Prior Authorization services

Prior Authorization Services for Pain Management

Most interventional pain procedures now need prior authorization from commercial plans and Medicare Advantage, and in some cases from traditional Medicare too. DOCS4DOCS obtains prior authorizations for pain practices by matching each request to the payer's medical necessity criteria, so approvals come faster and procedures are not denied after they are performed.

Updated October 12, 2026

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What’s included

How does prior authorization work for pain procedures?

Which pain procedures need prior authorization?

Most interventional pain procedures need prior authorization from commercial and Medicare Advantage plans, and some need it from traditional Medicare too. The ones we obtain approvals for include epidural steroid injections, facet injections and medial branch blocks, RFA, spinal cord stimulators, kyphoplasty, SI joint procedures and intrathecal pumps.

Epidural steroid injections (interlaminar and transforaminal)
Facet joint injections and medial branch blocks
Radiofrequency ablation of the facet, genicular and sacroiliac nerves
Spinal cord stimulator trials and permanent implants
Kyphoplasty and vertebroplasty
Sacroiliac joint injections and fusion
Intrathecal pump trials and implants

Does Medicare require prior authorization for pain procedures?

Yes, for some procedures. Since July 2023, traditional Medicare has required prior authorization for facet joint interventions performed in hospital outpatient departments. In 2026, the WISeR model added prior authorization in six states, including New Jersey, for services that include epidural steroid injections, spinal cord stimulators and kyphoplasty.

In 2026, Medicare's WISeR model added prior authorization for several pain and spine services in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. The services include epidural steroid injections, electrical nerve stimulators such as spinal cord stimulators, and percutaneous vertebral augmentation (kyphoplasty). In New Jersey the program is administered through Novitas.

How do you get a pain procedure approved?

An approvable request matches the payer's medical necessity criteria. That means confirming authorization is required, sending the clinical details payers look for, such as pain duration, conservative care, imaging and prior block results, following up until a decision is made, and tracking approved levels and dates so the procedure matches.

Confirm whether the payer, plan and CPT code require authorization
Collect the clinical details payers look for: duration of pain, conservative care tried, imaging findings, pain scores and functional limits
Include prior injection results, such as the percentage of relief from diagnostic blocks
Submit through the payer's portal or its radiology benefit manager
Follow up until a decision is made, and schedule peer-to-peer reviews when needed
Track approved units, levels and expiration dates so the procedure matches the approval

FAQ

Prior Authorization questions

Do epidural steroid injections need prior authorization?

Most commercial plans and Medicare Advantage plans require prior authorization for epidural steroid injections. Since January 2026, traditional Medicare also requires it in the six WISeR states, including New Jersey.

What is the Medicare WISeR model?

WISeR is a Medicare model that began in 2026 and adds prior authorization or pre-payment review for selected services in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. Pain-related services on the list include epidural steroid injections, electrical nerve stimulators and percutaneous vertebral augmentation.

What happens if a procedure is done without authorization?

The claim is usually denied, and many payers will not grant authorization after the fact. That is why we confirm authorization status before every scheduled procedure.

Sources

Coverage rules change; always check the current version of each policy and your payer’s own rules.

Keep reading

Related services and procedures

Pain Management Billing

Full revenue cycle management built only for pain practices: from eligibility to final payment.

Epidural Steroid Injections

Interlaminar and transforaminal ESI coding, LCD rules and prior authorization.

Spinal Cord Stimulation

SCS trials, permanent implants, revisions and programming, with prior authorization.

How it works

Let’s look at your billing

Tell us about your practice, your payers and where claims are getting stuck. A pain management billing specialist will get back to you and recommend a plan.

1
Tell us about your practice
Your procedures, payers, billing software and current challenges.
2
We review your billing
We look at where claims are denied, underpaid or delayed.
3
Get a clear plan
We recommend how we can take over or support your revenue cycle.

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