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An Algorithmic Approach to Epidural Steroid Injections

After being made aware that several physicians are being audited, we are concerned that some members are having difficulty conforming to the LCDs and medical policies. In response, ASIPP is providing you with an algorithmic approach and a checklist.

Regardless of the opinions you hold and the evidence that exists, it is crucial to follow the LCDs. Whatever is quoted in the LCD or medical policy is final and we must abide by those

Any changes you believe are warranted should be presented for consideration through a redetermination process for LCDs or medical policies for private insurers or Medicaid. They can be submitted during the next cycle of revisions.

You can use this algorithmic approach whenever you see your patients by utilizing these checklists for each patient prior to performing epidural steroid injections and facet joint interventions.

An Algorithmic Approach to Epidural Steroid Injections


  • The assessment as it relates to the complaint for that visit
  • Relevant medical history and physical examination
  • Results of pertinent tests/procedures
  • Signed and dated office visit record/operative report
  • Documentation to support the medical necessity of the procedure(s)

Radiculopathy or radicular pain and/or neurogenic claudication must meet 4 criteria

  • Pain duration of 4 weeks.
  • Inadequate improvement with 4 weeks of conservative management (chiropractic, physical therapy, structured exercise program, NSAIDs, and other drugs) with documentation of duration and results of therapy.
  • Effectiveness should be documented as defined by 3 months of pain relief of >/= 50%, in conjunction with conservative management. (The only exception is: following the first injection, a procedure may be repeated if the relief is not long-lasting after 14 days with a different technique or drug).
  • Pain scale or functional assessment should be documented.


  1. Limitations include steroid dosages of 80 mg of triamcinolone, or 12 mg of betamethasone, or 15 mg of dexamethasone. Methylprednisolone is not allowed.
  2. CT or fluoro is mandated except during pregnancy.
  3. Imaging requires a minimum of 2 views with final needle position in contrast flow to be retained.
  4. Only mild or light sedation is permitted.


  1. Multiple procedures are not permitted.
  2. Two unilateral or a bilateral transforaminal epidural injection may be performed. The maximum number of procedures is 4 per year per region.
  3. ICD-10 codes are limited compared to previous policies as enclosed (It is crucial that the physician always includes a radiculopathy or radiculitis code. Without that, payment will be denied and may lead to fraud and abuse investigations).

It would be appropriate to utilize a checklist to assure that these procedures are performed properly:

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