CurrentUnitedHealthcarePolicy 2026T0206DD

Epiduroscopy, Epidural Lysis of Adhesions, and Discography

UnitedHealthcare Commercial and Individual Exchange medical policy on the use and coverage stance for epiduroscopy, percutaneous/endoscopic epidural lysis of adhesions, chemonucleolysis, and discography for neck, back, or spinal disorders; applies to UnitedHealthcare Commercial and Individual Exchange members.

Policy Summary

PayerUnitedHealthcare

PolicyEpiduroscopy, Epidural Lysis of Adhesions, and Discography

Policy CodePolicy 2026T0206DD

Change TypeShared policy versioninformational updates

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionVerify member benefits and any applicable utilization management prior to service and document failure of conservative therapies when requesting prior authorization for percutaneous adhesiolysis.

SourceLink

POLICY UPDATE CHANGES

Created shared policy version to support application to Oxford plan membership and updated supporting information, description of services, clinical evidence, and references to reflect current information.

4procedures identified as unproven and not medically necessary

8applicable procedure codes listed

2benefit lines

multipleevidence sources

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Coverage Criteria

Chemonucleolysis and epiduroscopy — investigational / limited evidence considerations

ALL of the following

Chemonucleolysis: Evidence includes small randomized trials, single randomized multicenter RCTs, retrospective case series, and meta-analyses with mixed results. Some RCT data (Chiba et al., 2018) demonstrated greater improvement in leg pain versus placebo in selected participants with lumbar disc herniation (LDH), but limitations include exclusion of certain herniation types, limited long-term follow-up, and limited safety data.
Additional chemonucleolysis studies are heterogeneous: open-label and retrospective series (Okada et al., 2020; Marcia et al., 2018; Houra et al., 2018) report variable effectiveness and safety; meta-analyses and comparative reviews (Feng et al., 2017) show higher complication rates for some chemonucleolysis techniques compared with other surgical options and call for more high-quality RCTs.
Epiduroscopy (including spinal myeloscopy): Available literature is limited and of variable quality. Systematic reviews and updates (Helm et al., 2013, 2016) found limited evidence supporting endoscopic adhesiolysis; some RCTs and observational studies exist but methodological limitations and conflicts of interest were noted.
Percutaneous epidural lysis of adhesions (PA): Evidence includes several RCTs and systematic reviews with mixed findings. Some meta-analyses (Manchikanti et al., 2021, 2023) and a randomized multicenter trial (Gerdesmeyer et al., 2013 with long-term follow-up) reported significant improvements in pain and function for select patients, but overall literature limitations include heterogeneity of techniques, potential bias in studies, lack of placebo-controlled trials in some series, and inconsistent outcomes across trials.
Given the limited, heterogeneous, and methodologically variable evidence base for chemonucleolysis and epiduroscopy/endoscopic adhesiolysis, current data are insufficient to broadly conclude long-term safety and efficacy across indications. High-quality, adequately powered RCTs with standardized patient selection, procedural technique, and long-term outcomes are needed.
Operational note: When evaluating requests for chemonucleolysis or epiduroscopy/endoscopic adhesiolysis, document rationale, prior conservative management, prior imaging and clinical correlation, the specific product or device and technique to be used, and discussion of limited evidence and potential risks. FDA device listings or approvals are informational only and do not alone establish coverage.

Coding

Prior Authorization

Prior Authorization Required

Prior authorization is required for percutaneous adhesiolysis (epidural lysis of adhesions). Submit clinical documentation including prior conservative therapy trials, imaging, and rationale for adhesiolysis. Claims for procedures deemed not medically necessary may be denied.

Affected codes: 62263, 62264

Denial Risk

Not Medically Necessary Procedures

The following procedures are considered not medically necessary when performed for indications that do not meet the policy's clinical criteria, and may be denied: percutaneous adhesiolysis without prior conservative therapy documentation, chemonucleolysis without meeting conservative-care prerequisites, and discography when used for screening without impact on management.

Examples: 62263, 62264, 62292, 62290-62291, 72285, 72295

Provider Actions and Requirements

Prior Authorization

Prior authorization required for percutaneous adhesiolysis (PA)

Prior authorization should confirm that percutaneous adhesiolysis (epidural lysis of adhesions) is being considered for chronic low back and/or lower extremity radicular pain refractory to conservative management, and that prior fluoroscopically directed epidural steroid injections and other conservative measures have failed.

Document symptom duration and prior conservative treatments, including epidural steroid injections.
Confirm conservative management failure (physical therapy, structured exercise, medications) before PA is authorized.

Prior Authorization

Verify member benefits and utilization-management rules before service

Verify the member-specific benefit plan document and any applicable federal or state mandates prior to ordering or performing a procedure; UnitedHealthcare states the member-specific plan governs and may require adherence to policy or third-party utilization tools.

Check member-specific benefit plan terms — they govern in the event of conflict with this Medical Policy.
Confirm any utilization management requirements (e.g., InterQual) or PA processes before scheduling.

Background

Epiduroscopy and epidural lysis of adhesions are minimally invasive procedures intended to visualize and disrupt epidural adhesions and deliver medications such as steroids. Techniques may include use of an endoscope, catheter tip manipulation, saline flushing, and mechanical or chemical adhesiolysis (including catheter-directed approaches) to relieve chronic low back and/or radicular pain.

Definitions

Epiduroscopy — definition and components

DefinitionEndoscopic procedure to remove epidural adhesions and fibrosis using tools such as a laser and the tip of a flexible catheter, with saline flushing and often final steroid administration to cleanse inflammatory agents.

Typical componentsFlexible fiberoptic catheter/endoscope, laser or mechanical tip for adhesiolysis, saline irrigation, and steroid delivery.

Primary usesVisualization of epidural anatomy and pathology and mechanical disruption of scar tissue believed to cause pain.

Epidural lysis of adhesions (including Racz procedure)

DefinitionMinimally invasive catheter-based procedure to disrupt epidural fibrosis/adhesions using saline distention and mechanical manipulation; includes the Racz (percutaneous adhesiolysis) technique.

Alternate names

Conservative Treatment Requirements

Frequency Limits

Codes listed but no frequency limits specified

Codes listed in policyCPT codes included for reference: 62263, 62264, 62290, 62291, 62292, 64999, 72285, 72295.

Frequency limitsNo specific frequency limits or per-year maximums are specified in the policy excerpt for these codes.

Billing noteListing a code does not imply the service is covered; verify member benefits and applicable utilization requirements.

Percutaneous adhesiolysis (PA) — potential need for repeat procedures

Repeat procedures may be neededHayes report concluded adhesiolysis often must be repeated more than once a year to maintain benefit.

Evidence baseHayes review included six RCTs and concluded a small body of low-quality evidence supports PA for chronic LBP refractory to conservative care.

Imaging Requirements

Note

Imaging commonly used in studies (MRI, epidurogram) — no single universal imaging prerequisite specified

Imaging (MRI) was used in many studies to confirm disc herniation and radiologic findings; fluoroscopy and epidurogram are commonly used intra- and post-procedurally for adhesiolysis, but the policy excerpt does not specify a universal pre-authorization imaging requirement.

Obtain MRI to confirm disc herniation when clinically indicated (studies referenced MRI use).
Fluoroscopy/epidurogram often used intra-procedurally for PA/epiduroscopy; include imaging reports in documentation when available.

Documentation Required

Include MRI and relevant fluoroscopic/epidurogram imaging when available to support indication

For chemonucleolysis, PA, and epiduroscopy, MRI is frequently used to confirm pathology and fluoroscopy/epidurogram is commonly used intra- or peri-procedurally; include relevant imaging in the record to support clinical indication.

MRI findings (e.g., herniation, high-intensity zones) were associated with outcomes in chemonucleolysis studies.

Not Covered

Not covered under this policy are: Discography (provocative and functional anesthetic), Chemonucleolysis, and Epiduroscopy (including spinal myeloscopy). The policy denotes these services as unproven and not medically necessary for any neck, back, or spinal disorder.

Policy Summary

PayerUnitedHealthcare

PolicyEpiduroscopy, Epidural Lysis of Adhesions, and Discography

Policy CodePolicy 2026T0206DD

Change TypeShared policy versioninformational updates

Effective DateJan 1, 2026

Next Review DateN/A

SourceLink

On This Page

Note

NICE Governance Recommendation

Follow local governance and professional guidance (e.g., NICE recommendations) regarding the use of interventional spinal procedures. Consider multidisciplinary review and adherence to published guidance on indications and patient selection.

Documentation Required

Consent and Governance Documentation

Obtain and document informed consent that includes procedure-specific risks, expected benefits, alternatives (including continued conservative therapy), and the experimental/unproven status of certain procedures when applicable. Maintain documentation of governance review or multidisciplinary case discussion when required by payer policy.

Note

Conservative Care Before Chemonucleolysis (Evidence Context)

Before chemonucleolysis, document a trial of conservative care (e.g., physical therapy, medications, activity modification) and reasons chemonucleolysis is being considered. Provide imaging correlation and prior nonoperative treatment durations.

Relevant code: 62292

Step Therapy

Conservative Therapy Required Before PA

Conservative therapy (such as nonopioid analgesics, physical therapy, activity modification, and at least a defined trial of conservative management) is required prior to considering percutaneous adhesiolysis. Document the type, duration, and response to conservative therapies in the medical record.

Relevant codes: 62263, 62264

Reference CPT/HCPCS codes — informationalCPT

62263	Percutaneous lysis of epidural adhesions, multiple days
62264	Percutaneous lysis of epidural adhesions, single day
62290	Discography injection, each level; lumbar
62291	Discography injection, each level; cervical or thoracic
62292	Chemonucleolysis, including discography, lumbar
64999	Unlisted procedure, nervous system (functional anesthetic discography billing)
72285	Discography, cervical or thoracic, radiological supervision and interpretation
72295	Discography, lumbar, radiological supervision and interpretation

Informational device listing — FDA PMN databasemixed

FDA-PMN

Products such as endoscopes, catheters, and needles used for epidural lysis of adhesions; search device name in FDA PMN

FDA website access date

FDA PMN access dateAugust 19, 2025

Step Therapy

Require documentation of prior conservative care before chemonucleolysis

Studies of chemonucleolysis typically included patients who had failed conservative therapies (medications, physical therapy, block therapies); document prior conservative treatment when seeking authorization for chemonucleolysis.

Document prior conservative measures tried and failed (e.g., PT, medications, injections).
Note that many studies required prior conservative care before chemonucleolysis.

Step Therapy

Conservative therapy (and epidural steroid injections) required prior to PA

Percutaneous adhesiolysis is described in the evidence base as a treatment after failure of conservative management (physical therapy, structured exercise, medications) and fluoroscopically directed epidural steroid injections; authorization should reflect such stepwise failure.

Document failure of conservative therapies and prior epidural steroid injections.
Provide clinical history consistent with chronic radicular/back pain refractory to conservative measures.

Billing Rule

Coding note: functional anesthetic discography (CPT 64999)

Functional anesthetic discography should be billed with CPT code 64999 per the policy; the document provides a list of related procedure and radiology codes for reference.

Coding clarification: Functional anesthetic discography — bill with CPT 64999.
Use the provided code list for reference but verify member coverage and billing rules.

Documentation Required

Required clinical documentation elements for review

Clinical documentation submitted for authorization or review should include the indication (e.g., lumbar disc herniation or chronic radicular pain refractory to conservative therapy), prior conservative treatment details, pain scores (VAS/NRS), functional measures (e.g., ODI), imaging confirmation (MRI), and any prior surgeries.

Indication and symptom duration.
Details of conservative therapies tried and response (PT, medications, injections).
Objective outcome measures: VAS/NRS, ODI; relevant MRI findings; prior surgical history.

Documentation Required

Document informed consent and governance/audit/research arrangements for endoscopic procedures

When performing therapeutic endoscopic division of epidural adhesions (epiduroscopy/endoscopic procedures) document informed consent and, where applicable, clinical governance arrangements, audit participation, or research enrollment per NICE recommendations.

Document informed consent that addresses limited evidence and safety concerns.
Record any clinical governance, audit, or research oversight if the procedure is performed under special arrangements.

Denial Risk

Reminder: procedures considered not medically necessary (may be denied)

The policy states the following procedures are unproven and not medically necessary and may be denied: discography (provocative and functional anesthetic), chemonucleolysis, epiduroscopy (including spinal myeloscopy), and percutaneous and endoscopic epidural lysis of adhesions.

Discography — provocative and functional anesthetic
Chemonucleolysis
Epiduroscopy (including spinal myeloscopy)
Percutaneous and endoscopic epidural lysis of adhesions

Denial Risk

Evidence insufficiency may lead to denial

Insufficient or low-quality evidence for certain procedures (for example, epidural lysis of adhesions in some indications) may be interpreted as unsupported and could trigger coverage denial if local evidentiary requirements are not met.

Provide high-quality supporting documentation and outcomes when seeking coverage for procedures with limited evidence.
Be aware that paucity of RCTs or low-quality studies increases risk of denial.

Denial Risk

NICE: restrict use of therapeutic endoscopic division of epidural adhesions to governance/research settings

NICE recommends that therapeutic endoscopic division of epidural adhesions be used only with special arrangements for clinical governance, consent, audit, or research; lack of documented governance/consent/audit arrangements may result in noncoverage.

If performed, document case selection, governance, consent, and outcomes collection as recommended by NICE.
Absent such arrangements, the procedure may be restricted or denied.

Adhesiolysis, percutaneous epidural neuroplasty, epidurolysis, Racz procedure.

Intended goalDisrupt epidural scar tissue/adhesions to relieve chronic low back and radicular pain and allow delivery of medications.

Chemonucleolysis — historical definition and purpose

Historical definitionInjection of a proteolytic enzyme into the intervertebral disc to dissolve herniated nucleus pulposus; chymopapain was the first agent but was discontinued for safety reasons.

PurposeProposed as a minimally invasive option to bridge conservative therapy and surgical intervention for lumbar disc herniation by reducing disc material.

Agent historyChymopapain historically used; newer enzymes (e.g., condoliase) are under study with mixed evidence of effectiveness.

Provocative discography — definition and intended diagnostic use

DefinitionInvasive diagnostic procedure that injects contrast into the nucleus pulposus to reproduce pain under load, aiming to identify whether a disc is the source of chronic spine pain.

Diagnostic rationaleBased on the premise that an internally disrupted disc will be painful when mechanically loaded or pressurized with injected contrast.

Typical useUsed to determine discogenic pain and guide treatment options, although its standalone use for treatment planning is not generally recommended.

Functional anesthetic discography — definition and diagnostic comparison

DefinitionDiagnostic procedure in which an anesthetic agent is injected directly into the disc nucleus after provocative maneuvers to compare pain reduction and help confirm discogenic pain.

Diagnostic comparisonPerformed after provocative discography maneuvers — pain is provoked, then anesthetic given to assess whether pain is reduced, supporting disc as pain source.

Coding noteFunctional anesthetic discography is specifically addressed in the policy and billing guidance (CPT code clarification provided elsewhere).

Chemonucleolysis (alternate description)

Definition (percutaneous chemical injection)Percutaneous injection of an enzymatic or chemical agent into the intervertebral disc nucleus intended to reduce herniation size and radicular symptoms.

Examples of agentsCondoliase, gelified ethanol, DiscoGel; historically chymopapain (discontinued).

PurposeMinimally invasive alternative to surgery for lumbar disc herniation, intended to dissolve nucleus pulposus and relieve nerve compression.

Epiduroscopy (alternate) — endoscopic visualization and potential interventions

DefinitionEndoscopic visualization of the epidural space to assess anatomy and pathology, potentially allowing direct mechanical adhesiolysis or targeted medication delivery.

Clinical capabilityPermits identification of anatomical structures and pathologies (e.g., cauda equina, epidural scarring) and may aid procedural targeting.

LimitationsAlthough visualization is possible, evidence that epiduroscopy improves clinical management or long-term outcomes is limited.

Percutaneous epidural lysis of adhesions (PA/LOA) — definition and goal

DefinitionMinimally invasive catheter-directed mechanical and/or chemical disruption of epidural adhesions (percutaneous adhesiolysis) intended to relieve chronic low back or radicular pain.

Also known asPercutaneous neurolysis, adhesiolysis, epidurolysis; includes techniques studied in RCTs such as Gerdesmeyer et al.

Therapeutic goalRestore epidural space mobility, reduce nerve root irritation, and permit delivery of medications (e.g., steroids) to affected areas.

Endoscopic epidural lysis/adhesiolysis — therapeutic endoscopic division

DefinitionTherapeutic endoscopic division of epidural adhesions — an endoscopic procedure to mechanically divide epidural scar tissue to alleviate pain.

Intended effectDirectly separate or remove adhesions under endoscopic visualization to reduce nerve compression and pain.

Evidence and safety contextNICE and systematic reviews note limited short-term efficacy data and significant safety concerns, recommending use only with governance or research arrangements.

Implication for authorizationPrior authorization processes should consider that multiple procedures per year may be clinically justified in some patients.

Therapeutic endoscopic division of epidural adhesions / epiduroscopy — frequency context

Frequency limits not specifiedPolicy excerpt does not specify frequency limits for therapeutic endoscopic division of epidural adhesions (epiduroscopy).

NICE recommendationNICE recommends use only with special arrangements for governance, consent, audit, or research due to limited evidence and safety concerns.

Clinical implicationWhen performed, documentation of governance and outcomes collection is advised; coverage may depend on these arrangements.

Epidurogram/filling-defect assessments were used in PA studies though correlation with clinical outcome is inconsistent.

Note

Imaging referenced in studies but no universal mandate in policy excerpt — include imaging to support request

Several referenced studies included imaging or epidurographic findings, but the policy excerpt does not impose a universal imaging prerequisite prior to coverage decisions; still, providing imaging strengthens documentation for review.

When seeking authorization, attach pertinent imaging reports and images used in prior studies or evaluations.
Lack of imaging may weaken the case for medical necessity in procedures with limited evidence.