How to Get Insurance to Cover an Epidural Steroid Injection

Written by Aptiva Health Editorial Team · Medically reviewed by Thomas Huhn, MD · Reviewed by Crystal Brake, RCM Director · Editorial & review standards · How we research

An epidural steroid injection (ESI) places anti-inflammatory medicine near irritated spinal nerves. It is often used for pain that travels down an arm or leg, such as sciatica, from conditions like a herniated disc or spinal stenosis.

Injections are a common target for prior authorization and medical-necessity review. This guide explains what plans usually look for, how repeat injections are handled, and how to appeal a denial. It is part of the Coverage & Appeals Center.

Why injections get denied

• Not medically necessary. The records didn’t show the plan’s criteria. See not medically necessary denials.
• No prior authorization, or approval for a different level or approach. See missing prior authorization.
• Repeat injection not supported. The plan wants proof an earlier injection helped.
• Too many injections. The plan limits how many you can have in a period.
• Imaging missing. The plan wants imaging that matches your symptoms. See getting an MRI covered.

What plans usually look for

Each plan has its own policy. Many also follow national coverage guidance for spine injections. The criteria below are common examples only.

• A diagnosis that fits. Often radiating nerve pain (radiculopathy) rather than back pain alone.
• How long you have had pain, often several weeks.
• Conservative care tried first, such as physical therapy, medicine or activity changes.
• Imaging that matches the level and side of your symptoms.
• A pain or function score recorded before the injection.
• Image guidance (such as fluoroscopy) for the procedure.

Repeat injections

Plans often want proof the first injection worked before approving another. That usually means your records show:

• How much your pain improved, as a percentage or score.
• How long the relief lasted.
• What you could do afterward that you couldn’t before, such as walking farther or returning to work.

Ask your clinician’s office to record your pain and function scores before and after each injection. Without them, a repeat injection is harder to approve.

Medicare and the WISeR model

If you have Traditional Medicare, a model called WISeR began testing AI-assisted prior authorization in 2026, and it includes epidural steroid injections for pain (not facet joint injections) (Federal Register: WISeR notice, July 1, 2025). It runs in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. Kentucky and Indiana are not part of it. (CMS: WISeR Model)

Medicare Advantage plans must follow the 2026 federal prior authorization timelines: 72 hours for urgent requests and 7 calendar days for standard requests.

What to ask your clinician to document

1. Where the pain is and where it travels.
2. How long you have had it and how it affects daily life.
3. Exam findings, such as strength, reflexes and numbness.
4. Treatments tried, for how long, and the result.
5. Imaging results and how they match your symptoms.
6. Pain and function scores before and after any earlier injection.

How to get an epidural steroid injection covered

1. Confirm prior authorization is requested. Ask the clinician’s office for the request date and reference number.
2. Get the plan’s injection policy. Ask for the criteria for the specific injection planned.
3. Check your chart against it. Make sure diagnosis, duration, prior treatment and imaging are documented.
4. For a repeat injection, record your results. Make sure your pain scores and relief from the last injection are in your chart.
5. Match the approval to the procedure. The approved level, side and approach should match what is scheduled.
6. If denied, ask for a peer-to-peer and appeal. File an internal appeal with your clinician’s letter before the deadline (29 CFR 2560.503-1(h)(3)(i)).

Sample appeal letter

[Your name]
[Your address] · [Your phone] · [Your email]

[Date]

[Plan name] — Appeals Department
[Address or fax from your denial letter]

RE: Appeal of epidural steroid injection denial
Member name: [Name] · Member ID: [Number]
Reference / case number: [Number]
Procedure: [e.g., lumbar transforaminal epidural steroid injection, L5-S1, right]
Ordering clinician: [Name, credentials]
Date of denial: [Date]

To the Appeals Department:

I am appealing your denial of the injection listed above. Your letter says: "[exact reason]."

I meet your criteria, [policy name or number]:
- Diagnosis: [diagnosis] — see [record, date].
- Duration of symptoms: since [date] — see [record].
- Treatment tried first: [therapy / medicine, dates, result] — see [records].
- Imaging: [study, date] shows [finding] matching my symptoms.
[For a repeat injection:]
- Result of my last injection on [date]: [percent] pain relief lasting [weeks], with [function change] — see [record].

My clinician's enclosed letter explains why the injection is medically necessary.

Enclosed:
- Letter of medical necessity from [clinician]
- Visit notes and therapy records from [dates]
- Imaging report from [date]
- Your denial letter

Please approve the injection. If you uphold the denial, please give me the specific reason, the criteria used, and the steps for external review in writing.

Sincerely,
[Signature]
[Printed name]

Timelines

• Prior authorization decision: since January 1, 2026, Medicare Advantage, Medicaid and CHIP plans must decide within 72 hours (urgent) or 7 calendar days (standard) (CMS: CMS-0057-F fact sheet).
• Internal appeal: generally within 180 days under the federal rule (29 CFR 2560.503-1(h)(3)(i)); at least 180 days for most Kentucky state-regulated plans too (KY DOI UM Review Guide (2026)); check your denial letter.
• External review: generally within 4 months of the final internal denial (federal and Kentucky); 120 days in Indiana.

See the Kentucky and Indiana guides for details.

What the process looks like

1. Your clinician recommends an injection and documents why.
2. The office requests prior authorization for the exact injection: type, level, side and approach.
3. The plan reviews it against its spine injection policy. Plans covered by the 2026 federal rule must decide within 7 calendar days, or 72 hours if urgent.
4. The plan approves, asks for more information, or denies.
5. If approved, you schedule the injection within the approved dates.
6. Afterward, your pain and function are recorded at follow-up. These numbers matter for any repeat injection.

An example

*This is an illustrative example, not a real patient.*

Pat had an epidural steroid injection for sciatica. It helped a lot for a few months. When the pain came back, Pat’s clinician requested a second injection. The plan denied it, saying there was “no documentation of response to prior injection.”

Pat remembered the injection helped, but the chart only said “improved.” Pat’s clinician found the follow-up visit, where Pat’s pain score was recorded before and after, and wrote a letter giving the percentage of relief, how long it lasted, and that Pat had gone back to walking daily. With those details, Pat appealed.

The lesson: write down your pain score and what you can do, before and after each injection, and make sure it is in your chart.

Questions to ask before your injection

• “Has prior authorization been approved? What is the reference number?”
• “Does the approval match the planned level, side and approach?”
• “Will my pain and function scores be recorded before and after?”
• “How many injections will my plan cover in a year?”
• “What is my cost after insurance, and is there a cash-pay price?”

Common mistakes

• No before-and-after scores. This is the most common reason repeat injections are denied.
• Approval for a different level or side than the one injected.
• Missing imaging that matches your symptoms.
• Skipping the appeal because the injection already happened. You can usually still appeal.

What your denial letter should tell you

Since January 1, 2026, Medicare Advantage, Medicaid, CHIP and HealthCare.gov Marketplace plans must give a specific reason when they deny a prior authorization request (CMS: CMS-0057-F fact sheet). A vague reason makes an appeal harder, so it is fair to ask for more detail.

When you get a denial for an injection, check that the letter tells you:

• The exact service that was denied and the date.
• The specific reason, in words you can act on.
• The policy or criteria the plan used. If it doesn’t, ask for a copy (29 CFR 2560.503-1(g)(1)).
• Your deadline to appeal and how to send it.
• How to ask for an expedited review if it’s urgent.
• How to ask for an external review if the internal appeal fails.

If anything is missing, call the plan, ask for it in writing, and write down the date, the name of the person you spoke with, and a reference number.

Costs and your deductible while you wait

An appeal can take weeks. Meanwhile, it helps to understand what you might owe either way.

• If the appeal succeeds, the plan pays under your normal benefits. You still owe any deductible, copay or coinsurance. See how your deductible works.
• If you go ahead before a decision, you may owe the full bill if the appeal fails. Ask for a written cost estimate first.
• Check your EOB when the claim is processed. It shows what was billed, allowed and owed. See how to read your EOB.
• Ask about payment plans if a large bill arrives during the appeal. Ask the billing office to hold the account while the appeal is open.

If coverage doesn’t work out

• Ask for external review after a final internal denial.
• Ask about a cash-pay price. See cash-pay and self-pay options.
• Talk with your clinician about other treatment while you appeal, such as physical therapy.