Lysis of Epidural Lesions
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Defines the payer's coverage stance and supporting background for percutaneous and endoscopic lysis of epidural adhesions for chronic low back and lower extremity pain; applies to providers and members of health plans affiliated with Centene Corporation.
No material clinical or coverage changes in this revision.
Coverage Criteria
General coverage stance
Direct coverage stance from policy.
The policy states that current medical literature does not support the efficacy of lysis of epidural lesions. This includes both percutaneous epidural adhesiolysis and endoscopic epidural adhesiolysis, with or without use of an indwelling epidural Racz catheter. As a result, these procedures are not considered supported for efficacy under the health plans affiliated with Centene Corporation.
Per the policy statement, lysis of epidural lesions is not supported by current medical literature for efficacy and therefore is not favorably covered under this clinical policy. This statement applies to both percutaneous and endoscopic approaches, regardless of use of an indwelling Racz catheter.
For members enrolled in Medicaid, state Medicaid coverage provisions take precedence where they conflict with the coverage provisions in this clinical policy. Providers should consult the applicable state Medicaid manual for any differing coverage rules.
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 & Operational Notes
Prior Authorization & Effective Date
Prior authorization requirements and the effective date for this clinical policy are determined by the Health Plan. The date this policy is posted may not reflect the effective date that applies to a given member; providers should verify prior authorization requirements and the policy effective date with the member's specific Health Plan before submitting requests for services.
- Verify prior authorization requirements and effective date with the member's Health Plan prior to scheduling or performing services.
- Posting date may differ from the Health Plan-determined effective date; follow the Health Plan's operative effective date for coverage decisions.
Coverage Decisions & Administration of Benefits
Coverage decisions and administration of benefits are subject to the terms, conditions, exclusions and limitations of the member's coverage documents and applicable law and Health Plan administrative policies. This clinical policy is a guide to medical necessity and is not a guarantee of payment. Providers should confirm benefit coverage, applicable exclusions, and member-specific requirements (including prior authorization, network status, and benefit limits) before rendering services.
- Coverage is subject to the member's evidence of coverage, certificate of coverage, policy, or contract of insurance and to state and federal requirements.
- State Medicaid provisions supersede this clinical policy where conflicts exist; consult the state Medicaid manual for specific Medicaid coverage rules.
- For Medicare members, review applicable NCDs, LCDs, and Medicare Coverage Articles at http://www.cms.gov prior to applying this policy's criteria.
Coding, Documentation & Billing Notes
Providers must reference current coding guidance prior to claim submission and ensure required documentation supports medical necessity per the Health Plan. Inclusion of CPT codes in this policy does not guarantee coverage.
- Reference up-to-date professional coding guidance before submitting claims.
- CPT codes referenced in this policy (for informational purposes) include 62263 and 62264; inclusion does not assure payment.
- Ensure clinical documentation supports the medical necessity criteria and any prior authorization requests.
Conservative Treatment Requirements
Conservative treatment requirements
Policy and cited literature discuss use after failure of conservative therapies; however, the policy does not find the evidence sufficient to support efficacy.
Summarizes Hayes review and guideline context.
Supports statement that evidence is limited.
Guideline supports use after conservative therapy but recognizes evidence limitations.
Reflects policy coverage determination.
Imaging Requirements
Percutaneous/endoscopic adhesiolysis — include fluoroscopic localization
Perform percutaneous or endoscopic adhesiolysis with radiologic (fluoroscopic) localization as described in the CPT code definitions; ensure fluoroscopic imaging is documented in the medical record.
Not Covered
NOT COVERED: The policy explicitly states that lysis of epidural lesions (percutaneous epidural adhesiolysis and endoscopic epidural adhesiolysis), with or without an indwelling epidural Racz catheter, is not supported by current medical literature for efficacy and therefore is not favorably covered by health plans affiliated with Centene Corporation. Providers should also note that Medicaid-specific provisions may override this policy where applicable.
Definitions
Background
Background: Epidural adhesiolysis (percutaneous or endoscopic) is an interventional technique intended to treat chronic back and lower extremity pain attributed to epidural fibrosis or adhesions. Techniques described in the literature include injection of solutions (for example, hypertonic saline, enzymes, or steroids) and mechanical catheter disruption; endoscopic approaches permit direct visualization and targeted lysis. Despite these described techniques, the policy determination is that available evidence does not support efficacy for lysis of epidural lesions.
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