How to appeal an Epidural Steroid Injection (ESI) denial
ESI denials are dominated by prior auth and conservative-care requirements, payers want documented failed conservative treatment and cap the number of injections per year before they'll pay.
Common code: CPT 62321/62323 (lumbar w/ imaging), 62320/62322 (cervical/thoracic), 64479-64484 (transforaminal)Why it gets denied
- Prior authorization was required and not obtained, or obtained for the wrong level/code
- The payer's policy requires documented failed conservative therapy (PT, meds) first
- Injection frequency exceeds the annual cap per region
- Imaging guidance (fluoro/CT) is billed separately when it's bundled into the injection code
What overturns it
- Document the conservative-care trial and failure, plus the pain and functional findings that meet the policy
- Obtain the prior auth for the correct spinal level and code and link it to the claim
- Show the injections were spaced and medically necessary within or by exception to the frequency limit
- Confirm imaging guidance is included in 62321/62323 and not double-billed
Worth appealing? ESIs are a pain practice's bread-and-butter high-volume procedure, and prior-auth and conservative-care denials are among the most recoverable because the chart usually already contains the PT and medication history.
Common questions
How do I appeal an Epidural Steroid Injection (ESI) denial?
ESI denials are dominated by prior auth and conservative-care requirements, payers want documented failed conservative treatment and cap the number of injections per year before they'll pay. To overturn it: document the conservative-care trial and failure, plus the pain and functional findings that meet the policy; obtain the prior auth for the correct spinal level and code and link it to the claim; show the injections were spaced and medically necessary within or by exception to the frequency limit; confirm imaging guidance is included in 62321/62323 and not double-billed.
Why do Epidural Steroid Injection (ESI) claims get denied?
Prior authorization was required and not obtained, or obtained for the wrong level/code; The payer's policy requires documented failed conservative therapy (PT, meds) first; Injection frequency exceeds the annual cap per region; Imaging guidance (fluoro/CT) is billed separately when it's bundled into the injection code.
Is a Epidural Steroid Injection (ESI) denial worth appealing?
ESIs are a pain practice's bread-and-butter high-volume procedure, and prior-auth and conservative-care denials are among the most recoverable because the chart usually already contains the PT and medication history. You pay 25% only on what's recovered, so there's no cost to working the winnable ones.
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