CPT 64483 Denial Appeal Guide: Lumbar and Sacral Transforaminal Epidural Injections

CPT 64483 is the code for an image-guided transforaminal epidural steroid injection (TFESI) at a single lumbar or sacral level. The needle is guided to the neural foramen next to the exiting nerve root, and the medication spreads into the epidural space at that level. The fluoroscopic or CT guidance is included in the code.

This guide sorts 64483 denials into three groups: the record does not show the radicular pain the payer's policy requires, the injection goes past a frequency or level limit, or the claim was coded in a way the payer's edits reject. Each is covered below, followed by the appeal routes and deadlines.

First, confirm 64483 is the right code

If the service was a lumbar facet joint injection, it is not 64483, and the epidural policies below do not apply. Medicare reviews facet injections under each MAC's Facet Joint Interventions LCD. Noridian's current billing and coding article A58403, which covers its JE and JF jurisdictions, allows one or two levels per session per spinal region, so a third level reported with 64495 falls outside that limit. Facet joint interventions performed in a hospital outpatient department have required Medicare prior authorization since July 1, 2023 under the OPD prior authorization program, although CMS's code list shows the third-level facet codes 64492 and 64495 were removed from that requirement on August 16, 2024.

Coding points to check on a 64483 claim before you appeal anything:

• Level. Novitas's billing article A56681 says a transforaminal injection at T12-L1 is reported with 64479, not 64483.
• Add-on use. Palmetto GBA's billing article A58695 says 64484 is reported together with 64483. It is an add-on code and is not billed on its own.
• Units, sides and regions. The same Palmetto article says a unilateral injection goes on one line with one unit of service, and a bilateral injection goes on one line with modifier 50. It allows only two levels per session in total across 64479, 64480, 64483 and 64484, and only one spinal region per session. Novitas's article spells the two-level limit out as two unilateral or two bilateral levels.
• ASC claims. The Palmetto article and Wellpoint Federal's billing article A58745 both say that in an ASC the physician still uses modifier 50, while the ASC facility reports the code on two lines, one unit each, with RT and LT. Follow your own MAC's article.
• Imaging guidance. The guidance is included in 64483, so a separate fluoroscopy or CT guidance line for the same injection should not be billed.

Common 64483 denials and what to check

What Medicare requires: the epidural steroid injection LCDs

Each MAC publishes its own epidural steroid injection LCD, plus a billing and coding article with the covered diagnosis codes. The examples below come from Noridian's LCD L39240, Epidural Steroid Injections for Pain Management, revised for services on or after April 16, 2026, which describes itself as aligned with other MACs' epidural injection LCDs. Pull your own MAC's current version before you write.

Under L39240, an ESI is reasonable and necessary when the record shows all three of these:

• Radiculopathy, radicular pain or neurogenic claudication (from a disc herniation, osteophytes, or severe degenerative disc disease causing foraminal or central stenosis), post-laminectomy syndrome, or acute herpes zoster pain, supported by history, physical exam and concordant imaging.
• Symptoms severe enough to greatly affect quality of life or function, with an objective pain or function scale recorded at baseline and repeated at follow-up.
• Pain lasting at least four weeks, with failure of four weeks of noninvasive conservative care or documented inability to tolerate it. Acute herpes zoster pain does not need the four-week wait.

L39240 also sets these limits:

• The injection is done under CT or fluoroscopic guidance with contrast. If the patient has a documented contrast allergy or is pregnant, ultrasound guidance without contrast may be considered.
• Transforaminal injections are limited to two levels in one spinal region.
• No more than four sessions per spinal region in a rolling 12-month period.
• A repeat injection needs documentation of at least 50% consistent improvement in pain for at least three months, or at least 50% consistent improvement in previously painful movements and activities of daily living, measured on the same scale as the baseline.
• If the first injection does not work well, a repeat after 14 days using a different approach, level or medication is allowed when the rationale is documented.
• A predetermined series of injections is not covered.
• ESIs for nonspecific low back pain or axial spine pain are considered investigational. If the only diagnosis on the claim is a back pain code without radiculopathy, the claim does not meet the LCD.
• Other blocks in the same session (facet, sympathetic, trigger point and similar) are not considered reasonable and necessary, except for a facet synovial cyst treated in the same session as the ESI.
• Moderate or deep sedation, general anesthesia and monitored anesthesia care are described as usually unnecessary; an exceptional case needs documentation of the patient-specific reason.

The Palmetto, Novitas and Wellpoint billing articles linked above also ask practices to retain images with at least two views showing final needle position and contrast flow, and to make them available on request.

Traditional Medicare prior authorization in six states (WISeR)

Under CMS's WISeR model, epidural steroid injections, including 64483 and 64484, are subject to prior authorization or pre-payment medical review under Original Medicare for providers in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington, for dates of service on or after January 15, 2026. The WISeR operational guide (version 7.0, July 24, 2026) applies the model in offices, hospital outpatient departments and ambulatory surgical centers. What it says about denials:

• A claim sent with no prior authorization decision on file is suspended for pre-payment review. The provider has 45 days to answer the documentation request, and the claim is denied if no response arrives.
• A non-affirmed prior authorization request is not appealable, but it can be resubmitted with more documentation, with no limit on the number of resubmissions until the claim has been submitted and denied, and a peer-to-peer review can be requested with a resubmission.
• A denied claim keeps normal Medicare appeal rights.
• WISeR does not apply to Medicare Advantage.

The guide also asks for documentation that the patient is in an active rehabilitation, home exercise or functional restoration program, and that a bilateral transforaminal injection was clinically indicated (for example, documented bilateral foraminal stenosis or a central herniation affecting both roots).

Medicare Advantage

Under 42 CFR 422.101(b)(3), a Medicare Advantage plan must follow the written coverage decisions of the local Medicare contractors for its service area, which means the LCD. Paragraph (b)(6) lets a plan use its own internal coverage criteria only when coverage criteria are not fully established in Medicare statutes, regulations, NCDs or LCDs. For a 64483 that meets the applicable ESI LCD, cite both paragraphs.

Medicare Advantage plans may require prior authorization for epidural injections, so check the plan's list. Since January 1, 2026, CMS-0057-F requires Medicare Advantage plans to decide standard prior authorization requests within 7 calendar days and expedited ones within 72 hours, and to give a specific reason for a denial.

Commercial and Medicaid plans

Commercial plans and Medicaid programs publish their own epidural injection policies and may require prior authorization. Pull the version in effect on the date of service and match every criterion (conservative care duration, imaging, frequency, relief needed before a repeat) to a page in the chart. Do not assume the Medicare numbers apply. CMS-0057-F's 7-day and 72-hour prior authorization deadlines also apply to state Medicaid and CHIP programs, fee-for-service and managed care, but not to ordinary employer or commercial plans.

Documentation checklist for a 64483 appeal

• ☐ The denial notice or remit, with the CARC and any RARC
• ☐ The payer's policy or LCD in effect on the date of service, with the criteria you are answering marked
• ☐ History and exam showing radicular findings on the side and level injected
• ☐ Imaging report concordant with that level and side
• ☐ Baseline pain or function score on a named scale, dated before the injection
• ☐ Conservative care: what was tried, dates, duration, and the response or the reason it could not be tolerated
• ☐ Procedure note: approach, level, side, medication and dose, imaging modality, contrast (or the documented allergy), and the reason for any sedation
• ☐ Saved images showing final needle position and contrast flow
• ☐ For a bilateral injection, the clinical reason both sides were treated
• ☐ For a repeat injection, the dates of earlier sessions in the same region over the prior 12 months and the follow-up score on the same scale
• ☐ The prior authorization number, or the WISeR unique tracking number (UTN), if one applies
• ☐ A corrected claim instead of an appeal, if the problem was coding

Appeal routes and deadlines

First decide whether you need an appeal at all:

• Coding or clerical errors. For Medicare, 42 CFR 405.980(a)(3) requires the MAC to handle clerical errors, including minor errors and omissions, as reopenings rather than redeterminations. A claim returned with RARC MA130 is unprocessable and has no appeal rights: correct it and submit a new claim.
• Denied because records were not received. Under 405.980(a)(2), when a claim was denied because requested documentation did not arrive during medical review, a redetermination request is processed as a reopening. Send the records.

When it is a true appeal:

• Traditional Medicare. Request redetermination by the MAC within 120 days of receiving the initial determination (receipt is presumed 5 days after the notice date). Then reconsideration by a Qualified Independent Contractor within 180 days of receiving the redetermination, then an ALJ hearing (60 days), the Medicare Appeals Council (60 days) and federal court (60 days). The ALJ and federal court levels have amount-in-controversy thresholds that change every year.
• Medicare Advantage. The enrollee, or a non-contracted provider with a waiver of liability, requests plan reconsideration within 65 days of the notice. If the plan upholds the denial, the case goes automatically to the Independent Review Entity. Payment reconsiderations are decided within 60 days, standard pre-service ones within 30 days and expedited ones within 72 hours. Contracted providers' payment disputes follow their contract.
• Commercial and ERISA group health plans. The member, or an authorized representative such as the provider, has at least 180 days from the adverse benefit determination to file an internal appeal. After a final internal denial, federal external review must be requested within 4 months; state external review processes vary. Standard external review decisions come within 45 days and expedited ones within 72 hours, and a decision binds that claim only. Provider appeals under a participation contract follow the contract, so check the contract and the denial notice for the window.
• Medicaid. Appeal windows vary by state and managed care plan. Check the notice.

Sample appeal language

Adapt these to the facts in the chart. Every bracketed item should point to a dated page in the attached record.

Initial injection, medical necessity:

"[Patient] has [left L5 radiculopathy] from [finding] on the [MRI dated X], which matches the [exam findings] documented on [date]. Symptoms began on [date], and [conservative care] from [dates] did not relieve them [or: could not be tolerated because X]. Baseline [scale] score was [score] on [date]. On [date of service], a single-level [left L5-S1] transforaminal injection was performed under fluoroscopy with contrast. The record meets each coverage condition in [LCD number or policy name, section], as shown on the attached pages."

Repeat injection denied for frequency:

"This was the [second] session in the [lumbar] region in the 12 months before [date of service]. After the injection on [date], the patient's [scale] score went from [baseline] to [score] and stayed at that level through [date], documented on [pages]. [LCD or policy, section] covers a repeat injection when that improvement is documented, and the enclosed records document it."

Medicare Advantage plan applied criteria stricter than the LCD:

"The plan denied this service based on [internal criterion]. For this service in [state], [MAC] LCD [number] establishes the coverage criteria. Under 42 CFR 422.101(b)(3) and (b)(6), the plan must follow that LCD and may not substitute internal criteria where the LCD fully establishes coverage. The attached record meets each LCD criterion as follows: [list]."

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