Lysis of Epidural Lesions
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Defines the health plan's coverage stance and supporting evidence for percutaneous and endoscopic lysis of epidural adhesions for chronic low back and lower extremity pain; intended for providers seeking reimbursement and guidance under the payer's clinical policy.
No material clinical or coverage changes in this revision.
Coverage Determination
Coverage stance
Policy statement
Policy asserts lack of supportive evidence for efficacy
The policy states that current medical literature does not support the efficacy of lysis of epidural lesions, including both percutaneous epidural adhesiolysis and endoscopic epidural adhesiolysis, with or without an indwelling epidural Racz catheter. As a result, specific procedural uses of these techniques may be excluded from coverage based on the policy rationale and lack of demonstrated benefit.
Lysis of epidural lesions, whether performed percutaneously or endoscopically, is considered not supported by the available medical literature and therefore is not covered under this policy rationale.
When state Medicaid coverage provisions conflict with this clinical policy, state Medicaid provisions take precedence. Providers should consult the applicable state Medicaid manual for any differing coverage rules before applying this policy.
Procedure and Billing Codes
| 62263 | Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days. |
| 62264 | Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 1 day. |
Provider Responsibilities and Billing Guidance
Check Medicare and State Medicaid Coverage
Check applicable Medicare and state Medicaid coverage before applying this clinical policy. Review Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare Coverage Articles on the CMS website. For Medicaid members/enrollees, state Medicaid coverage provisions take precedence when they conflict with this clinical policy; refer to the applicable state Medicaid manual.
- Review applicable NCDs, LCDs, and Medicare Coverage Articles prior to applying policy criteria.
- Refer to the state Medicaid manual for Medicaid-specific coverage provisions.
Denial Risk for Efficacy
This policy concludes that current medical literature does not support the efficacy of lysis of epidural lesions (including percutaneous and endoscopic epidural adhesiolysis, with or without an indwelling Racz catheter). As a result, services may be denied when the medical record does not demonstrate coverage under the member's benefits or when the procedure is sought despite lack of supportive evidence of efficacy.
- Denial risk exists because evidence does not support efficacy for lysis of epidural lesions.
- When documentation does not justify medical necessity per this policy, expect claim denials.
Coverage Subject to Benefit Terms
Coverage determinations are subject to the member's benefit terms, conditions, exclusions, and limitations as set forth in the member's coverage documents. Verify member benefits and eligibility prior to performing services.
- Coverage is governed by the member's benefit plan documents; inclusion in this policy does not guarantee coverage.
- Verify eligibility and benefits prior to scheduling or performing services.
Provider Agreement and Claims
Providers submitting claims or providing services to members/enrollees are bound by the terms and conditions of their contracts and by this clinical policy. Where no contract exists, submission of services or claims constitutes agreement to be bound by the policy terms.
- Providers are responsible for compliance with contract terms and this clinical policy when submitting claims.
- Absence of a contract does not guarantee coverage; claims may still be governed by this policy.
Conservative-Treatment Prerequisite (Guideline Reference)
Conservative treatment must have been attempted and failed before considering percutaneous adhesiolysis. Guideline updates (ASIPP 2021) rate evidence supporting percutaneous adhesiolysis as moderate to strong for certain indications following failure of conservative care, but note limitations due to a paucity of high-quality RCTs. Document prior conservative therapies and rationale for proceeding.
- Document failure of conservative treatment prior to considering adhesiolysis.
- Reference ASIPP guideline update supporting use after conservative care failure; limitations in evidence should be noted in the record.
Prior Conservative Therapy
Conservative treatment requirements
Context noted in evidence and guidelines
Hayes review and ASIPP guideline update reference failure of conservative therapy as the usual context for evaluating adhesiolysis.
From Hayes systematic review.
From ASIPP 2021 guideline update.
Imaging and Procedural Guidance
Fluoroscopy required for epidural adhesiolysis
Fluoroscopic imaging is required for epidural adhesiolysis procedures; adhesions can be identified as non-filling lesions on fluoroscopy and radiologic localization is included in the CPT code descriptions.
- CPT descriptions include radiologic localization (includes contrast when administered).
- Fluoroscopy may identify adhesions as non-filling lesions and is the imaging modality referenced.
Terms and Definitions
Clinical and Evidence Background
Background: Epidural adhesiolysis (also called epidural neuroplasty or lysis of epidural adhesions) is a minimally invasive set of techniques used to treat chronic back and lower extremity pain attributed to epidural fibrosis or adhesions from prior surgery or degenerative spine disease. Methods include mechanical disruption with catheters and chemical disruption using injectates such as hypertonic saline, steroids, analgesics, or hyaluronidase; procedures are typically performed with fluoroscopic guidance and endoscopic techniques may provide direct visualization for targeted lysis.
NOT COVERED: Lysis of epidural lesions (percutaneous and endoscopic adhesiolysis) is considered not supported by the current medical literature and therefore is not covered per this clinical policy.
Services Not Covered
Policy statement: Lysis of epidural lesions is not covered due to lack of supportive evidence in the current medical literature for the efficacy of percutaneous and endoscopic epidural adhesiolysis, with or without an indwelling Racz catheter.
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