CurrentArizona Complete HealthPolicy CP.MP.116

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.

Policy Summary

PayerArizona Complete Health

PolicyLysis of Epidural Lesions

Policy CodePolicy CP.MP.116

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionInclude CPT codes 62263 and 62264 on claims and follow payer coding guidance; ensure documentation supports medical rationale.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not coveredcoverage stance

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CurrentArizona Complete HealthPolicy CP.MP.116

Lysis of Epidural Lesions

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Policy Summary

PayerArizona Complete Health

PolicyLysis of Epidural Lesions

Policy CodePolicy CP.MP.116

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionInclude CPT codes 62263 and 62264 on claims and follow payer coding guidance; ensure documentation supports medical rationale.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not coveredcoverage stance

Hayes review (6 RCTs)evidence cited

State overrideMedicaid note

Coverage Determination

Coverage stance

Policy statement

Primary policy conclusion: Current medical literature does not support the efficacy of lysis of epidural lesions, including percutaneous and endoscopic epidural adhesiolysis, with or without use of an indwelling epidural Racz catheter.

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

Referenced CPT CodesCPT

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

Prior Authorization

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

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.

Prior Conservative Therapy

Conservative treatment requirements

Context noted in evidence and guidelines

Context for evaluation: Adhesiolysis has generally been studied in patients who have failed conservative (nonoperative) treatment.

Hayes review and ASIPP guideline update reference failure of conservative therapy as the usual context for evaluating adhesiolysis.

Supporting evidence details: Hayes review of six RCTs (search through Sept 7, 2018) found a small body of low-quality evidence suggesting potential short- and intermediate-term improvement in chronic low back pain for patients who failed conservative treatment; long-term outcomes are uncertain and recent RCTs are lacking.

From Hayes systematic review.

Guideline position: ASIPP 2021 update rates evidence for percutaneous adhesiolysis as moderate to strong for certain indications (disc herniation, spinal stenosis) and strong for post-surgery syndrome after failure of conservative therapy and fluoroscopically guided epidural injections; the update does not address endoscopic adhesiolysis.

Imaging and Procedural Guidance

Documentation Required

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

Epidural adhesiolysis / epidural neuroplasty definition

TermEpidural adhesiolysis (epidural neuroplasty)

DefinitionMinimally invasive technique to mechanically or chemically disrupt epidural adhesions using catheter manipulation and injectates (e.g., hypertonic saline, steroids, analgesics, hyaluronidase), often guided by fluoroscopy.

Typical indicationChronic back and lower extremity pain associated with epidural fibrosis/adhesions (post‑laminectomy/failed back surgery syndrome or degenerative spine disease).

Mechanisms describedMechanical disruption by catheter manipulation and chemical disruption with hypertonic saline; hyaluronidase may enhance drug penetration into scar tissue.

Procedure notesProtocols vary; catheter may remain in place for serial treatment sessions over multiple days; fluoroscopic localization used to identify non‑filling lesions prior to treatment.

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.

Policy Summary

PayerArizona Complete Health

PolicyLysis of Epidural Lesions

Policy CodePolicy CP.MP.116

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionInclude CPT codes 62263 and 62264 on claims and follow payer coding guidance; ensure documentation supports medical rationale.

SourceLink

On This Page

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.

Note

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.

Note

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.

Documentation Required

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.

From ASIPP 2021 guideline update.

Endoscopic epidural adhesiolysis definition

TermEndoscopic epidural adhesiolysis

DefinitionUse of spinal endoscopy (flexible fiberoptic catheter) to directly visualize and lyse epidural adhesions and to more precisely place injectate onto the nerve root or specific epidural locations.

Technique detailsA flexible fiberoptic catheter is inserted (e.g., via the sacral hiatus) to steer toward adhesions and provide 3‑D visualization for targeted lysis and injectate delivery.

Relation to percutaneous approachEndoscopic guidance supplements percutaneous lysis by allowing direct visualization and potentially more targeted disruption compared with blind or fluoroscopically guided catheter manipulation.

Clinical policy definition — guide to medical necessity

PurposeClinical policy: provides a guide to medical necessity to assist in coverage decisions and administering benefits.

ScopeDeveloped from review of accepted standards of practice, peer‑reviewed literature, guidelines, governmental positions, and expert clinician input.

Not a contractDoes not constitute a contract or guarantee of payment or clinical results; coverage is subject to terms, conditions, exclusions and limitations of the member's coverage documents.

ApplicabilityConsistent with standards current at approval; Health Plan may change, amend, or withdraw the clinical policy as needed.