Epidural Steroid Injection Denied: How to Strengthen Medical Necessity and Appeal

When an insurance company denies an epidural steroid injection, the denial often sounds final: “not medically necessary,” “criteria not met,” or “insufficient documentation.” In reality, many denials are not a judgment that you do not hurt—they are a judgment that your chart does not clearly prove the insurer’s required elements.

Most insurers approve epidural steroid injections primarily for radicular pain (pain traveling along a nerve root into an arm or leg) supported by clinical findings and usually imaging, not for isolated “axial” neck pain or low back pain without nerve features. Recent payer policies spell this out clearly. For example, UnitedHealthcare’s commercial policy states epidural steroid injections are medically necessary when the injection is intended for radicular pain as evidenced by history and physical examination and other criteria are met. ^[1] Similar “medical necessity checklists” appear in other payer criteria documents. ^{[2, 3]}

This article shows you the exact details insurers look for—and how to assemble an appeal packet that has a real chance of approval.

Before writing an appeal, identify which bucket your denial falls into:

1. Medical necessity denial (most common)
2. Missing documentation (the right info wasn’t submitted)
3. Prior authorization issue (authorization expired or was never obtained)
4. Benefit limitation (frequency limits, too many injections too soon, wrong level/region)
5. Technique or setting issue (image guidance required; wrong approach; non-covered drug or method)

Medicare coverage policies, for example, commonly require image guidance (fluoroscopy or computed tomography guidance) with limited exceptions, and may treat injections without image guidance as not medically reasonable and necessary. ^[4] Commercial policies also frequently require image guidance and set limits on how many injection sessions are allowed per episode or per time window. ^{[3, 4]}

Below are the denial reasons that show up again and again, with the exact “fix” your appeal needs.

Insurers usually want documentation of radicular pain features such as:

• pain radiating below the knee (lumbar) or into the arm/hand (cervical)
• dermatomal distribution
• numbness/tingling in a nerve-root pattern
• weakness in a specific muscle group
• positive nerve tension signs when appropriate
• functional limitation tied to nerve symptoms

Payer policies explicitly emphasize radicular pain rather than non-specific spinal pain. ^{[1, 2]}

Appeal fix: Your clinician’s note must clearly state radicular symptoms and match them to exam findings (see the “medical necessity details” section below).

Many policies require imaging evidence that supports nerve root compression or a pain generator consistent with your symptoms—often magnetic resonance imaging or computed tomography. Medicare contractor guidance often expects concordant radiologic testing along with history and physical examination. ^[5] Commercial guidelines may specify imaging recency windows or accept exceptions in narrowly defined cases. ^[6]

Appeal fix: Attach the relevant imaging report(s), highlight the exact level (for example, lumbar L4-L5) and the finding (for example, disc herniation with nerve root impingement) and ensure the requested injection level matches the imaging and symptoms.

A denial often happens because the note says “pain radiating” but does not document the objective exam: strength, reflexes, sensation, gait, or specific nerve root signs.

Appeal fix: Ask your clinician to document (or add an addendum with) objective findings:

• strength deficits (for example, ankle dorsiflexion weakness)
• reflex asymmetry
• sensory loss pattern
• gait abnormality
• straight leg raise testing or other nerve root irritation signs if applicable

Most payer criteria require a trial of conservative management such as physical therapy, activity modification, and medication trials—unless there is a more urgent neurologic indication. Many utilization management guidelines specify minimum durations unless radiculopathy is clearly documented. ^[6]

Appeal fix: Provide a dated conservative care timeline:

• physical therapy start and end dates + response
• medication trials and intolerance/contraindications
• activity modification and home exercise
• work restrictions attempted
• documented persistence of function-limiting radicular symptoms

Many insurers limit the number of epidural steroid injection sessions per episode or per region and require evidence of meaningful benefit before repeating. Excellus BlueCross BlueShield’s policy, for example, describes limits such as a total number of sessions per episode/time window and includes guidance on repeat use when criteria are met. ^[3]

Appeal fix: If this is a repeat injection request, include:

• the date(s) of prior epidural steroid injections
• documented percent pain reduction and functional improvement
• how long benefit lasted
• why another injection is clinically appropriate now

Some policies explicitly state injections are not recommended for low back pain in the absence of significant radicular symptoms, reflecting evidence reviews and guideline summaries. ^[1]

Appeal fix: If you truly have radicular symptoms, the note must show them. If you do not, your clinician may need to consider other covered pathways (targeted rehabilitation, evaluation of other pain generators, or different injections depending on diagnosis).

The United States Food and Drug Administration warns that epidural corticosteroid injections have been associated with rare but serious neurologic problems and that corticosteroids are not approved by the Food and Drug Administration for epidural administration. ^[7] Separately, payers may require fluoroscopic or computed tomography guidance and may deny injections performed without appropriate imaging guidance except for specific contraindications. ^[4]

Appeal fix: Ensure the authorization request states the planned approach (for example, transforaminal vs interlaminar vs caudal), image guidance method, and safety plan (contrast use unless contraindicated).

A strong appeal packet proves these six elements. If even one is missing, denials are far more likely.

Most insurer criteria focus on radicular pain caused by conditions such as disc herniation or spinal stenosis with nerve root involvement. ^{[1, 2, 8]} Evidence reviews note epidural steroid injections can provide short-term relief for radicular pain in some patients, though long-term benefit is less certain. ^{[8, 9, 10]}

Your documentation should include:

• radicular pain distribution and severity
• functional limitations (walking tolerance, sitting tolerance, sleep disruption, ability to work)
• duration and progression (when it started, whether it is worsening)

Insurers respond to objective findings, not only reported pain. Examples to document (as appropriate):

• motor weakness in a myotomal pattern
• sensory loss in a dermatomal pattern
• reflex changes
• positive straight leg raise test (lumbar radicular pain)
• gait changes or foot drop red flags

Attach the imaging report and make the link obvious. Some payer policies and clinical discussions note that imaging timing requirements vary by guideline and policy, and in certain cases imaging may not be “mandated,” but insurers frequently expect it for authorization. ^{[6, 11]}

This is where many requests fail. The note must show what was tried, for how long, and what happened.

Include:

• physical therapy dates and outcome (no improvement, partial improvement, worsening)
• medication trials (anti-inflammatory drugs, neuropathic pain agents when appropriate, reasons stopped)
• activity modification and home program
• the clinician’s rationale for moving to an epidural steroid injection now

Insurers want to see that the injection is intended to help you resume function: walking, sleep, work, or rehabilitation progress.

Short-term benefit is often the objective—many evidence reviews emphasize that benefit tends to be greatest in the short term for radiculopathy. ^{[9, 10]}

If this is a repeat request, show:

• prior injection benefit and duration
• why the next injection is reasonable now
• confirmation it is within policy limits (or an explanation for an exception) ^[3]

Think of your appeal packet as three layers: a clean patient cover letter, clinician documentation, and policy alignment.

Include:

• your name, policy ID, claim number, denial date
• the exact service denied (epidural steroid injection, level/region)
• a 4–6 sentence summary proving the six medical necessity elements above
• list of attachments
• your request: overturn denial and approve the injection

Ask your clinic to include:

1. A medical necessity letter (brief but specific):
   • diagnosis and radicular symptoms
   • objective exam findings
   • imaging findings and level match
   • conservative care tried with dates and failure
   • functional impairment and goals
   • planned technique and image guidance
2. Recent office visit note with full neurologic examination
3. Imaging report(s) (magnetic resonance imaging or computed tomography)
4. Physical therapy notes (initial evaluation + progress/discharge summary)
5. Medication trial history and intolerance/contraindications if relevant
6. If repeat injection: prior response documentation and timeline

If your insurer used a specific medical policy, respond point-by-point. Use insurer language such as “radicular pain evidenced by history and physical examination” (or similar wording) because that is how utilization management decisions are made. ^{[1, 2]}

Many denials are overturned quickly when the treating clinician speaks directly with the insurer’s reviewing clinician and addresses the exact missing element (imaging match, exam detail, conservative care duration).

Healthcare.gov explains that if an insurer refuses to pay for a service, you have the right to appeal and the insurer must tell you why it denied and how you can dispute it. ^[12] Their internal appeals guidance also emphasizes submitting additional information such as a letter from the doctor. ^[13]

Healthcare.gov states you generally must request external review within four months of receiving a notice or final determination, and the insurer is required by law to accept the external reviewer’s decision. ^[14]

Federal guidance also explains plans must provide notice of internal appeals and external review rights and time limits. ^[15]

Subject: Appeal of Denial for Epidural Steroid Injection (Claim/Authorization #______)

To Whom It May Concern,

I am appealing the denial dated ______ for an epidural steroid injection ordered by ______ for severe, function-limiting radicular pain.

This epidural steroid injection is medically necessary because:

1. My symptoms are consistent with radicular pain documented by history and objective examination findings (see attached clinician note and neurologic examination).
2. Imaging findings are concordant with symptoms and support nerve root involvement at the requested spinal level (see attached imaging report).
3. I have completed a documented trial of conservative treatment including ______ from ______ to ______ with persistent functional impairment (see attached physical therapy records and treatment history).
4. The purpose of the injection is to improve function (walking tolerance/sleep/return to work/rehabilitation progress) and guide the next step in care.

Enclosed documents include:

• Medical necessity letter from treating clinician
• Recent clinic note with neurologic examination
• Imaging report(s)
• Physical therapy records and conservative care timeline
• Prior injection response documentation (if applicable)

I request that you overturn the denial and approve the epidural steroid injection.

Sincerely,

[Your Name]
[Phone] / [Email]

The United States Food and Drug Administration has warned about rare but serious neurologic events reported after epidural corticosteroid injections, including stroke, paralysis, and death, and notes corticosteroids are not approved by the Food and Drug Administration for epidural use. ^[7] A New England Journal of Medicine perspective also discussed serious neurologic events and the regulatory context following Food and Drug Administration communications. ^[16]

This does not mean epidural steroid injections are never appropriate—but it explains why payers emphasize:

• appropriate patient selection (radicular pain and concordant findings)
• image guidance requirements in coverage policies ^[4]
• careful documentation and monitoring

Severity alone is often not enough. Insurers typically want proof of radicular pain, objective exam findings, imaging that matches the requested level, a documented conservative care trial, and a function-based goal. ^{[1, 2, 5]}

Policies vary. Some clinical discussions note imaging may not be “mandated” by every guideline in every situation, but insurers often expect recent imaging to confirm the target level and diagnosis when authorizing injections. ^{[5, 6]}

A detailed clinician note (or medical necessity letter) that ties together radicular symptoms, neurologic exam findings, concordant imaging, conservative treatment failure, functional impairment, and the planned technique with image guidance. ^{[1, 4, 5]}

You may be eligible for external review by an independent reviewer. Healthcare.gov explains the external review must generally be requested within four months and that the insurer must accept the decision. ^[14]

Most epidural steroid injection denials can be improved by submitting a criteria-complete packet. Focus on what insurers actually decide on:

• radicular pain documented by history and exam ^{[1, 2]}
• objective neurologic findings
• imaging that matches symptoms and the injection level ^[5]
• conservative care tried with dates and outcomes ^[6]
• function-based goals
• repeat injection rules (documented benefit + frequency limits) ^[3]

When you present that clearly—and escalate through peer-to-peer review, internal appeal, and external review when needed—you dramatically improve your odds of approval. ^{[13, 14]}

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