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Cigna Healthcare (Commercial) · epidural steroid injection

v1verified 2026-07-24pending changemanual-pull source

✓ conditional · commercial

Pending change: CMM-200 successor effective 2026-08-04 exists (not yet in force). Re-pull on/after that date.

Criteria checklist

0 of 6 ticked
Indications
  • enumerated: yes
  • covered:
      • name: Radiculitis / radicular pain / radiculopathy
      • criteria:
        • imaging: concordant; advanced imaging within 24 months required for cervical/thoracic
        • imaging guided: fluoroscopy or CT with contrast
      • name: Spinal stenosis
      • criteria:
        • imaging: MRI/CT +/- myelography within 24 months
      • name: Diagnostic selective nerve root block (SNRB)
      • criteria:
        • anesthetic only: yes
        • single level: yes
  • investigational:
    • ultrasound-guided ESI / SNRB
    • any ESI without fluoroscopic/CT guidance + contrast (except emergent/pregnancy)
Conservative care
  • required: yes
  • min duration months: not stated in the policy
  • min duration weeks: 4
  • also requires: participation in a comprehensive pain program (PT, education, psychosocial support, oral meds)
  • satisfied by:
    • failed >=4 weeks + pain-program participation
    • contraindicated
  • modalities named:
    • physical therapy
    • patient education
    • psychosocial support
    • oral medications
Trial
  • required: no
  • min duration days: not stated in the policy
  • success criteria: not stated in the policy
  • threshold is binding: no
Psychological evaluation
  • required: no
  • must clear: no
  • note posture: not required (but a comprehensive pain program incl. psychosocial support is required)
Imaging guidance
  • required: yes
  • modalities:
    • fluoroscopy
    • CT
  • contrast: required
  • excluded:
    • ultrasound
Quantity limits
  • applies: yes
  • sessions per 6mo per region per episode: 3
  • sessions per region per 12mo: 4
  • repeat requires: >=50% relief for >=2 weeks
  • series of three: not supported
  • tfesi levels per session: 2
Payor-specific notes

Cigna delegates ESI to eviCore CMM-200 — radicular pain or stenosis with concordant imaging (advanced imaging within 24 months for cervical/thoracic), fluoro/CT with contrast. DISTINCTIVE: requires participation in a COMPREHENSIVE PAIN PROGRAM (PT + education + psychosocial + oral meds) in addition to >=4 weeks conservative care. Caps: <=3 sessions/6mo/region/episode and <=4/rolling- 12mo/region; "series of three" not supported; repeat needs >=50% relief for >=2 weeks. From the actual fetched eviCore PDF. PENDING: 2026-08-04 successor.

Ticks are a documentation aid — nothing is stored; they reset on reload.

Dot phrase

Lean narrative A&P attestation. `***` = fill-in. Fully self-contained — rendered from eviCore CMM-200, Cigna-delegated. DISTINCTIVE: comprehensive pain-program participation is required on top of the 4-week conservative floor; "series of three" is not supported.

.ESICIGNA
.ESICIGNA

Assessment: *** — radiculitis / radicular pain / radiculopathy in a *** (C/T/L-S)
distribution, or spinal stenosis, with concordant imaging at *** (advanced imaging within
24 months is required for cervical and thoracic levels; for stenosis, MRI/CT with or without
myelography within 24 months).

Medical necessity per Cigna eviCore CMM-200: conservative care has failed or was
contraindicated over >=4 weeks, and the patient has participated in a comprehensive pain
program — physical therapy, patient education, psychosocial support, and oral medications:
*** . The injection will be placed under fluoroscopy or CT with contrast; ultrasound is not
covered, and an ESI without fluoroscopic/CT guidance and contrast is not covered except in
emergent circumstances or pregnancy.

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, with TFESI
limited to <=2 levels per session, <=3 sessions per region per 6 months per episode, and
<=4 sessions per region per rolling 12 months. [If repeat:] the prior ESI gave >=50% relief
for >=2 weeks. Risks, benefits, and alternatives discussed; consent obtained.

Where this payor diverges from the Medicare baseline

  • diagnosis/imaging line (24-month advanced-imaging recency for cervical/thoracic)
  • conservative-care line (>=4 wk + comprehensive pain-program participation)
  • session/frequency limits (<=3/6mo/region/episode; <=4/12mo; no series-of-three; TFESI <=2 levels/session)
  • repeat-relief gate (>=50% for >=2 weeks)

Cautions

  • A predetermined "series of three" is NOT supported by CMM-200 — each session must be justified by the documented response to the last. eviCore / Evernorth prior authorization required. [!] CMM-200 successor effective 2026-08-04 exists (not yet in force) — re-verify against the policy file on/after that date. Regenerate if `cigna-commercial-esi.md` `version` advances past `source_version`.

Prior-auth pathway

  • required: yes
  • pathway: eviCore / Evernorth

Provenance

Report an issue with this cell

Change history

  • 2026-07-24commercial cells: re-verify 27 source PDFs by SHA-256 (Carelon/eviCore/UHC/Cigna) - all unchanged vs committed archive; last_verified -> 2026-07-24 3615c231f0
  • 2026-06-30Archive commercial source PDFs into sources/ + wire source_file/source_hash c5466694c8
  • 2026-06-28Add commercial ESI cells: Anthem(Carelon), UHC, Cigna(eviCore) ecc9a1b23e