Interventional pain is one of the most tightly managed areas in all of prior authorization — and it turns on precise, documentable rules, not the level of pain. Check an epidural, facet block, radiofrequency ablation, or spinal cord stimulator against your plan's real criteria below.
Spine injections and neuromodulation run through musculoskeletal benefit managers — eviCore (Cigna, Aetna, and many UnitedHealthcare plans) and Carelon (Anthem/Elevance) — with Medicare governed by Local Coverage Determinations. Their criteria converge on the same gates:
If you remember nothing else about interventional-pain prior auth, remember these:
Answer a few plain questions about the pain pattern, imaging, and prior steps, and see exactly what to document before the request is filed — about two minutes, free.
Check my coverageBecause radiofrequency ablation is only expected to work when the facet joints are truly the pain source. Payers (via eviCore and Carelon) require two separate diagnostic medial-branch blocks, each producing at least 80% concordant relief, to confirm that before approving the ablation. One block, or relief under 80%, generally isn't enough to get the RFA approved.
The most common reasons: the pain was documented as axial (central) rather than radicular (radiating in a nerve pattern), the imaging didn't correlate with the level, or there wasn't about 6 weeks of documented conservative care first. Epidurals are covered for radicular pain and claudication — matching the documentation to that indication is what gets them approved.
A qualifying refractory neuropathic diagnosis (most often failed back surgery syndrome or CRPS), documentation that conservative care and interventional procedures failed, a completed psychological evaluation before the trial, and a successful percutaneous trial (typically ≥50% relief) before the permanent implant. The psychological evaluation is the step people most often miss.
Yes, under medical necessity, with the specifics set in Local Coverage Determinations — L36920/L39240 for epidural injections, L33930 for facet interventions (including the dual-block requirement for ablation), and L35136 for spinal cord stimulators. The criteria closely track the commercial standard.
Related: Why was my MRI denied? · Advanced imaging coverage · Why prior authorizations get denied · all coverage tools