CurrentUnitedHealthcarePolicy CSNCT0206.04

Epiduroscopy, Epidural Lysis of Adhesions, and Discography (for North Carolina Only)

UnitedHealthcare medical policy (North Carolina only) addressing coverage stance, clinical evidence, and coding for epiduroscopy, epidural lysis of adhesions (LOA), chemonucleolysis, and discography (including provocative and functional anesthetic discography). It lists procedures considered unproven/not medically necessary and provides applicable CPT coding guidance and clinical evidence summaries.

Policy Summary

PayerUnitedHealthcare

PolicyEpiduroscopy, Epidural Lysis of Adhesions, and Discography (for North Carolina Only)

Policy CodePolicy CSNCT0206.04

Change TypeClarified / Revised (policy history entries)

Effective DateDec 1, 2024

Next Review Date

Key ActionFollow the North Carolina-specific UnitedHealthcare medical policy when managing coverage for these procedures for North Carolina members.

POLICY UPDATE CHANGES

Created state-specific policy version for North Carolina (no change to coverage guidelines).

Added application note that this Medical Policy does not apply to the states of Idaho and Kansas; refer to state-specific versions.

Removed reference link to several related medical policies and updated clinical evidence and references.

5Procedures designated unproven / not medically necessary

1State-specific application (North Carolina)

MultipleRCTs supporting percutaneous adhesiolysis

Coverage Summary

This UnitedHealthcare medical policy (Policy No. CSNCT0206.04) applies only to North Carolina and is effective December 1, 2024. The policy addresses coverage for epiduroscopy, epidural lysis of adhesions (LOA), chemonucleolysis, and discography (including provocative and functional anesthetic discography) and provides coding guidance and evidence summaries. The stated coverage stance designates these procedures as not medically necessary / unproven for the diagnosis or treatment of any neck, back, or spinal disorder where listed due to insufficient evidence of efficacy. The policy history notes creation of the state-specific North Carolina version (10/01/2025) without changes to coverage guidelines and prior administrative updates (see policy history). Statistics in the brief identify 5 procedures designated unproven / not medically necessary and the policy is explicitly applicable to 1 state (North Carolina).

Key facts

Policy numberCSNCT0206.04

Effective dateDecember 1, 2024

State applicabilityNorth Carolina

StatusCURRENT

Number of procedures listed as unproven / not medically necessary5

Medical-Necessity Criteria

Not Medically Necessary / Unproven

The following are unproven and not medically necessary for the diagnosis or treatment of any type of neck, back, or spinal disorder due to insufficient evidence of efficacy:

Not Medically Necessary / Unproven - top level

Functional anesthetic discography
Provocative discography: Discography: Provocative discography
Epiduroscopy (including spinal myeloscopy)
Chemonucleolysis

Coding

Procedure codes referenced (informational only)CPT

62263	Percutaneous lysis of epidural adhesions using solution injection (e.g., hypertonic saline, enzyme) or mechanical means (e.g., catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days
62264	Percutaneous lysis of epidural adhesions using solution injection (e.g., hypertonic saline, enzyme) or mechanical means (e.g., catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 1 day
62290	Injection procedure for discography, each level; lumbar
62291	Injection procedure for discography, each level; cervical or thoracic
62292	Injection procedure for chemonucleolysis, including discography, intervertebral disc, single or multiple levels, lumbar
64999	Unlisted procedure, nervous system (Coding clarification: Functional anesthetic discography should be billed with CPT code 64999)
72285	Discography, cervical or thoracic, radiological supervision and interpretation
72295	Discography, lumbar, radiological supervision and interpretation

Provider Actions & Billing Guidance

Documentation Required

State applicability

This medical policy applies only to the state of North Carolina; providers must follow this policy for North Carolina members.

Applies to North Carolina members

Billing Rule

Billing guidance for functional anesthetic discography

Functional anesthetic discography should be billed with CPT code 64999 (unlisted procedure, nervous system).

Codes: 64999

Background & Clinical Evidence

The background summarizes that the evidence base across these procedures is limited and of mixed quality, with multiple systematic reviews, randomized controlled trials, cohort studies, and observational reports cited but overall need for higher-quality randomized controlled trials and longer-term outcomes to establish safety and efficacy. For discography the evidence is described as limited and low quality and additional well-designed long-term RCTs are needed. Chemonucleolysis data are encouraging in some systematic reviews and trials but are limited by older studies, small samples, heterogeneous methods, and the need for contemporary large RCTs and longer follow-up. Evidence for epiduroscopy includes feasibility and observational studies and a 2021 systematic review showing clinically relevant pain reductions in some FBSS patients but overall a moderate-to-low quality evidence base and weak recommendations. Percutaneous adhesiolysis (PA) has some RCT support but trial quality and long-term outcomes remain concerns; endoscopic adhesiolysis has more limited evidence. Notably, NICE (2010) raised safety concerns for therapeutic endoscopic division of epidural adhesions and recommended its use only with special arrangements for clinical governance, consent, audit, or research.

Source	Summary
Hayes evidence analysis (discography)
Limited and low-quality evidence for clinical utility of discography; additional well-designed long-term RCTs needed (Hayes 2023).
Manchikanti systematic review (PA)
Some RCTs show benefit at 12 months for percutaneous adhesiolysis but evidence limited by trial quality and scarcity of placebo-controlled trials.
Gerdesmeyer RCT (percutaneous LOA)
Randomized trial reported significant improvement in ODI and VAS up to 12 months with percutaneous neurolysis; 10-year follow-up maintained differences.
ECRI (Discogel)
Limited evidence; no RCTs comparing Discogel to alternative treatments; low-quality evidence suggests safety and symptom reduction.
Helm et al. (2016)
Systematic review: PA supported by multiple RCTs; endoscopic adhesiolysis has limited evidence supporting its use.
NICE IPG333 (2010)
Therapeutic endoscopic division of epidural adhesions: limited short-term efficacy evidence and significant safety concerns; should be used only with special arrangements for governance, consent, audit, or research.
Geudeke et al. (2021) systematic review (epiduroscopy)
In failed back surgery syndrome, pooled analyses showed clinically relevant reductions in pain and disability at 6–12 months but quality graded moderate and recommendation weak.

Glossary: Functional anesthetic discography (FAD): Diagnostic procedure injecting an anesthetic into a disc via catheter to assess pain reproduction and confirm disc-level involvement; Provocative discography (PD): Injection of contrast into the nucleus pulposus to determine whether a disc is the origin of chronic spine pain by provoking pain; Epiduroscopy: Endoscopic visualization of the epidural space, used for diagnosis and possible lysis of adhesions; Chemonucleolysis: Injection of a proteolytic enzyme into the intervertebral disc to dissolve herniated nucleus pulposus; Percutaneous adhesiolysis (PA) / Racz procedure: Percutaneous technique using a catheter and injections (e.g., saline, enzymes) to disrupt epidural adhesions; Endoscopic adhesiolysis: Adhesiolysis performed using endoscopic techniques with limited supporting evidence compared to percutaneous adhesiolysis.

Revision History

2024-12-01revised

Removed related policy links and updated clinical evidence and references; previous policy version archived (CS040.N).

2025-06-01revised

Added application note that this Medical Policy does not apply to the states of Idaho and Kansas; refer to state-specific versions.

2025-10-01clarifiedLatest

Created state-specific policy version for North Carolina (no change to coverage guidelines).

Evidence summaries and guideline statements

Summaries of guideline positions and evidence on indications and limitations for procedures:

Evidence summaries and guideline statements - top level

Percutaneous adhesiolysis evidence: Percutaneous adhesiolysis (PA) is supported by multiple randomized controlled trials and considered safe and effective for refractory low back and lower extremity pain (post-lumbar surgery syndrome) in several systematic reviews.
references systematic reviews and RCTs
Endoscopic adhesiolysis evidence: Endoscopic adhesiolysis has limited evidence; effectiveness is less well supported compared to PA and additional studies are needed.
Helm et al. and others note limited evidence and need for more studies
Epiduroscopy trials: Epiduroscopy and epidural LOA have open clinical trials for low back pain but no trials identified for cervical spine conditions.
clinicaltrials.gov and policy statements
Guideline recommendations (examples)
- AANS/CNS discography: AANS/CNS: Discography as a stand-alone test is not recommended to formulate treatment strategies for LBP with abnormal imaging findings; discoblock may be considered as a diagnostic option.
  Eck et al. 2014 guidance
- ACR (2021) discography: ACR (2021): Discography is not supported for evaluation of subacute/chronic LBP without red flags or prior management; not supported for evaluation of new/progressing symptoms after previous lumbar surgery; not for initial imaging of CES or low back ± radiculopathy in certain high-risk populations.
  ACR appropriateness criteria 2021
- ASIPP recommendations: ASIPP: Provocative discography recommended with appropriate indications when other sources of pain excluded and a treatment is available; percutaneous adhesiolysis recommended for post-lumbar surgery syndrome and lumbar central spinal stenosis after failure of conservative management.
  ASIPP comprehensive guidelines
Conflicts of interest note: Some studies note conflicts of interest which may limit conclusions of certain systematic reviews.
Conflicts noted in Helm and other reviews