UnitedHealthcare® Medicare Advantage
Policy Guideline
EPIDURAL INJECTION
Guideline Number: MPG100.02
Table of Contents
Page
INSTRUCTIONS FOR USE .......................................... 1
POLICY SUMMARY .................................................... 1
APPLICABLE CODES ................................................. 2
REFERENCES ........................................................... 2
GUIDELINE HISTORY/REVISION INFORMATION ........... 3
Approval Date: November 9, 2016
Related Medicare Advantage Policy Guideline

Category III CPT Codes
Related Medicare Advantage Coverage Summaries

Pain Management and Pain Rehabilitation

Spine Procedures
INSTRUCTIONS FOR USE
This Policy Guideline is applicable to UnitedHealthcare Medicare Advantage Plans offered by UnitedHealthcare and its
affiliates for health care services submitted on CMS 1500 forms and, when specified, to those billed on UB04 forms
(CMS 1450), or their electronic comparative. The information presented in this Policy Guideline is believed to be
accurate and current as of the date of publication.
This Policy Guideline provides assistance in administering health benefits. All reviewers must first identify member
eligibility, any federal or state regulatory requirements, Centers for Medicare and Medicaid Services (CMS) policy, the
member specific benefit plan coverage, and individual provider contracts prior to use of this Policy Guideline. When
deciding coverage, the member specific benefit plan document must be referenced. The terms of the member specific
benefit plan document may differ greatly from the standard benefit plan upon which this Policy Guideline is based. In
the event of a conflict, the member specific benefit plan document supersedes this Policy Guideline. Other Policies and
Guidelines may apply. UnitedHealthcare reserves the right, in its sole discretion, to modify its Policies and Guidelines
as necessary.
UnitedHealthcare follows Medicare coverage guidelines and regularly updates its Medicare Advantage Policy Guidelines
to comply with changes in CMS policy. UnitedHealthcare encourages physicians and other healthcare professionals to
keep current with any CMS policy changes and/or billing requirements by referring to the CMS or your local carrier
website regularly. Physicians and other healthcare professionals can sign up for regular distributions for policy or
regulatory changes directly from CMS and/or your local carrier. This Policy Guideline is provided for informational
purposes. It does not constitute medical advice.
POLICY SUMMARY
Overview
The physician injects an anesthetic agent and/or a long-acting corticosteroid into the area between the protective
covering of the spinal cord (dura) and the bony vertebrae of the cervical, thoracic, lumbar, or sacral spine. Nerve
roots enter the body after exiting the spinal canal through tiny openings between the vertebrae (foraminae). Using
ultrasound guidance, the physician injects the appropriate substance between the foraminae into the area around a
selected nerve root.
Guidelines
The following list of examples is not all inclusive of the indications for injections of the spinal canal:

Intervertebral disc disease (with neuritis, radiculitis, sciatica) with or without myelopathy;

Complex regional pain syndrome;

Post herpetic neuralgia;

Traumatic neuropathy of the spinal nerve roots;

Postlaminectomy syndrome (failed back syndrome);

Chronic severe pain due to carcinoma;

Acute and chronic postoperative pain;

Chronic upper and lower extremity radicular symptoms (i.e., spinal stenosis).
Prior to any interventional pain procedure and regardless of the longevity of pain (i.e., acute, subacute, chronic, etc.),
a patient must have failed to respond to conservative management. Examples of conservative management include
physical therapy modalities, chiropractic manipulation, and medication management. The fact that a patient has
chronic pain does not preclude the option of a retrial of conservative management at some point during their care.
Epidural Injection
Page 1 of 3
UnitedHealthcare Medicare Advantage Policy Guideline
Approved 11/09/2016
Proprietary Information of UnitedHealthcare. Copyright 2016 United HealthCare Services, Inc.
Although conservative management should be attempted, this requirement may be waived for the infrequent patient
who is unable to tolerate it.
The use of fluoroscopic or computed tomographic (CT) guidance is required when performing injections of the spinal
canal.
Transforaminal epidural injections with ultrasound guidance (CPT codes 0228T-0231T) will be denied as
investigational.
APPLICABLE CODES
The following list(s) of codes is provided for reference purposes only and may not be all inclusive. Listing of a code in
this guideline does not imply that the service described by the code is a covered or non-covered health service.
Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws
that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or
guarantee claim payment. Other Policies and Guidelines may apply.
CPT Code
0228T
Description
Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with
ultrasound guidance, cervical or thoracic; single level
0229T
Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with
ultrasound guidance, cervical or thoracic; each additional level (List separately in
addition to code for primary procedure)
0230T
Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with
ultrasound guidance, lumbar or sacral; single level
0231T
Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with
ultrasound guidance, lumbar or sacral; each additional level (List separately in
addition to code for primary procedure)
CPT® is a registered trademark of the American Medical Association
REFERENCES
CMS Local Coverage Determinations (LCDs)
LCD
Medicare Part A
®
L33392 (Category III CPT Codes)
CT, IL, MA, ME, MN, NH, NY, RI, VT,
NGS
WI
L34555 (Non-Covered Category III
CPT Codes) Palmetto
Medicare Part B
CT, IL, MA, ME, MN, NH, NY, RI, VT,
WI
NC, SC, VA, WV
L33777 (Noncovered Services) First
Coast
FL, PR, VI
FL, PR, VI
L35094 (Services That Are Not
Reasonable and Necessary) Novitas
AR, CO, DC, DE, LA, MD, MS, NM,
NJ, OK, PA, TX
AR, CO, DC, DE, LA, MD, MS, NM,
NJ, OK, PA, TX
L34291 (Surgery: Injections of the
Spinal Canal) Cahaba
AL, GA, TN
AL, GA, TN
L25275 (Category III CPT® Codes)
NGS Retired 09/30/2015
CT, IL, MA, ME, MN, NH, NY, RI, VT,
WI
CT, IL, MA, ME, MN, NH, NY, RI, VT,
WI
L31686 (Services That Are Not
Reasonable and Necessary) Novitas
Retired 09/30/2015
DC, DE, MD, NJ, PA
DC, DE, MD, NJ, PA
L29288 (Noncovered Services) FC
Retired 09/30/2015
FL
FL
L29398 (Noncovered Services) FC
Retired 09/30/2015
PR, VI
PR, VI
L28991 (Noncovered Services) FC
Retired 09/30/2015
FL
FL
L29023 (Noncovered Services) FC
Retired 09/30/2015
PR, VI
PR, VI
Epidural Injection
Page 2 of 3
UnitedHealthcare Medicare Advantage Policy Guideline
Approved 11/09/2016
Proprietary Information of UnitedHealthcare. Copyright 2016 United HealthCare Services, Inc.
LCD
L31711 (Non-Covered Category III
CPT Codes) Palmetto
Retired 09/30/2015
Medicare Part A
L32112 (Surgery: Injections of the
Spinal Canal) Cahaba
Retired 09/30/2015
AL, GA, TN
Medicare Part B
NC, SC, VA, WV
AL, GA, TN
L33683 (Category III CPT Codes)
Noridian Retired 07/08/2015
AS, CA, GU, HI, MP, NV
CMS Articles
Article
A52796 (CPT Category III Non
Covered and Covered Codes)
Noridian Retired 03/01/2016
Medicare Part A
AK, AZ, ID, MT, ND, OR, SD, UT, WA,
WY
Medicare Part B
AK, AZ, ID, MT, ND, OR, SD, UT, WA,
WY
A52794 (Coverage and NonCoverage of CPT Category III Codes)
Noridian Retired 03/01/2016
AS, CA, GU, HI, MP, NV
AS, CA, GU, HI, MP, NV
A52792 (Coverage and NonCoverage of CPT Category III Codes)
Noridian Retired 03/01/2016
AS, CA, GU, HI, MP, NV
AS, CA, GU, HI, MP, NV
A52797 (CPT Category III Non
Covered and Covered Codes)
Noridian Retired 03/01/2016
AK, AZ, ID, MT, ND, OR, SD, UT, WA,
WY
AK, AZ, ID, MT, ND, OR, SD, UT, WA,
WY
A52790 (Coverage and NonCoverage of CPT Category III Codes)
Noridian Retired 09/30/2015
AS, CA, GU, HI, MP, NV
AS, CA, GU, HI, MP, NV
A52082 (CPT Category III Non
Covered and Covered Codes)
Noridian Retired 09/30/2015
AK, AZ, ID, MT, ND, OR, SD, UT, WA,
WY
AK, AZ, ID, MT, ND, OR, SD, UT, WA,
WY
A52083 (CPT Category III Non
Covered and Covered Codes)
Noridian Retired 09/30/2015
AK, AZ, ID, MT, ND, OR, SD, UT, WA,
WY
AK, AZ, ID, MT, ND, OR, SD, UT, WA,
WY
MLN Matters
Article SE1102, Inappropriate Medicare Payments for Transforaminal Epidural Injection Services
UnitedHealthcare Commercial Policies
Epidural Steroid and Facet Injections for Spinal Pain
GUIDELINE HISTORY/REVISION INFORMATION
Date
11/09/2016
Action/Description

Annual review
Epidural Injection
Page 3 of 3
UnitedHealthcare Medicare Advantage Policy Guideline
Approved 11/09/2016
Proprietary Information of UnitedHealthcare. Copyright 2016 United HealthCare Services, Inc.