CurrentColorado Rocky Mountain Health PlansPolicy 2026T0206DD

Epiduroscopy, Epidural Lysis of Adhesions, and Discography – Commercial and Individual Exchange Medical Policy

UnitedHealthcare Commercial and Individual Exchange medical policy describing coverage rationale, service descriptions, evidence summaries, and applicable procedure coding for discography (functional anesthetic and provocative), epiduroscopy (including spinal myeloscopy), percutaneous and endoscopic epidural lysis of adhesions, and chemonucleolysis. Part 1 of 2 provides coverage stance (not medically necessary/unproven for listed services), coding lists, service descriptions, and literature review summaries.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyEpiduroscopy, Epidural Lysis of Adhesions, and Discography – Commercial and Individual Exchange Medical Policy

Policy CodePolicy 2026T0206DD

Change TypeRevised (template updatedprior versions archived)

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionCounsel patients about the potential association between provocative discography and progression of degenerative disc disease and bill functional anesthetic discography with CPT 64999 per the policy coding clarification.

SourceLink

POLICY UPDATE CHANGES

Template updated; archived previous policy versions 2025T0206CC and PAIN 004.28.

4Procedures unproven / not medically necessary

8CPT codes referenced

limitedEndoscopic adhesiolysis evidence strength

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.

Coverage Summary

This policy part applies to UnitedHealthcare Commercial and Individual Exchange plans and states that the following services are considered not medically necessary / unproven for the diagnosis or treatment of any type of neck, back, or spinal disorder due to insufficient evidence of efficacy: discography (including functional anesthetic and provocative subtypes, and chemonucleolysis), epiduroscopy (including spinal myeloscopy), and percutaneous and endoscopic epidural lysis of adhesions. The scope covers descriptions, evidence summaries, and applicable procedure coding for these services and reflects the policy effective January 1, 2026.

Key policy datapoints

Effective DateJanuary 1, 2026

Policy Number2026T0206DD

Procedures listed as unproven / not medically necessary4

CPT codes referenced (count)8

Evidence Base summarymultiple RCTs and systematic reviews referenced (includes RCTs, observational studies, meta-analyses); evidence limited/variable across procedures

Medical Necessity / Unproven Criteria

Not Medically Necessary / Unproven Services

The following are 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:

ALL of the following

Discography subtypes
- Functional anesthetic discography
- Provocative discography
- Chemonucleolysis
Epiduroscopy (including spinal myeloscopy)

Applicable Procedure Codes and Coding Clarifications

Applicable Procedure CPT Codes (listed for reference)CPT

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.

Coding ClarificationCPT

64999

Functional anesthetic discography should be billed with CPT code 64999 (per policy coding clarification).

Provider Actions & Billing Guidance

Billing Rule

Billing code selection for functional anesthetic discography

Bill functional anesthetic discography with unlisted nervous system code CPT 64999 per coding clarification in the policy.

Codes: ["64999"]

Documentation Required

Counseling for Discography Risks

Providers should counsel patients regarding the potential association between provocative discography and progression of degenerative disc disease prior to performing discography.

Documentation Required

Background and Evidence Summary

Epiduroscopy is an endoscopic technique for direct visualization of the epidural space to remove adhesions/fibrosis and deliver therapies using tools such as a flexible catheter, laser, and saline flushing, often followed by steroid administration. Chemonucleolysis involves injection of a proteolytic enzyme (historically chymopapain; more recently agents such as condoliase or gelified ethanol/DiscoGel) into the disc to dissolve herniated nucleus pulposus; evidence is mixed with some RCTs and observational studies but limited long-term data and agent-specific safety concerns. Epidural lysis of adhesions (adhesiolysis/percutaneous adhesiolysis/Racz procedure) is a needle- or catheter-based mechanical and solution-based technique to disrupt epidural fibrosis/adhesions and has some RCTs and systematic reviews supporting benefit for refractory lumbar radicular pain. Discography variants include provocative discography (contrast injection to reproduce pain) and functional anesthetic discography (anesthetic injected into the nucleus with activity-based pain assessment); available evidence is limited and low quality, and safety concerns have been raised including a potential association between provocative discography and accelerated degenerative disc changes.

Evidence / Source	Summary
Discography evidence summary	Limited, low-quality evidence; safety concerns including potential to accelerate degenerative changes; observational studies report higher rates of subsequent surgery and degeneration; additional well-designed long-term RCTs needed.
Chemonucleolysis evidence summary	Mixed evidence with some RCTs and systematic reviews showing efficacy for certain agents (eg, condoliase, DiscoGel); overall limited long-term data; SAEs infrequent but study quality varies; larger high-quality RCTs recommended.
Epiduroscopy evidence summary	Observational and systematic review data demonstrate pain and function improvements in failed back surgery syndrome with moderate-quality evidence and weak recommendations; impact on management not fully established.
Epidural lysis of adhesions evidence summary	Some RCTs and meta-analyses report improvement in refractory chronic low back/lower extremity pain and sustained benefits at 12 months and beyond in select trials (including Gerdesmeyer et al.); evidence limited by risk of bias and need for more high-quality RCTs.
Percutaneous adhesiolysis RCT outcomes (Gerdesmeyer et al., 2013; 10-year follow-up 2021)	ODI improved from 55.3 to 26.4 at 3 months in lysis group vs 55.4 to 41.8 in placebo; VAS improved from 6.7 to 2.9 vs 6.7 to 4.8; significant improvements at 3, 6, 12 months and sustained differences up to 10 years with minor transient neurologic effects and no severe treatment-related adverse effects reported.
Systematic reviews (Helm et al.; Manchikanti reviews; Hayes)	PA supported by multiple RCTs per systematic reviews; endoscopic adhesiolysis has more limited evidence; overall evidence limited by study quantity, potential conflicts of interest, and methodological limitations.
Guideline statements (AANS/CNS, ACR, ASIPP, NICE)	AANS/CNS: discography not recommended as stand-alone test and counsel on possible DDD progression; ACR (2021): no relevant literature to support discography for several common indications; ASIPP: recommends provocation discography only when treatment available and PA recommended after conservative management failure; NICE: endoscopic adhesiolysis limited to special arrangements/research due to limited evidence and safety concerns.

Guideline positions differ in strength: ASIPP supports lumbar provocation discography and recommends percutaneous adhesiolysis for selected refractory lumbar conditions when conservative care fails, while AANS/CNS advises that discography should not be used as a stand-alone test and recommends counseling patients about a possible association with progression of degenerative disc disease. The ACR (2021) states there is no relevant literature to support discography for several common clinical scenarios. NICE (2010) found limited short-term evidence and safety concerns for therapeutic endoscopic adhesiolysis and recommends use only with special arrangements (governance, consent, audit, or research). Systematic reviews judge percutaneous adhesiolysis to have multiple RCTs showing benefit, whereas endoscopic adhesiolysis and epiduroscopy have more limited or lower-quality evidence and weaker recommendations.

Definitions

Term	Definition
Functional anesthetic discography	Diagnostic procedure injecting anesthetic into disc nucleus via catheter to assess pain reproduction and relief with anesthetic to confirm disc involvement.
Provocative discography	Diagnostic procedure injecting contrast into nucleus pulposus to reproduce pain and identify symptomatic disc.
Chemonucleolysis	Injection of proteolytic enzyme into intervertebral disc to dissolve herniated nucleus pulposus (examples include chymopapain historically; condoliase, DiscoGel in contemporary practice).
Epiduroscopy	Endoscopic visualization of the epidural space to remove adhesions/fibrosis and deliver therapies using a flexible catheter, laser, and saline flushing with possible steroid administration.
Percutaneous adhesiolysis (Racz procedure)	Needle-based technique to mechanically disrupt epidural adhesions with contrast and catheter-based interventions to distend/decompress the epidural space and perform mechanical manipulations.

Revision History

01/01/2026revisedLatest

Template updated to create shared policy version to support application to Oxford plan membership and supporting information updated in Description of Services, Clinical Evidence, and References.

Archived previous policy versions 2025T0206CC and PAIN 004.28.revised

Archived previous policy versions 2025T0206CC and PAIN 004.28.

Evidence and Guideline-based Statements (narrative criteria)

Summary of clinical guideline positions and evidence strength:

ALL of the following

Percutaneous adhesiolysis evidence: Percutaneous adhesiolysis (PA) has multiple randomized controlled trials showing benefit for chronic lumbosacral radicular pain and is supported by systematic reviews; recommended for refractory low back and lower extremity pain after failure of conservative management per ASIPP.
Endoscopic adhesiolysis evidence: Endoscopic adhesiolysis (spinal endoscopy) has more limited evidence; evidence judged limited to short-term efficacy and safety concerns by NICE and systematic reviews; considered lower strength of evidence compared to PA.
AANS/CNS discography guidance: Discography: AANS/CNS recommends discography not be used as a stand-alone test to formulate treatment strategies; consider discoblock as diagnostic option; counsel patients on potential association between discography and progression of degenerative disc disease.
ACR 2021 position: ACR (2021) states there is no relevant literature to support the use of discography for specified indications including acute uncomplicated LBP, subacute/chronic LBP without red flags or prior management, initial imaging for cauda equina, evaluation of new/progressing symptoms after prior lumbar surgery, and initial imaging for LBP with certain risk factors.
ASIPP recommendations: ASIPP recommends lumbar provocation discography with appropriate indications only when a treatment is available; cervical discography indicated only when a treatment is available and appropriate screening performed; thoracic discography can be performed if indication appropriate and treatment available; PA is recommended in patients with post-lumbar surgery syndrome and lumbar central spinal stenosis after failure of conservative management.
NICE statement: NICE (2010) recommends therapeutic endoscopic division of epidural adhesions only with special arrangements for clinical governance, consent, audit, or research due to limited evidence and safety concerns.