Anthem Blue Cross Blue Shield / Elevance (Commercial) · epidural steroid injection

.ESIANTHEM

Assessment: *** — significant radicular pain in a *** (C/T/L-S) distribution, or lumbar
neurogenic claudication with functional impairment, with MRI/CT showing nerve-root
compression from HNP (imaging within the last 18 months) or spinal stenosis at ***,
correlating with the symptoms and examination findings. This is not isolated axial neck,
mid-back, or low-back pain.

Medical necessity per Carelon MSK01-0626.1: conservative care has failed or was
contraindicated over >=4 weeks — or over >=2 weeks where radiculopathy is clear (dermatomal
pain with myotomal weakness or reflex change), per the policy's escape — comprising
pharmacotherapy, physical therapy, and activity modification: *** . The injection will be
placed under fluoroscopy or CT with contrast; ultrasound is not covered.

Plan: *** epidural steroid injection — transforaminal (64483/64484 lumbar-sacral;
64479/64480 cervical-thoracic) or interlaminar (62323 lumbar-sacral; 62321
cervical-thoracic) — at level ***, under fluoroscopic/CT guidance with contrast, to one
spinal region this session, with TFESI limited to <=2 per setting and <=4 sessions per
region per rolling 12 months. [If the initial injection failed:] relief was <50% at 2 weeks
and I am proceeding with a one-time second injection >=2 weeks later using a different
approach, level, or steroid. [If repeat:] the prior ESI gave >=50% relief with functional
improvement for >=3 months. Risks, benefits, and alternatives discussed; consent obtained.