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Injections and insurance

bryan868bbryan868 Posts: 21
edited 01/22/2017 - 2:53 PM in Spinal Injections
I had one treatment on 12/23 that included two transforaminal epidural steroid injections at S1 and L5 for S1 nerve root pinch from herniated disc. Unfortunately all my pain was back by day 2 and I'm still in pain 4 weeks later.

My pain management doc said because I did not get any relief from one treatment, my insurance will not cover any more. Apparently my insurance requires 50% improvement - which seems silly and arbitrary.

My doctor said I could pay out of pocket for another treatment, but he felt it probably wouldn't do anything anyway and recommended I see a surgeon.

 Maybe that's true, but I just didn't like how this whole discussion was framed with the insurance issue. Anyone else experience this?


  • jimandjrjimandjr Dallas TXPosts: 735
    When a nerve is pinched, for me, and ESI did nothing, the next step was surgery for me. This happened 3 times for me. 
  • dilauroddilauro ConnecticutPosts: 12,072
    I have never heard of that restriction with Insurance companies.

    I do know that with physical therapy, when a patient reaches a plateau, the center will discharge them because no follow on treatments are going to help (eyes of the insurance company)

    In the past 20 years, when it has come to ESI, the only restriction I have heard about is 3 injections maximum per year, thats it.

    Personally, I would not pay out of pocket and would get back to your insurance company to plead your case.

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  • Bryan, are you saying that you have received just one set of epidural and because you did not receive at least a 50% improvement ,then your insurance will not pay for a second one? may want to contact your insurance company to verify that

    I do know with my insurance that I have to have a certain % improvement from an epidural before they'll allow a nerve block...then if the nerve block is good then on to a rhizotomy...but never not being allowed to get a second ESI just because the first one didn't help much...sometimes it takes more than one to help...other times after three they don't help much...but to cut it off after one I don't see

    ...but like dilauro said, I've never run into a problem getting 3 epidural in a year's time...then could do another set the next year

    good luck...hope you get it sorted out
  • When I had an epidural in my neck, because i didn't have any real improvement, my insurance wouldn't cover more. I don't know what percentage was needed. My neurosurgeon sent me for nerve root block injections as a diagnostic test after that, so they covered those.

    With my lumbar issues, I had a facet joint injection. It gave maybe 50% relief for about a day. Insurance wouldn't cover another because for that injection to be repeated it had tho be about 80% better. For lumbar tranforaminal epidural, there didn't seem to be a pre-set percentage, and I had two, both of which only helped for about a day.

    My insurance is an HMO. I'm wondering if the type of insurance you have might make a difference. 
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