CurrentmhnPolicy CP.MP.116

Lysis of Epidural Lesions

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.

Policy Summary

Payermhn

PolicyLysis of Epidural Lesions

Policy CodePolicy CP.MP.116

Change TypeNo material change

Effective Date

Next Review Date

Key ActionReference current professional coding guidance and verify CPT codes 62263 and 62264 prior to claim submission.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1policy statement (efficacy not supported)

2CPT codes listed

6RCTs referenced

2021ASIPP guideline year

2010NICE statement year

3document chunks

Coverage Criteria

General coverage stance

Policy: 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 epidural adhesiolysis and endoscopic epidural adhesiolysis, with or without use of an indwelling epidural Racz catheter.

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.

Policy Summary

Payermhn

PolicyLysis of Epidural Lesions

Policy CodePolicy CP.MP.116

Change TypeNo material change

Effective Date

Next Review Date

Key ActionReference current professional coding guidance and verify CPT codes 62263 and 62264 prior to claim submission.

SourceLink

On This Page

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.

Provider Actions & Operational Notes

Prior Authorization

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.

Documentation Required

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.

Billing Rule

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.

Context: Evidence and guideline statements address percutaneous adhesiolysis for patients who have failed conservative therapy, but limitations in the evidence base are noted (small number of low-quality RCTs and lack of recent trials).

Summarizes Hayes review and guideline context.

Hayes review findings: A Hayes review of six randomized controlled trials (search through Sept 7, 2018) found a small body of low-quality evidence suggesting potential short- and intermediate-term benefit of percutaneous adhesiolysis in chronic low back pain unresponsive to other treatments, but long-term outcomes are undetermined and recent RCTs are lacking.

Supports statement that evidence is limited.

ASIPP guideline update: The 2021 ASIPP update rates the quality of evidence for percutaneous adhesiolysis as moderate to strong for certain indications after failure of conservative treatment (including disc herniation, spinal stenosis, and post-surgery syndrome), but notes a paucity of high-quality RCTs and does not address endoscopic adhesiolysis.

Guideline supports use after conservative therapy but recognizes evidence limitations.

Payer conclusion: Although studies and guidelines evaluate adhesiolysis in patients after failure of conservative therapies, the health plan concludes that current medical literature does not support the efficacy of lysis of epidural lesions and therefore does not favorably cover these procedures.

Reflects policy coverage determination.

Definitions

Epidural adhesiolysis / lysis of epidural lesions — definition

TermEpidural adhesiolysis (lysis of epidural lesions)

DescriptionMinimally invasive procedure (percutaneous or endoscopic) for chronic back pain associated with epidural fibrosis/adhesions; may follow prior spinal surgery or degenerative spine disease.

Techniques / agentsPercutaneous: epidural injections (e.g., hypertonic saline) often with steroids, analgesics, and/or hyaluronidase; mechanical catheter manipulation may be used.

Endoscopic approachSpinal endoscopy permits direct visualization and targeted lysis via a flexible fiberoptic catheter inserted through the sacral hiatus for 3‑D guidance.

MechanismHypertonic saline may mechanically disrupt adhesions and reduce edema; catheter manipulation can physically disrupt scar tissue; hyaluronidase may enhance drug penetration into scar.

'Health Plan' definition and related notes

Definition'Health Plan' means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan's affiliates.

ScopeApplies to providers, members/enrollees, and their representatives bound by contract terms or by provision of services/submission of claims.

Authority and limitationsClinical policy provides guidance on medical necessity and coverage decisions but does not guarantee payment or constitute a contract; Health Plan may change or withdraw the policy.

Relation to state/Medicare rulesState Medicaid provisions take precedence where they conflict; Medicare NCDs/LCDs should be reviewed for Medicare members.

OpenPayer

Lysis of Epidural Lesions

Coverage Criteria

Coding

Provider Actions & Operational Notes

Conservative Treatment Requirements

Imaging Requirements

Not Covered

Definitions

Background

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.