmed to apply to the specific QualCare member, then CMM-200 V1.0.2026 governs and its criteria are recorded in full on the Cigna row for this same procedure (payer 28, procedure 411) — including at least 4 weeks of failed conservative treatment, participation in an active rehabilitation/home exercise/functional restoration program, advanced imaging within 24 months for cervical/thoracic ILESI and TFESI, CT or fluoroscopic guidance, up to 3 sessions per episode per region in 6 months and 4 per rolling 12 months, TFESI at no more than 2 contiguous levels per session, and repeat injection no sooner than 14 days with documented >= 50% relief for >= 2 weeks. Those criteria are NOT asserted for QualCare here. CONSERVATIVE DEFAULT: verify the governing program and criteria directly with QualCare before submitting or before telling a user this procedure is or is not covered.

Commonly required documentation

• Not established. Determine the governing program with QualCare before assembling a packet.

How to submit

• Method: Not confirmed. Verify with QualCare whether interventional pain prior authorization is handled by QualCare directly or delegated to eviCore under the Cigna program.

Sources & verification

• UnverifiedSource — Cigna Provider Resources — solutions eviCore manages for Cigna (QualCare not named; used to document what could NOT be confirmed).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 QualCare prior authorization requirements

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