Chronic Pelvic Pain, Endometriosis, and Other Indications: Selected Treatments (CPB 0754, reviewed 2025-10-30)
Effective date
Not stated in the notice
Identified
Aug 15, 2026
Summary
Cannabinoids, hypnotherapy, hypogastric plexus neurolysis for chronic pelvic pain associated with endometriosis, neuromodulation (dorsal root ganglion stimulation, posterior tibial nerve stimulation, sacral nerve stimulation, and spinal cord stimulation), peritoneal excision (stripping) for endometriosis, superior hypogastric plexus block with traditional pharmacological treatments, and uterine nerve ablation, laparoscopic uterine nerve ablation and presacral neurectomy for chronic pelvic pain or other indications are considered experimental, investigational, or unproven because their effectiveness has not been established. The policy lists CPT codes not covered for the indications it lists, including neurostimulator implantation, revision, removal and programming codes, superior hypogastric plexus injection code 64517, and hypnotherapy code 90880, along with ICD-10 diagnosis codes not covered for those indications. Peritoneal excision (stripping) has no specific code in this policy.
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01Billing team: Do not bill the services this policy lists as experimental, investigational, or unproven for chronic pelvic pain or endometriosis, which are cannabinoids, hypnotherapy, hypogastric plexus neurolysis for chronic pelvic pain associated with endometriosis, neuromodulation (dorsal root ganglion, posterior tibial nerve, sacral nerve and spinal cord stimulation), peritoneal excision (stripping) for endometriosis, superior hypogastric plexus block with traditional pharmacological treatments, and uterine nerve ablation, laparoscopic uterine nerve ablation and presacral neurectomy for chronic pelvic pain or other indications.
02The CPT codes listed in this policy are not covered for the indications it lists, and the listed ICD-10 diagnosis codes are not covered for those indications.
03Peritoneal excision (stripping) has no specific code, and HCPCS code C1886 is listed as related to this policy.
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