Lysis of Epidural Adhesions

POLICY NUMBER

L.8.01.407

DESCRIPTION

Lysis of epidural adhesions involves passing a catheter, either endoscopically or percutaneously, under fluoroscopic guidance into the epidural space to break up adhesions and reduce pain and inflammation.

Epidural Fibrosis and Adhesive Arachnoiditis

Epidural fibrosis with or without adhesive arachnoiditis most commonly occurs as a complication of spinal surgery and may be included under the diagnosis of "failed back surgery syndrome." Both conditions result from manipulation of the supporting structures of the spine. Epidural fibrosis can occur in isolation, but adhesive arachnoiditis is rarely present without associated epidural fibrosis. Arachnoiditis is most frequently seen in patients who have undergone multiple surgical procedures.

Epidural fibrosis and adhesive arachnoiditis are related to inflammatory reactions that result in the entrapment of nerves within dense scar tissue, increasing the susceptibility of the nerve root to compression or tension. The condition most frequently involves the nerves within the lumbar spine and cauda equina. Signs and symptoms indicate the involvement of multiple nerve roots and include low back pain, radicular pain, tenderness, sphincter disturbances, limited trunk mobility, muscular spasm or contracture, and motor sensory and reflex changes. Typically, the pain is characterized as constant and burning. In some cases, the pain and disability are severe, leading to analgesic dependence and chronic invalidism.

TreatmentLysis of epidural adhesions, also called the Racz procedure, has been investigated as a treatment option. The Racz procedure involves the passage of a fluoroscopically guided catheter (the Racz catheter), inserted either endoscopically or percutaneously, and the use of epidural injections of hypertonic saline in conjunction with corticosteroids and analgesics. Theoretically, the use of hypertonic saline results in a mechanical disruption of the adhesions. The saline may also function to reduce edema within previously scarred and/or inflamed nerves. Finally, manipulating the catheter at the time of the injection may disrupt adhesions. Spinal endoscopy has been used to guide the lysis procedure, but the procedure is more commonly performed percutaneously using epidurography to guide catheter placement and identify nonfilling adhesions that indicate epidural scarring. Using endoscopy guidance, a flexible fiberoptic catheter is inserted into the sacral hiatus, providing 3-D visualization to steer the catheter toward the adhesions. With the increased visualization, the catheter is more apt to precisely place the injectate in the epidural space and onto the nerve root. Various protocols for lysis have been described; in some situations the catheter may remain in place for several days for serial treatment sessions.

Endoscopic epidurolysis is also being investigated to treat degenerative chronic low back pain, including spondylolisthesis, stenosis, and hernia associated with radiculopathy. Along with mechanical adhesiolysis, hyaluronidase, ciprofloxacin, and ozone have been applied.

Lysis of epidural adhesions is a surgical procedure and, as such, is not subject to regulation by the U.S. Food and Drug Administration.

POLICY

Catheter-based techniques for lysis of epidural adhesions, with or without endoscopic guidance, are considered investigational. Techniques used either alone or in combination include mechanical disruption with a catheter and/or injection of hypertonic solutions with steroids, analgesics, or hyaluronidase.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

10/3/2006: Policy added.

1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions.

8/3/2007: Policy reviewed, no changes.

04/26/2010: Policy description updated regarding treatment protocols. Policy statement unchanged. Updated the codes table to indicate that CPT code 0027T was deleted on 12/31/2008. Also, moved CPT code 64999 to a separate row in the codes table. Removed deleted CPT code 76003 as this code was deleted on 12/31/2006.

04/20/2011: Policy description and statement unchanged. Removed deleted CPT code 0027T from the Code Reference section.

01/19/2012: Policy reviewed; no changes.

04/02/2013: Policy reviewed; policy statement unchanged. Added ICD-9 procedure code 03.6 to the Code Reference section.

03/12/2014: Policy reviewed; no changes.

01/21/2015: Policy description updated regarding endoscopic epidurolysis. Policy statement unchanged.

08/31/2015: Code Reference section updated for ICD-10.

01/18/2016: Policy reviewed. Policy statements unchanged. Policy guidelines updated to add investigative definition.

05/25/2016: Policy number A.8.01.18 added.

12/30/2016: Code Reference section updated to revise code description for CPT code 77002.

01/10/2018: Policy description updated regarding FDA regulation. Policy statement unchanged.

01/11/2019: Policy reviewed; no changes.

12/13/2019: Policy reviewed; no changes.

12/13/2021: Code Reference section updated to make note of deleted CPT code.

01/01/2022: Policy updated to change the medical policy number from "A.8.01.18" to "L.8.01.407."

05/02/2023: Policy reviewed. Policy statement unchanged. Code Reference section updated to remove deleted CPT codes 76005 and 72275 from the code descriptions of CPT codes 62263 and 62264.

06/06/2024: Policy reviewed; no changes.

08/04/2025: Policy reviewed. Policy statement unchanged. Sources updated.

SOURCE(S)

1. Blue Cross Blue Shield Association Policy # 8.01.18

2. Urits I, Schwartz RH, Brinkman J, Foster L, Miro P, Berger AA, Kassem H, Kaye AD, Manchikanti L, Viswanath O. An Evidence Based Review of Epidurolysis for the Management of Epidural Adhesions. Psychopharmacol Bull. 2020 Oct 15;50(4 Suppl 1):74-90. PMID: 33633419; PMCID: PMC7901122. Accessed April 2025.

CODE REFERENCE

This may not be a comprehensive list procedure codes applicable to this policy.

Investigational Codes

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