ModifiedUnitedHealthcarePolicy CS040OH.C

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

This Medical Policy governs coverage and medical necessity determinations for epiduroscopy, epidural lysis of adhesions, discography, chemonucleolysis and related interventional spine procedures for members in Ohio; it applies to requests evaluated under Ohio Administrative Code 5160-101.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS040OH.C

Change TypeDescription, clinical evidence and reference updatesremoved related policy links

Effective DateMar 1, 2026

Next Review Date

Key ActionWhen requesting coverage, document prior conservative therapy failure and reference InterQual or applicable UnitedHealthcare criteria for medical necessity determinations.

SourceLink

POLICY UPDATE CHANGES

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

Removed reference link to the Medical Policy titled: Discogenic Pain Treatment (for Ohio Only); Epidural Steroid Injections for Spinal Pain (for Ohio Only); Interspinous Fusion and Decompression Devices (for Ohio Only); Minimally Invasive Spine Surgery Procedures (for Ohio Only); Spinal Fusion and Decompression (for Ohio Only).

Ohiojurisdiction

CS040OH.Cpolicy identifier

Not medically necessarydiscography stance

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.

03/01/2026policy revision

Coverage Criteria and Policy Stance

Procedures deemed unproven/not medically necessary

The following procedures are designated unproven and not medically necessary for diagnosis or treatment of any neck, back, or spinal disorder:

Not medically necessary procedures: Discography (including functional anesthetic discography and provocative discography), epiduroscopy (including spinal myeloscopy), and percutaneous and endoscopic epidural lysis of adhesions are considered unproven and not medically necessary due to insufficient evidence of efficacy.

Refer to InterQual CP: Procedures: Discography, Spine, Lumbar for medical necessity clinical coverage criteria for discography; evaluations use Ohio Administrative Code 5160-101.

Evidence summaries that would inform coverage

Summarized evidence from randomized trials, observational studies, and systematic reviews that inform coverage reasoning:

Chemonucleolysis evidence summary: Randomized and observational studies of chemonucleolysis (condoliase, gelified ethanol, DiscoGel) report improvements in VAS and ODI in selected patients with lumbar disc herniation; a multicenter RCT reported significant improvement versus placebo (Chiba et al.), single‑study reports showed effectiveness rates of ~85% (Okada et al.) and ~72% in a phase 3 trial. Limitations include exclusion of certain herniation types, small samples, short follow‑up, and limited long‑term RCT data.

Chunks 18,19,20

Epiduroscopy evidence summary: Systematic reviews and observational studies report modest to moderate reductions in pain and disability at 6–12 months in some populations (including failed back surgery syndrome) but overall evidence quality is limited and recommendations are weak; diagnostic/prognostic utility primarily demonstrated in nonrandomized studies.

Chunk 22

Percutaneous epidural lysis of adhesions (PA) evidence summary: Multiple randomized trials and systematic reviews (including Manchikanti et al. systematic review and the Gerdesmeyer randomized placebo-controlled trial) report significant improvements in pain and function at 3–12 months in selected patients with chronic radicular pain refractory to conservative care; however, evidence quality varies and some reviews note high risk of bias and need for further robust RCTs.

Chunks 24,25,30

The policy lists several procedures as unproven and not medically necessary for the diagnosis or treatment of any neck, back, or spinal disorder because of insufficient evidence of efficacy. These include discography (both provocative and functional anesthetic techniques), epiduroscopy (including spinal myeloscopy), and percutaneous and endoscopic epidural lysis of adhesions. The designation reflects limited and low-quality evidence for clinical utility and concerns about safety and long-term effects for some of these procedures.

Chemonucleolysis trials have routinely enrolled patients after failure of conservative care, but many studies excluded certain herniation morphologies (for example, sequestrated or transligamentous extrusions), limiting generalizability of results. Ongoing clinical trials are listed on ClinicalTrials.gov, and the available RCTs and observational series have relatively small samples, variable follow-up, and limited long-term safety data.

Therapeutic endoscopic division of epidural adhesions carries recognized safety concerns and limited evidence of benefit beyond short-term follow-up; therefore, its use should be restricted to settings with special arrangements for clinical governance, informed consent, and audit, or be performed only in the context of research, consistent with the NICE recommendation.

Discography (including functional anesthetic discography and provocative discography) is considered not medically necessary due to limited, low-quality evidence for clinical utility and documented safety concerns, including reports suggesting potential acceleration of degenerative changes. Additional well-designed, long-term RCTs are needed to establish efficacy and safety.

A National Institute for Health and Care Excellence (NICE) statement (2010) concluded that evidence for therapeutic endoscopic division of epidural adhesions is limited to short‑term efficacy and identified significant safety concerns; NICE advised that the procedure be used only with special arrangements for governance, consent, and audit or in research settings.

NICE specifically raised safety issues and emphasized that the procedure’s efficacy beyond the short term is not established. Because of these concerns, routine use is not supported and careful case selection, governance, and monitoring are required where the procedure is undertaken.

Procedure Codes and Billing Notes

Prior Authorization

Prior Authorization (Ohio)

This Medical Policy applies only to the state of Ohio. Prior authorization (PA) is required for the procedures listed below when performed in Ohio; providers should submit PA requests in accordance with Ohio Administrative Code 5160-1-01 and UnitedHealthcare Ohio PA processes.

Prior authorization required for procedures listed in this policy when performed in Ohio.
PA requests may require documentation of prior conservative therapy (see items below).

Documentation Required

Conservative Therapy Before Authorization

Prior authorization may require documentation that conservative therapy was attempted before approval is granted. Typical conservative therapy documented in studies includes at least 6 weeks to 3 months of nonoperative management such as physical therapy, activity modification, oral analgesics/anti-inflammatories, and, where appropriate, documented trials of epidural steroid injection or other guideline-recommended nonsurgical measures. For chemonucleolysis specifically, evidence contexts and prior studies generally describe a trial of conservative therapy before the procedure.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

PA may require documentation of failed conservative therapy

Prior authorization decisions for percutaneous adhesiolysis may require documentation that conservative therapy failed; randomized trials of PA enrolled patients who did not respond to conservative care and some analyses note prior epidural steroid injection failure as an inclusion consideration.

PA evidence comes from RCTs and systematic reviews in patients refractory to conservative treatment.
Expect documentation of prior conservative management and possibly prior epidural steroid injection failure when requesting PA.

Note

Use InterQual first; fallback to UHC/OAC‑approved criteria

UnitedHealthcare uses InterQual for primary medical/surgical criteria; if InterQual does not have applicable criteria, UnitedHealthcare may use its Medical Policies, Coverage Determination Guidelines, and/or Utilization Review Guidelines approved by the Ohio Department for Medicaid Services for prior authorization decisions.

Document that InterQual criteria were used when applicable; if not available, reference UnitedHealthcare criteria approved by Ohio Medicaid.
Follow federal, state (OAC), or contractual benefit terms when applying the policy.

Requirements Related to Conservative Therapy

Evidence supports use after failure of conservative therapy

Evidence and study protocols commonly indicate treatment is used after failure of conservative therapy; policy text does not specify a mandatory duration for conservative therapy but cited studies often required at least 1 month:

Conservative therapy prerequisite (evidence context): Chemonucleolysis trials and reports generally enrolled patients who had failed conservative management (eg, medications, physical therapy, structured exercise, or prior epidural injections); several studies note conservative treatment for at least 1 month as part of inclusion criteria.often >= 1 month in cited studies

Chunks 19,16

Documentation of failure of conservative measures typically required by studies

Typical documentation elements observed in clinical studies and often expected when demonstrating prior conservative care:

Documentation of failed conservative measures:

Imaging and Procedural Guidance

Documentation Required

Use fluoroscopy and MRI as documented for these procedures

Procedures described in the policy commonly used imaging guidance — fluoroscopy for procedural guidance and MRI for preprocedural assessment; include relevant imaging (e.g., MRI) and procedural fluoroscopic documentation in the authorization package.

Discography includes radiological supervision and interpretation codes (72285, 72295).
Chemonucleolysis and PA studies used MRI confirmation of disc herniation and fluoroscopic guidance during injection.
Provide fluoroscopic imaging documentation and MRI reports when applicable.

Documentation Required

Include MRI confirmation or epidurogram where used in studies

Chemonucleolysis and percutaneous adhesiolysis studies frequently required MRI confirmation of disc herniation and/or use of an epidurogram for assessment; include these imaging findings with the authorization request.

MRI was used to confirm herniation in DiscoGel and condoliase studies.
Epidurograms were used to assess filling defects before and after PA in study protocols.

Definitions and Procedural Descriptions

inv-23: Epiduroscopy / Epidural lysis of adhesions — definition and brief description.

DefinitionMinimally invasive procedures to remove epidural adhesions and fibrosis using devices such as a flexible catheter or laser, combined with saline flushing and often steroid administration to reduce inflammation and visualize epidural anatomy.

Typical techniqueMechanical disruption of scar tissue or adhesions via catheter manipulation or fiberoptic endoscope with injection of saline to distend the epidural space and steroid instillation in the final stage.

Clinical intentIntended to relieve radicular or back pain attributed to epidural adhesions and to improve access of the epidural space for therapeutic injections.

Evidence noteSystematic reviews report clinically relevant reductions in pain and disability at 6–12 months in selected failed back surgery syndrome patients, but evidence quality is moderate and recommendations are weak.

inv-24: Functional anesthetic discography — definition and procedural summary.

Frequency and Re-treatment Considerations

inv-34: No explicit frequency limits stated in this portion of the document — placeholder indicating lack of explicit limits.

Policy statementThis portion of the document does not state explicit frequency limits for the listed procedures.

Coding implicationAbsence of frequency limits in this section does not preclude that other policies, InterQual criteria, or state/contractual rules might impose limits.

RecommendationCheck current InterQual, UnitedHealthcare criteria, or Ohio Administrative Code requirements for any applicable frequency restrictions for specific services.

inv-35: Percutaneous adhesiolysis — may need to be repeated more than once a year to maintain benefits (per Hayes report).

Repeat proceduresHayes review concluded that percutaneous adhesiolysis may need to be repeated more than once a year to maintain clinical benefits in many cases.

Services Not Covered / Not Medically Necessary

Not covered procedures include: discography (provocative and functional anesthetic discography), epiduroscopy (including spinal myeloscopy), and percutaneous and endoscopic epidural lysis of adhesions. In addition, therapeutic endoscopic division of epidural adhesions is not supported for routine use outside of research or settings with special governance and consent arrangements due to limited evidence and safety concerns.

Background and Clinical Context

Background: Epiduroscopy, epidural lysis of adhesions (percutaneous or endoscopic), discography (provocative and functional anesthetic techniques), and chemonucleolysis are interventional procedures proposed for diagnosis or treatment of spinal pain. The quality of evidence varies by procedure: discography has limited and low-quality evidence with safety concerns; chemonucleolysis studies (including RCTs of condoliase and series of gelified ethanol/DiscoGel) show short-term improvements in selected lumbar herniation patients but exclude certain herniation types and lack long-term data; epiduroscopy and epidural adhesiolysis have mixed evidence with some moderate-quality findings for short-term pain and disability reduction but variable recommendation strength. Overall, safety considerations and insufficient long-term RCT evidence inform the policy’s restrictive coverage stance.

Policy Revisions

2026-03-01policy_revisionLatest

Archived prior policy version CS040OH.B; updated Description of Services, Clinical Evidence, and References sections; removed reference links to several Ohio-only related medical policies.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS040OH.C

Change TypeDescription, clinical evidence and reference updatesremoved related policy links

Effective DateMar 1, 2026

Next Review Date

Key ActionWhen requesting coverage, document prior conservative therapy failure and reference InterQual or applicable UnitedHealthcare criteria for medical necessity determinations.

SourceLink

On This Page

Conservative therapy typically documented: physical therapy, medications, activity modification, and selective injections.
For chemonucleolysis, conservative therapy preceding the procedure is generally expected in the literature and may be required for PA.

Denial Risk

Denial Triggers and Evidence Limitations

Requests lacking adequate documentation of conservative therapy, or lacking the clinical information and references supporting medical necessity, may be denied. Denial triggers include: absence of prior conservative management when expected by the evidence, incomplete clinical documentation, or when the requested procedure is considered unproven by policy.

Omissions in documentation of prior conservative therapy may lead to denial.
Procedures characterized as unproven or experimental in this policy may be denied as not medically necessary.

Note

Evidence Limitations and NICE Guidance

The evidence for some procedures in this policy is limited or conflicting. When the available clinical evidence does not demonstrate safety and effectiveness, the procedure may be considered unproven and subject to denial. Where applicable, the National Institute for Health and Care Excellence (NICE) safety and governance advice should be considered — caution and appropriate governance/safety measures may be required when offering such procedures.

Limited or conflicting evidence may result in coverage denial.
Follow NICE safety/governance cautions when applicable.

Documentation Required

Typical Documentation Observed in Studies

Studies commonly report the following documentation as typical when evaluating candidates for diagnostic or therapeutic disc procedures: detailed history and physical exam correlating symptoms to imaging, prior conservative treatment records (duration and modalities), imaging reports (MRI/CT) with level(s) identified, previous interventional procedure records and responses, and informed consent describing risks/benefits and alternative treatments.

History/physical exam correlating symptoms to imaging.
Prior conservative treatment records with duration and response.
Imaging reports specifying levels involved.
Previous procedures and response documentation.
Informed consent and discussion of alternatives.

Documentation Required

Reference Requirements and Documentation

Reference requirements for PA and medical necessity review include submission of the clinical notes, imaging reports, prior treatment documentation, and any supporting literature citations that justify the requested procedure. Lack of these references may delay review or result in denial.

Submit clinical notes, imaging, prior treatment records, and supporting literature with PA request.
Incomplete submissions may delay review or trigger denial.

Billing Rule

Coding Clarification

Coding Clarification: Functional anesthetic discography should be billed with CPT code 64999 (Unlisted procedure, nervous system). Be aware that billing functional anesthetic discography with another specific discography CPT may lead to coding disputes. Providers should include adequate operative/procedure reports to support use of an unlisted code.

Functional anesthetic discography — bill with 64999 and include procedure report.
Ensure documentation supports use of an unlisted code to facilitate PA and claims review.

Reference CPT codes (neutral)CPT

62263	Percutaneous lysis of epidural adhesions, multiple days
62264	Percutaneous lysis of epidural adhesions, 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, lumbar
64999	Unlisted procedure, nervous system (e.g., functional anesthetic discography)
72285	Discography, cervical or thoracic, R/S/I
72295	Discography, lumbar, R/S/I

Note

Chemonucleolysis typically studied after failed conservative therapy

Evidence for chemonucleolysis in cited studies generally involves treatment after failed conservative therapy; RCTs and observational studies enrolled patients who had not improved with conservative measures prior to injection.

Chemonucleolysis trials (including the multicenter RCT) enrolled patients who failed conservative treatment before receiving the intervention.
Study inclusion commonly required MRI confirmation of herniation and prior conservative management.

Documentation Required

Document failure of conservative measures before PA/chemonucleolysis

Many PA and chemonucleolysis studies required failure of conservative measures (e.g., medications, physical therapy, structured exercise, or prior epidural injections) before enrollment; prior authorization requests should include documentation of these conservative treatments.

Conservative measures cited include physical therapy, medications, structured exercise programs, and fluoroscopically directed epidural injections.
Provide documentation of conservative care attempts when submitting PA or chemonucleolysis for review.

Step Therapy

Check current criteria for step therapy requirements

Policy content and supporting evidence have been updated; required conservative therapy steps may change — verify current InterQual criteria and the latest UnitedHealthcare policy version for any specific step therapy requirements before submitting authorization requests.

Policy revisions updated Description of Services and Clinical Evidence (03/01/2026).
Check InterQual and current UHC policy for any updated step therapy prerequisites.

Documentation Required

Include imaging and prior conservative treatment proof in documentation

Studies commonly required documentation of prior conservative treatment failure and objective imaging such as MRI confirmation of disc herniation; include these elements in the record when seeking authorization.

Include MRI confirmation of disc herniation where applicable.
Document prior conservative treatment attempts and outcomes (e.g., response to epidural steroid injections).

Documentation Required

Reference OAC/InterQual and document criteria used

When making coverage decisions reference federal, state (Ohio Administrative Code 5160-101), or contractual benefit terms and document the use of InterQual or applicable UnitedHealthcare criteria as part of the decision-making record.

In the event of conflict, federal/state/contractual requirements govern.
Record which criteria (InterQual or UHC/OAC-approved guidelines) were applied in the authorization review.

Denial Risk

Denial risk: procedures designated unproven/not medically necessary

Requests for services listed as unproven or not medically necessary (discography, epiduroscopy, percutaneous/endoscopic epidural lysis of adhesions) will be evaluated under Ohio Administrative Code 5160-101 and may be denied because these procedures are designated unproven/not medically necessary in this policy.

Discography (including functional anesthetic and provocative), epiduroscopy, and percutaneous/endoscopic epidural lysis of adhesions are listed as unproven and not medically necessary.
Such requests are subject to medical necessity evaluation under Ohio Administrative Code 5160-101 and may be denied.

Denial Risk

Denial risk when evidence is limited or low quality

Insufficient or low‑quality evidence for some procedures (for example epidural adhesiolysis/endoscopic adhesiolysis) is identified in systematic reviews and may lead to noncoverage or additional review for medical necessity.

Systematic reviews note limited RCTs, methodological flaws, and moderate-to-low quality evidence for some adhesiolysis studies.
Lack of robust evidence may be a basis for noncoverage or further review.

Denial Risk

NICE caution: governance/consent required for endoscopic adhesiolysis

NICE concluded that therapeutic endoscopic division of epidural adhesions has limited evidence of short‑term efficacy and significant safety concerns; use outside special arrangements for clinical governance, consent, audit, or research may risk non‑coverage.

NICE advises use only with special arrangements for governance and research due to safety concerns.
Routine use outside these arrangements is not supported and may be denied.

Record of prior nonoperative care such as physical therapy, medications (analgesics/anti‑inflammatory agents), structured exercise programs, and failed fluoroscopically directed epidural steroid injections; objective imaging confirming the target pathology (eg, MRI showing disc herniation) and standardized outcome measures (eg, VAS, ODI) used for baseline and follow‑up assessments.

Note

Follow InterQual/UHC guidance for imaging and device planning

Device approvals and procedural planning referenced by the policy point to FDA device listings; follow InterQual or UnitedHealthcare guidelines for specific imaging and device-related requirements when preparing authorization documentation.

FDA device database may be referenced for device-specific information (informational only).
Adhere to InterQual/UHC imaging requirements and device guidance when applicable.

DefinitionDiagnostic procedure in which an anesthetic agent is injected directly into the disc nucleus via a catheter; the patient attempts to reproduce symptoms by activity before and after anesthetic to confirm the disc as a pain source.

Procedure stepsCatheter placement into disc nucleus, provocation of pain with activities (e.g., sitting, bending), injection of anesthetic, and comparison of pain intensity to determine disc involvement.

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

inv-25: Provocative discography — definition and procedural summary.

DefinitionInvasive diagnostic spine procedure involving pressurization of the intervertebral disc by injection of radiographic contrast into the nucleus pulposus to reproduce pain and identify symptomatic, internally disrupted discs.

PurposeUsed to determine whether a particular disc is the origin of chronic spinal pain by mechanically loading the disc with contrast to provoke the patient’s typical pain.

Associated servicesTypically performed with radiologic supervision/interpretation (CPT codes 72285 for cervical/thoracic or 72295 for lumbar) and reported with discography injection CPTs (62290/62291).

inv-26: Chemonucleolysis — definition (intradediscal enzyme injection) and context.

DefinitionMinimally invasive treatment that injects a proteolytic enzyme into the intervertebral disc to dissolve herniated nucleus pulposus, proposed as a bridge between conservative therapy and surgery.

Historical contextChymopapain was the first enzyme used but was discontinued for safety reasons; new agents (e.g., condoliase) are under study for safety and effectiveness.

Evidence considerationsEvidence is limited and additional long-term randomized controlled trials are needed to establish safety, efficacy, and optimal agents and patient selection.

inv-27: Percutaneous enzymatic decomposition of nucleus pulposus — synonym/related description for chemonucleolysis (condoliase, gelified ethanol, DiscoGel).

Synonyms/agentsPercutaneous enzymatic decomposition of the nucleus pulposus; examples include condoliase, gelified ethanol, and DiscoGel.

Procedure descriptionUnder fluoroscopic guidance, a small volume of an enzymatic or chemical agent is injected into the nucleus pulposus to reduce herniation and radicular symptoms.

Clinical findingsStudies report variable effectiveness (e.g., phase 3 trial ~72% effectiveness; single-study reports up to 85%), but limitations include short follow-up and selective inclusion criteria.

inv-28: Percutaneous Epidural Lysis of Adhesions (PA) definition — minimally invasive mechanical/chemical disruption of epidural adhesions.

DefinitionMinimally invasive mechanical and/or chemical disruption of epidural adhesions performed percutaneously using catheter-based techniques to lyse fibrosis and improve epidural space patency.

TechniquesMay include catheter manipulation, saline/distention injection, chemical agents, and radiologic guidance; percutaneous adhesiolysis (Racz procedure) is a common approach.

Intended benefitAims to relieve radicular low back pain thought to be due to epidural adhesions and to facilitate subsequent targeted epidural injections.

inv-29: Epiduroscopy — endoscopic visualization of the epidural space definition and uses.

DefinitionEndoscopic visualization of the epidural space using a fiberoptic endoscope to inspect anatomy and pathology and, when indicated, perform mechanical adhesiolysis.

Diagnostic utilityCan aid visualization of spinal structures such as the cauda equina and epidural space; earlier feasibility studies show anatomical assessment but limited data on impact to clinical management.

Therapeutic roleUsed to mechanically disrupt adhesions and administer steroids; observational and systematic review data suggest moderate-quality evidence for pain and disability reduction in select FBSS patients.

inv-30: Therapeutic endoscopic division of epidural adhesions — definition and NICE advisory context.

DefinitionAn endoscopic procedure intended to divide or lyse epidural adhesions to alleviate chronic low back and/or radicular pain.

Regulatory/advisory contextNICE (2010) concluded evidence is limited to short-term efficacy and noted significant safety concerns; recommended use only with special arrangements for clinical governance, consent, audit, or in research.

Evidence implicationRoutine coverage is not supported by NICE without special governance or research context; further research should specify case selection and outcomes including duration of effect.

Evidence qualityHayes characterized the evidence base as small and of low quality but consistent in showing benefit versus sham or epidural steroid injections in selected, refractory chronic LBP patients.

Clinical implicationWhen considering PA, document prior conservative treatment failure and discuss the potential need for repeat procedures with the patient.