Epidural Lysis of Adhesions (Epidural Adhesiolysis) — Clinical Review Criteria
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Defines Kaiser Permanente Washington's clinical review criteria and coverage stance for epidural lysis of adhesions for chronic low-back pain; applies to providers and members of Kaiser Foundation Health Plan of Washington and its Options, Inc.
No material clinical or coverage changes in this revision.
Coverage Criteria
Not Medically Necessary
Evidence summary: Three randomized controlled trials and additional studies were reviewed; limitations and inconsistent evidence reported (see evidence appraisal).
Coding
| 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 Actions and Requirements
Prior authorization / review: include recent clinical notes
CPT 62263 and 62264 are listed as considered not medically necessary; if you are requesting a clinical review/authorization for these codes, include the last 6 months of clinical notes with the submission.
- Include notes from the requesting provider and/or specialist covering the prior 6 months.
Conservative therapy context: document failed conservative treatments
Background states that epidural adhesiolysis is performed after failure of conservative treatments and cites ASIPP guidance on limits to repeated interventions; document prior conservative therapy attempts when considering this procedure in the clinical context.
- ASIPP: limit to 2 interventions/year for 3-day protocol and 4/year for 1-day protocol; spinal endoscopic adhesiolysis limited to 2/year if ≥50% pain reduction for ≥2 months.
Required documentation for review: last 6 months of notes
If requesting review for this service, send the last 6 months of clinical notes from the requesting provider and/or specialist as part of the documentation packet.
- Provide clinical progress notes, prior interventions, and specialist evaluations from the preceding 6 months.
Background
Epidural lysis of adhesions (epidural adhesiolysis) is a percutaneous procedure intended to break down epidural fibrous adhesions and deliver medication (for example, hypertonic saline, enzyme, anesthetic, and corticosteroid) to putative pain generators in the epidural space. Techniques may use a catheter (such as a Racz catheter) with injection or mechanical manipulation; protocols described in the literature range from the original multi-day (3-day) approaches to modified 1-day protocols. The procedure typically includes radiologic localization with contrast (epidurogram) to visualize catheter position and dye spread. Potential complications reported include dural puncture, infection, catheter shearing, and rare events such as spinal cord compression.
Definitions
Conservative Treatment Requirements
Frequency Limits
Imaging Requirements
Imaging requirement: radiologic localization/contrast epidurogram
Radiologic localization with contrast epidurogram is described as part of the procedure and is referenced as the imaging method used to visualize contrast spread and identify defects; include imaging (epidurogram/contrast) when applicable.
- Procedure description: contrast material is injected and an epidurogram is performed to visualize spread and identify defects.
- CPT descriptions include radiologic localization (includes contrast when administered).
Not Covered
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