Medicare Part B covers epidural steroid injections, but you pay a share of the cost

Yes, Medicare Part B covers epidural steroid injections when a doctor orders them to treat nerve pain in your back, neck, or legs. You will pay 20% of the approved amount after you meet your yearly Part B deductible (which is $240 in 2024, though this amount changes each year). The injection itself is billed as an outpatient procedure, usually done in a hospital outpatient department or an imaging center.

The injection must be medically necessary — meaning your doctor has documented that you have a condition like a herniated disc, spinal stenosis, or nerve root compression that causes pain, and that other treatments have not worked or are not suitable. Medicare will not cover the injection if it is purely for comfort or if your doctor has not documented the medical reason.

The facility where you receive the injection may also bill a separate facility fee. This is in addition to the doctor's fee and the cost of the medication itself. All three parts count toward your out-of-pocket costs.

Key Takeaways

  • Medicare Part B covers epidural steroid injections when ordered by a doctor for documented nerve pain conditions like herniated discs or spinal stenosis.
  • You pay 20% of the Medicare-approved amount after meeting your yearly Part B deductible, plus any facility fees charged by the outpatient center.
  • The injection must be medically necessary and documented in your medical record; Medicare does not cover injections for comfort alone.
  • If you have a Medigap or Medicare Advantage plan, your out-of-pocket costs may be lower because those plans cover some or all of your Part B coinsurance.
  • The number of injections Medicare will cover in a year varies by your specific condition and what your doctor documents, so ask your doctor how many they plan to order.

How Medicare decides whether to cover your injection

Medicare uses something called a Local Coverage information (LCD) to decide whether an epidural steroid injection is covered in your area. An LCD is a rule set by the regional Medicare contractor that processes claims where you live. The LCD lists the medical conditions that may have access to, the documentation your doctor must provide, and how many injections Medicare will pay for in a given time period.

Your doctor's office should know the LCD for your region before ordering the injection. If they do not, you can ask them to look it up, or you can search for it yourself on the Medicare website by entering your state and the procedure code (usually 62311 or 62312 for epidural injections). The LCD will tell you exactly what your doctor needs to document and what limits explore.

Common reasons Medicare approves epidural steroid injections include herniated discs with nerve compression, spinal stenosis (narrowing of the spinal canal), radiculopathy (nerve root pain), and failed back surgery syndrome. Your doctor must show that the injection targets the specific nerve causing your pain and that imaging (like an MRI or CT scan) supports the diagnosis.

What you will pay out of pocket

Your costs depend on whether you have Original Medicare alone, a Medigap plan, or a Medicare Advantage plan. With Original Medicare, you pay your Part B deductible (if you have not met it yet in that year) plus 20% of the approved amount for the doctor's service and the injection medication. The facility where the injection is done may charge a separate facility fee, which is also subject to the 20% coinsurance.

If you have a Medigap plan, it may cover some or all of your 20% coinsurance, depending on which Medigap plan you chose. Plans G, N, and F (if you were may be able to access before 2020) typically cover the coinsurance. Check your Medigap plan documents or call your plan to confirm.

If you have a Medicare Advantage plan, your costs work differently. Instead of 20% coinsurance, you typically pay a copay or coinsurance amount set by your plan. This amount varies widely — some plans charge $100 to $300 per injection, while others charge a percentage of the cost. Call your plan before the procedure to find out your exact cost.

The medication itself (the steroid and local anesthetic) is usually included in the procedure cost, not billed separately. However, if your doctor uses a brand-name steroid or adds other medications, there may be an additional charge.

Limits on how many injections Medicare will cover

Medicare does not cover unlimited epidural steroid injections. The number covered in a year depends on your condition and what the LCD in your region allows. Many LCDs limit coverage to three or four injections per year for the same spinal level, with a waiting period between injections (often 14 days or more).

If you need injections at different spinal levels (for example, one in your lower back and one in your neck), those may be counted separately, so you could potentially receive more total injections. Your doctor should tell you upfront how many injections they plan to order and whether Medicare will cover all of them.

If your doctor wants to order more injections than the LCD allows, they can request an exception from Medicare, but this is not may provide to be approved. Ask your doctor whether they think an exception is likely before proceeding.

How to find out what your specific plan covers

The best way to know your exact costs is to contact your insurance plan directly before the procedure is scheduled. If you have Original Medicare, call Medicare at 1-800-MEDICARE (1-800-633-4227) and ask about epidural steroid injection coverage in your area. Have your doctor's diagnosis and the procedure code ready.

If you have a Medigap plan, call the Medigap insurance company and ask what percentage of the coinsurance they cover for epidural injections. If you have a Medicare Advantage plan, call your plan's customer service number (on your insurance card) and ask for your copay or coinsurance amount for this procedure.

You can also ask your doctor's office to check your coverage before scheduling. Many offices have staff who verify coverage with insurance plans and can tell you what you will owe. This takes a day or two but saves you from surprises at the time of the procedure.

What happens if Medicare denies your injection

If Medicare denies your injection, your doctor's office will send you a notice called an Explanation of Benefits (EOB). The EOB will explain why the claim was denied — for example, because the medical documentation was incomplete, because you have already used your yearly limit, or because the condition does not meet the LCD criteria in your region.

You have the right to appeal a denial. The appeal process has several levels: first, your doctor's office can resubmit the claim with additional documentation if the denial was due to missing information. If that does not work, you can file a formal appeal with Medicare. Your doctor's office can help with this, or you can do it yourself by following the instructions on the EOB.

If you believe the denial is wrong, you can also contact your State Health Insurance information Program (SHIP), which offers free help with Medicare appeals. Find your state's SHIP by calling 1-877-839-2675 or visiting the SHIP website.

Epidural injections versus other pain treatments Medicare covers

Medicare also covers other treatments for nerve pain, including physical therapy, oral medications, and in some cases, spinal cord stimulation. If your doctor recommends an epidural injection, it is usually because they believe it offers the best chance of relief for your specific condition. However, if the injection is denied or if you want to explore other options, ask your doctor about these alternatives.

Physical therapy is often covered with a copay or coinsurance under Part B. Some oral pain medications are covered under Part D (your prescription drug plan). Spinal cord stimulation is a surgical procedure that Medicare covers in certain cases, but it requires a trial period first and has stricter approval requirements than injections.

Your doctor can help you understand which treatment is most likely to work for your condition and which ones Medicare will cover in your situation.

Frequently Asked Questions

Will Medicare cover epidural injections if I have not tried physical therapy first?

Medicare does not always require physical therapy first, but many doctors recommend it and some regional LCDs prefer to see documentation that you tried it. Ask your doctor whether they think physical therapy first would strengthen your case or whether your condition warrants an injection right away. If your doctor believes the injection is medically necessary without prior physical therapy, they can document that reasoning.

How long does it take Medicare to approve an epidural injection?

Medicare usually processes the claim after the procedure is done, not before. Your doctor's office submits the claim, and Medicare typically responds within two to four weeks. If you want to know whether Medicare will cover it before you have the procedure, ask your doctor's office to submit a pre-authorization request, though Medicare does not always require this step.

What if my Medicare Advantage plan denies the injection but Original Medicare would cover it?

Medicare Advantage plans can have stricter rules than Original Medicare, including requiring prior authorization or limiting the number of injections. If your plan denies the injection, you can appeal through your plan. You cannot switch to Original Medicare mid-year just because of one denial, but you can switch during the annual open enrollment period (October 15 to December 7) if you want more flexibility.

Do I need imaging like an MRI before the injection?

Most LCDs require imaging (MRI or CT scan) to confirm the diagnosis before Medicare will cover the injection. If you do not have recent imaging, your doctor will likely order it. This imaging is usually covered by Medicare, though you will pay your Part B coinsurance for it.

Can I get epidural injections at a doctor's office, or do they have to be done at a hospital?

Epidural injections can be done in a hospital outpatient department, an ambulatory surgery center, or a doctor's office, depending on the facility's equipment and licensing. Medicare covers the procedure in any of these settings. The facility fee may vary slightly depending on where it is done, so ask your doctor where they plan to do the injection and whether there are cost differences.