Laparoscopic uterine nerve ablation (LUNA)(58999) is considered experimental/investigational in the treatment of severe refractory dysmenorrhea and chronic disabling midline pelvic pain.  The published data regarding the efficacy and long term outcomes of this procedure are inadequate to permit scientific conclusions.  Laparoscopic uterine nerve ablation is not covered and not eligible for payment.  A participating, preferred, or network provider can bill the member for this procedure.

Presacral neurectomy (PSN)(58999) is considered eligible for the treatment of refractory dysmenorrhea and chronic disabling midline pelvic pain in cases where conservative non-surgical treatment options (oral contraceptives or other hormonal therapies and/or non-steroidal anti-inflammatory drugs NSAIDs) have been exhausted.  The use of PSN in the absence of documented failure of non-surgical treatment options, or for lateral rather than midline pelvic pain, is considered not medically necessary, and is not eligible for coverage.  A participating, preferred, or network provider cannot bill the member for the denied service.

Description

Dysmenorrhea is defined as the occurrence of painful menstrual cramps of uterine origin.  Dysmenorrhea has been categorized as either primary or secondary.  Primary dysmenorrhea occurs in the absence of pelvic pathology or other identifiable cause.  Secondary dysmenorrhea refers to pelvic pain from an identifiable pathologic cause, such as pelvic inflammatory disease, endometriosis, adenomyosis, intrauterine adhesions, fibroids, etc. 

Chronic pelvic pain is commonly treated using non-steroidal anti-inflammatory drugs (NSAIDS), oral contraceptives, and other hormonal therapies.  Patients with secondary dysmenorrhea may undergo surgery for lysis of adhesions, removal of areas of endometriosis, or other procedures to correct the underlying cause of chronic pelvic pain.

Laparoscopic uterine nerve ablation and presacral neurectomy involve the interruption of pelvic sensory nerve fibers in order to reduce or eliminate chronic disabling midline pelvic pain and severe refractory dysmenorrhea in women who have failed more conservative attempts at treatment.

Laparoscopic uterine nerve ablation involves the transection of the uterosacral ligaments at their insertion into the cervix.  These ligaments contain the main nerve supply to the uterus and cervix.  Presacral neurectomy interrupts a greater number of nerve pathways than LUNA, and involves the interruption of the presacral nerves through the transection of the superior hypogastric plexus, at the level of the sacrum.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Under the Federal Employee Program program, laparoscopic uterine nerve ablation (LUNA)(58999) and presacral neurectomy (PSN)(58999) are not covered procedures.

PRN References

08/2005, Coverage guidelines for laparoscopic uterine nerve ablation (LUNA) and presacral neurectomy (PSN)

Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea, Medical Policy Reference Manual, Policy 4.01.17, 04/16/04

A Double-Blind Randomised Controlled Trial of Laparoscopic Uterine Nerve Ablation for Women with Chronic Pelvic Pain, British Journal of Obstetrics and Gynecology, Vol. 111, September 2004 

Laparoscopic Uterosacral Ligament Resection for Dysmenorrhea Associated with Endometriosis: Results of a Randomized Controlled Trial, Fertility and Sterility, Vol. 80, August, 2003 

Addition of Laparoscopic Uterine Nerve Ablation to Laparoscopic Bipolar Coagulation of Uterine Vessels for Women with Uterine Myomas and Dysmenorrhea, The Journal of the American Association of Gynecologic Laparoscopists, Vol. 8, November 2001 

Consensus Statement for the Management of Chronic Pelvic Pain and Endometriosis: Proceedings of an Expert-Panel Consensus Process, Fertility and Sterility, Vol. 78, November 2002 

Comparison of Laparoscopic Presacral Neurectomy and Laparoscopic Uterine Nerve Ablation for Primary Dysmenorrhea, The Journal of Reproductive Medicine, Vol. 41, July 1996 

Long-Term Effectiveness of Presacral Neurectomy for the Treatment of Severe Dysmenorrhea Due to Endometriosis, The Journal of the American Association of Gynecologic Laparoscopists, Vol. 11, February 2004 

Effectiveness of Presacral Neurectomy in Women with Severe Dysmenorrhea Caused by Endometriosis Who Were Treated with Laparoscopic Conservative Surgery:  A 1-Year Prospective Randomized Double-Blind Controlled Trial, The American Journal of Obstetric Gynecology, July 2003 

Are the Long Term Adverse Effects of Laparoscopic Presacral Neurectomy for the Management of Central Pain Associated with Endometriosis Acceptable?  The Primary Care Update for OB/Gyns, Vol. 5, July 1998 

The Efficacy and Complications of Laparoscopic Presacral Neurectomy in Pelvic Pain, Obstetrics and Gynecology, Vol. 90, December 1997