CMM-200: Epidural Steroid Injections

Cigna/eviCore covers single‑level diagnostic selective nerve root blocks (SNRBs) with anesthetic and initial epidural steroid injections (interlaminar, caudal, transforaminal) for level‑specific radiculitis/radiculopathy or neurogenic claudication when criteria are met, and excludes ultrasound guidance, biologic injectates (PRP, stem cells, amniotic fluid), repeat/therapeutic SNRBs, epidurals for axial pain or other non‑indicated conditions. Key requirements: failure of ≥4 weeks conservative care plus participation in a comprehensive pain program for ESIs; detailed neurologic exam within 3 months and concordant MRI/CT or diagnostic EMG within 24 months for radiculopathy; fluoroscopic/CT guidance with contrast (no ultrasound), TFESI limited to ≤2 contiguous levels, and repeat ESI must be ≥14 days from prior with ≥50% pain relief for ≥2 weeks plus documented functional improvement or reduced medication use.

"An initial level diagnostic selective nerve root block (SNRB) is considered medically necessary when ALL of the following criteria have been met:"