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Medical Policy: 04.01.10
Original Effective Date: June 2008
Reviewed: September 2011
Revised:
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
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 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 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.”
Uterine nerve ablation and presacral neurectomy are 2 laparoscopic surgical approaches that have been investigated as techniques to interrupt the majority of the cervical sensory nerve fibers in patients with dysmenorrhea. Uterine nerve ablation involves the transection of the uterosacral ligaments at their insertion into the cervix, while presacral neurectomy involves the removal of the presacral nerves lying within the interiliac triangle. Presacral neurectomy interrupts a greater number of nerve pathways compared to laparoscopic uterine nerve ablation (LUNA), and is technically more demanding. Either LUNA or presacral neurectomy can be performed as adjuncts to conservative surgical therapy in patients with secondary dysmenorrhea.
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Prior Approval:
Not applicable
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Policy:
Laparoscopic uterine nerve ablation (LUNA) and presacral neurectomy are considered investigational as techniques to treat primary or secondary dysmenorrhea.
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Procedure Codes and Billing Guidelines:
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To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
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58578 Unlisted laparoscopy procedure, uterus
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Selected References:
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Zullo F, Palomba S, Zupi E et al. Effectiveness of presacral neurectomy in women with severe dysmenorrhea casued 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):5-10.
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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.
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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):310-19.
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Gambone JC, Mittman BS, Munro MG et al. Consensus statement for the management of chronic pelvic pain and endometriosis: proceeding of an expert-panel consensus process. Fertil Steril 2002; 78(5):961-72.
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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.
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ECRI Institute. Plymouth Meeting (PA). Laparoscopic Uterosacral Nerve Ablation for Dysmenorrhea. Hotline Response. 2008 March 12.
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Nezhat C, Morozov V. Robot-assisted laparoscopic presacral neurectomy: feasibility, techniques, and operative outcomes. J Minim Invasive Gynecol. 2010 Jul-Aug; 17(4):508-12.
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Policy History:
Date Reason Action
September 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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