Epidural Steroid Injections Under WISeR: The Documentation Checklist

Which codes are covered

The service follows three Local Coverage Determinations: L39015, L39240 and L36920. WISeR covers codes 62321, 62323, 64479, 64480, 64483 and 64484 (Appendix A, Table A10). Code 62323 needs WISeR review only when it is used for an epidural steroid injection. Used for anything else, such as implanting an intrathecal pump, it does not (Section 6.2.10). The diagnosis codes that support medical necessity are in your MAC’s Local Coverage Article for these LCDs.

The documentation checklist

Before you send the request, the record should show each of these (Section 6.2.10):

1. A qualifying diagnosis

History, physical exam and imaging showing one of:

• Radiculopathy, radicular pain or neurogenic claudication in the lumbar, cervical or thoracic spine, from disc herniation, osteophytes or severe degenerative disc disease causing foraminal or central stenosis
• Post-laminectomy syndrome: persistent or recurrent pain after earlier spine surgery
• Acute herpes zoster pain

2. Severity, measured the same way every time

• Pain severe enough to greatly affect quality of life or function
• An objective pain scale or functional assessment recorded at baseline, before any intervention
• The same scale repeated at every follow-up

3. Duration and conservative care

• Pain for at least 4 weeks, and either the patient cannot tolerate noninvasive conservative care or 4 weeks of it failed
• For acute herpes zoster that does not respond to conservative care, the 4-week wait does not apply

4. How many sessions

• The anticipated number of sessions, four or fewer per spinal region in a rolling 12 months
• For a repeat session: at least 50% sustained improvement in pain or function from baseline, on the same scale, for at least 3 months
• If the first injection underperforms, a repeat after 14 days may be done with a different approach, level or medication and a clear rationale

5. The plan for the procedure

• The image guidance to be used: fluoroscopy or CT with contrast. With a documented contrast allergy or pregnancy, ultrasound without contrast may be considered.
• The planned approach, levels and regions. Transforaminal injections up to two levels in one region; interlaminar or caudal up to one level in one region; bilateral transforaminal only when clinically indicated, such as documented bilateral foraminal stenosis.
• Moderate or deep sedation, general anesthesia or monitored anesthesia care only in exceptional cases, with the patient-specific reason documented

6. Treatment alongside the injection

• The injection is given together with conservative treatment, such as medication, physical therapy, spinal manipulation, cognitive behavioral therapy or a home exercise program
• The patient is in an active rehabilitation, home exercise or functional restoration program

7. No contraindications

• An assessment documenting none of: active localized spinal or systemic infection, compressive lesions of the spinal cord, or conus medullaris or cauda equina

Where requests usually fall short

Reading the list, a few items are easy to miss because they depend on what was recorded weeks earlier:

• No baseline score. The pain or function scale has to be recorded before the first intervention, then repeated on the same scale.
• Different scales at different visits. A repeat session needs improvement measured on the same scale.
• Session count not stated. The anticipated number of sessions per region belongs in the request.
• Image guidance and levels not named. The plan must say which guidance and which levels.
• Conservative care described but not dated. The 4 weeks have to be visible in the record.

Check it before you send it

MedMojo™ turns this list into a pre-flight check on the request itself: each requirement shows as met, missing or needing confirmation, with its source, before the request goes out. When a non-affirmation comes back, its list of missing items maps straight onto the same rows. Complete requests mean fewer non-affirmations, and every approval moves your doctors closer to exemption.