CurrentCignaPolicy 0587

Open Neuroplasty of the Lumbar Plexus (Coverage Criteria)

Defines Cigna coverage criteria for open surgical neuroplasty (CPT 64714) of the lumbar plexus for members whose plans follow this policy; applies to providers submitting claims for that procedure.

Policy Summary

PayerCigna

PolicyOpen Neuroplasty of the Lumbar Plexus (Coverage Criteria)

Policy CodePolicy 0587

Change TypeNew policy

Effective DateDec 1, 2025

Next Review Date

Key ActionObtain prior authorization and submit claims with the appropriate covered code(s) (CPT 64714) and required clinical documentation demonstrating nerve compression and prior conservative therapy failure.

SourceLink

POLICY UPDATE CHANGES

New coverage policy for open neuroplasty of the lumbar plexus (CPT 64714) effective 12/1/2025.

1CPT code specifically addressed

12/1/2025Effective date

1New coverage policy

173Patients in literature review

Coverage Criteria for Open Neuroplasty of the Lumbar Plexus

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Medically Necessary Criteria

Open Neuroplasty Lumbar Plexus is considered medically necessary when ALL of the following are met:

Documented nerve compression of the lumbar plexus demonstrated by imaging or electrodiagnostic testing (MRI, CT, EMG/NCS, US) causing significant symptoms.

supported by diagnostic modalities listed in policy

Conservative therapy failure or not indicated: Conservative treatments (i.e., physical therapy, oral medications, injection-based treatment) have failed or are not indicated (e.g., acute trauma).

policy lists examples of conservative treatments

Imaging and clinical correlation: Imaging and clinical findings support surgical intervention.

clinical and imaging concordance required

Open neuroplasty of the lumbar plexus is not medically necessary for any other indication beyond documented lumbar plexus compression meeting the policy criteria. Examples of excluded indications include, but are not limited to, routine lumbar spine decompression procedures that do not document focal lumbar plexus compression by imaging or electrodiagnostic testing.

Procedures performed for indications other than documented lumbar plexus compression that meet the stated criteria are considered not medically necessary. For example, routine lumbar spine decompression or similar spine procedures performed without documented lumbar plexus nerve compression (by MRI, CT, EMG/NCS, or ultrasound) and without failed or contraindicated conservative therapy are not covered under this policy.

Coding

Considered Medically Necessary when criteria metCPTCovered

64714

Neuroplasty, major peripheral nerve, arm, or leg, open; lumbar plexus

Code applicability date (as of 12/1/2025)

Effective date for code useUse the most appropriate codes as of the policy effective date: 12/1/2025.

Primary covered CPT code64714 — Neuroplasty, major peripheral nerve, arm, or leg, open; lumbar plexus (covered when criteria met)

Coding maintenance noteCode list may not be all‑inclusive; AMA and CMS updates may occur more frequently than policy updates.

Deleted/ineffective codesDeleted codes or codes not effective at the time of service may not be eligible for reimbursement.

Provider Actions and Requirements

Prior Authorization

Prior authorization and coding requirement (CPT 64714)

Prior authorization is required when submitting claims for CPT 64714; providers must submit services with the appropriate covered code(s).

Use the most appropriate codes as of the effective date of the submission.
Claims submitted for services that are not accompanied by covered code(s) will be denied as not covered.

Step Therapy

Conservative therapy failure required

Conservative treatments (physical therapy, oral medications, injection-based treatment) must have failed prior to open neuroplasty or be documented as not indicated (for example, acute trauma).

Document trials of conservative therapies and outcomes or document why such therapies are not indicated.

Documentation Required

Required clinical documentation for medical necessity

Documented nerve compression of the lumbar plexus must be demonstrated by imaging or electrodiagnostic testing (MRI, CT, EMG/NCS, or ultrasound) and prior conservative treatment (or why it was not indicated) must be recorded in the medical record.

Include imaging or electrodiagnostic reports (MRI, CT, EMG/NCS, US) showing nerve compression.
Record prior conservative treatment attempts or clinical justification for omission.

Denial Risk

Denial risk for unsupported codes or indications

Claims submitted without a covered code (e.g., not billed as CPT 64714 when applicable) or for services that do not meet the policy's medical necessity criteria will be denied as not covered.

Deleted or ineffective codes at the time of service may not be eligible for reimbursement.
Ensure the billing code matches the procedure and that documentation supports the criteria in the policy.

Definitions

Open Neuroplasty — lumbar plexus (CPT 64714) definition and scope

Procedure term and CPTOpen neuroplasty of the lumbar plexus — CPT 64714.

Procedure definitionDirect open surgical neuroplasty to decompress the lumbar plexus by addressing scar tissue, adhesions, or other compressive factors to relieve nerve pressure.

Indications/goalIntended for symptomatic nerve compression (pain, muscle weakness, functional impairment) of the lumbar plexus that has not responded to conservative treatments.

Anatomic scopeTargets the lumbar plexus (anterior rami of L1–L4, occasionally T12) to restore nerve function and improve mobility and pain.

Diagnostic requirementsDocumentation of nerve compression via imaging or electrodiagnostic testing (MRI, CT, EMG/NCS, ultrasound) and clinical–imaging correlation required by policy.

Background

The lumbar plexus is a network of nerves formed primarily by the anterior rami of L1–L4 (and sometimes contributions from T12) that supplies sensory and motor innervation to the lower abdomen, thigh, and medial leg. Lumbosacral plexopathies can produce asymmetric focal weakness, numbness, dysesthesia, or paresthesia across contiguous nerve distributions.

Open neuroplasty of the lumbar plexus (CPT 64714) is a direct open surgical procedure intended to decompress the lumbar plexus by addressing scar tissue, adhesions, or other compressive factors when conservative measures have failed or are not indicated. Clinical evaluation of suspected lumbar plexus compression typically includes neuroimaging (MRI or CT) and electrodiagnostic testing (EMG/NCS), with clinical and imaging findings correlated to support the need for surgical intervention.