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Two laparoscopic surgical approaches are proposed as adjuncts to conservative surgical therapy for the treatment of primary and secondary dysmenorrhea. These approaches are laparoscopic uterine nerve ablation (LUNA) and presacral neurectomy (PSN).
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 incompletely understood but is thought to be related to the overproduction of uterine prostaglandins. Therefore, first-line pharmacologic therapy typically includes non-steroidal 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 adhesions. Collectively, these surgical procedures may be referred to as “conservative surgical therapy.”
Uterine nerve ablation (UNA) or presacral neurectomy (PSN) are two laparoscopic surgical approaches that have been investigated as techniques to interrupt the majority of the cervical sensory nerve fibers in patients with dysmenorrhea. UNA involves the transection of the uterosacral ligaments at their insertion into the cervix, while PSN involves the removal of the presacral nerves lying within the interiliac triangle. PSN interrupts a greater number of nerve pathways compared to laparoscopic uterine nerve ablation (LUNA), and is technically more demanding. Either LUNA or PSN can be performed as adjuncts to conservative surgical therapy in patients with secondary dysmenorrhea.
POLICYLaparoscopic uterine nerve ablation (LUNA) and laparoscopic presacral neurectomy (LPSN) are considered investigational as techniques to treat primary or secondary dysmenorrhea.
POLICY EXCEPTIONSFederal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Conservative surgical therapy includes ablation or excision of endometrial deposits or lysis of pelvic adhesions, typically performed during laparoscopy. Presacral neurectomy may be performed at the time of this laparoscopy.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
2/14/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
5/28/2002: Code Reference section completed, ICD-9 procedure code 05.24 added, ICD-9 diagnosis code 617.0-617.9, 625.0, 625.3, 625.9 added
6/23/2004: Policy reviewed, Sources updated
8/26/2005: Code Reference section updated, CPT code 58578, 58999 added, ICD-9 procedure code 05.24 deleted, ICD-9 diagnosis code 617.0-617.9, 625.0, 625.3, 625.9 deleted
4/4/2006: Policy name updated
3/30/2009: Policy reviewed, no changes
04/26/2010: Policy description and guidelines updated regarding dysmenorrhea and treatment approaches. Policy statement unchanged. FEP verbiage added to the Policy Exceptions section. Deleted outdated references from the Sources section.
06/13/2011: Policy reviewed; no changes.
04/26/2012: Policy reviewed; no changes.
08/07/2013: Policy reviewed; no changes.
06/13/2014: Policy reviewed; no changes.
07/23/2015: Code Reference section updated for ICD-10.
09/14/2015: Policy reviewed; policy statement unchanged. Investigative definition updated in Policy Guidelines section.
05/27/2016: Policy number A.4.01.17 added.
SOURCE(S)Blue Cross Blue Shield Association policy #4.01.17
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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