Lysis of Epidural Lesions (Epidural Adhesiolysis)
Customize your policy alerts
Sign up for Health Net Policy CP.MP.116 alerts
Get alerted when Policy CP.MP.116 changes without checking for updates manually.
Monitor payer policy activity
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.
No material clinical or coverage changes in this revision.
Coverage Stance and Evidence
Overall coverage stance and evidence
Policy position and evidence summary
Policy statement asserting lack of supportive evidence
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
| 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 Requirements, Authorization, and Documentation
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.
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
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
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.
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
Document prior conservative therapies when seeking consideration of adhesiolysis
Hayes review and endoscopic evidence emphasize prior treatment failures
Guideline context referencing failure of conservative treatment
Imaging and Visualization Requirements
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
Noncoverage Notes
The policy does not list any procedures explicitly under a "not covered" list beyond its central conclusion that current medical literature does not support the efficacy of lysis of epidural lesions. As a result, services may be denied or determined not medically necessary based on that evidence assessment; providers should review member-specific coverage documents and applicable state or Medicare determinations when planning care or submitting claims.
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.