Is an injection of diagnostic or therapeutic substance(s) into the interlaminar epidural or subarachnoid space, cervical or thoracic, with imaging guidance (CPT 62321) medically indicated for a patient with a diagnosis of Radiculopathy, cervical region (M54.12) and Spinal stenosis, cervical region (M48.02)?

Medical Necessity Assessment for Cervical Epidural Steroid Injection (CPT 62321)

Yes, this cervical interlaminar epidural steroid injection with imaging guidance is medically indicated for this patient with cervical radiculopathy (M54.12) and cervical spinal stenosis (M48.02), provided the patient has failed conservative management and imaging demonstrates nerve root compression correlating with clinical symptoms. 1

Evidence-Based Rationale for Cervical Radiculopathy

Primary Indication Support

• Cervical radiculopathy is characterized by upper limb pain or sensorimotor deficit secondary to cervical nerve root impingement and/or irritation, which can result from spinal stenosis, disc herniation, or spondylarthrosis. 2 The combination of M54.12 (cervical radiculopathy) and M48.02 (cervical spinal stenosis) represents the classic anatomic substrate for epidural steroid injection.

• Epidural steroid injections are strongly recommended specifically for patients with radicular pain or radiculopathy as part of a multimodal treatment regimen. 1 This recommendation applies to both lumbar and cervical radiculopathy, though the evidence base is more robust for lumbar interventions.

• 75% to 90% of cervical radiculopathy patients achieve symptomatic relief with nonoperative conservative therapy, making epidural injection a reasonable intervention before surgical consideration. 2

Critical Prerequisites for Medical Necessity

Conservative Management Failure:

• The patient must have failed at least 4-6 weeks of conservative treatments including physical therapy, NSAIDs, and activity modification before epidural injection is considered. 1 This is a non-negotiable requirement across all major guidelines.

Imaging Correlation:

• MRI evaluation must demonstrate nerve root compression that correlates with the patient's clinical symptoms and examination findings. 1, 3 The diagnosis of cervical radiculopathy cannot be made on MRI alone and must always be interpreted in combination with clinical findings, given frequent false-positive and false-negative MRI findings. 2

• MRI is the preferred initial imaging modality for cervical radiculopathy, providing excellent soft-tissue contrast and accurate depiction of disc degeneration, the thecal sac, neural structures, and nerve root compression. 2, 3

Clinical Presentation Requirements:

• The patient must demonstrate true radicular symptoms (pain radiating into the upper extremity with or without sensory or motor deficits) rather than isolated axial neck pain. 2, 1 Epidural injections are explicitly NOT recommended for non-radicular axial spine pain. 1

Procedural Requirements and Safety Considerations

Mandatory Image Guidance:

• Fluoroscopic guidance must be used for cervical epidural injections to ensure correct needle placement and minimize complications. 1 This is a strong recommendation with high-quality evidence supporting reduced complication rates with image guidance.

Shared Decision-Making:

• The patient must be counseled about potential complications including dural puncture, insertion-site infections, sensorimotor deficits, cauda equina syndrome, discitis, epidural granuloma, and retinal complications. 1 While rare, catastrophic complications including paralysis and death have been reported with epidural steroid injections. 1

Multimodal Treatment Context:

• Epidural injections must be provided as part of a comprehensive pain management program that includes physical therapy, patient education, psychosocial support, and oral medications where appropriate. 1 The injection is not a standalone treatment but rather one component of comprehensive care.

Contraindications and Red Flags

Absolute Contraindications:

• Active systemic infection, particularly spinal infection 2
• Uncorrectable bleeding diathesis 2
• Insufficient cardiopulmonary health to safely tolerate sedation 2

Relative Contraindications:

• Significant spinal canal stenosis or compressive myelopathy resulting from retropulsion of fractured fragment or epidural tumoral extension 2
• Radiculopathy symptoms that are minimal compared to predominant axial neck pain 2

Clinical Pitfalls to Avoid

Imaging-Clinical Mismatch:

• Do not proceed with injection if there is clear disparity between physical examination findings and imaging, or if there is a clear alternative source of neck pain. 2 Degenerative changes on MRI are common in asymptomatic individuals over 30 years of age and correlate poorly with the presence of neck pain. 2

• In a study of 1,581 patients, 53.9% demonstrated disc degenerative changes, with prevalence increasing with age, but the association with clinical symptoms remains unclear. 2

Inappropriate Patient Selection:

• Do not perform epidural injection for isolated axial neck pain without radicular symptoms. 1 The evidence explicitly recommends against epidural injections for non-radicular spine pain.

• Ensure the patient is an actual candidate for intervention before ordering advanced imaging. 1, 3 Imaging should not be performed unless the results will change management.

Expected Outcomes and Follow-Up

Efficacy Data:

• Studies report pain relief for assessment periods ranging from 2 weeks to 3 months following epidural steroid injection. 1 The duration of benefit is variable and patient-specific.

Repeat Injection Criteria:

• Additional therapeutic injections should only be performed if the initial injection resulted in at least 50% pain relief for at least 2 weeks. 1 Repeat injections without documented benefit from prior injections expose patients to unnecessary risk.

Documentation Requirements

Essential Clinical Documentation:

• Duration and character of radicular symptoms (upper extremity pain, numbness, weakness) 2
• Failed conservative management for minimum 4-6 weeks 1
• Physical examination findings including point tenderness, motor/sensory deficits, reflex changes 2
• MRI findings demonstrating nerve root compression at specific level(s) correlating with symptoms 1, 3
• Absence of alternative pain generators (facet arthropathy, shoulder pathology) 1
• Discussion of risks, benefits, and alternatives with patient 1