Print

Date Printed: October 23, 2017: 02:14 AM

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-61000-28

Original Effective Date: 11/15/00

Reviewed: 09/26/13

Revised: 06/15/14

Subject: Lysis of Epidural Adhesions

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Updates  

DESCRIPTION:

Lysis of epidural adhesions, also called the Racz procedure, involves passage of a catheter (Racz catheter) endoscopically or percutaneously under fluoroscopic guidance into the epidural space under general anesthetic or conscious sedation. Various protocols for breaking up adhesions and reducing pain and inflammation have been described. The catheter may then be manipulated to mechanically break up adhesions, and various agents, that may include anesthetics, corticosteroids, hyaluronidase, and hypertonic saline, are injected. In some early protocols, the catheter was left in place and injections repeated over several days.

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 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.

Both conditions 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.

Lysis of epidural adhesions, using fluoroscopic guidance, with epidural injections of hypertonic saline in conjunction with corticosteroids and analgesics has been investigated as a treatment option. Theoretically, the use of hypertonic saline results in a mechanical disruption of the adhesions. It may also function to reduce edema within previously scarred and/or inflamed nerves. Finally, manipulating the catheter at the time of injection may disrupt adhesions. Spinal endoscopy has been used to guide the lysis procedure. Prior to the use of endoscopy, adhesions can be identified as non-filling lesions on fluoroscopy. Using endoscopy guidance, a flexible fiber optic catheter is inserted into the sacral hiatus, providing 3-D visualization to steer the catheter toward the adhesions, to more 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 for the treatment of degenerative chronic low back pain, including spondylolisthesis, stenosis, and hernia associated with radiculopathy. Along with mechanical adhesiolysis, hyaluronidase, ciprofloxacin and ozone have been applied.

POSITION STATEMENT:

Catheter-based techniques (e.g. percutaneous lysis of epidural adhesions, percutaneous epidural neuroplasty, lysis of epidural adhesions, epidural adhesiolysis, Racz procedure) for lysis of epidural adhesions, with or without endoscopic guidance, are considered experimental or investigational. There is insufficient clinical evidence in the peer-reviewed medical literature to support the safety and effectiveness of this treatment.

NOTE: Lysis of epidural adhesions includes epidurography.

Spinal endoscopy/epiduroscopy/myeloscopy is considered experimental or investigational, as there is insufficient clinical evidence in the peer-reviewed medical literature to support its safety and effectiveness.

BILLING/CODING INFORMATION:

There is no specific CPT or HCPCS code for spinal endoscopy/epiduroscopy/myeloscopy.

CPT 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 (investigational)

62264

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; 1 day (investigational)

62280

Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; subarachnoid (investigational)

62281

Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, cervical or thoracic (investigational)

62282

Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, lumbar, sacral (caudal) (investigational)

REIMBURSEMENT INFORMATION:

Refer to sections entitled POSITION STATEMENT and PROGRAM EXCEPTIONS.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products: The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Endoscopic and Percutaneous Lysis of Epidural Adhesions (L29256) located at fcso.com.

DEFINITIONS:

Adhesion: a fibrous band or structure by which parts abnormally adhere.

Arachnoiditis: Inflammation of the middle layer of membranes covering the brain and spinal cord. Arachnoiditis can occur as a complication of procedures such as myelograms, spinal operations, epidural steroid injections, and injury to the spine.

Epidural: outside the dura mater (outermost, toughest, most fibrous of the three membranes covering the brain and spinal cord); the space between the bony vertebral canal and the dura mater (the spinal cord does not fill the bony vertebral canal). The space remaining between the dura mater and the bone of the vertebra is the epidural space.

Epidurography: radiography of the spine after a radiopaque contrast agent has been injected into the epidural space.

Fluoroscopy: a radiographic technique in which an object, such as the human body, is examined visually in real time by transmitting X-rays through the object onto a fluorescent screen. The resulting picture on the screen is made up of shadows created by the transmission of different amounts of X-rays through body structures of varying depth and size.

Hypertonic: a solution with a higher salt concentration than in normal cells of the body and the blood.

Lysis: destruction; rupture of cell membrane and loss of cytoplasm.

Neurolysis: destruction of nerve tissue, freeing of a nerve from inflammatory adhesions.

Percutaneous: performed through the skin.

Radiculopathy: any disease of the spinal nerve roots and spinal nerves.

RELATED GUIDELINES:

None applicable.

OTHER:

Other names used to report Percutaneous Lysis of Epidural Adhesions:

Epidural Adhesiolysis
Epidural Neurolysis
Epidurolysis
Hypertonic Saline Injections
Injections, Epidural, Hypertonic Saline
Lysis of Epidural Adhesions
Neurolysis, Epidural
Percutaneous Epidural Neuroplasty
Racz Procedure

REFERENCES:

  1. AHRQ National Guideline Clearinghouse. Guideline Summary NGC-9330. Chronic pain disorder medical treatment guidelines. Denver (CO): Colorado Division of Workers' Compensation; 2011 Dec 27.
  2. AHRQ National Guideline Clearinghouse. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician 2009 Jul-Aug;12(4):699-802.
  3. American Board of Interventional Pain Management website, Racz procedure.
  4. Belozer M, Wang G. Epidural Adhesiolysis for the Treatment of Back Pain. Health Technology Assessment. Olympia, WA: Washington State Department of Labor and Industries, Office of the Medical Director; July 13, 2004.
  5. Birkenmaier C, Baumert S, Schroeder C, Jansson V, Wegener B. A Biomechanical Evaluation of the Epidural Neurolysis Procedure. Pain Physician 2012; 15:E89-E97.
  6. Blue Cross Blue Shield Association. Medical Policy Reference Manual. 8.01.18 Lysis of Epidural Adhesions, (12/12).
  7. Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, Sehgal N, Shah RV, Singh V, Benyamin RM, Patel VB, Buenaventura RM, Colson JD, Cordner HJ, Epter RS, Jasper JF, Dunbar EE, Atluri SL, Bowman RC, Deer TR, Swicegood JR, Staats PS, Smith HS, Burton AW, Kloth DS, Giordano J, Manchikanti L; American Society of Interventional Pain Physicians. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. 2007 Jan; 10(1):7-111.
  8. Boswell MV, Shah RV, Everett CR, Sehgal N, Brown AM, Abdi S, Bowman RC 2nd, Deer TR, Datta S, Colson JD, Spillane WF, Smith HS, Lucas LF, Burton AW, Chopra P, Staats PS, Wasserman RA, Manchikanti L. Interventional techniques in the management of chronic spinal pain: evidence-based practice guidelines. Pain Physician. 2005 Jan;8(1): 1-47.
  9. Chopra P, Smith HS, Deer TR, Bowman RC. Role of Adhesiolysis in the Management of Chronic Spinal Pain: A Systematic Review of Effectiveness and Complications. Pain Physician. 2005 Jan;8(1): 87-100.
  10. Chou R, Qaseem A, Snow V, Casey D, Cross Jr. JT, Shekelle P, Owens DK. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine. 2007 Oct;147(7):478-491.
  11. Chou R, et al. Interventional Therapies, Surgery, and Interdisciplinary Rehabilitation for Low Back Pain An Evidence-Based Clinical Practice Guideline From the American Pain Society. Spine Volume 34, Number 10, 2009.
  12. ClinicalTrials.gov, Effectiveness of Percutaneous Lumbar Epidural Adhesiolysis and Neurolysis on Low Back Pain, sponsored by Pain Management Center of Paducah. NCT00370994. Accessed 06/27/12.
  13. ClinicalTrails.gov, A Randomized, Equivalence Trial of Percutaneous Lumbar Adhesiolysis and Caudal Epidural Steroid Injections, sponsored by Pain Management Center of Paducah. NCT01053273. Accessed 06/27/12.
  14. ClinicalTrials.gov. Role of Steroids and 10% Hypertonic Sodium Chloride in Adhesiolysis in Post Lumbar Surgery Syndrome Patients, sponsored by Pain Management Center of Paducah. NCT01053572. Accessed 06/27/12.
  15. ECRI Hotline Response: Epidurolysis Procedure Using Racz Catheter for Low Back Pain, (06/26/03).
  16. ECRI. Custom Hotline Response. Epidurolysis for Low Back Pain. PA: ECRI. 10/09/07.
  17. Epter, RS, Helm S, Hayek SM, Benyamin RM, Smith HS., and Abdi S. Systematic Review of Percutaneous Adhesiolysis and Management of Chronic Low Back Pain in Post Lumbar Surgery Syndrome. Pain Physician. 2009; 12; 361-378.
  18. First Coast Service Options, Inc. LCD for Endoscopic and Percutaneous Lysis of Epidural Adhesions (L29256), 02/02/09. (Accessed 08/12/13).
  19. Gerdesmeyer L, et al. Percutaneous Epidural Lysis of Adhesions in Chronic Lumbar Radicular Pain: A Randomized, Double-Blind, Placebo-Controlled Trial. Pain Physician 2013; 16:185-196.
  20. Hayek SM, Hel m S, Benyamin RM, Singh V, Bryce DA, and Smith HS. Effectiveness of Spinal Endoscopic Adhesiolysis in Post Lumbar Surgery Syndrome: A Systematic Review. Pain Physician. Mar/April 2009;12;419-435.
  21. Hayes, Inc., Health Technology Brief. Epidural Adhesiolysis For Chronic Back Pain Lansdale, PA: Hayes, Inc. 10/11/06. Update performed 10/05/07.
  22. Helm S, et al. Spinal Endoscopic Adhesiolysis in Post Lumbar Surgery Syndrome: An Update of the Assessment of the Evidence. Pain Physician 2013; 16:SE125-SE150.
  23. Impiombato FA, et al. Use of an Angiographic Catheter in Place of the Racz Epidural Catheter in the Lysis of Epidural Space Adhesions: A Technical Note. Interventional Neuroradiology 17: 501-505, 2011.
  24. Justiz R, Taylor V, Day M. Neurogenic Bladder: A Complication After Endoscopic Adhesiolysis with Return of Bladder Function While Using Nitrofurantoin. Anesthesia and Analgesia. May 2010 ,Volume 110 , Number 5.
  25. Lee JH, Lee SH. Clinical Effectiveness of Percutaneous Adhesiolysis Using Navicath for the Management of Chronic Pain Due to Lumbosacral Disc Herniation. Pain Physician 2012; 15:213-221.
  26. Manchikanti L, Boswell MV, Rivera JJ, Pampati VS, Damron KS, McManus CD, Brandon DE, Wilson SR. A randomized, controlled trial of spinal endoscopic adhesiolysis in chronic refractory low back and lower extremity pain. BMC Anesthesiol. 2005 Jul 6; 5: 10.
  27. Manchikanti L, Cash KA, McManus CD, et al, The Preliminary Results of a Comparative Effectiveness Evaluation of Adhesiolysis and Caudal Epidural Injections in Managing Chronic Low Back Pain Secondary to Spinal Stenosis: A Randomized, Equivalence Controlled Trial, Pain Physician 2009; 12:E341-E354.
  28. Manchikanti L, Rivera JJ, Pampati V, Damron KS, McManus CD, Brandon DE, Wilson SR. One day lumbar epidural adhesiolysis and hypertonic saline neurolysis in treatment of chronic low back pain: a randomized, double-blind trial. Pain Physician. 2004 Apr; 7(2): 177-86.
  29. Manchikanti, L, Boswell, MV, Singh V, Benyamin RM, Fellows B, Salahadin A, Buenaventur RM, Conn A, Datta S, Derby R, Falco FJE, Erhart S, Diwan S, Hayek SM, Helm S, Parr AT, Schultz DM, Smith HS, Wolfer LR, & Hirsch JA. Comprehensive Evidence-Based Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain. Pain Physician 2009; 12;699-802. (Accessed 08/12/13)
  30. Manchikanti L, Singh V, Cash KA, et al, A Comparative Effectiveness Evaluation of Percutaneous Adhesiolysis and Epidural Steroid Injections in Managing Lumbar Post Surgery Syndrome: A Randomized, Equivalence Controlled Trial, Pain Physician 2009; 12:E355-E368.
  31. National Institute for Clinical Excellence (NICE). Interventional procedures overview of Endoscopic division of epidural adhesions. London, UK: NICE; October 2002.
  32. National Institute for Clinical Excellence (NICE), Therapeutic Endoscopic Division of Epidural Adhesions, February 2010.
  33. Park CH, Lee SH, Jung JY. Dural Sac Cross-Sectional Area Does Not Correlate with Efficacy of Percutaneous Adhesiolysis in Single Level Lumbar Spinal Stenosis. Pain Physician 2011; 14:377-382.
  34. Trescot AM, Chopra P, Abdi S, Datta S, Schultz DM. Systematic review of effectiveness and complications of adhesiolysis in the management of chronic spinal pain: an update. Pain Physician. 2007 Jan; 10(1): 129-46. Review.
  35. Veihelmann A, Devens C, Trouillier H, Birkenmaier C, Gerdesmeyer L, Refior HJ. Epidural neuroplasty versus physiotherapy to relieve pain in patients with sciatica: a prospective randomized blinded clinical trial. J Orthop Sci. 2006 Jul; 11(4): 365-9.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 09/26/13.

GUIDELINE UPDATE INFORMATION:

11/19/00

Outpatient Pain Management Medical Coverage Guideline #02-61000-01 approved by MPCC.

09/15/03

Developed separate Medical Coverage Guideline for Lysis of Epidural Adhesions from Outpatient Pain Management 02-61000-01.

02/15/04

Revised Medical Coverage Guideline. Added additional statements regarding non-coverage for Epiduroscopy and Program Exception for Medicare and More.

09/15/04

Review and revision of guideline; consisting of updated references and various formatting changes. No change to investigational status.

11/15/04

Revision of guideline; consisting of adding an investigational statement for Spinal Endoscopy.

09/15/05

Review and revision of guideline; consisting of updated references.

09/15/06

Review and revision of guideline consisting of updated references.

11/15/06

Revision of guideline.

07/15/07

Annual review; investigational status maintained, guideline reformatted, references updated.

09/15/08

Review and revision of guideline consisting of updated references.

01/01/09

Annual HCPCS coding update: deleted code 0027T.

09/15/09

Scheduled review; no change in position statement. Update references.

08/15/10

Annual review: position statements maintained and references updated.

08/15/12

Scheduled review. Revised description section. Position statement maintained. Deleted CPT code 72275. Updated references.

10/15/13

Scheduled review. Position statement maintained. Revised program exceptions section and updated references.

06/15/14

Revision; added codes 62280, 62281 and 62282.

Date Printed: October 23, 2017: 02:14 AM