Anthem Blue Cross Connecticut SURG.00072 Lysis of Epidural Adhesions Form

This document addresses lysis of epidural adhesions, which refers to the disruption of fibrous tissue in the epidural space of the spine. Epidural adhesions are similar to scar tissue and are most commonly observed following invasive procedures, such as spinal surgery, catheter placement or injections. This procedure is also known as the RACZ procedure or epidural neurolysis. During the procedure, a special epidural catheter is inserted into the epidural space for injection of hypertonic saline with or without other medications or manipulation of the catheter alone. Additional lysis methods have been proposed, such as radiofrequency ablation.

Note: Please see the following related document for additional information:

• SURG.00073 Epiduroscopy

Position Statement

Investigational and Not Medically Necessary:

Lysis of epidural adhesions by any means, including but not limited to, use of hypertonic saline injections, mechanical catheter manipulation, hyaluronidase, whether done with or without steroids or analgesics, is considered investigational and not medically necessary.