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Lysis of Epidural Adhesions (Epidural Adhesiolysis)
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Defines Univera Healthcare's coverage stance on catheter-based or endoscopic lysis of epidural adhesions for back pain and summarizes supporting evidence and coding. Applies to clinical review of these procedures for members under Univera Healthcare.
No material clinical or coverage changes in this revision.
Coverage Determination
Investigational / Not Covered
Coverage determination:
Policy classifies procedure as investigational; see evidence summary for rationale.
Univera Healthcare classifies lysis of epidural adhesions (epidural adhesiolysis) performed by catheter-based techniques or endoscopically for the treatment of back pain as investigational. This designation indicates the procedure is not considered a covered, medically necessary therapy under this policy because available evidence does not establish its safety and/or effectiveness for the indicated use.
Coverage for services described in this policy is contract dependent. If a specific product does not cover a service, the medical policy criteria do not apply. When a commercial, Medicaid (absent state Medicaid guidance), or Medicare product does cover the service and there is no applicable Medicare national or local coverage determination, this policy’s criteria will be applied to that benefit.
Billing and Coding
| 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; 1 day. |
| 62280 | Injection/infusion of neurolytic substance (e.g., alcohol, phenol, iced saline solutions), with or without other therapeutic substance; subarachnoid. |
| 62281 | Injection/infusion of neurolytic substance; epidural, cervical or thoracic. |
| 62282 | Injection/infusion of neurolytic substance; epidural, lumbar, sacral (caudal). |
| No codes listed |
| Multiple | Multiple ICD-10 codes (not enumerated in this section) |
Provider Requirements and Prior Authorization
Product-dependent prior authorization and applicability
Medical policy criteria apply only when the product covers the service; prior authorization requirements are governed by the product contract (commercial, Medicaid without eMedNY guidance, or Medicare when no CMS decision exists).
- If product does not cover service, policy criteria do not apply
- Commercial, Medicaid (no eMedNY), or Medicare (no CMS decision) → medical policy criteria apply
Conservative care and epidural injection failure required in cited guidance
Guidelines and cited evidence indicate percutaneous adhesiolysis is considered only after failure of conservative management and fluoroscopically guided epidural injections for selected lumbar indications, even though this policy deems the procedure investigational.
- ASIPP: percutaneous adhesiolysis recommended after failure of conservative management and fluoroscopically guided epidural injections (lumbar/caudal)
- Multiple RCTs and reviews referenced support this sequence though evidence limitations are noted
Document required procedural details (technique, approach, agents, sessions, imaging)
Document the procedural technique, approach, and agents used: specify whether catheter-based (percutaneous) or endoscopic technique was used; approach (caudal, transforaminal, cervical/thoracic/lumbar); agents administered (e.g., hypertonic saline, corticosteroids, analgesics, hyaluronidase); number/duration of sessions; and use of fluoroscopic or endoscopic guidance.
- Technique: catheter-based vs endoscopic
- Approach: caudal, transforaminal, cervical/thoracic/lumbar
- Agents: hypertonic saline, corticosteroids, analgesics, hyaluronidase, etc.
- Number/duration of sessions and catheter dwell time
- Fluoroscopic or endoscopic guidance used
Investigational procedure — high risk of denial
Because the policy classifies catheter-based and endoscopic lysis of epidural adhesions as investigational, requests for these procedures are subject to denial as not covered under this policy.
- Procedures performed by catheter-based techniques or endoscopically are considered investigational and may be denied as not covered
Verify product coverage before submitting authorization
If the product does not cover the service, medical policy criteria do not apply; verify member’s product contract before submitting authorization to determine applicability of this policy.
- Confirm product-level coverage before relying on medical policy criteria
- Prior authorization requirements are product-governed
Contract- and Medicare HMO‑DSNP-dependent coverage note
Services are contract dependent; for Medicare HMO-DSNP products, if the Medicare product does not cover a specific service and there is no national or local Medicare coverage decision, apply medical policy criteria as directed—otherwise follow Medicare coverage determinations.
- Services are contract dependent
- Medicare HMO-DSNP: apply policy only when no CMS national/local decision exists
Prerequisites and Conservative Management
Failure of conservative management and fluoroscopically guided epidural injections noted in guidelines as prerequisite for consideration in studies/clinical guidance
Guideline context — noted prerequisites in cited guidance/studies:
ASIPP guidance and related systematic reviews/RTC evidence specify prior failure of conservative care and fluoroscopically guided epidural injections as prerequisites for considering adhesiolysis in the lumbar region.
Reflects scope of evidence referenced by ASIPP and cited systematic reviews.
Additional conservative-treatment criteria placeholder
Conservative-treatment components commonly referenced in the evidence base (policy does not make these coverage-permissive):
Documented trials and guidelines reference failure of conservative management but do not specify exact durations; use of standard conservative modalities is implied by cited guidance.
ASIPP and trial evidence characterize prior fluoroscopically guided epidural injections as part of the therapeutic sequence.
Trials and systematic reviews cited pertain to these patient populations; the policy itself remains investigational for the procedures.
Imaging and Guidance
Fluoroscopic guidance or endoscopic visualization required for adhesiolysis
Epidural adhesiolysis procedures must be performed with fluoroscopic guidance or endoscopic visualization to guide catheter placement and identify epidural scarring, per the procedure description in the policy.
- Fluoroscopic guidance and epidurography to guide catheter placement and identify non-filling adhesions
- Endoscopic visualization is an alternative for direct placement
Studies focus on post‑surgical patients; imaging likely used though no extra imaging mandates
The clinical studies cited in the policy largely pertain to post‑surgical patients and imply use of imaging in those contexts, although the policy text does not state additional explicit imaging requirements beyond fluoroscopic or endoscopic guidance.
- Referenced trials and systematic reviews focus on post‑surgical (failed back surgery) populations
- Policy does not add further explicit imaging conditions beyond fluoroscopy/endoscopy
Background and Rationale
Epidural adhesiolysis (also known as the Racz procedure) refers to techniques that place a catheter into the epidural space—percutaneously or endoscopically—to mechanically disrupt epidural scar and adhesions and deliver therapeutic solutions such as hypertonic saline, steroids, or enzymes. Approaches vary (caudal, transforaminal, cervical/thoracic/lumbar), and protocols described in the literature include single- or multi-day catheter procedures, serial sessions, and adjunctive agents; however, despite these described techniques, the procedure is considered investigational for treatment of back pain in this policy.
Definitions
Not Covered Services
Policy Revision History
Policy effective date updated to 2026-10-15; Medicare (CMS) has no national or regional coverage determinations for lysis of epidural adhesions, which may affect product-specific coverage decisions.
Earlier policy history entries exist dating back to 2006 documenting prior iterations of the lysis of epidural adhesions policy; Medicare (CMS) continued to have no national or regional coverage determinations during the policy history period.
Added recent systematic review and meta-analysis references summarizing randomized controlled trials and long-term follow-up studies of percutaneous epidural adhesiolysis (e.g., Manchikanti 2023; Gerdesmeyer 2021).
Systematic review on efficacy, effectiveness, safety, and cost-effectiveness of epidural adhesiolysis for failed back surgery syndrome (Brito-Garcia 2019) included in references.
Randomized, double-blind, placebo-controlled trial of percutaneous epidural lysis of adhesions (Gerdesmeyer 2013) cited in the evidence section.
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