CurrentUnitedHealthcarePolicy CSNCT0206.05

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

North Carolina–only UnitedHealthcare medical policy defining coverage rationale, evidence review, and applicable CPT/HCPCS codes for discography, epiduroscopy, percutaneous/endoscopic epidural lysis of adhesions, and chemonucleolysis. This part (1 of 2) contains coverage rationale, descriptions, evidence summaries, and referenced procedure codes.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CSNCT0206.05

Change TypeAdded code annotation; content updates

Effective DateFebruary 1, 2026

Next Review Date

Key ActionThis medical policy applies only to North Carolina; providers must verify NC Medicaid coverage for CPT 64999 prior to billing and follow state-specific determinations.

SourceLink

POLICY UPDATE CHANGES

Added notation that CPT code 64999 is not on the North Carolina Medicaid Fee Schedule and therefore may not be covered by the North Carolina Medicaid Program.

Updated Description of Services, Clinical Evidence, and References sections to reflect the most current information.

5Procedures listed as unproven/not medically necessary

9Procedure codes referenced

Coverage Summary

This UnitedHealthcare medical policy is North Carolina–only (state-specific) and is identified as policy number CSNCT0206.05 with an effective date of February 1, 2026. The policy takes a mixed coverage stance across the procedures addressed: epiduroscopy, epidural lysis of adhesions (including percutaneous adhesiolysis/Racz procedure), chemonucleolysis, and diagnostic discography procedures (both provocative and functional/anesthetic discography). This part of the policy contains coverage rationale (including procedures designated as unproven/not medically necessary), concise procedure descriptions, summaries of clinical evidence and guidelines, and referenced CPT procedure codes and annotations.

Policy numberCSNCT0206.05

Effective dateFebruary 1, 2026

ScopeNorth Carolina only

Coverage stancemixed

Medical-Necessity / Unproven 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 - leaf list

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

Referenced Procedure Codes

Referenced Procedure Codes (for reference 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.

CPT code with NC Medicaid noteCPT

64999

Not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the North Carolina Medicaid Program (notation added 02/01/2026).

State Fee Schedule NotationCPT

64999

Code not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program.

Actionable Provider Guidance

Documentation Required

State-specific applicability

This medical policy applies only to the state of North Carolina; providers must follow North Carolina–specific policy determinations when using this guidance.

Billing Rule

Billing for Functional Anesthetic Discography

Functional anesthetic discography should be billed with CPT code 64999 per the coding clarification provided in the policy.

Background and Evidence Summary

Epiduroscopy is an endoscopic technique to visualize the epidural space and remove adhesions and fibrosis using devices such as a catheter tip, laser, and saline flushing with steroid administration. Chemonucleolysis is the injection of a proteolytic enzyme into the intervertebral disc to dissolve herniated nucleus pulposus (historically chymopapain; newer agents such as condoliase under study). Epidural lysis of adhesions (adhesiolysis/percutaneous adhesiolysis/Racz procedure) is a minimally invasive set of techniques—including saline injection, catheter manipulation, and mechanical disruption—to break epidural scar and adhesions thought to cause chronic low back or radicular pain. Functional (anesthetic) discography involves injecting an anesthetic into the disc via a catheter while the patient performs provocative activities to assess pain change, whereas provocative discography uses contrast injection into the nucleus pulposus to reproduce pain and evaluate whether a disc is the pain generator.

Source	Key finding
Hayes Evidence Analysis / ECRI / systematic reviews	Multiple reviews conclude limited/low-quality evidence; recommend further RCTs; some short- to intermediate-term benefit reported for adhesiolysis but overall insufficient evidence for discography and epiduroscopy.
Gerdesmeyer et al. RCT	Randomized, double-blind trial showed percutaneous neurolysis had significantly greater ODI and VAS improvement at 3, 6, 12 months versus placebo; durable differences reported up to 10 years.
Chemonucleolysis trials	Mixed evidence from RCTs and observational studies; newer agents (condoliase) show promising short-term results but limitations include retrospective designs and short follow-up; systematic review/meta-analysis finds chemonucleolysis superior to placebo but calls for higher-quality trials.
Helm systematic review	Evidence rated fair that endoscopic adhesiolysis is effective for chronic low back/lower extremity pain in post-lumbar surgery syndrome; limited number of studies and potential conflicts of interest noted.
NICE IPG333	Concluded therapeutic endoscopic division of epidural adhesions has limited evidence and safety concerns; should be used only with special arrangements for governance, consent, audit or research.
FDA device note	FDA lists endoscopes, catheters, needles and diagnostic products used for epidural LOA/epiduroscopy; approvals are informational and not a basis for coverage decisions.

Definitions

Epiduroscopy: Procedure using endoscopic visualization, catheter/laser, saline flushing, and steroids to remove epidural adhesions and identify epidural pathology.

Functional anesthetic discography: Injection of anesthetic into a disc via catheter with patient activity to compare pain before and after anesthetic.

Provocative discography (PD): Injection of contrast into the nucleus pulposus to provoke pain and assess the disc as a pain source.

Chemonucleolysis: Injection of a proteolytic enzyme into the intervertebral disc to dissolve herniated nucleus pulposus (eg, condoliase; historical agent chymopapain discontinued).

Epidural lysis of adhesions (PA / percutaneous adhesiolysis / Racz procedure): Minimally invasive disruption of epidural fibrosis/adhesions using saline distention, catheter manipulation, mechanical disruption, and contrast epidurogram.

Revision History

2026-02-01addedLatest

Change recorded in Summary of Changes on 02/01/2026 under Applicable Codes: Added notation that CPT code 64999 is not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the North Carolina Medicaid Program.

2026-02-01revised

Archived previous policy version CSNCT0206.04; Updated Description of Services, Clinical Evidence, and References sections to reflect the most current information.

Clinical evidence and guideline summaries (informational supporting coverage decisions)

Summaries of clinical trials, systematic reviews, and specialty society recommendations relevant to epiduroscopy/epidural LOA and discography:

Clinical evidence and guideline summaries (informational)

RCTs of percutaneous adhesiolysis (Gerdesmeyer et al.): Randomized controlled trials of percutaneous adhesiolysis showed significant improvements in ODI and VAS at 3, 6, 12 months and up to 10 years in some studies (Gerdesmeyer et al. 2013; Gerdesmeyer et al. 2021).
Authors note limitations including inability to isolate effects of single treatment components and lack of imaging at long-term follow-up.
Systematic reviews on PA and endoscopic adhesiolysis: Systematic reviews (Helm et al. 2013, 2016; Brito-García et al. 2019; Hayes assessments) found evidence supporting PA for refractory low back/lower extremity pain post-lumbar surgery syndrome, with limited evidence for endoscopic adhesiolysis.
Evidence quality variable; conflicts of interest and paucity of high-quality studies noted.
Ongoing trials for epiduroscopy/LOA: Clinical trials of epiduroscopy and epidural LOA for low back pain are ongoing; no identified trials for cervical spine conditions (clinicaltrials.gov).
Accessed Aug 19, 2025.
AANS/CNS guideline on discography: AANS/CNS (Eck et al., 2014) recommends that discography as a stand-alone test is not recommended to formulate treatment strategies for LBP with abnormal imaging findings; discoblock may be a diagnostic option; counsel patients regarding possible association between provocative discography and progression of degenerative disc disease.
Guideline-based diagnostic caution.
ACR 2021 appropriateness criteria: ACR 2021 states there is no relevant literature to support discography for acute uncomplicated LBP, evaluation of subacute/chronic LBP without red flags/prior management, initial imaging for cauda equina suspicion, evaluation of new/progressing symptoms post-lumbar surgery, or initial imaging in certain contexts (low-velocity trauma, osteoporosis, older individual, chronic steroid use, suspicion of cancer/infection/immunosuppression).
ASIPP recommendations: ASIPP: Provocative lumbar discography recommended with appropriate indications to prove discogenic pain only after excluding other sources and when a treatment is available; cervical and thoracic discography indicated similarly only when treatment is available; anesthetic (functional) discography has mixed evidence. PA recommended for post-lumbar surgery syndrome and lumbar central spinal stenosis after failure of conservative management.
ASIPP also recommends PA for post-lumbar surgery syndrome and lumbar central spinal stenosis after failure of conservative management.
NICE IPG333 on endoscopic division of epidural adhesions: NICE (2010) concluded therapeutic endoscopic division of epidural adhesions limited evidence and safety concerns; should be used only with special arrangements for governance, consent, audit, or research.
FDA device approvals informational note: FDA: devices (endoscopes, catheters, needles) used for epidural LOA and diagnostic products exist; FDA approvals are informational and not a basis for coverage decisions.
Links to FDA PMN search provided (accessed Aug 19, 2025).