CurrentHealth NetPolicy CP.MP.116

Lysis of Epidural Lesions (Epidural Adhesiolysis)

Defines the medical policy stance and coding implications for percutaneous and endoscopic lysis of epidural adhesions for chronic low back and lower extremity pain for Health Net/Centene-affiliated health plans.

Policy Summary

PayerHealth Net

PolicyLysis of Epidural Lesions (Epidural Adhesiolysis)

Policy CodePolicy CP.MP.116

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIf prior authorization is required, submit requests using CPT codes 62263 or 62264 with clinical rationale and supporting documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

efficacy not supportedEvidence stance

62263-62264Procedure codes

Hayes 6 RCTsSystematic review

ASIPP 2021Guideline cited

Centene-developedPolicy owner

Coverage Stance and Evidence

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.

Overall coverage stance and evidence

Policy position and evidence summary

Policy stance: It is the policy of health plans affiliated with Centene Corporation 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 epidural Racz catheter.

Policy statement asserting lack of supportive evidence

Evidence summary: Some controlled trials and systematic reviews report short- and intermediate-term improvements with percutaneous and endoscopic adhesiolysis in patients with chronic low back pain who have failed conservative therapy, but the body of evidence is limited by small numbers of RCTs, methodological issues, predominance of observational studies for endoscopic techniques, and lack of long-term outcomes; guideline updates (ASIPP 2021) rate percutaneous adhesiolysis as moderate-to-strong for select indications after failure of conservative therapy but note persistent limitations.

Summarizes Hayes review, endoscopic evidence, and ASIPP guideline context

No specific procedural exclusions are listed in this clinical policy. The policy's primary coverage conclusion is that current medical literature does not support the efficacy of lysis of epidural lesions, including both percutaneous and endoscopic epidural adhesiolysis (with or without an indwelling epidural Racz catheter); this evidence-based stance is the basis for coverage determinations rather than an enumerated list of excluded procedures.

The policy states that current medical literature does not support the efficacy of lysis of epidural lesions (percutaneous or endoscopic epidural adhesiolysis). Clinically, this means that claims for these procedures may be subject to denial or considered not medically necessary on the basis of insufficient supportive evidence; providers should document clinical rationale and prior conservative therapies if requesting coverage or prior authorization.

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 to Medicaid members.

Relevant Procedure 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

Percutaneous epidural adhesiolysis — frequency/usage note

CPT code for multi-day sessions62263 — Percutaneous lysis of epidural adhesions; multiple adhesiolysis sessions, 2 or more days.

CPT code for single-day session62264 — Percutaneous lysis of epidural adhesions; multiple adhesiolysis sessions, 1 day.

Coding implicationCodes explicitly distinguish single-day (62264) versus multi-day (62263) adhesiolysis sessions — select the code that matches the number of days of procedure activity.

Provider Requirements, Authorization, and Documentation

Prior Authorization

Prior Authorization and CPT Codes

Prior authorization may be required. Providers must obtain any required prior authorization before performing lysis of epidural lesions procedures and include supporting clinical documentation with the request.

Check plan-specific prior authorization rules
Use specified CPT codes when requesting authorization: 62263, 62264

Note

Pre-coverage Review

Review applicable Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Medicare Coverage Articles, and state Medicaid provisions before applying this policy. When state Medicaid provisions conflict with this clinical policy, state provisions take precedence.

Refer to CMS website for NCDs/LCDs and Coverage Articles
Consult the state Medicaid manual for Medicaid members

Documentation Required

Conservative Therapy Documentation

Document prior conservative therapies and evidence of failure before considering lysis of epidural lesions. Include dates, modalities, duration, and outcomes of conservative treatments in the medical record and with all authorization and claim submissions.

Examples: physical therapy, pharmacologic management, epidural steroid injections, activity modification
Document objective measures of failure (eg, persistent pain, functional limitation) and duration

Billing Rule

Coding and Documentation Guidance

Reference the most up-to-date professional coding guidance prior to claim submission. Include supporting clinical documentation with claims to substantiate medical necessity and the services billed.

Covered CPT codes referenced in this policy: 62263, 62264
Ensure code descriptors and modifiers match the performed service per current CPT edition

Denial Risk

Claims and Policy Adherence

Providers submitting claims or providing services to members are bound by the terms of this policy and applicable contract terms. Claims may be denied if documentation does not support medical necessity or if the procedure is considered not supported by current literature.

Claims may be denied for lack of efficacy evidence or insufficient documentation
Medicaid and Medicare rules and manuals remain applicable where relevant

Requirement for Prior Conservative Therapy

Failure of conservative therapy before considering adhesiolysis

Covered when documentation shows ALL of the following

Conservative therapy context: Clinical evidence and guideline recommendations referenced in this policy generally apply to patients who have failed conservative therapy for chronic low back and/or lower extremity pain.

Document prior conservative therapies when seeking consideration of adhesiolysis

Evidence linkage: Randomized trials and systematic reviews cited in the literature typically evaluated adhesiolysis in patients unresponsive to other treatments; endoscopic studies that showed benefit were largely observational but included RCTs in populations who had failed conservative care.

Hayes review and endoscopic evidence emphasize prior treatment failures

Guideline recommendation note: ASIPP 2021 guideline update provides moderate-to-strong ratings for percutaneous adhesiolysis for select indications specifically after failure of conservative therapy; the guideline update does not address endoscopic adhesiolysis.

Guideline context referencing failure of conservative treatment

Imaging and Visualization Requirements

Step Therapy

Use fluoroscopy and/or endoscopic visualization as described in technique

Fluoroscopic radiologic localization and/or endoscopic visualization are described components of the technique and should be used as indicated by the procedure.

Radiologic localization (fluoroscopy) is included in the CPT descriptions.
Endoscopic visualization may be used to provide 3-D visualization for targeted delivery.

Clinical Background

Epidural adhesiolysis (percutaneous or endoscopic) is intended to target epidural fibrosis and adhesions often associated with post‑laminectomy/failed back surgery syndrome, disc herniation, or spinal stenosis. Techniques described in the literature include injection of hypertonic saline with steroids or enzymes, mechanical catheter manipulation, and endoscopic visualization to target adhesions; protocols and use of indwelling catheters vary across studies and reports.

Key Definitions

Epidural adhesiolysis — definition and synonyms

Primary termEpidural adhesiolysis — also called epidural neuroplasty or lysis of epidural adhesions.

SynonymCaudal neuroplasty — term used interchangeably in the description of the procedure.

Technique summaryMinimally invasive procedure using solution injection (eg, hypertonic saline, enzyme) and/or mechanical catheter manipulation; may use endoscopic guidance for 3-D visualization and targeted delivery.

Clinical policy — scope and limitations

Purpose of policyProvides a guide to medical necessity used to assist coverage decisions and administering benefits.

Not a contract or guaranteeThis clinical policy does not constitute a contract or guarantee regarding payment or results.

Provider responsibilityDoes not dictate medical practice; providers should exercise professional judgment and are responsible for patient care and treatment decisions.