Caudal or Interlaminar Epidural Steroid Injections

This policy addresses caudal or interlaminar epidural steroid injections (ESI), including local anesthetic with or without steroids, for acute and chronic radicular pain, neurogenic claudication, and chronic low back pain due to disc herniation, spinal stenosis, or degenerative changes when specific clinical criteria are met. Coverage requires documented conservative management (specified durations of physical therapy/chiropractic/home exercise, activity modification, and NSAID trial), imaging guidance, one procedure per visit, and limits on repeats (single‑level second ESI ≥2 weeks after the first; third/subsequent only if prior injections produced ≥50% relief for ≥2 months and fewer than four injections in 12 months, with no continuation beyond 12 months), while noting uncertain long‑term efficacy and that some uses are considered not medically necessary.

"Caudal or interlaminar epidural steroid injection (ESI) — one ESI for acute pain (pain < 3 months) when the policy's specific criteria are met."