ModifiedColorado Rocky Mountain Health PlansPolicy CS040.P

Epiduroscopy, Epidural Lysis of Adhesions, and Discography

Defines coverage stance for epiduroscopy, epidural lysis of adhesions (including percutaneous and endoscopic techniques), discography (provocative and functional anesthetic), and chemonucleolysis for diagnosis or treatment of neck/back/spinal disorders for Colorado Rocky Mountain Health Plans members; identifies states with separate state-specific policies.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyEpiduroscopy, Epidural Lysis of Adhesions, and Discography

Policy CodePolicy CS040.P

Change TypeUpdated clinical evidence, descriptions, and referencesremoved Louisiana-specific language

Effective DateFeb 1, 2026

Next Review Date

Key ActionWhen submitting claims or requests, follow payer prior authorization processes and include the CPT/diagnosis codes referenced by the policy.

SourceLink

POLICY UPDATE CHANGES

Updated Description of Services, Clinical Evidence, and References sections to reflect the most current information.

Removed content/language pertaining to the state of Louisiana.

3primary procedures

8procedure codes referenced

mixed/limitedevidence characterization

notedsafety concern

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

multiplepeer-reviewed refs

Coverage Determinations

Unproven / Not Medically Necessary

Not medically necessary when used for diagnosis or treatment due to insufficient evidence:

Not medically necessary list

Discography (including): Functional anesthetic discography and provocative discography are unproven and not medically necessary; available evidence is limited and low quality and safety concerns (including potential to accelerate degenerative changes) have been reported.
See evidence limitations and safety concerns in cited reviews.
Chemonucleolysis (chemical disc ablation) is listed as unproven/not medically necessary when used for diagnosis or treatment across spinal disorders due to insufficient high-quality, long-term evidence of efficacy and safety.
Trials show mixed results and have methodological limitations.
Epiduroscopy and adhesiolysis: Epiduroscopy (including spinal myeloscopy) and percutaneous or endoscopic epidural lysis of adhesions are unproven and not medically necessary for diagnosis or treatment based on currently insufficient evidence of benefit across spinal disorders.
Policy groups epiduroscopy and epidural adhesiolysis within unproven procedures.

PA / Epidural LOA - supported with limitations

Evidence-supported conditions and settings where benefit has been demonstrated in trials and reviews

PA evidence-supported scenario: Percutaneous adhesiolysis (percutaneous epidural lysis of adhesions) has randomized trial and systematic review evidence showing significant improvements in pain and function for selected patients with chronic lumbosacral radicular pain or failed back surgery syndrome who have not responded to conservative treatments.based on RCTs and meta-analyses

Manchikanti systematic review and Gerdesmeyer randomized trial demonstrated benefit at 3–12 months; ASIPP recommends PA after failure of conservative management.

Chemonucleolysis - investigational/limited

Chemonucleolysis (disc chemical ablation) evidence summary

Chemonucleolysis evidence: Randomized trials (e.g., condoliase RCT) and retrospective series (DiscoGel, gelified ethanol) report that some patients experience clinically meaningful pain and function improvement, but studies are limited by small samples, exclusions, short follow-up, lack of adequate controls, and limited long-term safety data; further high-quality RCTs and longer-term follow-up are needed.varied results; further RCTs needed

Some series report substantial short-term improvement (eg, condoliase studies), but meta-analyses note higher complication rates for some chemonucleolysis agents compared with other surgical options.

Epiduroscopy - limited/moderate evidence

Epiduroscopy evidence summary

Epiduroscopy diagnostic/therapeutic value: Observational studies and a systematic review/meta-analysis report clinically relevant reductions in pain and disability at 6–12 months in failed back surgery syndrome, with moderate-quality evidence but weak recommendation strength; diagnostic findings from epiduroscopy may have prognostic value, but impact on long-term management and durable benefit remains uncertain.short- to intermediate-term benefit reported

Authors recommend weighing potential benefits against risks and note limitations in study designs and certainty of long-term effects.

This policy addresses discography (including provocative and functional anesthetic techniques), epiduroscopy (including spinal myeloscopy), and percutaneous and endoscopic epidural lysis of adhesions. These procedures are considered unproven and not medically necessary for the diagnosis or treatment of any type of neck, back, or spinal disorder due to insufficient evidence of efficacy.

The National Institute for Health and Care Excellence (NICE) concluded that evidence for therapeutic endoscopic division of epidural adhesions is limited and raises significant safety concerns; NICE recommends this procedure only be used with special arrangements for clinical governance, consent, audit, or research, and that further research should clearly describe case selection and report outcomes including pain relief and duration of effect.

FDA listings for devices (endoscopes, catheters, needles) are provided for informational purposes only; FDA approval alone is not a basis for coverage. Per the policy revision history, administrative language specific to Louisiana has been removed from this document.

Explicitly named as not medically necessary / unproven in this policy are: discography (both provocative and functional anesthetic), epiduroscopy (including spinal myeloscopy), and percutaneous and endoscopic epidural lysis of adhesions.

The American College of Radiology (ACR) states there is no relevant literature to support use of discography for several common indications, including acute uncomplicated low back pain, subacute or chronic low back pain without red flags or prior management, initial imaging for certain presentations, and evaluation of new or progressing symptoms after prior lumbar surgery.

Procedure and Device Codes

Applicable CPT CodesCPT

62263	Percutaneous lysis of epidural adhesions using solution injection (e.g., hypertonic saline, enzyme) or mechanical means (e.g., catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days.
62264	Percutaneous lysis of epidural adhesions using solution injection (e.g., hypertonic saline, enzyme) or mechanical means (e.g., catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 1 day.
62290	Injection procedure for discography, each level; lumbar.
62291	Injection procedure for discography, each level; cervical or thoracic.
62292	Injection procedure for chemonucleolysis, including discography, intervertebral disc, single or multiple levels, lumbar.
64999	Unlisted procedure, nervous system.
72285	Discography, cervical or thoracic, radiological supervision and interpretation.
72295	Discography, lumbar, radiological supervision and interpretation.

Device/PMN references (informational)mixed

No codes listed

Provider Requirements and Billing Guidance

Prior Authorization

Prior Authorization and Coding

Prior authorization and coding — Procedures listed with CPT codes should follow the plan's prior authorization processes. Verify whether prior authorization is required with the member's benefit plan before scheduling services.

Prior authorization: Confirm PA requirements with the member's specific plan — this policy does not substitute for benefit verification.
Coding note: Functional anesthetic discography should be billed with CPT 64999 as an unlisted procedure.
Code list provided is for reference only and does not guarantee coverage or payment.

Note

No PA Codes Listed

No explicit prior authorization code list is provided in this section. Providers must obtain PA information from the member's benefit plan or payer portal.

No PA-specific codes or direct authorization rules are specified here.
Use the payer's PA tool/portal or contact the plan to determine authorization requirements for listed procedures.

Background and Evidence Summary

Epiduroscopy and epidural lysis of adhesions are minimally invasive procedures intended to visualize and mechanically or chemically disrupt epidural adhesions and administer therapeutic agents into the epidural space with the goal of reducing radicular or low back pain and improving function. Evidence cited in the policy includes observational studies and systematic reviews reporting short- to intermediate-term reductions in pain and disability for selected patients, but overall quality and long-term benefit remain uncertain.

Procedure Definitions

inv-25: Epiduroscopy / Epidural lysis of adhesions — Definition and brief description

DefinitionMinimally invasive procedures to remove epidural adhesions and fibrosis using techniques such as laser, flexible catheter manipulation, saline flushing, and administration of steroids; may include mechanical disruption under fluoroscopic or endoscopic guidance.

Primary intentRelieve chronic low back and radicular pain attributed to epidural adhesions by mechanically or pharmacologically disrupting scar tissue and restoring epidural space mobility.

Common techniques/aliasesEpiduroscopy, epidural lysis of adhesions, adhesiolysis, percutaneous epidural neuroplasty, epidurolysis, Racz procedure.

Typical intra-procedural actionsInjection of normal saline to distend the epidural space, mechanical manipulation of a catheter or fiberoptic endoscope, and final administration of steroids to reduce inflammation.

inv-26: Functional anesthetic discography — Definition and brief description

Prior Conservative Management

Conservative treatment commonly expected prior to chemonucleolysis in cited literature

Conservative treatment commonly expected prior to chemonucleolysis in the cited literature

Conservative therapy before chemonucleolysis: Patients considered for chemonucleolysis in the cited studies had previously failed conservative therapies such as medications, physical therapy, and epidural or other block therapy; chemonucleolysis was evaluated as an option for individuals who did not respond to conservative management.

Multiple chemonucleolysis series and the condoliase RCT enrolled patients after failed conservative care and recommend further trials with larger samples and longer follow-up.

Conservative therapies must have been attempted and failed prior to considering PA — ASIPP guidance

ASIPP conservative therapy requirement for PA: Percutaneous adhesiolysis is recommended by ASIPP for post-lumbar surgery syndrome and lumbar central spinal stenosis only after failure of conservative management, including physical therapy, chiropractic treatment, drug therapy, structured exercise programs, and fluoroscopically directed epidural injections.

Procedure Frequency

inv-38: No explicit frequency limits provided in this portion of the document

Frequency limits statementNo explicit frequency limits for these procedures are provided in this portion of the document.

Coding contextApplicable CPT codes are listed for reference but do not imply frequency or coverage determinations.

Plan variabilityBenefit coverage and any frequency restrictions are determined by federal, state, or contractual plan requirements and may differ from this policy.

inv-39: Percutaneous adhesiolysis / epidural LOA — may require more than one procedure per year to maintain benefit (evidence comment)

Frequency note for PAPercutaneous adhesiolysis/epidural lysis of adhesions may need to be repeated more than once per year to maintain clinical benefit according to the Hayes evidence review.

Evidence basis

Imaging and Guidance

Documentation Required

Imaging commonly used (MRI or fluoroscopy) though specifics not mandated

MRI or fluoroscopic guidance is commonly used to confirm disc pathology and guide these procedures, but this policy does not mandate specific imaging protocols; obtain appropriate imaging per practice standards.

Document MRI confirmation of disc herniation when relying on this to support a procedure.

Documentation Required

Use MRI to confirm disc pathology and fluoroscopy during procedures

Studies and series of chemonucleolysis, epiduroscopy, and PA routinely used MRI to confirm disc herniation or to evaluate outcomes and used fluoroscopic guidance during the procedures.

Ensure procedural imaging (e.g., fluoroscopy) is documented in the operative or procedure note.

Note

Procedures Not Covered

Not covered under this policy are: discography (provocative and functional anesthetic); epiduroscopy (including spinal myeloscopy); and percutaneous and endoscopic epidural lysis of adhesions. NICE additionally advises that therapeutic endoscopic division of epidural adhesions be limited to settings with special governance or research oversight, and FDA device listings referenced in the policy are informational only and do not by themselves establish coverage.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyEpiduroscopy, Epidural Lysis of Adhesions, and Discography

Policy CodePolicy CS040.P

Change TypeUpdated clinical evidence, descriptions, and referencesremoved Louisiana-specific language

Effective DateFeb 1, 2026

Next Review Date

Key ActionWhen submitting claims or requests, follow payer prior authorization processes and include the CPT/diagnosis codes referenced by the policy.

SourceLink

On This Page

Prior Authorization

Verify Plan Authorization Requirements

Verify plan authorization requirements and governing benefit terms before performing services. Federal, state, or contractual requirements may differ from this policy and will govern in the event of a conflict.

Confirm whether the member’s plan requires prior authorization for the requested service and follow the plan’s authorization process.
When plan terms differ from this policy, the plan/federal/state contractual requirements take precedence.

Denial Risk

Denial for Unproven / Not Medically Necessary Services

Denial risk — Procedures identified as unproven or not medically necessary per this policy may be denied under standard benefit determinations. Coverage is determined by the member's plan terms and applicable laws.

Services listed as unproven/not medically necessary may be denied.
Submit complete documentation demonstrating medical necessity and conservative treatment attempts when applicable to support coverage review.

Note

No Direct Authorization Rules Specified

No direct authorization rules specified in this policy — always follow the member’s benefit plan, payer prior authorization requirements, and any applicable state or federal mandates.

This policy does not replace plan-specific PA criteria or state/federal mandates.
If uncertain, obtain written authorization from the plan prior to performing the procedure.

Documentation Required

Coding / Documentation Note

Coding and documentation — Provide complete clinical documentation, including prior conservative therapy attempts, diagnostic findings, and rationale for the procedure. Use the unlisted CPT 64999 for functional anesthetic discography per coding clarification.

Document conservative management efforts (physical therapy, medications, injections, structured exercise) and duration.
If billing an unlisted code (e.g., 64999), include operative report and justification to support reimbursement.
Include imaging, prior surgery history, and any guideline-recommended screening in the claim documentation.

Note

Guideline Statements — Patient Selection and Counseling

Guideline recommendations — Professional society guidance emphasizes careful patient selection, counseling on risks (including potential disc degeneration with provocative discography), and reserving certain procedures for patients who have failed appropriate conservative management.

Inform patients about possible risks and alternatives prior to performing discography or related procedures.
Follow guideline recommendations for patient selection and ensure other pain sources have been excluded prior to invasive diagnostics.

Note

Device and Benefit Verification

Device and benefit verification — Verify FDA regulatory status of devices used (endoscopes, catheters, needles) and confirm whether use of specific devices is covered under the member's benefit plan.

Check FDA device listings as informational background (http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm).
Confirm device coverage and benefit applicability with the payer prior to procurement or scheduling.

Step Therapy

Conservative Therapy Expectation

Conservative therapy expectations — Many societies and evidence reviews recommend exhausting conservative management (e.g., physical therapy, structured exercise, medications, fluoroscopically directed epidural injections) prior to considering adhesiolysis, discography, chemonucleolysis, or epiduroscopy.

Document trials of conservative therapy and outcomes before requesting authorization for invasive procedures.
Conservative therapies include physical therapy, chiropractic care, medications, structured exercise programs, and epidural steroid injections as appropriate.

Step Therapy

Conservative Therapy Required Before PA

Conservative therapy required before prior authorization — For certain procedures (e.g., percutaneous adhesiolysis/PA), prior authorization criteria typically expect failure of conservative management before approval is considered.

When submitting PA requests for adhesiolysis or related procedures, include documented failure of conservative therapies.
Failure of conservative therapy may include inadequate response to physical therapy, injections, medications, or structured exercise programs.

Note

Use of External Utilization Management Tools

Use of external utilization management tools — The payer may use third-party tools (for example, InterQual®) to assist in administering health benefits and determining medical necessity.

Be prepared to supply documentation that aligns with third-party criteria if the payer references InterQual® or similar tools.
Third-party tool determinations are used in conjunction with the plan's benefit terms and the provider's clinical judgment.

DefinitionDiagnostic procedure injecting an anesthetic agent directly into a spinal disc via a catheter to assess whether anesthetic reduces pain reproduced by provocative maneuvers (e.g., sitting, walking, bending).

PurposeCompare pain reproduction with and without anesthetic to confirm discogenic pain and identify the symptomatic disc for treatment planning.

Procedure notesAfter catheter placement in the disc nucleus, the patient attempts to recreate symptoms; anesthetic is then injected and symptom change is observed and compared.

inv-27: Provocative discography — Definition and brief description

DefinitionInvasive diagnostic spine procedure injecting contrast into the nucleus pulposus to reproduce discogenic pain by pressurization and thereby identify a symptomatic, internally disrupted disc.

Diagnostic principleBased on the premise that a painful, internally disrupted disc will produce pain when mechanically loaded or pressurized with contrast.

Typical indicationAssessment of suspected discogenic sources of chronic spine pain where reproduction of concordant pain may guide management decisions.

inv-28: Chemonucleolysis — Definition (proteolytic enzyme injection) and intent

DefinitionInjection of a proteolytic enzyme into the intervertebral disc aimed at dissolving herniated nucleus pulposus to reduce radicular symptoms and potentially avoid surgery.

Historical agentsChymopapain was an early enzyme used but was discontinued due to safety concerns; newer agents are under study.

IntentBridge the gap between conservative therapy and surgical intervention by reducing disc volume and nerve root compression via chemical dissolution.

inv-29: Chemonucleolysis — alternate definition and examples (condoliase, DiscoGel, gelified ethanol)

Alternate definitions/examplesPercutaneous chemical dissolution of intervertebral disc material using agents such as condoliase, gelified ethanol (DiscoGel), and oxygen-ozone; intended to reduce disc herniation and radicular pain.

Examples cited in evidence baseCondoliase (chondroitinase-ABC), gelified ethanol (DiscoGel), and oxygen-ozone chemonucleolysis are discussed in trials and reviews.

Evidence contextTrials and retrospective series show some patients achieve clinically meaningful improvement, but studies are limited by sample size, design, and follow-up duration.

inv-30: Epiduroscopy — Endoscopic visualization definition and potential treatments during procedure

DefinitionEndoscopic visualization of the epidural space allowing identification of anatomy and pathology (e.g., fibrosis, nerve roots, cauda equina) and guiding targeted treatments.

Potential intra-procedural treatmentsMechanical adhesiolysis, targeted injection of corticosteroids or local anesthetic, delivery of enzymatic agents (in some protocols), and lavage with saline.

Diagnostic/therapeutic roleProvides direct visualization that may inform prognosis and selection of therapeutic maneuvers, though impact on long-term outcomes remains uncertain.

inv-31: Percutaneous adhesiolysis (PA) / Epidural LOA — Definition and brief description

DefinitionMinimally invasive procedures (including percutaneous adhesiolysis/Racz procedure) that mechanically and/or pharmacologically disrupt epidural adhesions to relieve radicular or low back pain.

Typical technique elementsNeedle entry to epidural space, introduction of nonionic contrast and lumbar epidurogram, catheter-based saline distension, mechanical manipulation and possible injection of medications (e.g., steroids, hyaluronidase).

Usual clinical settingPerformed for patients with suspected epidural adhesions after failure of conservative therapy; may be done under fluoroscopic guidance with local anesthesia and sedation.

inv-32: Epidural adhesiolysis / epiduroscopy — Additional definition/terminology

TerminologyEpidural adhesiolysis and epiduroscopy encompass procedures intended to lyse epidural adhesions and administer therapeutic agents to the epidural space; terms include epidural lysis of adhesions (LOA), adhesiolysis, epidurolysis, and epiduroscopy.

ScopeThese procedures are used diagnostically (visualization) and therapeutically (mechanical or pharmacologic disruption) for chronic low back and radicular pain, including failed back surgery syndrome.

Evidence summary noteSystematic reviews and RCTs report short- to intermediate-term improvements in pain and function for selected patients, but evidence quality and recommendation strength vary.

inv-33: Chemonucleolysis (condoliase, oxygen-ozone, other agents) — Definition and trial summary note

DefinitionEnzymatic or chemical treatment of lumbar disc herniation using agents (e.g., condoliase, oxygen-ozone, gelified ethanol) to reduce disc volume and radicular symptoms.

Trial evidence summaryRandomized and nonrandomized trials and retrospective series report clinically meaningful pain and function improvements for some patients, but studies are limited by exclusions, small samples, and variable follow-up; further high-quality RCTs are needed.

Safety noteHistorical agent chymopapain was discontinued due to safety concerns; contemporary agents have variable complication profiles reported and require further evaluation.

inv-34: Provocative discography — Definition reiterated with evidence context

Definition reiteratedProvocative discography involves injection of contrast into the disc nucleus to reproduce pain under pressurization and assess concordance to identify a symptomatic disc.

Evidence contextGuideline and evidence assessments (e.g., ACR, AANS/CNS, Hayes) have raised concerns about diagnostic utility and potential for disc injury; literature does not support routine use for many common indications.

Safety considerationSome studies identify potential risks including accelerated disc degeneration after discography; counseling and careful patient selection are recommended.

ASIPP guidance specifies PA as a later-line interventional option after these conservative treatments have been attempted and failed.

Conservative treatment requirement placeholder (no top-level nodes extracted)

Conservative treatment requirement (plan-specific verification)

Plan and contractual requirements: When applying conservative treatment prerequisites, verify and comply with the member's federal, state, or contractual benefit plan requirements, which may specify particular conservative therapies, durations, or prior authorization rules.

UnitedHealthcare instructions specify that federal/state/contractual requirements govern and tools such as InterQual may be used to assist in administering benefits.

Hayes review of RCTs and trials noted consistent findings of short- and intermediate-term benefit but indicated many cases required repeat procedures to sustain effect.

Clinical implicationWhen considering PA, clinicians should anticipate potential need for additional procedures within a 12-month period for ongoing symptom control.

Reference ACR Appropriateness Criteria for imaging decisions

The policy references the ACR Appropriateness Criteria for Low Back Pain as a source for imaging appropriateness and recommends using established imaging guidance documents when evaluating patients.