Lysis of Epidural Lesions

This policy addresses lysis of epidural lesions (epidural adhesiolysis/epidural neuroplasty—percutaneous and endoscopic techniques, including use of Racz or indwelling sacral catheters) for adults with chronic, refractory low back and lower‑extremity pain such as failed‑back/post‑laminectomy syndrome, disc herniation, spinal stenosis, and degenerative or age‑related epidural adhesions. Major limitations: current evidence is low quality with only short‑term benefit and safety concerns, does not demonstrate durable efficacy, and the procedures are considered not supported/not covered by this policy (or acceptable only under special arrangements after failure of conservative therapies), with coverage subject to the member’s plan terms.

"Epidural adhesiolysis (epidural neuroplasty/lysis of epidural adhesions/caudal neuroplasty) for chronic back pain associated with epidural fibrosis or adhesions"