CurrentUnitedHealthcarePolicy 2025T0206CC

Epiduroscopy, Epidural Lysis of Adhesions, and Discography

Defines UnitedHealthcare coverage stance for epiduroscopy, epidural lysis of adhesions, discography (including functional and provocative), chemonucleolysis, and related procedures for diagnosis or treatment of neck, back, or spinal disorders for UnitedHealthcare Commercial and Individual Exchange plans.

Policy Summary

PayerUnitedHealthcare

PolicyEpiduroscopy, Epidural Lysis of Adhesions, and Discography

Policy CodePolicy 2025T0206CC

Change TypeNo material change

Effective DateMay 1, 2025

Next Review Date

Key ActionConfirm prior authorization requirements and document failure of conservative management (e.g., PT, medications, epidural steroid injections) with supporting imaging and outcome measures before requesting coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6unproven procedures

71DiscoGel sample

62chemonucleolysis studies

1.4%serious AE rate

10ylong-term follow-up

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Coverage Criteria

Unproven / Not Medically Necessary

Not medically necessary / unproven

Unproven and Not Medically Necessary Procedures: Functional anesthetic discography; Discography; Provocative discography; Epiduroscopy (including spinal myeloscopy); Chemonucleolysis; Percutaneous and endoscopic epidural lysis of adhesions are unproven and not medically necessary for diagnosis or treatment of any type of neck, back, or spinal disorder due to insufficient evidence of efficacy.

Interventional procedure eligibility (evidence-contextual criteria)

Covered when ALL of the following are met (based on study populations and specialty guidance):

Population and prior care: Chronic lumbar or radicular pain (including failed back surgery syndrome) refractory to conservative management such as physical therapy, medications, structured exercise programs, and prior fluoroscopically directed epidural steroid injections, with documentation in the medical record of failure of these conservative measures.

Supported by ASIPP recommendations and clinical trials enrolling patients refractory to conservative therapy

Procedure-specific evidence is present in populations similar to the patient: percutaneous adhesiolysis (PA) — randomized and observational studies (including Gerdesmeyer RCT and Hayden/Manchikanti reviews) reporting improved ODI and VAS up to 12 months and longer-term follow-up; epiduroscopy — observational studies and a systematic review/meta-analysis in FBSS reporting clinically relevant pain and disability reduction at 6–12 months (quality described as moderate; recommendation weak); chemonucleolysis — limited and heterogeneous evidence including retrospective DiscoGel series and systematic reviews/meta-analyses indicating insufficient high-quality RCT data to establish definitive efficacy.

Documented in cited studies

The listing of procedure, radiology, and billing codes in this policy is provided for reference only and does not imply coverage. Coverage and reimbursement for services described by any code are determined by the member-specific benefit plan document and applicable laws; inclusion of a code in this policy is not a guarantee of payment. Providers should verify prior authorization requirements and member benefits before scheduling services referenced in this policy.

Randomized controlled trial evidence is lacking for use of epidural lysis of adhesions/epiduroscopy in the cervical spine; available cervical studies are nonrandomized and the systematic review authors noted important methodological limitations. Reported cervical interventions were also associated with higher complication rates compared with other spinal levels. Overall, the evidence base for these procedures is limited by a paucity of high-quality randomized studies and inconsistent findings across reviews, which reduces confidence in efficacy for cervical indications.

The National Institute for Health and Care Excellence (NICE) concluded in 2010 that evidence for therapeutic endoscopic division of epidural adhesions is limited and there are significant safety concerns; NICE recommends this procedure only be used within special arrangements for clinical governance, informed consent, audit, or research, with clear case selection and outcome monitoring.

This policy addresses several procedures proposed for diagnosis or treatment of spinal disorders, including: functional anesthetic discography; discography (provocative and other forms); epiduroscopy (including spinal myeloscopy); chemonucleolysis; and percutaneous and endoscopic epidural lysis of adhesions.

Professional society guidance does not support routine use of discography as a standalone diagnostic test. The AANS/CNS guidance states discography as a stand-alone test is not recommended to formulate treatment strategies for low back pain, and the ACR notes there is no relevant literature supporting discography for evaluation of subacute or chronic low back pain without red flags or for routine postoperative evaluation.

Coding References

Applicable CPT/Unlisted/Radiology CodesCPT

62264	Percutaneous lysis of epidural adhesions 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
62290	Percutaneous lysis of epidural adhesions 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
62291	Injection procedure for discography, each level; lumbar
62292	Injection procedure for discography, each level; cervical or thoracic
62292-dup	Injection procedure for chemonucleolysis, including discography, intervertebral disc, single or multiple levels, lumbar (62292 appears listed for chemonucleolysis description as well)
64999	Unlisted procedure, nervous system
72285	Discography, cervical or thoracic, radiological supervision and interpretation
72295	Discography; lumbar; radiological supervision and interpretation

Provider Actions and Authorization

Prior Authorization

Prior authorization and plan-specific requirements

Verify member benefit plan requirements and prior authorization needs before scheduling services. Providers should confirm whether the member's specific plan requires prior authorization for epidural adhesiolysis, epiduroscopy, chemonucleolysis, discography, or related procedures and submit documentation as required by the plan.

Prior authorization may be required by the member-specific benefit plan.
In Medicare Advantage cases, check for any applicable NCD/LCD or plan-specific MAO determinations.

Denial Risk

Denial risk for unproven procedures

Procedures identified in this policy as unproven or not medically necessary (for example: functional anesthetic discography, provocation discography when not indicated, epiduroscopy, chemonucleolysis, percutaneous and endoscopic epidural lysis of adhesions in settings not supported by evidence) have a higher risk of denial. Authorization may be refused if the submitted indications, prior treatments, or supporting evidence do not meet medical necessity criteria.

Conservative Treatment Requirements

Documented failure of conservative care prior to intervention

Conservative care requirement: Documented failure of conservative care prior to consideration of interventional procedures, including but not limited to a trial of physical therapy, medications/medical management, structured exercise programs, and fluoroscopically guided epidural steroid injections, with details of duration and responses recorded in the medical record.

Prior authorization should confirm failure of conservative management as described in evidence and guideline sources

Imaging and Procedural Guidance

Billing Rule

Require fluoroscopy/radiologic localization for listed interventional procedures

Fluoroscopic guidance or radiologic localization is required for procedures such as epiduroscopy, epidural lysis of adhesions, discography, and chemonucleolysis; radiology supervision/interpretation codes are listed for discography.

Perform procedures with fluoroscopy and radiologic localization (e.g., lumbar epidurogram)
Use radiology supervision/interpretation CPTs (72285, 72295) where applicable

Documentation Required

Recommend MRI and/or epidurography documentation before chemonucleolysis/adhesiolysis/epiduroscopy

Documentation of pre-procedure MRI and/or epidurography is recommended for chemonucleolysis, epiduroscopy, and adhesiolysis to confirm anatomy and disc herniation and to support medical necessity.

Definitions

inv-22: Epiduroscopy — definition and typical technique elements

DefinitionEpiduroscopy: endoscopic procedure for visualization of the epidural space with direct removal/disruption of adhesions and fibrosis using a flexible catheter, mechanical measures, saline flushing and laser, with steroids administered in the final stage to reduce inflammation.

Typical anesthesia/sedationOften performed with local anesthesia and mild sedation so the patient can communicate about pain source.

Technical elementsFlexible fiberoptic endoscope or catheter introduced into the epidural space, saline injection to distend the space, direct visualization of anatomy and pathology, mechanical disruption and laser ablation of scar tissue, and epidural steroid administration.

PurposeDetect and treat epidural pathology and adhesions potentially related to chronic low back or radicular pain by direct visualization and intervention.

inv-23: Epidural lysis of adhesions (LOA)/percutaneous adhesiolysis — definition and technique summary

Frequency and Repeat Procedure Guidance

inv-32: percutaneous adhesiolysis — may require repeated procedures more than once a year to maintain benefit (Hayes observation)

Key observationPercutaneous adhesiolysis (PA) may require repeated procedures more than once a year to maintain benefit, as noted in the Hayes evidence brief summarizing the PA literature.

Evidence baseHayes review summarized six RCTs and concluded a small body of low-quality evidence supports PA for chronic LBP refractory to conservative treatment, but long-term outcomes remain uncertain.

Clinical implicationFrequency limits for PA are informational; repeated treatments have been reported in trials and observational reports rather than prescriptive coverage limits.

inv-33: (empty frequency limits placeholder from inventory)

Frequency placeholderNo formal annual frequency limit specified in policy; informational note acknowledges repeat procedures may be needed for maintained benefit.

Background

Epiduroscopy, epidural lysis of adhesions, discography (including functional/provocative techniques), and chemonucleolysis are minimally invasive procedures that have been proposed for diagnosis or treatment of neck and back disorders such as chronic low back pain, radiculopathy, disc herniation, and failed back surgery syndrome. Descriptions in the literature include endoscopic visualization and mechanical or chemical disruption of epidural adhesions, intradiscal injection of enzymes or agents to reduce herniated nucleus pulposus, and diagnostic intradiscal injections with provocative maneuvers.

Not Covered Procedures

The following procedures are not covered/considered not medically necessary due to insufficient evidence of efficacy: Functional anesthetic discography; Discography (provocative and other); and Epiduroscopy (including spinal myeloscopy).

Policy Revision History

05/01/2025RevisionLatest

Template update and creation of shared policy version to support application to Rocky Mountain Health Plans membership and Individual Exchange; removed language excluding Colorado; archived previous policy version 2025T0206BB.

Policy Summary

PayerUnitedHealthcare

PolicyEpiduroscopy, Epidural Lysis of Adhesions, and Discography

Policy CodePolicy 2025T0206CC

Change TypeNo material change

Effective DateMay 1, 2025

Next Review Date

SourceLink

On This Page

Services listed as unproven / not medically necessary in the Coverage Rationale are subject to denial.
Claims lacking adequate documentation of indication and prior conservative therapy are at increased risk of denial.

Denial Risk

Limited/high-risk evidence may affect authorization

Limited, inconsistent, or controversial evidence for some procedures (for example, epiduroscopy and certain forms of chemonucleolysis and adhesiolysis) may result in authorization denial or requirement for additional documentation. When evidence is limited or outcomes are uncertain, payers may require stronger documentation of prior conservative care, objective diagnostic findings, and rationale for the chosen procedure.

Procedures with limited or mixed evidence bases may require additional clinical rationale and stronger supporting documentation.
Repeat or high-risk procedures may prompt more stringent review.

Note

NICE governance requirement

For procedures such as therapeutic endoscopic division of epidural adhesions (epiduroscopy), follow NICE guidance: these interventions should be used only with special arrangements for clinical governance, patient consent, audit, and/or research when evidence is limited. Ensure appropriate governance, informed consent, and outcome audit arrangements are in place when seeking authorization.

Follow NICE requirement for clinical governance, consent and audit when evidence is limited.
Document research or audit arrangements, if applicable, when submitting prior authorization requests.

Documentation Required

Coding and documentation note

Include applicable CPT, HCPCS, and diagnosis codes on authorization requests and claims. Verify correct coding for adhesiolysis, discography, chemonucleolysis, and related procedures; improper or nonspecific coding (e.g., unlisted codes) may delay review. Provide complete operative notes, fluoroscopy reports, and level-specific documentation to support medical necessity.

Common CPTs referenced in policy: 62264, 62290, 62291, 62292, 72285, 72295, 64999 (unlisted).
When using unlisted codes (e.g., 64999), provide detailed procedural description and intraoperative documentation.

Documentation Required

Suggested supporting documentation

Suggested supporting documentation to include with prior authorization and claims: pre-procedure imaging (MRI/CT) demonstrating disc herniation or epidural pathology; records of failed conservative management (physical therapy, medications, structured exercise, chiropractic care); prior epidural steroid injection attempts and dates; objective pain and functional scores (VAS, ODI) over time; and procedural details such as fluoroscopy guidance, volumes/agents injected, and any dural puncture or complications.

Recent MRI/CT confirming the anatomic lesion targeted.
Documentation of prior conservative therapies and dates (PT, medications, epidural steroid injections).
Objective baseline and follow-up measures (VAS, ODI) demonstrating treatment response.
Procedure notes including levels treated, imaging guidance, agent type/volume, and complications (e.g., dural puncture).

Prior Authorization

Coverage decision documentation

When rendering a coverage decision, reference the member-specific benefit plan and any applicable federal or state mandates. This Medical Policy is an interpretive guide; final determinations must align with the member's plan language, benefit limits, and any Medicare NCD/LCD or state-specific requirements.

Member-specific benefit plan document governs coverage — check exclusions, benefit limits, and prior authorization rules.
Apply applicable federal/state mandates and Medicare coverage guidance when present.

Step Therapy

Step therapy expectations per ASIPP

Per ASIPP guidance, adhesiolysis (percutaneous adhesiolysis / epidural lysis of adhesions) is generally recommended only after failure of conservative management, including physical therapy, structured exercise programs, medications, and adequately performed fluoroscopically guided epidural steroid injections. Prior authorization reviewers should confirm documented failure of these conservative measures before approval.

Documented failure of conservative therapy (PT, medications, structured exercise) and fluoroscopically directed epidural injections is expected prior to adhesiolysis.
Include dates and outcomes of prior treatments in the authorization request.

Marcia DiscoGel study performed MRI on all participants pre-procedure
Epidurography often used to assess filling defects in adhesiolysis studies

Note

Follow imaging guidance (ACR criteria and referenced studies) for documentation and decision-making

The policy cites imaging guidance sources (for example, the ACR Appropriateness Criteria for Low Back Pain and multiple imaging-related studies) indicating imaging considerations are relevant to clinical decision-making and documentation.

Reference ACR Appropriateness Criteria for Low Back Pain when considering imaging
Multiple cited studies address the role of imaging in procedure selection and evaluation

DefinitionEpidural lysis of adhesions (LOA)/percutaneous adhesiolysis: minimally invasive mechanical and/or chemical disruption of epidural scar tissue/adhesions via catheter or needle with saline and contrast under imaging guidance (Racz procedure/PA).

Common technique elementsNeedle or catheter introduced into epidural space at suspected level, injection of nonionic contrast for epidurogram, saline to distend space, mechanical manipulation of catheter and/or chemical agents to disrupt adhesions, performed under fluoroscopic guidance.

Typical anesthesiaOften performed using local anesthesia with mild sedation allowing patient communication about pain during the procedure.

Evidence contextDescribed in RCTs and reviews for chronic LBP refractory to conservative care; Hayes and systematic reviews note PA may need repeat procedures to maintain benefit.

inv-24: Functional anesthetic discography (FAD) — definition and diagnostic intent

DefinitionFunctional anesthetic discography (FAD): diagnostic procedure in which an anesthetic agent is injected directly into the disc nucleus via a catheter to reprovoke the patient’s typical pain with provocative maneuvers and then anesthetize the disc to confirm a discogenic pain source.

Diagnostic intentUsed to determine whether an intervertebral disc is the origin of chronic spine pain by reproducing pain during mechanical loading and then assessing relief after anesthetic injection.

Procedure elementsCatheter placement into nucleus pulposus, provocative maneuvers (e.g., sitting, walking, bending) to reproduce pain, followed by injection of anesthetic to confirm pain origin.

inv-25: Chemonucleolysis — definition and agents referenced (chymopapain, condoliase, DiscoGel)

DefinitionChemonucleolysis: intradiscal injection of proteolytic enzymes intended to dissolve herniated nucleus pulposus as a minimally invasive alternative to surgery.

Historical and referenced agentsChymopapain (first agent; discontinued for safety concerns), condoliase, and gelified or radiopaque formulations such as DiscoGel are referenced in the evidence base.

Evidence noteSystematic reviews and trials (including meta-analyses) report heterogeneous evidence; additional RCTs are needed to establish safety and long-term efficacy.

inv-26: Failed back surgery syndrome (FBSS) — definition used in study populations

Definition used in studiesFailed back surgery syndrome (FBSS): chronic low back and/or lower extremity pain following lumbar spine surgery; commonly the population studied for epiduroscopy and adhesiolysis interventions.

Study contextSystematic reviews and meta-analyses of epiduroscopy and adhesiolysis frequently evaluate outcomes specifically in FBSS cohorts.

Clinical implicationFBSS patients are described as refractory populations in which interventions aim to reduce pain and disability when conservative measures have failed.

inv-27: Chemonucleolysis (DiscoGel) — percutaneous injection details and reported volumes

Procedure descriptionDiscoGel chemonucleolysis: percutaneous fluoroscopically guided injection of a gelified radiopaque chemical agent into the nucleus pulposus for symptomatic disc herniation.

Reported injection volumesReported volumes in the retrospective DiscoGel study: 0.8 mL for lumbar discs and 0.3 mL for cervical discs.

Imaging and anesthesiaPerformed under fluoroscopic guidance with local anesthesia; pre-procedure MRI was performed to confirm disc herniation in the study cohort.

inv-28: Epiduroscopy / percutaneous epidural adhesiolysis — therapeutic endoscopic division of epidural adhesions

Therapeutic intentEndoscopic division of epidural adhesions (epiduroscopy/percutaneous epidural adhesiolysis) aims to mechanically remove or divide epidural scar tissue to relieve pain and restore epidural space anatomy.

Technique elementsUses flexible endoscope or catheter to directly visualize adhesions, mechanical disruption or laser ablation of fibrosis, saline flushing, and administration of steroids; may be performed percutaneously (PA/Racz) or endoscopically.

Governance cautionNICE (2010) notes limited evidence and significant safety concerns for therapeutic endoscopic division of epidural adhesions, recommending use only with special arrangements for governance, consent, audit, or research.

Policy applicationMember-specific benefit documents and plan requirements determine coverage and any applicable frequency constraints; providers should verify prior authorization requirements.

Evidence contextHayes and other reviews report repeat procedures in clinical practice and trials, but the policy does not set a numeric frequency cap.