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You asked about Epidural steroid injection (ESI). Humana Gold Plus (Medicare Advantage, HMO) is governed by a framework cell — read the per-procedure line inside it and the embedded Traditional-Medicare criteria below.

Humana Gold Plus (Medicare Advantage, HMO) · all interventional pain

v1verified 2026-07-24needs re-verificationmanual-pull source

✓ conditional · medicare advantage

Criteria checklist

0 of 1 ticked
Indications
  • enumerated: no
  • description: Humana Gold Plus (HMO MA) applies the Traditional Medicare coverage FLOOR. NCD/LCD procedures (SCS, DRG, PNS, ITDD, MILD, facet, ESI, kyphoplasty, SI fusion) use the corresponding `medicare-in-ky-*` criteria + Humana MA PA (cannot be more restrictive). For R&N procedures (Intracept, ReActiv8, endoscopic), the plan may apply its own internal criteria — pull the policy. HMO: in-network + referral rules apply.
Payor-specific notes

POINTER cell. Criteria = the Traditional Medicare cell per procedure + Humana MA PA. Gold Plus is the HMO product (contrast HumanaChoice PPO). Per CMS-4201-F, no internal criteria stricter than a governing NCD/LCD; internal criteria only for R&N procedures (Intracept, ReActiv8, endoscopic). MSK/spine PA may route through Cohere Health in some Humana markets — confirm (needs_reverification).

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

Prior-auth pathway

  • required: yes
  • pathway: Humana MA prior authorization (MSK/spine often Cohere Health — confirm)

Provenance

  • authority:
    • type: medicare_advantage
    • floor: Traditional Medicare NCD/LCD per procedure — see policies/<procedure>/medicare-in-ky-*.md
    • plan um: Humana MA prior authorization / utilization management (MSK/spine PA often via Cohere Health — confirm)
    • applies because: Per CMS-4201-F (2024) / 42 CFR 422.101, MA must follow Traditional Medicare coverage criteria where an NCD/LCD fully establishes them; plan internal criteria only where Medicare is silent (R&N procedures)
  • source: https://www.ecfr.gov/current/title-42/section-422.101
  • effective: 2024-01-01 · payor last reviewed: — · we verified: 2026-07-24 · v1

Report an issue with this cell

Change history

  • 2026-07-24framework cells (MA x3, Medicaid IN/KY, VA): re-reviewed regulatory basis 2026-07-24 (42 CFR 422.101/CMS-4201-F, 405 IAC Art.5, KY KAR 907:3:130, 38 CFR 17.38(b) all current); plan/state-specific operational details (MA PA vendor, Medicaid interactive fee-schedule PA flags + MCO scopes, VA gated SEOC catalog/Optum manual/image-only CPG) remain gated -> needs_reverification kept; last_verified 2026-07-24 86bd4bd0b9
  • 2026-06-29Add Medicare Advantage pointer cells (Aetna, Humana Gold HMO, HumanaChoice PPO) 86a5e15292

Embedded cell · Traditional Medicare baseline

Medicare (Traditional Part A & B) — epidural steroid injection

v2verified 2026-07-24

✓ conditional · medicare lcd

Criteria checklist

0 of 8 ticked
Indications
  • enumerated: yes
  • covered:
      • name: Radiculopathy, radicular pain and/or neurogenic claudication
      • criteria:
        • etiology: disc herniation, osteophyte(s)/osteophyte complexes, or severe degenerative disc disease producing foraminal or central spinal stenosis
        • evidence: history + physical exam + CONCORDANT radiological image-based diagnostic testing (WPS/CGS text names imaging only — no electrodiagnostic route)
        • severity: severe enough to greatly impact quality of life or function; objective pain or functional scale at baseline, repeated at each follow-up (same scale)
        • min duration: >=4 weeks of pain AND (documented failure of >=4 weeks of noninvasive conservative care OR inability to tolerate it)
        • imaging guided: CT or fluoroscopy with contrast (see exception in imaging_guidance)
      • name: Post-laminectomy syndrome
      • criteria:
        • evidence: history + physical exam + concordant radiological image-based diagnostic testing
        • severity: greatly impacts quality of life or function; baseline + follow-up scale required
        • min duration: >=4 weeks of pain AND (failed >=4 weeks noninvasive conservative care OR unable to tolerate)
      • name: Acute herpes zoster-associated pain refractory to conservative management
      • criteria:
        • wait exception: the 4-week wait is NOT required
  • investigational:
    • non-specific low back pain, axial spine pain, CRPS, widespread diffuse pain, neuropathy from other causes, cervicogenic headache
    • ultrasound guidance or no image guidance — EXCEPT documented contrast allergy or pregnancy, where ultrasound without contrast may be considered
    • repeat injection without documented >=50% improvement (pain or ADL/function, same scale) for >=3 months from the prior ESI (exception: failed initial ESI may be repeated after >=14 days with a different approach/level/medication, rationale documented)
    • exceeding 4 sessions per spinal region per rolling 12 months; more than 1 spinal region per session
    • TFESI at >2 nerve-root levels per session; CESI/ILESI at >1 level per session; bilateral CESI/ILESI
    • a predetermined series of ESIs
    • biologicals or substances not FDA-designated for epidural use
    • multiple blocks (sympathetic, facet, trigger point) in the same session as ESI — except facet-synovial-cyst + ESI
    • continuation beyond 12 months without the documented continuation criteria (see quantity_limits)
Documented pathology (objective basis)required
Conservative care
  • required: yes
  • min duration months: not stated in the policy
  • satisfied by:
    • tried and failed >=4 weeks
    • unable to tolerate
    • acute herpes zoster refractory to conservative management (no 4-week wait)
  • modalities named:
    • NSAIDs / analgesics
    • physical therapy
    • spinal manipulation
    • activity modification / other
  • note: ESIs should be performed in conjunction with conservative treatment; patient should be in an active rehab / home-exercise / functional-restoration program
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
Imaging guidance
  • required: yes
  • modalities:
    • fluoroscopy
    • CT
  • contrast: required — initial contrast injection confirms epidural placement
  • excluded:
    • ultrasound
    • no-imaging / landmark-only
  • exception: documented contrast allergy or pregnancy: ultrasound guidance without contrast may be considered
Quantity limits
  • applies: yes
  • repeat requires: >=50% improvement (pain or ADL/function, same scale as baseline) for >=3 months from the prior injection
  • failed initial repeat: if the initial ESI fails, one repeat after >=14 days with a different approach/level/medication, with documented rationale
  • sessions per region per 12mo: 4
  • regions per session: 1
  • tfesi max levels per session: 2
  • cesi ilesi max levels per session: 1
  • beyond 12 months: requires severe functional/vocational disability + >=50% sustained improvement (pain and/or function) + documented rationale (high-risk surgical candidate / declines surgery / recurrence after >=3-month relief) + PCP notified; may trigger focused medical review
  • no predetermined series: yes
Device / waveformnot_applicable
Payor-specific notes

Governed by the harmonized multi-MAC "Epidural Steroid Injections for Pain Management" LCD — WPS L39054 (IN), CGS L39015 (KY). ESI is for RADICULAR-pattern pathology (radiculopathy / radicular pain / neurogenic claudication, post-laminectomy syndrome, acute herpes zoster pain) — the mirror image of the facet LCD (axial pain). Key gates: >=4 weeks of pain AND failure of (or inability to tolerate) >=4 weeks of noninvasive conservative care (herpes zoster exempt from the wait); CONCORDANT radiological imaging supporting the diagnosis; CT/fluoro guidance WITH CONTRAST (ultrasound only for documented contrast allergy or pregnancy); TFESI <=2 levels, CESI/ILESI 1 level, one region per session; repeat only after >=50% improvement x >=3 months (or one 14-day different-approach retry after a failed initial); <=4 sessions/region/rolling 12 months; continuation past 12 months needs the documented continuation criteria. Sedation (moderate/deep, MAC, GA) is rarely indicated and not reasonable-and-necessary absent case-specific documentation — oral anxiolytics typically suffice. Contraindicated with spinal/systemic infection, cord/conus/cauda compressive lesions, or major cancer risk factors. Criteria VERIFIED 2026-07-24 against both LCD bodies read directly from the MCD (browser pull); WPS/CGS texts materially identical. The IN/KY billing articles are A58777 (WPS) / A58731 (CGS).

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

Dot phrase

Lean narrative A&P attestation. `***` = fill-in. Maps to WPS L39054 (IN) / CGS L39015 (KY) "Epidural Steroid Injections" LCD (bodies verified 2026-07-24). This is the RADICULAR mirror of the facet phrase — name the nerve root and the concordant imaging.

.ESIMCARE
.ESIMCARE

Assessment: *** — [radiculopathy / radicular pain / neurogenic claudication due to ***
(disc herniation, osteophyte complex, severe DDD with foraminal/central stenosis) |
post-laminectomy syndrome | acute herpes zoster-associated pain] in a *** (C/T/L-S)
distribution, severe enough to greatly impact function and quality of life (baseline
pain/functional scale ***), with concordant radiological imaging at *** correlating with the
symptomatic level.

Medical necessity per the Medicare LCD (Epidural Steroid Injections for Pain Management):
pain has been present >=4 weeks, and >=4 weeks of noninvasive conservative care —
NSAIDs/analgesics, physical therapy, spinal manipulation, and activity modification — has
failed or was not tolerated: *** . [Herpes zoster: refractory to conservative management; no
4-week wait required.] The patient is participating in an active rehabilitation,
home-exercise, or functional-restoration program. There is no contraindication: no spinal or
systemic infection, no cord/conus/cauda compression, and no major cancer risk. The injection
will be placed under fluoroscopy or CT with contrast, the initial contrast confirming
epidural placement. [Contrast allergy or pregnancy documented: ultrasound without contrast.]

Plan: *** epidural steroid injection — transforaminal (64483/64484 lumbar-sacral; 64479/64480
cervical-thoracic; <=2 levels, bilateral only if clinically indicated) or interlaminar/caudal
(62323 lumbar-sacral; 62321 cervical-thoracic; 1 level, unilateral) — to a single spinal
region this session under fluoroscopic/CT guidance with contrast. [If repeat:] the prior ESI
gave >=50% improvement in pain or function on the same scale for >=3 months [or: the initial
ESI failed and I am repeating after >=14 days via a different approach/level/medication
because ***]. Risks, benefits, and alternatives discussed; consent obtained.

Where this payor diverges from the Medicare baseline

  • diagnosis line (radicular + concordant-imaging evidence)
  • imaging+contrast line
  • repeat/relief line
  • level/region caps

Cautions

  • Within limits: <=4 sessions per spinal region per rolling 12 months; no predetermined series; continuation beyond 12 months requires the LCD's continuation criteria (severe disability, >=50% sustained improvement, documented rationale, PCP notified). Regenerate if `medicare-in-ky-esi.md` `version` advances past `source_version`.

Prior-auth pathway

  • required: no
  • verified: no
  • note: Not on a verified OPD prior-auth category for ESI codes; confirm if furnished hospital-outpatient.

Provenance

  • authority:
    • type: lcd
    • title: Epidural Steroid Injections for Pain Management
    • lcds:
      • IN: L39054 (WPS, J8) — v17 eff 2026-04-30 (body verified via MCD browser pull 2026-07-24)
      • KY: L39015 (CGS, J15) — v16 eff 2026-04-16 (body verified via MCD browser pull 2026-07-24; WPS/CGS texts materially identical)
    • applies because: WPS (IN) and CGS (KY) each publish this LCD; criteria are the harmonized multi-MAC standard
    • billing articles:
      • A58777 (WPS, IN)
      • A58731 (CGS, KY)
  • source: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=39054&ver=17
  • effective: 2026-04-30 · payor last reviewed: 2026-04-30 · we verified: 2026-07-24 · v2