Is a transforaminal epidural steroid injection (64483) medically necessary for a patient with spinal stenosis of the lumbar region (M46.061)?

Medical Necessity Determination for Transforaminal Epidural Steroid Injection (CPT 64483)

This transforaminal epidural steroid injection is NOT medically necessary because the patient has spinal stenosis without documented radiculopathy (M48.061 explicitly excludes neurogenic claudication), and critical medical necessity criteria have not been met, specifically the absence of documented failure of conservative therapy including physical therapy. 1

Critical Missing Documentation

Absence of Radicular Pain Documentation

• The diagnosis code M48.061 specifically indicates "spinal stenosis, lumbar region WITHOUT neurogenic claudication," which fundamentally disqualifies this patient for epidural steroid injection. 1, 2
• The American Society of Anesthesiologists strongly recommends epidural steroid injections specifically for patients with radicular pain or radiculopathy, NOT for non-radicular back pain from spinal stenosis alone. 3, 1, 2
• Radicular pain must be defined as pain and/or numbness that radiates below the knee to meet authorization criteria. 1, 4
• The 2025 BMJ guideline provides a strong recommendation against epidural injections for chronic axial spine pain without radiculopathy, stating "all or nearly all well-informed people would likely not want such interventions." 3

Inadequate Conservative Treatment Documentation

• The American College of Physicians strongly recommends that patients must fail at least 4-6 weeks of conservative treatments, including physical therapy, NSAIDs, and activity modification, before considering epidural injections. 1
• The current documentation shows only pregabalin medication and prior epidural injections, but no evidence of physical therapy trial. 1
• MCG criteria require failure of noninvasive treatment (NSAIDs, exercise, physical therapy, spinal manipulation therapy), which is UNCLEAR IF MET based on the documentation provided. 1

Insufficient Physical Examination Documentation

• The documentation lacks critical examination findings including straight leg raise testing, neurological examination (motor strength, sensory deficits, reflex testing), and specific dermatomal distribution of symptoms. 1
• The prior authorization denial (MR [ID]) specifically cited "Insufficient PE, other potential causes of pain being ruled out not documented." 1

Guideline-Based Medical Necessity Criteria NOT Met

Radiculopathy Requirement

• The American College of Occupational and Environmental Medicine guideline explicitly recommends AGAINST lumbar epidural injections for spinal stenosis in the absence of significant radicular symptoms. 3, 1
• The American Academy of Neurology explicitly recommends against epidural steroid injections for non-radicular low back pain, as evidence is limited. 1
• The 2022 American Society of Pain and Neuroscience guideline recommends epidural injections for chronic low back pain due to disc disease, spinal stenosis, or post-surgical syndrome, but this is contradicted by higher quality 2025 BMJ evidence showing strong recommendation AGAINST such injections for non-radicular pain. 3

Imaging Correlation Requirement

• While the patient has MRI evidence of L4-L5 stenosis with foraminal stenosis, the clinical documentation does not establish clear correlation between imaging findings and radicular symptoms below the knee. 1
• The British Pain Society emphasizes that imaging findings must correlate with clinical presentation, which is not adequately documented here. 1

Evidence Regarding Prior Injection Response

Requirement for Documented Benefit

• The Spine Intervention Society's appropriate use criteria explicitly state that repeat injection with steroid is appropriate ONLY if there was at least 50% relief for at least 2 months after the first injection. 1
• The documentation states "Reports at least 70% relief with epidural steroid injections in the past," but the prior authorization (MR [ID]) was non-certified due to "no documentation of >70% pain relief from prior injection." 1
• The American Society of Anesthesiologists requires that additional therapeutic TFESIs should only be performed if the initial injection resulted in at least 50% pain relief for at least 2 weeks. 1

Safety and Risk Considerations

Procedural Risks Without Clear Benefit

• Transforaminal epidural injections carry significant risks including dural puncture, insertion-site infections, cauda equina syndrome, sensorimotor deficits, discitis, epidural granuloma, retinal complications, and rare catastrophic complications including paralysis and death. 3, 1, 4
• The transforaminal approach requires particular attention to technique due to its higher risk profile compared to interlaminar approaches. 1, 4
• Exposing the patient to these risks without documented radiculopathy and without documented failure of conservative therapy is not justified. 1

Evidence Quality Assessment

Long-Term Efficacy Concerns

• The 2022 JAMA review states that "long-term benefits of epidural steroid injections for lumbar spinal stenosis have not been demonstrated." 5
• Observational studies show variable outcomes: one study reported 32% surgery rate at 2 years after TFESI for stenosis 6, while another showed no difference between transforaminal and interlaminar approaches 7
• Studies demonstrate better outcomes with mild-to-moderate stenosis (87.1% success) versus severe stenosis (42.3% success) at 3 months, but this patient's stenosis severity and radicular component are not adequately characterized. 8

Alternative Diagnostic Considerations

Sacroiliac Joint Pathology

• The prior authorization history shows a request for sacroiliac joint injections (27096 x2) for M46.08 (spinal enthesopathy, sacral region), suggesting alternative pain generators. 1
• If sacroiliac joint provocation tests are positive, diagnostic sacroiliac joint injection should be considered before proceeding with epidural injections. 1

Facet-Mediated Pain

• The MRI shows "multilevel disc bulge and facet arthropathy at L1-L2, L2-L3, L3-L4, and L5-S1," which could be the primary pain generator rather than nerve root compression. 1
• The 2025 BMJ guideline provides a strong recommendation in favor of conventional or cooled lumbar radiofrequency ablation for low back pain, which may be more appropriate for facet-mediated pain. 1

Required Documentation for Medical Necessity

To establish medical necessity, the following must be documented:

1. Radicular pain radiating below the knee with specific dermatomal distribution 1, 4
2. Positive straight leg raise test or other radiculopathy signs (motor weakness, sensory deficits, reflex changes) 1
3. Documented failure of at least 4-6 weeks of physical therapy 1
4. Documented failure of NSAIDs and activity modification 1
5. Clear correlation between MRI findings and clinical radicular symptoms 1
6. Objective documentation of >50% pain relief lasting >2 months from prior epidural injection if this is a repeat procedure 1
7. Exclusion of alternative pain generators (sacroiliac joint, facet joints, hip pathology) 1

Experimental/Investigational Determination

This procedure is NOT experimental or investigational per se, but it is NOT MEDICALLY NECESSARY for this patient's documented condition (spinal stenosis without radiculopathy). 3, 1

• Transforaminal epidural steroid injections are an established procedure with CPT code 64483 and are included in MCG guidelines. 1
• However, the 2025 BMJ guideline notes significant variability in guideline recommendations, with some guidelines providing strong recommendations in favor and others providing strong recommendations against the same procedures. 3
• The procedure is considered standard of care for radicular pain/radiculopathy but is explicitly NOT recommended for non-radicular spinal stenosis pain. 3, 1

Recommendation Algorithm

DENY this request based on:

1. Diagnosis code explicitly excludes radiculopathy (M48.061 without neurogenic claudication) 1, 2
2. Insufficient documentation of conservative therapy failure, specifically physical therapy 1
3. Inadequate physical examination documentation to establish radiculopathy 1
4. Unclear documentation of benefit from prior injections despite patient report 1

Request the following information for reconsideration:

1. Corrected diagnosis code if radiculopathy is present (M48.062 if neurogenic claudication exists) 1
2. Documentation of 4-6 weeks of physical therapy with specific dates, frequency, and response 1
3. Complete neurological examination including motor strength testing, sensory examination with dermatomal mapping, reflex testing, and straight leg raise results 1
4. Objective documentation from prior injection records showing percentage pain relief and duration of benefit 1
5. Documentation excluding alternative pain generators (sacroiliac joint examination, hip examination) 1