|
Medical Policy: 08.01.12
Original Effective Date: May 1999
Reviewed: November 2011
Revised: May 2004
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Epidural fibrosis with or without adhesions most commonly occurs as a complication of spinal surgery, and is sometimes referred to as “failed back syndrome”. This sometimes results from manipulation of the supporting structures of the spine and can also result in adhesive arachnoiditis. This condition causes entrapment of nerves in the lumber region leading to chronic low back pain, radicular pain, tenderness or other symptoms.
Lysis of epidural adhesions using fluoroscopic guidance with epidural injections of hypertonic saline in conjunction with steroids and analgesics or hyaluronidase, has been investigated as a treatment option. It is presumed that injection of saline or one of the other substances, may cause mechanical disruption of adhesions and manipulating the catheter at the time of injection may also disrupt adhesions. This procedure can also be done endoscopically instead of transcutaneously.
 Top
Prior Approval:
Not applicable
Top
Policy:
Lysis of epidural adhesions is considered investigational for any diagnosis. Current scientific evidence does not support the efficacy of this treatment.
Larger high-quality, multicenter controlled studies are needed to establish the safety and effectiveness of epidural lysis of adhesions in comparison with placebo and alternative procedures.
Top
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 62263 Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days.
- 62264 Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 1 day.
- 64999 Unlisted procedure, Nervous system
Top
Selected References:
- Manchikanti L, Pakanati RR, Bakhit CE, et al. Role of adhesiolysis and hypertonic saline neurolysis in management of low back pain: evaluation of modification of the Racz protocol. Pain Digest 1999; (9) 91-9.
- Heavner JE, Racz GB, Raj P.Percutaneous epidural neuropalasty: prospective evaluation of 0.9% NaCl versus 10% NaCl with or without Hyaluronidase. Reg Anesth Pain Med 1999May-June;24(3):198-201.
- Nelemans PJ, de Bie RA, de Vet HC, Sturmans F. Injection therapy for subacute and chronic benign low back pain. Cochrane Database of Systematic Reviews 2000;(2):CD001824.
- Manchikanti L, Rivera JJ, Pampati V, et al. One day lumbar epidural adhesiolysis and hypertonic saline neurolysis in treatment of chronic low back pain: a randomized, double blind trial. Pain Phys 2004: (7) 177-186.
- Manchikanti L, Boswell MV, et al. A randomized, controlled trial of spinal endoscopic adhesiolysis in chronic refractory low back and lower extremity pain. BMC Anesthesiol. 2005 Jul 6;5:10.
- Veihelmann A, Devens C, et al. 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.
- Boswell MV, Trescot AM, et al. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. 2007 Jan;10(1):7-111.
- Trescot AM, Chopra P, et al. 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.
- Racz G; Heavner J; Trescot A. Percutaneous lysis of epidural adhesions--evidence for safety and efficacy. Pain Pract 2008 Jul-Aug;8(4):277-86.
- National Institute for Health and Clinical Excellence (NICE). Therapeutic endoscopic division of epidural adhesions. Interventional procedure guidance 333. London, UK: NICE; 2010 February. Available at URL address: http://www.nice.org.uk.
Top
Policy History:
Date Reason Action
November 2010 Annual review Policy renewed
November 2011 Annual review Policy renewed
Top
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
|
 |
