Pain Management Prior Authorization and Denial Guide

Prior authorization requirements, step-therapy documentation criteria, and appeal frameworks for interventional pain procedures: epidural steroid injections, facet joint blocks, medial branch blocks, radiofrequency ablation, spinal cord stimulation, and nerve blocks. Grounded in operative Aetna CPBs, UHC CDGs, Cigna MCPs, eviCore Pain Management criteria, and CMS Local Coverage Determinations for pain management procedures.

Epidural steroid injections (CPT 62321, 62323, 64483, 64484) require prior authorization from most commercial payers. Most payers limit coverage to 3 injections per spinal region per year. Documentation must include MRI or CT confirming the structural pathology (herniated disc, spinal stenosis, foraminal stenosis), the dermatomal or radicular distribution of symptoms correlating with the imaging findings, and evidence that conservative treatment (physical therapy, oral medications) has been tried. Repeat injections within the same region typically require documentation of functional improvement from the prior injection.

Spinal cord stimulation (CPT 63650, 63685) requires prior authorization from all payers and a trial period with documented success criterion. Aetna and UHC require documented failure of at least 6 months of conservative care, a psychological evaluation clearing the patient for implant, and a trial period of 3–7 days with at least 50% pain reduction demonstrated before permanent implant approval. Radiofrequency ablation (CPT 64633–64636) requires documentation of positive response to diagnostic medial branch block injections (typically two diagnostic blocks with 50–80% pain relief depending on payer).

• All specialty guides
• Appeal Letter Builder
• Neurosurgery guide — spinal surgery prior auth