570 Form

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Medical Policy Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 570

BCBSA Reference Number: 4.01.17A (For Plan internal use only) NCD/LCD: NA Related Policies
None Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

Laparoscopic uterine nerve ablation (LUNA) and laparoscopic presacral neurectomy (LPSN) are considered INVESTIGATIONAL as techniques to treat primary or secondary dysmenorrhea.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) This is not a covered service. Commercial PPO and Indemnity This is not a covered service. Medicare HMO BlueSM This is not a covered service. Medicare PPO BlueSM This is not a covered service. CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

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Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. CPT Codes There is no specific CPT code for this service. Description Dysmenorrhea is defined as the occurrence of painful menstrual cramps. Primary dysmenorrhea occurs in the absence of an identifiable cause, while secondary dysmenorrhea is related to an identifiable pathologic condition, such as endometriosis, adenomyosis, or pelvic adhesions. The etiology of primary dysmenorrhea is thought to be related to the overproduction of uterine prostaglandins. Therefore, first-line pharmacologic therapy typically includes nonsteroidal anti-inflammatory drugs (NSAIDs), which reduce prostaglandin production. Oral contraceptives are another approach. Patients with secondary dysmenorrhea may be offered both, NSAIDs and oral contraceptives as well as a variety of other hormonal therapies. Patients with endometriosis frequently undergo surgery to ablate, excise, or enucleate endometrial deposits or lyse pelvic adhesion. Collectively, these surgical procedures may be referred to as “conservative surgical therapy.”

Two surgical approaches performed as adjuncts to conservative surgical therapy in patients with secondary dysmenorrhea are laparoscopic uterine nerve ablation (LUNA) and laparoscopic presacral neurectomy (LPSN). LUNA and LPSN have been investigated as techniques to interrupt the majority of the cervical sensory nerve fibers in patients with dysmenorrhea. LUNA involves the transection of the uterosacral ligaments at their insertion into the cervix, while LPSN involves the removal of the presacral nerves lying within the interiliac triangle.
Summary The evidence is insufficient that LUNA improves health outcomes of patients with primary or secondary dysmenorrhea. Studies comparing LUNA to diagnostic laparoscopy alone have not found consistent benefit of the intervention. In addition, sample sizes were small in many studies, and there are few studies with follow-up of 12 months or longer.

The evidence on presacral neurectomy for treating primary dysmenorrhea is insufficient; no randomized trials were identified. For secondary dysmenorrhea, only one recent well-conducted trial on presacral neurectomy was identified; this trial found improvement in pain outcomes but also higher complication rates. The net health benefit considering the balance of risks and benefits remains unclear and need to be assessed in additional trials.

Thus, given that the evidence is insufficient, laparoscopic uterine nerve ablation and presacral neurectomy are investigational for the treatment of primary and secondary dysmenorrhea.
Policy History Date Action 11/2022 Annual policy review. Policy updated with literature review through October 2022.
No references added. Policy statements unchanged. 2/2020 Policy updated with literature review through February 1, 2020, references added. Policy statements unchanged. 7/2014 Annual policy review. New references added. 6/2013 Annual policy review. New references added. 11/2011- 4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates. No changes to policy statements.
12/1/2011 New policy, effective 12/1/2011, describing ongoing non-coverage. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information:

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Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References

1. Proctor ML, Latthe PM, Farquhar CM et al. Surgical interruption of pelvic nerve pathways for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev 2005; (4):CD001896.
2. Latthe PM, Proctor ML, Farquhar CM et al. Surgical interruption of pelvic nerve pathways in dysmenorrhea: a systematic review of effectiveness. Acta Obstet Gynecol Scand 2007; 86(1):4-15.
3. Lichten EM, Bombard J. Surgical treatment of primary dysmenorrhea with laparoscopic uterine nerve ablation. J Reprod Med 1987; 32(1):37-41.
4. Johnson NP, Farquhar CM, Crossley S et al. A double-blind randomized controlled trial of laparoscopic uterine nerve ablation for women with chronic pelvic pain. Bjog 2004; 111(9):950-9.
5. Tjaden B, Schlaff WD, Kimball A et al. The efficacy of presacral neurectomy for the relief of midline dysmenorrhea. Obstet Gynecol 1990; 76(1):89-91.
6. Vercellini P, Aimi G, Busacca M et al. Laparoscopic uterosacral ligament resection for dysmenorrhea associated with endometriosis: results of a randomized, controlled trial. Fertil Steril 2003; 80(2-Jan):310-9.
7. Sutton C, Pooley AS, Jones KD. A prospective, randomized, double-blind controlled trial of laparoscopic uterine nerve ablation in the treatment of pelvic pain associated with endometriosis. Gynaecol Endosc 2001; 10(4):217-22.
8. Daniels J, Gray R, Hills RK et al. Laparoscopic uterosacral nerve ablation for alleviating chronic pelvic pain. Jama 2009; 302(9):955-61.
9. El-Din Shawki H. The efficacy of laparoscopic uterosacral nerve ablation (LUNA) in the treatment of unexplained chronic pelvic pain: a randomized controlled trial. Gynecol Surg 2011; 8(1):31-39.
10. Candiani GB, Fedele L, Vercellini P et al. Presacral neurectomy for the treatment of pelvic pain associated with endometriosis: a controlled study. Am J Obstet Gynecol 1992; 167(1):100-3.
11. Zullo F, Palomba S, Zupi E et al. 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. Am J Obstet Gynecol 2003; 189(1- Jan):5-10.
12. Zullo F, Palomba S, Zupi E et al. Long-term effectiveness of presacral neurectomy for the treatment of severe dysmenorrhea due to endometriosis. J Am Assoc Gynecol Laparosc 2004; 11(1):23-8.
13. Chen FP, Chang SD, Chu KK et al. Comparison of laparoscopic presacral neurectomy and laparoscopic uterine nerve ablation for primary dysmenorrhea. J Reprod Med 1996; 41(7):463-6.
14. National Institute for Health and Clinical Evidence (NICE). Laparoscopic uterine nerve ablation (LUNA) for chronic pelvic pain. NICE Interventional Procedure Guidance 234. 2007. Available online at: http://guidance.nice.org.uk/IPG234/Guidance/pdf/English. Last accessed March, 2014.