| Coverage Decisions for Medical Technologies & Procedures |  | |
Epidural adhesiolysis
Coverage decision
L&I or self-insurer does not cover epidural adhesiolysis conducted with the 3-day protocol.
The insurer does cover the new 1-day protocol with prior authorization.
Effective November 1, 2004, the 1-day protocol is covered for patients who meet all of the following criteria:
- The worker has experienced acute low back pain or acute exacerbation of chronic low back pain of no more than 6 months duration.
- The physician intends to conduct the adhesiolysis in order to administer drugs closer to a nerve.
- The physician documents strong suspicion of adhesions blocking access to the nerve.
- Adhesions blocking access to the nerve have been identified by
- Gallium MRI, or
- Fluoroscopy during epidural steroid injections.
Background
Epidural adhesiolysis is a catheterization procedure to treat chronic back pain that has not responded to conservative treatments. The procedure is intended to eliminate fibrous tissue from the epidural space to allow application of drugs to the nerves.
Epidural adhesiolysis is also known as:
- Percutaneous lysis of epidural adhesions.
- Epidural decompressive neuroplasty.
- Racz neurolysis.
A 16-gauge RK needle is followed by a Racz catheter; entering the epidural space either caudally, using an interlaminar approach, or by a transforaminal approach. Under radiographic control, lidocaine and steroid are injected into the epidural space through the catheter.
Originally a 3-day procedure, epidural adhesiolysis has since been condensed into a 1-day procedure.
Billing code
Use CPT™ code 62264.
For more information:
Epidural adhesiolysis technology assessment (149 KB PDF).
Contact information.
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