Payer PolicyActive
CMM-207: Epidural Adhesiolysis
EVICORE-CIGNA-CMM-207
EviCore by Evernorth
Effective: July 1, 2025
Updated: January 13, 2026
created · Dec 3, 2025
Policy Summary
Epidural adhesiolysis (catheter or endoscopic) for back pain is considered experimental, investigational, or unproven and is not supported as a covered indication in this policy. CPT codes are informational only (inclusion does not imply coverage or prior authorization); actual coverage, documentation needs, and prior‑authorization requirements are determined by the member’s specific benefit plan and applicable laws/regulations.
Coverage Criteria Preview
Key requirements from the full policy
"None identified. The policy states there is insufficient scientific evidence to support the use of epidural adhesiolysis (performed by catheter or endoscopically) as a treatment for back pain."
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