Aetna clinical policy bulletin 0805 considers pudendal nerve decompression experimental, investigational, or unproven for indications including chronic pelvic pain, interstitial cystitis, penile numbness and erectile dysfunction, persistent genital arousal disorder, pudendal neuralgia, and vulvodynia. The policy also considers pudendal nerve hydrodissection for chronic pelvic pain syndrome and urinary incontinence, and pudendal neurolysis for persistent genital arousal disorder and pudendal nerve entrapment syndrome, experimental, investigational, or unproven. The policy does not apply to pudendal nerve blocks used in obstetrics and other operative procedures.
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01Billing team: do not bill CPT 64430 (pudendal nerve injection), 64630 (pudendal nerve neurolytic destruction), or 64722 (decompression of unspecified nerve) for the listed indications, because the policy states these codes are not covered for those indications.
02Pudendal nerve hydrodissection has no specific code under this policy.
03Do not report the ICD-10 codes the policy lists as not covered for these indications, including F52.21 and F52.22 (persistent genital arousal disorder), N30.10 and N30.11 (interstitial cystitis), N94.810 to N94.819 (vulvodynia), G57.00 to G57.93 and G58.8 to G58.9 (pudendal nerve entrapment), and R10.2 to R10.24 (chronic pelvic and perineal pain).
04The limitation on pudendal nerve blocks does not apply to obstetric and other operative procedures, so those claims fall outside this policy.
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