ModifiedUnitedHealthcarePolicy CS040NE.P

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

Defines UnitedHealthcare Nebraska coverage stance on epiduroscopy, percutaneous and endoscopic epidural lysis of adhesions, chemonucleolysis, and discography procedures for diagnosis or treatment of spinal disorders; applies to providers and members in Nebraska.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS040NE.P

Change TypeUpdated clinical evidence, descriptions, and references

Effective Date02/01/2026

Next Review Date

Key ActionObtain and document prior conservative therapy failure (including epidural steroid injections) before requesting prior authorization for percutaneous adhesiolysis.

SourceLink

POLICY UPDATE CHANGES

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

FDA information is provided for informational purposes only and FDA approval alone is not a basis for coverage.

3Procedures listed as NMN

8Referenced CPT codes

NebraskaApplies to

>=62Studies in review

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.

Avg pain relief (epiduroscopy)

02/01/2026Revision effective

Coverage Criteria

Unproven / Not Medically Necessary

Not medically necessary / unproven

Unproven and Not Medically Necessary Procedures: 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: functional anesthetic discography, provocative discography, chemonucleolysis, epiduroscopy (including spinal myeloscopy), and percutaneous and endoscopic epidural lysis of adhesions.

Policy lists these procedures as unproven and not medically necessary.

Percutaneous epidural lysis of adhesions (PA) — conditional coverage

Coverage considerations reflect the evidence base summarized below; where multiple RCTs support benefit (PA), coverage may be considered with criteria:

Percutaneous adhesiolysis (PA) candidate: Patient has chronic low back and/or lower extremity radicular pain refractory to conservative management (including physical therapy, structured exercise, medications) and fluoroscopically directed epidural injectionsfailure of conservative therapy and epidural injections

Supported by multiple RCTs and systematic reviews showing pain/function improvement up to 12 months in some trials; evidence quality variable

Epiduroscopy — limited evidence

Epiduroscopy (diagnostic or therapeutic) — evidence summary for consideration:

Epiduroscopy: May provide diagnostic visualization and in some series reduce pain/disability at 6-12 months in failed back surgery syndrome (FBSS), but evidence quality is moderate to limited and recommendations are weak; consider only after weighing risks and benefits and after prior conservative managementdocumented FBSS and prior conservative management

Systematic review reported average VAS and ODI improvements; quality described as moderate and recommendation as weak

Chemonucleolysis

Chemonucleolysis — agent-specific evidence:

Condoliase chemonucleolysis: Randomized controlled trial (condoliase vs placebo) demonstrated greater improvement in leg pain VAS for the condoliase group with follow-up assessments up to 52 weeks; RCT excluded certain herniation morphologies and had limited long-term safety datadocumented lumbar disc herniation (LDH) and prior conservative therapy

Evidence promising but with limitations; ongoing trials and additional long-term data needed

Gelified ethanol / DiscoGel chemonucleolysis: Observational and retrospective series report reductions in pain and disability (VAS, ODI) after gelified ethanol (DiscoGel) injection, but randomized comparative data versus surgery are limited and sample sizes are smalldocumented LDH and prior conservative therapy

Further prospective randomized trials required to establish comparative effectiveness

The policy considers functional anesthetic discography, provocative discography, epiduroscopy (including spinal myeloscopy), and percutaneous and endoscopic epidural lysis of adhesions to be unproven and not medically necessary for the diagnosis or treatment of any neck, back, or spinal disorder due to insufficient evidence of efficacy.

The available evidence and clinical trials cited in this policy pertain to lumbar procedures (e.g., lumbar epiduroscopy and epidural lysis of adhesions); no trials for cervical spine conditions evaluating epiduroscopy or epidural LOA were identified in the literature review.

Discography is not recommended as a standalone diagnostic test to guide treatment strategies. Guideline bodies (AANS/CNS, ACR) state discography should be used cautiously, and provocative discography may be associated with accelerated degenerative changes — risks that should be discussed with patients prior to performing the procedure.

Information about U.S. Food and Drug Administration (FDA) clearance or approval of devices used for these procedures is provided for informational purposes only. FDA approval alone is not a basis for coverage; coverage determinations must be made in the context of applicable federal, state, or contractual benefit plan requirements.

Restating the policy stance: discography, epiduroscopy, and percutaneous or endoscopic epidural lysis of adhesions are considered unproven and not medically necessary for evaluation or treatment of spine disorders based on current evidence; percutaneous adhesiolysis (PA) is the one area where multiple RCTs exist and evidence may be considered separately in documented, guideline-consistent scenarios.

Therapeutic endoscopic division of epidural adhesions has limited evidence of benefit and notable safety concerns. NICE recommends that this procedure should only be used with special arrangements for clinical governance, consent, audit, or research because of uncertainty about long-term outcomes and safety.

Coding

Referenced CPT CodesCPT

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

Studies included in systematic review — counts and populations

Total studies included62 studies

Total individuals reported12,368 individuals

PopulationIndividuals with single- or multi-level lumbar disc herniation (LDH) who received chemonucleolysis

Provider Actions and Requirements

Note

Check benefit plan and possible third‑party criteria

Check the member's benefit plan and any applicable federal, state, or contractual requirements before relying on this policy. Contract terms, state mandates, or plan-specific provisions take precedence and may require coverage or impose additional criteria. UnitedHealthcare may also use third‑party tools (for example, InterQual®) in benefit determinations.

Verify federal, state, and contractual requirements before applying policy
Confirm whether third‑party criteria (eg, InterQual®) apply

Denial Risk

Denial triggers

Procedures listed as unproven or not medically necessary (for example, discography, epiduroscopy, percutaneous/endoscopic adhesiolysis) are common denial triggers when requested without documentation meeting policy clinical criteria or when the benefit plan excludes them. Prior authorization may be required; absence of required documentation (see documentation callout) often results in denial.

Denial risk for: provocative or functional discography, chemonucleolysis, epiduroscopy, percutaneous or endoscopic epidural lysis of adhesions

Background

Background: Discography refers to invasive diagnostic procedures (provocative or functional anesthetic) in which contrast or anesthetic is injected into the intervertebral disc to reproduce or anesthetize pain. Epiduroscopy is endoscopic visualization of the epidural space that can be used diagnostically or to perform adhesiolysis. Epidural lysis of adhesions (epidural LOA/adhesiolysis) includes percutaneous or endoscopic mechanical or chemical disruption of epidural scar or adhesions (procedures such as the Racz technique) intended to relieve radicular pain. Chemonucleolysis involves injection of enzymatic or gelified agents (for example, condoliase or gelified ethanol/DiscoGel) into the disc nucleus to reduce herniation and radicular symptoms. FDA device listings and approvals for instruments used in these procedures are available but do not determine coverage.

Definitions

Epiduroscopy / Epidural lysis of adhesions — definition

DefinitionEndoscopic or percutaneous procedure to remove epidural adhesions and fibrosis using mechanical means, laser, saline flushing, and often followed by steroid administration to reduce inflammation

Common techniquesRacz procedure, mechanical lysis with fiberoptic endoscope, saline distention and contrast epidurogram

Clinical purposePerformed to visualize epidural space anatomy, identify pathology, and attempt to relieve radicular pain from adhesions or scar tissue

Functional anesthetic discography — definition

DefinitionDiagnostic procedure injecting an anesthetic agent directly into the disc nucleus via a catheter; patient performs activities to compare pain before and after anesthetic injection

Procedure goal

Conservative Treatment Requirements

Conservative management expected prior to considering chemonucleolysis in study populations

Conservative management is generally expected prior to considering chemonucleolysis in study populations.

Conservative management prior to chemonucleolysis: Patient has undergone and failed an adequate trial of conservative management (examples in studies include physical therapy, oral analgesics, NSAIDs, and structured exercise).at least 1 month cited in some studies

Study populations for chemonucleolysis typically required prior conservative therapy; continued conservative treatments during follow-up were noted as potential confounders

Documentation of failed conservative therapies and prior epidural injections prior to considering PA or chemonucleolysis

Failed conservative therapy documentation:

Frequency Limits

Epidural lysis of adhesions — repeat procedure frequency

Frequency observationMany cases require repeat epidural lysis/adhesiolysis procedures more than once a year to maintain clinical benefit

Evidence contextShort- and intermediate-term efficacy suggested in some studies but long-term durability is uncertain

Clinical implicationFrequency limits may be individualized per patient history and documented response to prior procedures

Imaging Requirements

Documentation Required

Imaging expectation — MRI commonly required for LDH evaluation and follow‑up

MRI is frequently required to confirm lumbar disc herniation and to evaluate outcomes in the studies reviewed for discography and chemonucleolysis; obtain MRI imaging when clinically appropriate.

Pre-procedure MRI was used to confirm disc herniation in several chemonucleolysis and discography studies.
MRI was used to evaluate disc height and degeneration in follow‑up assessments.

Documentation Required

Imaging for chemonucleolysis and PA — MRI and/or epidurogram as indicated

For chemonucleolysis and PA, obtain MRI and consider epidurogram as clinically indicated; many studies used epidurogram to assess epidural filling defects pre‑ and post‑procedure.

Epidurogram was used in studies assessing changes in epidural filling defects after PA.
Use MRI and epidurogram selectively based on clinical presentation and procedural planning.

Not Covered

The following procedures are listed as not covered / not medically necessary: Functional anesthetic discography, Provocative discography, and Epiduroscopy (including spinal myeloscopy). These services may be denied when billed because the evidence does not demonstrate efficacy and safety sufficient to support coverage.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS040NE.P

Change TypeUpdated clinical evidence, descriptions, and references

Effective Date02/01/2026

Next Review Date

Key ActionObtain and document prior conservative therapy failure (including epidural steroid injections) before requesting prior authorization for percutaneous adhesiolysis.

SourceLink

On This Page

Prior authorization may be required per plan

Documentation Required

Evidence limitations and need for prior therapies

Evidence for some interventions (for example, epiduroscopy and adhesiolysis) is limited or mixed; where evidence is insufficient or conflicting, coverage decisions require documentation that conservative therapies were tried and failed and a clear rationale linking the procedure to the member's clinical status. Lack of prior conservative therapy or insufficient supporting evidence may prompt noncoverage.

Insufficient/low‑quality evidence noted for epiduroscopy and certain adhesiolysis techniques
Evidence limitations may necessitate denial or request for additional documentation of prior therapies and clinical response

Note

FDA approval not sole basis for coverage

FDA marketing clearance or approval of devices (endoscopes, catheters, needles) is informational only and does not by itself establish that a procedure is covered. Coverage decisions consider clinical evidence and plan terms in addition to device regulatory status.

FDA approval/clearance of devices is not sole basis for coverage decisions
Search FDA PMN database for device details if needed

Note

Reference plan contract requirements

This policy is informational and does not replace the member's plan contract. In a conflict between this policy and a member's federal, state, or contractual benefit terms, the benefit terms govern. UnitedHealthcare may update policies; always verify current policy and plan terms before authorizing services.

Policy does not override plan contract — plan terms govern in case of conflict
Check for policy updates and plan‑specific provisions

Step Therapy

Conservative‑first context

A conservative‑first approach is expected for most spinal interventions covered here: noninvasive therapies (eg, physical therapy, medications, epidural steroid injections where appropriate) should be attempted and documented prior to considering invasive diagnostic or therapeutic procedures.

Conservative therapies (eg, PT, pharmacologic management, epidural steroid injections) should be documented and exhausted as clinically appropriate

Step Therapy

Stepwise conservative therapy expected

Stepwise conservative therapy is expected and should be documented in the medical record: list prior therapies, duration, and objective response (eg, VAS, ODI). Typical expectations include a course of conservative care and failure to respond before consideration of invasive procedures; state or plan rules may define specific timeframes.

Document prior conservative treatments, dates, duration, and clinical response (eg, VAS, ODI)
If prior injections were used, document type (eg, epidural steroid injection), number, and response
Provide rationale why continued conservative management is unlikely to succeed

Confirm level of disc involvement by temporary anesthetic blockade during provocative maneuvers

Clinical use noteUsed to help determine additional treatment options if pain reproduction and anesthetic response localize symptoms to a disc

Provocative discography — definition

Test premiseSymptomatic, internally disrupted discs cause pain when pressurized; reproduction of usual pain supports discogenic pain

Clinical cautionEvidence for clinical utility is limited and provocative discography may be associated with disc degeneration in some studies

Chemonucleolysis — general definition

General definitionMinimally invasive procedure injecting a proteolytic enzyme into the intervertebral disc to dissolve herniated nucleus pulposus and reduce radicular symptoms

Agents historically usedChymopapain (discontinued) and newer agents such as condoliase; gelified ethanol (DiscoGel) also described

Intended roleProposed as a bridge between conservative therapy and surgery for lumbar disc herniation

Chemonucleolysis — alternate definition entry

Agent-specific exampleCondoliase: enzymatic chemonucleolysis evaluated in RCTs showing greater leg pain improvement vs placebo in select LDH populations

Alternate agentsGelified ethanol (DiscoGel) and other enzyme formulations have been studied in observational series with mixed results

Evidence limitationsLong-term safety and comparative effectiveness vs surgery require further high-quality RCTs

Epiduroscopy — definition

DefinitionEndoscopic visualization of the epidural space to identify anatomy and pathology and to potentially perform mechanical or drug-assisted adhesiolysis

Procedure componentsFlexible fiberoptic endoscope, saline flushing, mechanical disruption, and often steroid administration during final stage

Diagnostic valueCan aid visualization of cauda equina and epidural pathology but evidence for impact on management/outcomes is limited

Percutaneous epidural lysis of adhesions (PA) — definition

DefinitionMinimally invasive mechanical and/or chemical disruption of epidural adhesions (adhesiolysis, percutaneous epidural neuroplasty, Racz procedure) often using needles, catheters, solutions, or mechanical devices under fluoroscopic guidance

PurposeIntended to relieve radicular pain by lysing scar tissue and improving epidural space patency

Typical adjunctsContrast epidurogram for localization and steroid injection after lysis

Epidural Lysis of Adhesions (Epidural LOA) — definition

TerminologyEpidural Lysis of Adhesions (Epidural LOA) encompasses percutaneous or endoscopic procedures intended to lyse scar tissue/adhesions in the epidural space

DevicesVarious endoscopes, catheters, and needles may be used; multiple FDA-listed products exist (FDA listing referenced for informational purposes)

Clinical intentPerformed to relieve nerve root impingement and radicular pain attributed to epidural adhesions or fibrosis

Provocative Discography (Discography) — definition and clinical utility note

DefinitionProvocative discography (discography) is a diagnostic procedure that reproduces pain by pressurizing a disc and injecting contrast to assess discogenic pain

Clinical utility noteClinical utility is limited per guideline and evidence summaries; discography is not recommended as a standalone test for treatment planning in many scenarios

Risk considerationsSome studies and guidance raise concerns about possible acceleration of disc degeneration and limited diagnostic specificity

Documented failure of conservative management including physical therapy, chiropractic care, pharmacologic therapy, structured exercise program, and at least one fluoroscopically directed epidural steroid injection as clinically appropriate.

failure of conservative therapy and prior epidural injections

Systematic reviews and guideline summaries indicate PA is considered after conservative measures and epidural injections have failed; documentation should include types, duration, and objective measures (e.g., VAS, ODI) where available

Documentation Required

Diagnostic workup — follow referenced clinical guidance (ACR Appropriateness Criteria)

Follow referenced clinical guidance for the diagnostic workup of low back pain (e.g., ACR Appropriateness Criteria); use imaging and diagnostic tests consistent with guideline recommendations.

Refer to ACR Appropriateness Criteria for Low Back Pain and other guidance cited in the policy when planning diagnostic workup.
Ensure imaging and tests are documented and aligned with guideline‑based indications.