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    v1.0.28
    OpenPayerPolicy UpdatesPain ManagementExcellus Epidural Adhesiolysis Coverage | OpenPaye…
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    CurrentExcellus Health Plan IncPolicy 7.01.73

    Lysis of Epidural Adhesions

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    This policy governs coverage of catheter-based or endoscopic epidural adhesiolysis, also called the Racz procedure, for back pain. The procedure is considered investigational and is not covered under this policy for members requiring medical-necessity review.

    Policy Summary
    PayerExcellus Health Plan Inc
    PolicyLysis of Epidural Adhesions
    Policy CodePolicy 7.01.73
    Change TypeAnnual review — no material change
    Effective DateOctober 15, 2026
    Next Review DateJune 1, 2027
    Key ActionCatheter-based or endoscopic epidural adhesiolysis for back pain is considered investigational and may be denied as an experimental or investigational service.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    InvestigationalCoverage status
    5CPT codes listed
    9 RCTs

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Clinical trials cited
    510(k)FDA clearance
    6Policy pages
    NoneMedicare determinations

    Coverage Determination

    Catheter-Based or Endoscopic Epidural Adhesiolysis

    The following service is considered investigational and is not covered under this policy for treatment of back pain:

    Investigational status: Lysis of epidural adhesions (epidural adhesiolysis) performed by catheter-based techniques or endoscopically as a treatment for back pain is considered investigational.

    Applies to both catheter-based and endoscopic techniques.

    Coding Information

    Experimental CPT CodesCPTExperimental
    62263Percutaneous 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.
    62264Percutaneous 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), 1 day.
    62280Injection/infusion of neurolytic substance (e.g., alcohol, phenol, iced saline solutions), with or without other therapeutic substance; subarachnoid.
    62281Injection/infusion of neurolytic substance (e.g., alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, cervical or thoracic.
    62282Injection/infusion of neurolytic substance (e.g., alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, lumbar, sacral (caudal).
    HCPCS CodesHCPCS
    No codes listed
    ICD-10 CodesICD-10
    No codes listed

    Provider Guidance

    Denial Risk

    Investigational epidural adhesiolysis

    Lysis of epidural adhesions or epidural adhesiolysis performed by catheter-based techniques or endoscopically as a treatment for back pain is considered investigational and may be denied as an experimental or investigational service.

    Clinical Background

    Lysis of epidural adhesions, also called the Racz procedure, uses a catheter introduced either percutaneously or endoscopically to deliver epidural injections of hypertonic saline with corticosteroids and analgesics. The treatment is intended to mechanically disrupt presumed epidural scar tissue and reduce edema. Percutaneous procedures are commonly guided by epidurography, while endoscopic epidurolysis uses a flexible fiberoptic catheter inserted through the sacral hiatus to visualize and steer the catheter toward adhesions.

    Terminology and Procedure Definitions

    Lysis of Epidural Adhesions (Racz Procedure)
    ProcedureLysis of epidural adhesions, also called the Racz procedure, involves passage of a fluoroscopically guided Racz catheter inserted either endoscopically or percutaneously.
    Injection treatmentThe procedure uses epidural injections of hypertonic saline in conjunction with corticosteroids and analgesics.
    Intended mechanismHypertonic saline is intended to mechanically disrupt adhesions and may reduce edema within scarred or inflamed nerves; catheter manipulation may also disrupt adhesions.
    Percutaneous guidanceWhen performed percutaneously, epidurography may guide catheter placement and identify non-filling adhesions that indicate epidural scarring.
    Endoscopic Epidurolysis
    Catheter

    Conservative Treatment Context

    Conservative Treatment and Prior Epidural Injections

    Supporting guideline evidence describes selected indications for lumbar percutaneous adhesiolysis when both of the following have occurred. These considerations do not change the policy determination that the service is investigational.

    Supporting guideline considerations

    • The patient has failed conservative management.
    • The patient has failed fluoroscopically guided epidural injections.

    Imaging and Localization

    Note

    Use fluoroscopic or radiologic localization

    For percutaneous epidural adhesiolysis, use fluoroscopic or radiologic localization. The procedure is commonly performed using epidurography to guide catheter placement and identify non-filling adhesions; applicable coding includes radiologic localization.

    • Fluoroscopy or epidurography may guide catheter placement.
    • Radiologic localization is included in the descriptions for CPT codes 62263 and 62264.

    Services Not Covered

    The following services are not covered when performed to treat back pain: catheter-based lysis of epidural adhesions and endoscopic epidural adhesiolysis. These procedures are considered investigational.

    Policy Summary
    PayerExcellus Health Plan Inc
    PolicyLysis of Epidural Adhesions
    Policy CodePolicy 7.01.73
    Change TypeAnnual review — no material change
    Effective DateOctober 15, 2026
    Next Review DateJune 1, 2027
    Key ActionCatheter-based or endoscopic epidural adhesiolysis for back pain is considered investigational and may be denied as an experimental or investigational service.
    SourceLink
    On This Page
    Coverage DeterminationCoding InformationProvider GuidanceClinical BackgroundTerminology and Procedure DefinitionsConservative Treatment ContextImaging and LocalizationServices Not Covered
    A flexible fiberoptic catheter is inserted through the sacral hiatus.
    VisualizationThe catheter provides three-dimensional visualization to steer it toward epidural adhesions.
    Treatment deliveryEnhanced visualization is intended to facilitate precise placement of injectate in the epidural space and onto the nerve root.
    Clinical use describedEndoscopic epidurolysis is also being investigated for degenerative chronic low back pain, including spondylolisthesis, stenosis, and hernia associated with radiculopathy.
    Terminology
    Also calledEpidural adhesiolysis.
    Primary termLysis of epidural adhesions.
    Policy terminologyThe terms refer to the same procedure in this policy.