Prior Authorization Required for Specified Procedures/Devices

Prior authorization is required for neurostimulation device procedures and related implantation/revision codes listed below. Submit a preauthorization request when considering spinal or dorsal root ganglion neuromodulation for chronic pelvic pain.

• Prior authorization required for CPT codes: 63650, 63655, 63663, 63664, 63685, 63688, 95970, 95971.
• Prior authorization recommended for HCPCS/CPT codes related to neurolytic procedures of pelvic plexuses (e.g., 64680, 64681).

Prior Authorization Likely for DRGS and Advanced Neuromodulation

Dorsal root ganglion stimulation (DRGS) and other advanced neuromodulation approaches for chronic pelvic pain frequently require prior authorization; coverage is limited and clinical evidence is evolving. Consider case-by-case review for patients refractory to conservative care.

• DRGS candidates should have documentation of failure of conservative therapies and multidisciplinary evaluation.
• Preauthorization likely for sacral or DRG neuromodulation procedures (implantation, revision, generator placement).

Denial Risk — Experimental / Investigational Procedures

Procedures identified as experimental or investigational are not covered. Expect denial when these are billed for chronic pelvic pain or endometriosis because effectiveness has not been established.

• Claims for DRGS, hypogastric plexus neurolysis, peritoneal excision (stripping) for endometriosis, UNA/LUNA, and PSN may be denied as experimental/investigational.
• Deny when submitted evidence does not meet medical necessity or when the procedure is explicitly labeled experimental in policy.

Denial Risk — Procedures with Limited Evidence

Certain nerve-dividing surgeries and presacral neurectomy have limited and inconsistent evidence of benefit; these procedures carry a higher denial risk when used for chronic pelvic pain or endometriosis.

• Presacral neurectomy (PN/PSN) and other nerve‑dividing procedures may be denied or require strong supporting documentation due to limited evidence and potential harms (e.g., postoperative constipation).
• Peritoneal excision (stripping) for endometriosis may be considered in select circumstances but is not uniformly supported; review clinical details carefully.

Coding and Documentation Guidance

Provide complete coding and operative details to facilitate review. When billing for neuromodulation or neurolytic procedures, include the specific CPT/HCPCS codes, device model (if applicable), and relation to pelvic pain diagnosis.

• Include CPT codes: 63650, 63655, 63663, 63664, 63685, 63688, 95970, 95971, 64680, 64681 where applicable.
• If there is no specific code (e.g., UNA/LUNA/PSN), clearly describe the procedure performed, operative approach, and rationale; consider unlisted procedure coding with operative report attached.

Required Supporting Clinical Documentation for Prior Authorization

Preauthorization and medical necessity reviews require detailed supporting documentation showing a stepwise treatment approach and failure of conservative therapies before advanced or surgical interventions.

• Document trial and failure of conservative medical therapy (NSAIDs, oral contraceptives, progestins, GnRH analogs, other second‑line pharmacologics) with dates and response.
• Document non‑surgical interventions attempted: pelvic floor physical therapy, behavioral therapy, other modalities and duration.
• Provide multidisciplinary evaluation notes (gynecology, pain management, physical therapy, psychiatry/psychology as indicated).
• Include pain diary, imaging (ultrasound), laparoscopy findings if performed, and prior operative reports when applicable.

Stepwise Care and Step Therapy Preference for Conservative Treatments

Conservative medical therapy and stepwise care are expected before surgical options. Prior authorization reviews will assess whether less invasive treatments were tried and documented.

• Stepwise care should include first-line treatments: NSAIDs and hormonal therapy (oral contraceptives) for endometriosis.
• Second-line pharmacologic trials (danazol, GnRH analogs, aromatase inhibitors) and documented response or intolerance are expected prior to considering surgery/neuromodulation.
• Pelvic floor physical therapy and behavioral interventions should be trialed when indicated.
• Hysterectomy considered only after failed conservative measures and when clinically appropriate.