Are Transforaminal Epidural Steroid Injections (TESI) (CPT/HCPCS Code: 64483) medically necessary for a patient with radiculopathy, and are they considered experimental?

Medical Necessity Assessment for Transforaminal Epidural Steroid Injections

Transforaminal epidural steroid injections (TFESI) are medically necessary for this patient with lumbosacral radiculopathy (M54.17, M54.16), but NOT for spondylosis without radiculopathy (M47.816). The presence of true radiculopathy is the critical determining factor for medical necessity.

Key Determination Factors

Radiculopathy vs. Non-Radicular Pain

The medical necessity hinges entirely on whether this patient has true radicular pain versus mechanical back pain:

• For radiculopathy diagnoses (M54.17, M54.16): The American Society of Anesthesiologists strongly recommends epidural steroid injections with or without local anesthetics specifically for patients with radicular pain or radiculopathy as part of a multimodal treatment regimen 1, 2
• For spondylosis without radiculopathy (M47.816): The American Academy of Neurology explicitly recommends against epidural steroid injections for non-radicular low back pain, as evidence is limited 1, 3
• Critical clinical criterion: Radicular pain must radiate below the knee to meet authorization criteria 1

Required Pre-Authorization Criteria

Before TFESI can be considered medically necessary, the following must be documented:

• Conservative treatment failure: Minimum 4-6 weeks of failed conservative therapy including physical therapy, NSAIDs, and activity modification 1
• MRI correlation: Imaging must demonstrate nerve root compression or moderate to severe disc herniation that correlates anatomically with clinical symptoms 1, 2
• Imaging recency: Advanced diagnostic imaging must have been performed within 24 months prior to injection 1
• Clinical examination findings: Documentation of decreased sensation in lower extremities, positive straight leg raise test, or other objective signs of radiculopathy 1

Procedural Requirements for Medical Necessity

If the above criteria are met, the procedure must be performed correctly:

• Fluoroscopic guidance is mandatory: Image guidance must be used for transforaminal epidural injections to ensure correct needle position and minimize complications 1, 3, 2
• Shared decision-making documentation: Patient must be counseled about potential complications including dural puncture, insertion-site infections, cauda equina syndrome, sensorimotor deficits, discitis, epidural granuloma, and retinal complications 1, 3
• Multimodal context: TFESI must be part of a comprehensive pain management program including physical therapy, patient education, psychosocial support, and oral medications 1

Experimental Status Determination

TFESI is NOT experimental for radiculopathy when performed according to established guidelines. The procedure has strong guideline support:

• The American Society of Anesthesiologists provides strong recommendations for epidural steroid injections in radicular pain with high strength of evidence 1, 2
• Fluoroscopic guidance is considered the gold standard for targeted transforaminal epidural steroid injections 1
• Research demonstrates 84% success rates at 1.4 years for fluoroscopically guided TFESI in lumbosacral radiculopathy secondary to herniated nucleus pulposus 4

However, TFESI would be considered experimental or not medically necessary if used for:

• Non-radicular mechanical low back pain from spondylosis alone 3
• Patients who have not failed conservative therapy 1
• Patients without MRI correlation of nerve root compression 1

Critical Documentation Gaps to Address

The following must be clearly documented to establish medical necessity:

• Pain radiation pattern: Does pain radiate below the knee? 1
• Conservative treatment timeline: Has patient completed minimum 4-6 weeks of physical therapy, NSAIDs, and activity modification? 1
• MRI findings and correlation: Does imaging show nerve root compression at the level corresponding to clinical symptoms? 1, 2
• Objective examination findings: Are there sensory deficits, motor weakness, or positive provocative tests? 1
• Functional impairment: Document specific limitations in activities of daily living 1

Common Pitfalls to Avoid

• Do not perform TFESI for spondylosis without clear radiculopathy: The diagnosis code M47.816 explicitly indicates absence of radiculopathy, which would make TFESI not medically necessary 3
• Do not skip conservative treatment: Performing injections without documented 4-6 week trial of conservative therapy violates guideline recommendations 1
• Do not proceed without imaging correlation: MRI findings must anatomically correspond to clinical presentation 1, 2
• Do not use interlaminar approach without consideration: While both approaches show efficacy, transforaminal allows more targeted delivery 5

Expected Outcomes

When appropriately indicated and performed:

• 59.6% of patients report successful outcomes at one week, 55.8% at one month, 37.2% at one year 6
• 84% success rate at average 1.4-year follow-up for herniated nucleus pulposus with radiculopathy 4
• Significant pain reduction maintained throughout 6 months of follow-up 5
• 60% of patients exceed minimal clinically important difference thresholds at 12 months 7