Medicare prior authorization · 64479

64479 — Epidural Steroid Injections for Pain Management

Subject to WISeR prior authorization or pre-payment review in AZ, NJ, OH, OK, TX, WA for dates of service 2026-01-15 through 2031-12-31, in hospital outpatient, ambulatory surgical center, office and home settings. The decision is made on Medicare’s existing coverage policy; nothing in these programs changes what is covered.

WISeR

Decision: 3 days; 2 days expedited; unlimited resubmissions
If no request is made: the claim goes to pre-payment medical review
Policies CMS cites (Appendix A): L39015 · L39240 · L36920
Participant by state: AZ: Zyter · NJ: Genzeon · OH: Innovaccer · OK: Humata Health · TX: Cohere Health · WA: Virtix Health
Exemption: NPI-level, after ≥10 requests and the participant’s affirmation-rate threshold in an assessment period; granted quarterly from July 2026; held at least a year.
CMS note: 62323 is not WISeR for indications outside the selected LCDs (e.g., intrathecal pump implantation).

What CMS lists for the record

From the WISeR Operational Guide, verbatim. The coverage policy governs; use the check below for the diagnosis and state.

CMS WISeR documentation checklist · §6.2.10

Operational Guide v7.0, last updated July 24, 2026 · retrieved 2026-09-14

Epidural Steroid Injections for Pain Management (L39015, L39240, L36920)

CMS: “To meet coverage criteria, the patient’s medical record must contain documentation that fully supports the medical necessity of services. Subsections 6.2.1 to 6.2.13 list the documentation requirements for example services. For detailed documentation requirements, providers who choose to submit a prior authorization request for a WISeR Select Item or Service should refer to the relevant NCDs and/or their MAC jurisdiction’s LCDs and Local Coverage Articles (LCAs), if available, for guidance. They can be found on the Medicare Coverage Database website.”

Prior authorization and pre-payment review are being implemented for CPT code 62323 only when used for Epidural Steroid Injections (ESI). Please note that CPT code 62323 does not require prior authorization or pre-payment review under WISeR when submitted for indications other than specified in the selected LCDs, including but not limited to implantation of an intrathecal pump for treatment of pain or spasticity. General documentation requirements for ESI for pain management are as follows:

Documentation of history, physical examination, and radiological testing demonstrating one of the following: a) Lumbar, cervical, or thoracic radiculopathy; radicular pain and/or neurogenic claudication due to disc herniation; osteophyte or osteophyte complexes; severe degenerative disc disease, producing foraminal or central spinal stenosis; OR b) Post-laminectomy syndrome (persistent or recurrent spinal pain after a prior spine surgery); OR c) Acute herpes zoster–associated pain; AND
Documentation that radiculopathy, radicular pain, and/or neurogenic claudication is severe enough to greatly impact quality of life or function, including documentation that an objective pain scale or functional assessment was performed at baseline (prior to interventions) and that the same scale was repeated at each follow-up for assessment of response; AND
Documentation of pain duration of at least 4 weeks and the inability to tolerate noninvasive conservative care OR medical documentation of failure to respond to 4 weeks of noninvasive conservative care OR acute herpes zoster refractory to conservative management where a 4- week wait is not required
Documentation of anticipated number of ESI sessions (four or less) per spinal region in a rolling 12-month period. For repeat sessions, documentation of at least 50% sustained improvement in pain or function from baseline on the same scale for at least 3 months • Of note, if the first ESI underperforms, a repeat session after 14 days may be done with a different approach/level/medication and a clear rationale
If applicable: In exceptional and unique cases, documentation establishing the patient-specific need for moderate or deep sedation, general anesthesia, or monitored anesthesia care, as these are generally not required for the procedure.
Documentation of the type of image guidance (fluoroscopy or CT with contrast) to be used. If the patient has a documented contrast allergy or pregnancy, ultrasound guidance without contrast may be considered.
Documentation of the planned approach, including targeted level(s) and region(s) • Of note, transforaminal ESIs (TFESIs) up to two levels in one spinal region; interlaminar ESIs or caudal ESIs up to one level in one spinal region; and bilateral TFESI only when clinically indicated (e.g., documented bilateral foraminal stenosis or central herniation affecting both roots) are considered medically reasonable and necessary.
Documentation that the ESI is performed in conjunction with conservative treatments, such as but not limited to: • Medication • Physical therapy • Spinal manipulation therapy • Cognitive behavioral therapy • Home exercise program
Documentation that the patient is part of an active rehabilitation program, home exercise program, or functional restoration program
Assessment and documentation of none of the following contraindications: • Active localized spinal infection or systemic infection • Compressive lesions of the spinal cord • Conus medullaris or cauda equina

[18] Please reference the associated LCD Reference Articles for the selected LCDs for more information about ICD-10 codes that support medical necessity for this service as defined by the MAC.

Read the guide on CMS →

The coverage policy the reviewer applies, by state

Each state’s Medicare contractor writes its own LCD, so the policy that decides a 64479 request depends on the state. The documentation requirements below are quoted from the policy or its Billing & Coding article as captured; the linked CMS document is authoritative.

OH · CGS Administrators

L39015 — Epidural Steroid Injections for Pain Management — CGS · CMS version 16 · captured 2026-07-28

Billing & Coding articles: A58899 · A58731

Documentation requirements · A58731
“1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request. 2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient. 3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed. 4. Selective nerve root blocks (SNRBs) and TFESIs: The procedural report should clearly document the indications and medical necessity for the injections, along with the baseline pain score. …”
Continues in the CMS document.

AZ, WA · Noridian

L39240 — Epidural Steroid Injections for Pain Management — Noridian · CMS version 15 · captured 2026-07-28

Billing & Coding articles: A59079 · A58993

Documentation requirements · A58993
“1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request. 2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient. 3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed. 4. Selective nerve root blocks (SNRBs) and TFESIs: The procedural report should clearly document the indications and medical necessity for the injections, along with the baseline pain score. …”
Continues in the CMS document.

NJ, OK, TX · Novitas

L36920 — Epidural Steroid Injections for Pain Management — Novitas · CMS version 107 · captured 2026-07-28

Billing & Coding article: A56681

Documentation requirements · A56681
“All documentation must be maintained in the patient's medical record and made available to the contractor upon request. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed. SNRBs and TESIs: The procedural report should clearly document the indications and medical necessity for the injections, along with the baseline pain score. SNRBs only: The procedural report should include the baseline pain score and percent (%) pain relief achieved immediately after the injection. …”
Continues in the CMS document.

Check 64479 for your state, diagnosis and setting

The governing policy as it stands today, whether the diagnosis is on its list, and the documentation the policy’s own text requires — quoted, source-linked, free.

Run the check →

Full lists: WISeR code list · WISeR rules and exemption

Same family: 62321 · 62323 · 64480 · 64483 · 64484

Sources: CMS WISeR Provider and Supplier Operational Guide v7.0 (2026-07-24), Appendix A; CMS list of OPD services requiring prior authorization (2024-08-05); CMS list of ambulatory surgical center services for prior authorization (2026-03-05) and the ASC Operational Guide (2026-03-03). Codes are shown as numbers only, as CMS lists them. CPT® is a registered trademark of the American Medical Association.