Medical Necessity Assessment: Thoracic Transforaminal Epidural Steroid Injections (CPT 64479,64480) for M54.6 (Pain in Thoracic Spine)
Primary Recommendation
Based on current evidence-based guidelines, these thoracic transforaminal epidural steroid injections were NOT medically necessary because the diagnosis code M54.6 (pain in thoracic spine) represents axial spine pain without documented radiculopathy, and guidelines explicitly recommend against epidural steroid injections for non-radicular spine pain. 1, 2
Critical Deficiencies in Medical Necessity Documentation
Missing Radiculopathy Documentation
The diagnosis code M54.6 specifically excludes radiculopathy, which is the primary indication for transforaminal epidural steroid injections. 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. 1, 2
The American Academy of Neurology explicitly recommends against epidural steroid injections for non-radicular spine pain, as evidence for their use is limited. 1
The clinical documentation states "bilateral thoracic chest wall and back pain" following "T10, T11, T12 dermatomes," but dermatomal pain distribution alone does not establish radiculopathy—objective neurological findings are required. 1
Insufficient Objective Neurological Examination
The documentation states "no new changes" on examination but fails to document the critical objective findings required for radiculopathy diagnosis:
No documentation of motor weakness in specific myotomal distributions (required per criteria). 1
No documentation of sensory deficits to light touch, pressure, or pinprick in dermatomal distributions (required per criteria). 1
No documentation of reflex changes (diminished, absent, or asymmetric reflexes required per criteria). 1
The statement "outlines pain which predominantly follows the bilateral T10, T11, T12 dermatomes" describes subjective pain distribution, not objective sensory examination findings. 1
Inadequate Conservative Treatment Documentation
The American College of Physicians strongly recommends at least 4-6 weeks of documented conservative therapy before considering epidural injections. 1
While the documentation mentions "at least six weeks of conservative care," it lacks specific details about:
- Duration and frequency of physical therapy sessions
- Specific medications tried, dosages, and duration
- Response to each conservative modality
- Reasons for failure or intolerance 1
Thoracic-Specific Evidence Concerns
Limited Efficacy Data for Thoracic Injections
A multicenter study of thoracic transforaminal epidural steroid injections showed only 30% of patients achieved ≥50% pain relief at short-term follow-up, which is substantially lower than success rates for cervical and lumbar regions. 3
The same study found only 42% experienced at least a 2-point improvement in pain scores, with median improvement of only -1 point on the numeric rating scale. 3
This represents the largest series reporting outcomes from thoracic TFESI to date, and the observed success rate was notably low. 3
Guideline-Based Medical Necessity Criteria NOT Met
Diagnostic TFESI Criteria (Not Met)
For diagnostic transforaminal epidural steroid injections, guidelines require:
Classic mono-radicular pain with radiological abnormality related to an adjacent nerve root—bilateral pain at multiple levels does not meet this criterion. 1
Uncertainty in diagnosis after standard evaluation—the documentation does not indicate diagnostic uncertainty requiring selective nerve root blocks. 1
Therapeutic TFESI Criteria (Not Met)
For therapeutic transforaminal epidural steroid injections, guidelines require:
Documented radiculopathy with objective neurological findings (motor weakness, sensory deficits, or reflex changes)—not documented. 1
Radicular pain consistent with radiologic findings—while imaging may show abnormalities, the diagnosis code M54.6 explicitly indicates absence of radiculopathy. 1, 2
Pain radiating in a dermatomal distribution with functional limitations—subjective pain distribution alone is insufficient without objective neurological signs. 1
Risk-Benefit Analysis
Significant Procedural Risks
Transforaminal epidural injections carry risks including dural puncture, insertion-site infections, cauda equina syndrome, sensorimotor deficits, discitis, epidural granuloma, and rare catastrophic complications including paralysis and death. 1
Thoracic transforaminal injections may carry unique anatomical risks given the narrow thoracic spinal canal and proximity to the spinal cord. 3
Exposing patients to these risks without meeting evidence-based indications is not justified. 1, 2
Limited Expected Benefit
With only 30% success rate for thoracic TFESI even in appropriate candidates, performing the procedure for non-radicular pain (where guidelines recommend against it) has minimal likelihood of benefit. 3
The 2025 BMJ guideline provides a strong recommendation against epidural injections for chronic axial spine pain, stating "all or nearly all well-informed people would likely not want such interventions." 1
Alternative Diagnostic Considerations
Facet-Mediated Pain
Bilateral thoracic pain without radiculopathy suggests facet joint pathology rather than nerve root compression. 4
Facet injections or medial branch blocks would be more appropriate diagnostic and therapeutic interventions for axial thoracic spine pain. 4
Other Pain Generators
- Thoracic discogenic pain without radiculopathy
- Costovertebral or costotransverse joint pathology
- Intercostal neuralgia (which would require different diagnostic codes and treatment approaches)
- Myofascial pain syndrome 4
Documentation Requirements for Future Authorization
If transforaminal epidural steroid injections are reconsidered, the following must be documented:
Objective Neurological Findings
Specific motor weakness in named muscles or myotomal distributions with manual muscle testing grades 1
Sensory deficits documented with specific testing modalities (light touch, pinprick, temperature) in dermatomal distributions 1
Reflex examination with specific documentation of diminished, absent, or asymmetric reflexes 1
Appropriate Diagnosis Code
M54.14 (Radiculopathy, thoracic region) rather than M54.6 (Pain in thoracic spine) 1
Correlation between clinical radiculopathy and imaging findings demonstrating nerve root compression 1
Conservative Treatment Failure
Minimum 4-6 weeks of documented physical therapy with specific exercises, frequency, and response 1
Trial of NSAIDs with specific medications, dosages, duration, and reasons for discontinuation if applicable 1
Activity modification attempts and their outcomes 1
Imaging Correlation
MRI or CT demonstrating nerve root compression at the specific levels corresponding to clinical symptoms 1
Radiologist report confirming pathology at T10, T11, T12 levels 1
Common Pitfalls to Avoid
Do not equate dermatomal pain distribution with radiculopathy—objective neurological signs are required. 1
Do not perform epidural injections for axial spine pain regardless of severity or chronicity. 1, 2
Do not use bilateral multi-level injections when guidelines specify mono-radicular pain for diagnostic purposes. 1
Do not proceed with therapeutic injections without documented objective neurological findings consistent with radiculopathy. 1, 2
Do not ignore alternative pain generators such as facet joints when clinical presentation suggests mechanical rather than radicular pain. 4, 1