CurrentUnitedHealthcarePolicy CS040KS.02

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

Clinical coverage policy for epiduroscopy, percutaneous and endoscopic epidural lysis of adhesions, chemonucleolysis, and discography applicable to UnitedHealthcare members in Kansas.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS040KS.02

Change TypeAdministrative updatecontent revision

Effective DateFeb 1, 2026

Next Review Date

Key ActionRefer to InterQual CP: Procedures: Discography, Spine, Lumbar for medical necessity criteria and document care consistent with those requirements.

SourceLink

POLICY UPDATE CHANGES

Removed reference link to the Medical Policy titled: Discogenic Pain Treatment (for Kansas Only); Epidural Steroid Injections for Spinal Pain (for Kansas Only); Facet Joint and Medial Branch Block Injections for Spinal Pain (for Kansas Only); Minimally Invasive Spine Surgery Procedures (for Kansas Only).

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

Kansas onlyState scope

Discography, epiduroscopy, adhesiolysis, chemonucleolysisProcedures discussed

Multiple systematic reviews and RCTs citedEvidence sources summarized

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Medical Necessity and Unproven Procedures

Not medically necessary / Unproven

The following procedures are considered unproven and not medically necessary due to insufficient evidence of efficacy:

ALL of the following

Functional anesthetic discography
Provocative discography
Chemonucleolysis
Epiduroscopy (including spinal myeloscopy)
Percutaneous and endoscopic epidural lysis of adhesions

Discography — reference to InterQual

For medical necessity clinical coverage criteria for discography, refer to InterQual CP: Procedures: Discography, Spine, Lumbar.

ALL of the following

Provider must refer to InterQual CP: Procedures: Discography, Spine, Lumbar for medical necessity criteria

Evidence summary and guideline-aligned recommendations (narrative)

Guideline and systematic-review summaries relevant to epidural lysis of adhesions, epiduroscopy, and discography:

ALL of the following

Randomized and observational studies show epidural lysis of adhesions (percutaneous adhesiolysis) can provide significant pain and functional improvement for chronic lumbosacral radicular pain and failed back surgery syndrome, with some RCTs reporting benefits at 3, 6, 12 months and up to 10 years in one follow-up.
Endoscopic adhesiolysis (spinal endoscopy) has more limited evidence compared to percutaneous adhesiolysis; systematic reviews indicate limited but some short-term efficacy and low risk of serious adverse events, but overall paucity of high-quality literature.
Provocative discography: AANS/CNS states discography as a stand-alone test is not recommended to formulate treatment strategies for LBP with abnormal imaging; discoblock may predict fusion outcomes better in one randomized cohort; patients should be counseled about possible progression of degenerative disc disease after provocative discography.

Referenced Procedure Codes

Procedure codes referencedCPT

62263	Percutaneous lysis of epidural adhesions using solution injection or mechanical means, multiple adhesiolysis sessions; 2 or more days
62264	Percutaneous lysis of epidural adhesions using solution injection or mechanical means, 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
72285	Discography, cervical or thoracic, radiological supervision and interpretation
72295	Discography, lumbar, radiological supervision and interpretation

Codes referenced in document text (none explicitly listed in this part)mixed

No codes listed

What Providers Must Do

Documentation Required

Refer to InterQual for discography medical necessity

Use InterQual CP: Procedures: Discography, Spine, Lumbar as the source for medical necessity determinations for discography and ensure documentation aligns with InterQual requirements.

62290
62291
72285
72295

Billing Rule

Functional anesthetic discography billing code

Bill functional anesthetic discography using CPT 64999 (unlisted procedure, nervous system) per the policy's coding clarification.

Clinical and Evidence Context

This policy summarizes the evidence for diagnostic and therapeutic intradiscal and epidural procedures, specifically discography (provocative and functional anesthetic), epiduroscopy, epidural lysis/adhesiolysis (percutaneous and endoscopic), and chemonucleolysis. Overall, the evidence base is mixed: the literature for discography is limited and generally low quality with safety concerns including possible acceleration of degenerative disc disease and higher rates of subsequent spine surgery in some long-term cohort studies; given these limitations the policy emphasizes caution and defers to InterQual for specific medical necessity determinations for lumbar discography.

Evidence for epiduroscopy is also limited; observational and systematic-review data show potential diagnostic value and short-term improvements in pain and function in failed back surgery syndrome, but high-quality trials demonstrating management-changing clinical benefit are lacking. Percutaneous adhesiolysis (epidural lysis of adhesions) has a stronger, though still imperfect, evidence base: multiple RCTs and systematic reviews report low-to-moderate quality evidence of short- to intermediate-term pain and functional benefit in selected patients (including post‑lumbar surgery syndrome and chronic lumbosacral radicular pain), with some trials showing durable effects out to 12 months and one follow-up reporting differences up to 10 years.

The evidence for chemonucleolysis is evolving: recent randomized and observational studies (including trials of condoliase) and meta-analyses report clinical improvements and generally low rates of serious adverse events, but many studies are retrospective, have short follow-up, heterogeneous methods, or are limited in size. Systematic reviews call for larger, long-term RCTs to better define efficacy, safety, and patient selection. Taken together, the policy characterizes discography and epiduroscopy as having limited/low-quality evidence with safety considerations, recognizes percutaneous adhesiolysis as supported by some low-to-moderate quality trials showing benefit in selected populations, and describes chemonucleolysis evidence as promising but constrained by study limitations and the need for further high-quality research.

Outcome Thresholds Used in Evidence

Pain relief primary outcome in systematic reviews>= 50% improvement

Functional improvement primary outcome in systematic reviews>= 40% improvement

Defined Terms

EpiduroscopyEndoscopic visualization of the epidural space for identification and removal of adhesions/fibrosis; may include laser and direct mechanical methods followed by steroid administration.

Epidural lysis of adhesions (adhesiolysis, percutaneous epidural neuroplasty, epidurolysis)Minimally invasive procedures to disrupt epidural scar tissue/adhesions using mechanical means, injectate, and/or catheters (e.g., Racz procedure).

Provocative discographyInjection of contrast into the disc nucleus to provoke pain and determine whether a specific disc is a pain generator.

Functional anesthetic discographyInjection of anesthetic into a disc while the patient performs activities to assess pain relief and identify symptomatic disc level.

ChemonucleolysisInjection of a proteolytic enzyme (e.g., condoliase) into the disc to dissolve herniated nucleus pulposus.

PAPercutaneous adhesiolysis (lysis of epidural adhesions).

Policy Updates

2026-02-01removed

Removed related-policy reference links to four Kansas-only medical policies: Discogenic Pain Treatment; Epidural Steroid Injections for Spinal Pain; Facet Joint and Medial Branch Block Injections for Spinal Pain; and Minimally Invasive Spine Surgery Procedures.

2026-02-01revisedLatest

Updated the Description of Services, Clinical Evidence, and References sections to reflect current information and archived the previous policy version CS040KS.01.

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

Medical Necessity and Unproven Procedures

Referenced Procedure Codes

What Providers Must Do

Clinical and Evidence Context

Outcome Thresholds Used in Evidence

Defined Terms

Other Policies to Read

Policy Updates