ModifiedUnitedHealthcarePolicy CS040NJ.L

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

This New Jersey–specific medical policy governs coverage and clinical stance for epiduroscopy, epidural lysis of adhesions (including percutaneous and endoscopic approaches), chemonucleolysis, and discography procedures for UnitedHealthcare members in New Jersey.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS040NJ.L

Change TypeUpdated clinical evidence, description of services, and referencesadded NICE/FDA citations

Effective DateFeb 1, 2026

Next Review Date

Key ActionObtain and document prior authorization and record prior conservative therapy attempts and baseline/follow-up ODI or VAS when seeking coverage for percutaneous adhesiolysis.

SourceLink

POLICY UPDATE CHANGES

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

Included citations and guidance referencing NICE and FDA information about epidural adhesiolysis and related devices.

4procedures listed as unproven/not medically necessary

NJstate this policy applies to

8 codesprocedure CPT codes cited

12,368participants in chemonucleolysis 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.

49%pooled pain relief after epiduroscopy

Coverage Criteria

Procedures considered unproven / not medically necessary

Not medically necessary/unproven

Primary NMN list

Procedures: Discography (provocative discography, functional anesthetic discography)
Procedures: Chemonucleolysis
Procedures: Epiduroscopy (including spinal myeloscopy)
Procedures: Percutaneous and endoscopic epidural lysis of adhesions

Percutaneous adhesiolysis / Epidural LOA coverage criteria

Covered when ALL of the following are met (as supported by evidence summaries):

Primary coverage group: Patient has chronic low back and/or radicular pain refractory to conservative management (including physical therapy, structured exercise, medications, and fluoroscopically directed epidural steroid injections).documented failure of conservative care

Supported by systematic reviews and RCTs indicating PA is used after failed conservative therapy.

Objective baseline and follow-up measures: Objective baseline and follow-up outcome measures (for example, baseline ODI and VAS/NRS and documented post-procedure follow-up assessments) are recorded in the medical record.ODI/VAS recorded pre-procedure and at follow-up intervals

Randomized trials and systematic reviews emphasize these measures.

Clinical and imaging correlation:

Epiduroscopy

Covered with consideration (supporting evidence)

Epiduroscopy diagnostic/therapeutic role: Epiduroscopy may provide diagnostic and prognostic information and is associated with clinically relevant reductions in pain and disability at 6–12 months in patients with failed back surgery syndrome (FBSS); clinicians should weigh potential benefits against procedure risks.improvement in VAS/ODI

Systematic review reported ~49% with significant pain relief at 6 months; quality graded moderate with weak recommendation.

Chemonucleolysis

Investigational / insufficient evidence

Chemonucleolysis (including agents such as condoliase, gelified ethanol/DiscoGel and other products) has limited and mixed evidence; small RCTs and observational series report variable efficacy and safety, and longer-term high-quality randomized trials are needed.lack of consistent high-quality RCT evidence and long-term safety data

Multiple retrospective cohorts and a single RCT exist; ongoing trials noted.

Discography

Discography — diagnostic use limited and conditionally recommended

Provocative discography should not be used as a standalone test to formulate treatment strategies and should be considered only after exclusion of other sources of pain, when a management option is available and the patient has been counseled about potential risks and implications (including possible association with progression of disc degeneration).appropriate patient selection and counseling

AANS/CNS, ACR, and ASIPP guidance recommend limited and conditional use; ACR lists scenarios where discography is not supported.

The policy states that the following procedures 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: Discography (functional anesthetic and provocative), Chemonucleolysis, Epiduroscopy (including spinal myeloscopy), and Percutaneous and endoscopic epidural lysis of adhesions.

The American College of Radiology (ACR) 2021 update states there is no relevant literature to support the use of discography for several common low back pain scenarios, including: acute uncomplicated low back pain; subacute or chronic low back pain without red flags or prior management; initial imaging for suspected cauda equina syndrome; evaluation of new or progressing symptoms after prior lumbar surgery; and initial imaging in patients with risk factors such as low‑velocity trauma, osteoporosis, older age, chronic steroid use, or suspicion of cancer, infection, or immunosuppression.

The National Institute for Health and Care Excellence (NICE) 2010 statement raised significant safety concerns regarding therapeutic endoscopic division of epidural adhesions and concluded available evidence showed only short‑term efficacy. NICE recommended that this procedure should be used only with special arrangements for clinical governance, informed consent, and audit or research, and that further research should clearly describe case selection and outcomes including pain relief and duration of effect.

Explicitly listed as unproven and not medically necessary are: Provocative discography, Functional anesthetic discography, Chemonucleolysis, Epiduroscopy (including spinal myeloscopy), and Percutaneous and endoscopic epidural lysis of adhesions.

Therapeutic endoscopic division of epidural adhesions carries limited evidence of efficacy and notable safety concerns. NICE limited its use to settings with special governance, consent, and audit or research oversight, reflecting that routine therapeutic endoscopic adhesiolysis has insufficient support for unrestricted clinical use.

NICE concluded that the existing evidence base for therapeutic endoscopic division of epidural adhesions is limited to short‑term efficacy, and that information on longer‑term benefit and safety is lacking; therefore routine, unrestricted use is not supported without special governance or research arrangements.

Applicable Codes and Device References

Applicable 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.

Device/Regulatory referencesmixed

device PMNs referenced

FDA device premarket notification listings for endoscopes, catheters, needles and diagnostic products (no specific CPT/HCPCS codes listed in this portion).

Informational device listingsmixed

device listings

FDA product listings for endoscopes, catheters, needles and other devices used in epidural LOA (see FDA PMN database).

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Note

Prior authorization may be required. CPT/HCPCS/ICD codes listed in the policy are for reference only and do not guarantee coverage or reimbursement. Verify prior authorization requirements and obtain approval per the member's federal, state, and contractual benefit plan prior to scheduling services.

Refer to member-specific benefit plan for prior authorization rules and timelines
Listing of a code does not imply coverage; obtain PA when required by contract

Step Therapy

Prior Conservative Therapy Required

For procedures such as percutaneous adhesiolysis (PA), documentation must demonstrate failure of an adequate trial of conservative therapy before consideration of PA. Conservative measures commonly include physical therapy, activity modification, structured exercise programs, nonsteroidal anti-inflammatory drugs, and a trial of epidural steroid injections when clinically appropriate.

Conservative therapy should be documented in the medical record with start/end dates and responses to treatment

Background and Scope

Epiduroscopy and epidural lysis of adhesions are minimally invasive procedures intended to visualize and disrupt epidural fibrosis and adhesions to relieve radicular low back pain. Techniques may include direct endoscopic visualization with mechanical removal or laser, catheter‑based mechanical manipulation, saline distention, and delivery of therapeutic agents (for example, corticosteroids) into the epidural space. These procedures are typically performed under imaging guidance and are intended for patients with clinical and imaging correlation for epidural scarring or failed back surgery syndrome.

Definitions

inv-28: Epiduroscopy — definition and short attributes

DefinitionEpiduroscopy — endoscopic visualization of the epidural space with removal/disruption of adhesions and fibrosis using a flexible catheter (and laser or mechanical tip) with saline flushing; steroids are often administered at the end of the procedure.

Typical techniquePerformed with a flexible fiberoptic endoscope/catheter to monitor anatomy and identify pathology while mechanically disrupting scar tissue and adhesions via catheter tip or laser and saline distention.

Indications describedUsed to visualize epidural anatomy and pathology and may be considered in patients with failed back surgery syndrome (FBSS) or suspected epidural adhesions when other treatments have failed.

inv-29: Epidural lysis of adhesions — definition

DefinitionEpidural lysis of adhesions — minimally invasive procedures (adhesiolysis, percutaneous epidural neuroplasty, epidurolysis) that disrupt epidural adhesions by saline distention, mechanical manipulation, catheter-based techniques (eg, Racz procedure) and/or injection of solutions to decompress the epidural space.

Conservative Treatment Requirements

Document prior conservative therapy attempts and failure before considering PA

Document prior conservative therapy attempts and failure before considering percutaneous adhesiolysis (PA).

Conservative therapy documented: Medical record documents prior conservative treatments including but not limited to physical therapy/structured exercise, medications, chiropractic care, and fluoroscopically directed epidural steroid injections, with documented inadequate response or failure.

Evidence and guidelines describe PA as an option after failure of conservative measures and epidural steroid injections.

Frequency Limits

inv-40: Discography/chemonucleolysis coding references include fluoroscopic guidance; no explicit frequency limits

Coding referencesApplicable CPT codes listed for discography and chemonucleolysis include 62290, 62291, 62292 and radiology supervision codes 72285, 72295; functional anesthetic discography is billed with 64999.

Fluoroscopic guidancePolicy descriptions and study reports reference use of fluoroscopic guidance for discography and chemonucleolysis procedures (radiologic supervision codes included).

Frequency limitsNo explicit frequency limits for discography or chemonucleolysis are provided in this section of the policy.

inv-41: Percutaneous adhesiolysis — may require repeat procedures more than once a year per Hayes commentary

Hayes commentaryHayes report concluded that in many cases percutaneous adhesiolysis must be repeated more than once a year to maintain benefit.

Imaging and Procedural Guidance

Documentation Required

Use MRI and fluoroscopic guidance as commonly described in studies

MRI is commonly used for pre‑procedure diagnostic evaluation and fluoroscopic guidance is commonly described for discography, chemonucleolysis, and epidural procedures; ensure appropriate imaging and fluoroscopic guidance are documented.

Descriptions reference MRI for diagnosis and fluoroscopic guidance for procedural localization and radiologic supervision

Documentation Required

Pre‑procedure MRI and follow‑up epidurogram commonly used for PA/epiduroscopy

For percutaneous adhesiolysis and epiduroscopy, MRI is often used before the procedure and an epidurogram may be performed for follow‑up assessment; document relevant imaging correlation.

Studies note MRI for selection and epidurogram for assessment of epidural filling defects after PA

Not Covered Procedures

Not covered under this policy are the following procedures: Discography (provocative and functional anesthetic), Chemonucleolysis, and Epiduroscopy (including spinal myeloscopy). The policy also identifies percutaneous and endoscopic epidural lysis of adhesions among procedures considered unproven and not medically necessary.

Policy Revision History

2026-02-01revisionLatest

Updated Description of Services, Clinical Evidence, and References sections; archived previous policy version CS040NJ.K.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS040NJ.L

Change TypeUpdated clinical evidence, description of services, and referencesadded NICE/FDA citations

Effective DateFeb 1, 2026

Next Review Date

Key ActionObtain and document prior authorization and record prior conservative therapy attempts and baseline/follow-up ODI or VAS when seeking coverage for percutaneous adhesiolysis.

SourceLink

On This Page

Clinical presentation and relevant imaging (eg, MRI demonstrating correlating pathology or evidence of postoperative epidural adhesions/FBSS) support selection of percutaneous adhesiolysis or epiduroscopy, and other indicated treatment options have failed.

clinical and imaging correlation

Evidence strongest for PA in FBSS and chronic radicular pain (see Gerdesmeyer RCT and systematic reviews).

If epidural steroid injections (ESIs) were used, document number, dates, and clinical response

Note

Prior Authorization Guidance and Benefit Plan Conflicts

Before relying on this policy for coverage decisions, providers must check and follow applicable federal, state, and contractual requirements. Where benefit plan language conflicts with this policy, the federal/state/contract governs and may result in coverage or denial contrary to this policy's statements.

Confirm if the member's plan requires prior authorization and the specific submission process
In case of conflict among policy, state law, and contract, the governing requirement prevails

Denial Risk

Discography Guideline Limitations

Discography is identified in specialty society guidance as limited or not recommended in many scenarios. AANS/CNS guidance discourages use of discography as a stand-alone test to formulate treatment strategies for LBP with abnormal imaging and recommends counseling patients regarding potential risks. ACR appropriateness criteria do not support discography for many common LBP presentations.

Discography is listed in this policy as unproven and not medically necessary for evaluation/treatment of neck, back, or spinal disorders
Functional anesthetic and provocative discography are not recommended as sole determinants of treatment strategy; document alternative diagnostic reasoning if performed

Billing Rule

Coding and Documentation

Document all coding and billing information clearly. Use the codes listed in the policy for reference and follow coding guidance: e.g., functional anesthetic discography billed with CPT 64999 per Coding Clarification. Include procedure-level documentation, laterality, number of levels, and any unlisted code rationale when applicable.

62263, 62264, 62290-62292, 64999, 72285, 72295 are provided for reference only
Functional anesthetic discography billed with CPT 64999 (per policy coding clarification)
When using unlisted codes, include detailed operative and device documentation to support coding

Documentation Required

Outcome Measurement Documentation

Measure and document baseline and follow-up outcomes to support medical necessity and to monitor response to treatment. Commonly used validated scales include the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) for pain. Record baseline scores prior to the procedure and follow-up scores at appropriate intervals (for example, 3, 6, and 12 months) to demonstrate clinical benefit.

Document baseline ODI/VAS and subsequent follow-up scores in the medical record
Include objective functional improvements and pain reduction relative to baseline

Documentation Required

Documentation and Governing Requirements

Document device/product names, model numbers, and manufacturers when devices (eg, endoscopes, catheters) or implants are used. Maintain operative notes, informed consent that discusses risks/benefits and alternative treatments, and follow any manufacturer or FDA-labeled follow-up requirements when applicable.

Record device/product name, model/lot numbers, and manufacturer in the operative or procedure note
Include informed consent documentation noting discussion of alternatives and potential risks

Note

Conservative Therapy Context

Clinical studies and trials of interventions (for example, chemonucleolysis and PA) frequently enrolled patients only after failure of conservative therapy and sometimes after unsuccessful epidural steroid injections. The policy expects conservative care to precede consideration of invasive procedures in typical care pathways.

When citing clinical evidence to support a procedure, include documentation that conservative therapy failed as defined in the member's care plan
Studies often required prior conservative measures before enrollment

Step Therapy

Stepwise Care Before Prior Authorization

Prior authorization is typically considered after stepwise care has been attempted and documented. For percutaneous adhesiolysis, show evidence of inadequate response to conservative therapies and, when applicable, prior epidural steroid injections before requesting authorization for PA.

Provide records of prior therapies (dates, providers, clinical response) when submitting PA authorization requests
Authorization reviewers will evaluate the stepwise care history when determining medical necessity

Approach/techniqueMay be performed percutaneously using a needle and catheter with radiologic localization and contrast (epidurogram); mechanical and chemical methods described in the literature.

Clinical contextDescribed for patients with chronic low back and radicular pain thought to be related to epidural adhesions, often after failure of conservative care and epidural steroid injections.

inv-30: Functional anesthetic discography — definition

DefinitionFunctional anesthetic discography — diagnostic procedure that injects an anesthetic agent directly into the disc nucleus via a catheter; the patient reproduces pain with activity before and after anesthetic to assess whether the disc is the pain source.

PurposeCompare pain reproduction during activities (eg, sitting, walking, bending) before and after anesthetic to confirm disc-level involvement and guide treatment decisions.

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

inv-31: Provocative discography — definition

DefinitionProvocative discography — invasive diagnostic procedure that injects contrast into the nucleus pulposus to provoke pain and determine whether a disc is the origin of chronic spinal pain.

Clinical cautionGuideline bodies (AANS/CNS, ASIPP) advise that provocative discography should not be used as a standalone test to formulate treatment strategies and patients should be counseled about potential risks, including possible association with progression of disc degeneration.

Use criteriaConsider only after exclusion of other pain sources and when a treatment is available; appropriate patient selection and counseling are required.

inv-32: Chemonucleolysis — definition

DefinitionChemonucleolysis — injection of a proteolytic or chemical agent into the intervertebral disc nucleus to dissolve herniated nucleus pulposus and reduce disc mass.

Agents notedHistorically chymopapain (discontinued); newer agents include condoliase, gelified ethanol, and products such as DiscoGel described in clinical studies.

Evidence summaryEvidence is limited and mixed; additional high-quality RCTs and longer-term safety data are needed before broad adoption.

inv-33: Percutaneous adhesiolysis (PA) / Epidural LOA — definition

DefinitionPercutaneous adhesiolysis (PA) / Epidural LOA — minimally invasive procedures that mechanically and/or chemically disrupt epidural scar tissue or adhesions (eg, via catheter-based adhesiolysis, Racz procedure) to relieve radicular low back pain.

Procedure elementsMay include needle access to the epidural space, injection of saline or solutions to distend the space, mechanical catheter manipulation, and radiologic localization/epidurogram.

Clinical evidence contextSystematic reviews and RCTs provide limited/moderate evidence supporting PA for chronic LBP refractory to conservative care, often requiring documentation of prior failed conservative treatments.

inv-34: Chemonucleolysis — alternate definition / agents

Alternate definition/agentsChemonucleolysis — delivery of enzymatic or chemical agents (eg, condoliase, gelified ethanol, DiscoGel) into the nucleus pulposus under fluoroscopic guidance to dissolve disc material.

Historical agentChymopapain was the first enzyme used but was discontinued because of safety concerns.

Clinical trial contextStudies report variable efficacy and safety; many trials enrolled patients after failure of conservative therapy and used fluoroscopic guidance for injection.

inv-35: Discography (provocative) — definition and guideline caution

DefinitionDiscography (provocative) — invasive diagnostic test that pressurizes the disc with contrast to reproduce pain and help identify discogenic pain.

Guideline cautionAANS/CNS and other guideline statements caution against using discography as a standalone diagnostic test and recommend patient counseling about potential risks and the limited utility in many common low back pain scenarios.

Practice implicationUse only with appropriate patient selection, after exclusion of other pain sources, and when results will influence a specific treatment decision.

inv-36: Epiduroscopy / endoscopic adhesiolysis — definition

DefinitionEpiduroscopy / endoscopic adhesiolysis — endoscopic therapeutic division or mechanical disruption of epidural adhesions under direct visualization using endoscopes and catheter-based tools.

Safety/efficacy noteNICE (2010) concluded evidence is limited to short-term efficacy and raised significant safety concerns, recommending use only with special arrangements for governance, consent, audit, or research.

Clinical roleMay provide diagnostic visualization and potential symptom relief in FBSS or select patients; practitioners should weigh benefits against potential risks and limited long-term data.

Implication for frequency

Repeat PA procedures may be clinically necessary at intervals shorter than annual for sustained symptom relief per evidence commentary.

DocumentationProviders should document prior treatments and rationale for repeat procedures given evidence that benefits may not be durable without re-treatment.

Note

Follow cited imaging appropriateness references for diagnostic evaluation and discography considerations

Consult imaging guidance references (eg, ACR Appropriateness Criteria and other cited resources) when evaluating low back pain and considering discography; follow recommended imaging appropriateness to support diagnostic decisions.

Multiple references (ACR Appropriateness Criteria, systematic reviews) provide imaging considerations for LBP evaluation