LCD/NCD Portal

L29256

 

ENDOSCOPIC AND PERCUTANEOUS LYSIS OF EPIDURAL ADHESIONS

 

 

Indications and Limitations of Coverage and/or Medical Necessity

• Medicare will consider the use of endoscopic and percutaneous lysis of epidural adhesions to be medically reasonable and necessary in the treatment of

o Chronic refractory cervical pain that has failed to respond to more conservative treatment measures.

o Chronic refractory lumbar pain that has failed to respond to more conservative treatment measures.

o Chronic refractory thoracic pain that has failed to respond to more conservative treatment measures.

• Conservative treatment may include

o local heat,

o traction,

o nonsteroidal anti-inflammatory medications, and

o Anesthetic and/or steroid epidural injections.

• The chronic refractory low back pain may be secondary to

o post lumbar laminectomy syndrome,

o intervertebral lumbar disc disruption,

o lumbar epidural adhesions, and/or

o Lumbar degenerative disc disorder.

• It is not expected that services will exceed one every six months to the same anatomical region.

• (Services exceeding one every six months should be subject to medical review.)

 

 

CPT/HCPCS Codes

 

64999 Unlisted procedure, nervous system (Endoscopic lysis of epidural adhesions with the epiduroscope)

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

 

 

ICD-9 Codes that Support Medical Necessity

 

722.0 DISPLACEMENT OF CERVICAL INTERVERTEBRAL DISC WITHOUT MYELOPATHY

722.10 DISPLACEMENT OF LUMBAR INTERVERTEBRAL DISC WITHOUT MYELOPATHY

722.4 DEGENERATION OF CERVICAL INTERVERTEBRAL DISC

722.52 DEGENERATION OF LUMBAR OR LUMBOSACRAL INTERVERTEBRAL DISC

722.73 INTERVERTEBRAL DISC DISORDER WITH MYELOPATHY LUMBAR REGION

722.81 POSTLAMINECTOMY SYNDROME OF CERVICAL REGION

722.82 POSTLAMINECTOMY SYNDROME OF THORACIC REGION

722.83 POSTLAMINECTOMY SYNDROME OF LUMBAR REGION

723.0 SPINAL STENOSIS IN CERVICAL REGION

723.4 BRACHIAL NEURITIS OR RADICULITIS NOS

724.01 SPINAL STENOSIS OF THORACIC REGION

724.02 SPINAL STENOSIS, LUMBAR REGION, WITHOUT NEUROGENIC CLAUDICATION

724.03 SPINAL STENOSIS, LUMBAR REGION, WITH NEUROGENIC CLAUDICATION

724.4 THORACIC OR LUMBOSACRAL NEURITIS OR RADICULITIS UNSPECIFIED

 

 

Documentation Requirements

• Medical record should clearly document the nature of the

o Cervical.

o Lumbar.

o Thoracic pain.

• This should include the

o Location.

o Intensity.

o Type of pain present.

o Contributing factors (if any).

o Duration of condition.

o Treatment regimes that have been utilized.

• Documentation should demonstrate failure of more conservative management in the treatment of the patient’s condition.

• This more conservative treatment may include

o Local heat.

o Traction.

o Nonsteroidal anti-inflammatory medications.

o Anesthetic and/or steroid epidural injections.

 

 

Treatment Logic:

• Endoscopic epidural lysis of adhesions (also known as endoscopic lysis) and percutaneous epidural lysis of adhesions (also referred to as epidural neuroplasty or epidural adhesiolysis) are interventional pain management techniques that are used to treat chronic cervical, lumbar, and thoracic pain.

• The basis for performing this procedure is the premise that fibrous adhesions (scar tissue) develops after surgery, trauma, and/or inflammation that compounds pain associated with the nerve root by fixing it in one position and thus increasing the susceptibility of the nerve root to tension or compression.

• This scar tissue also prevents the direct application of medications to relieve pain (local anesthetics and corticosteroids) to the problem area.

• The goal of the procedure is to break down these fibrous adhesions to allow for delivery of high concentrations of injected drugs to the target area and free the nerve from mechanical tension/compression.

• The procedure usually involves adhesiolysis procedures performed over a 1-3 day period (CPT code 62263 – more than 2 days or 62264 – one day).

• Adhesiolysis can be accomplished by solution injection (commonly hypertonic saline and/or hyaluronidase) and/or by mechanical means (by maneuvering a specially designed epidural catheter or epiduroscope).

 

 

Sources of Information and Basis for Decision

 

Boswell, M. V., Trescot, A. M., et al Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician 10:7 pp 48-51.

 

Manchikanti, l., Heavner, J., Boswell, M.V. (2007) Endoscopic lumbar epidural adhesions. Intervential Techniques in Chronic Spinal Pain. Pp 507-526

 

Manchikanti, L., Boswell, M.V., et al. A randomized controlled trial of spinal endoscopic adhesiolysis in chronic refractory low back and lower extremity pain. BMC Anesthesiology 2005 (5) 10

 

Manchikanti, L., Singh, V (2007) Pecutaneous lysis of lumbar epidural adhesions. Interventional Techniques in Chronic Spinal Pain. Pp479-506

 

Racz, G.B., Heavner, J.E., Trescot, A. (2008) Percutaneous lysis of epidural adhesions-evidence for safety and efficacy. Pain Practice 8 (4) 277-286.

 

Trescot A.M., Chopra P., Abdi S., Datta S., Schultz D.M. Systematic review of effectiveness and complications of adhesiolysis in the management of chronic spinal pain: An update. Pain Physician 2007; 10: 129-146. http://www.painphysicianjournal.com/2007/january/2007;10;129-146.pdf

 

Revised Effective Date: 10/01/2010

 

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/ .

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

 

CMS LCD ENDOSCOPIC AND PERCUTANEOUS LYSIS OF EPIDURAL ADHESIONS