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AetnaAll Plans · Coverage · Pharmacy · Pain Management, Neurology, NeurosurgeryMedium impact

Transforaminal Epidural Injections (CPB 0722, reviewed 2026-10-14)

Effective date
Not stated in the notice
Identified
Oct 19, 2026

Summary

Aetna's Clinical Policy Bulletin 0722 covers transforaminal epidural steroid injections (TFESIs) performed with imaging guidance (fluoroscopy or CT) when the criteria for diagnostic or therapeutic use are met. Diagnostic selective TFESIs are considered medically necessary for identifying the etiology of pain in persons with symptoms suggestive of chronic radiculopathy when the diagnosis remains uncertain after standard evaluation. An initial therapeutic TFESI is considered medically necessary for radiculopathy when non-invasive measures such as physical therapy and non-narcotic analgesics have failed or become intolerant, and additional therapeutic TFESIs are considered medically necessary when the initial injection produced at least two specified outcomes for at least 2 weeks. Aetna considers TFESIs at more than two contiguous vertebral levels or more than four TFESIs in a single session not medically necessary.

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What to do

Action · 9 steps
01Already effective 04/04/2006: Billing team: bill TFESI codes 64479 and 64480 (cervical or thoracic) and 64483 and 64484 (lumbar or sacral) only when imaging guidance (fluoroscopy or CT) was used and the policy criteria are documented.
02Document radiculopathy as the policy defines it: pain, dysaesthesias or paraesthesias in a specified dermatomal distribution of a named spinal root causing significant functional limitations, plus either a concordant detailed neurologic exam within the prior three months or a concordant MRI or CT interpretation or EMG/NCV study within the prior 12 months.
03Therapeutic TFESIs must be given as part of a comprehensive pain management program, and the documentation must show failure or intolerance of physical therapy and non-narcotic analgesics.
04Additional therapeutic TFESIs need documented results from the initial injection: at least 50% pain relief, increased function or physical activity, or reduced pain medication or other care, lasting at least 2 weeks.
05Do not schedule or bill more than four TFESIs in one session, which the policy describes as not medically necessary, or more than three sessions per episode of pain per spinal region in six months.
06Do not schedule TFESI sessions more often than every two weeks, and do not schedule more than four sessions per spinal region in 12 months.
07The policy considers a maximum of twelve TFESIs per spinal region, given in a maximum of three sessions, for an episode of pain lasting six months.
08Codes 64635 and 64636 are listed as not covered for the indications in this policy.
09Combined pulsed radiofrequency with TFESI for lumbar radiculopathy (ICD-10 M54.16) and for herpes zoster pain (ICD-10 B02.21 to B02.29) is listed as experimental, investigational, or unproven, as are ultrasound-guided TFESIs and diagnostic or therapeutic TFESIs for indications not listed in the medical necessity section.

Codes mentioned

644796448064483644846463564636M54.16M79.2

Original notice

Transforaminal Epidural Injections (CPB 0722, reviewed 2026-10-14)
aetna.com · Always check the source before changing claims.
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Related policy hubs

Aetna policiesPain ManagementNeurologyNeurosurgeryCode 64479Code 64480Code 64483Code 64484Code 64635Code 64636Code M54.16Code M79.2

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