Cigna modified MM 0368 for pelvic denervation procedures — presacral neurectomy (PSN) and laparoscopic uterosacral nerve ablation (LUNA) — effective September 26, 2025. Here's what changes for billing teams.
Cigna Healthcare updated its pelvic denervation coverage policy under MM 0368, covering two surgical interventions for chronic pelvic pain. The two codes in play are CPT 58578 (unlisted laparoscopy procedure, uterus) and CPT 64999 (unlisted procedure, nervous system). Both are unlisted codes — which means your documentation game has to be airtight to avoid a claim denial.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Cigna Healthcare |
| Policy | Pelvic Denervation Procedures — MM 0368 |
| Policy Code | MM 0368 |
| Change Type | Modified |
| Effective Date | September 26, 2025 |
| Impact Level | Medium |
| Specialties Affected | OB/GYN, Gynecologic Surgery, Pain Management, Minimally Invasive Surgery |
| Key Action | Audit claims billed under CPT 58578 and 64999 against updated medical necessity criteria before September 26, 2025 |
Cigna Pelvic Denervation Coverage Criteria and Medical Necessity Requirements 2025
The Cigna pelvic denervation coverage policy under MM 0368 addresses two distinct surgical procedures. Presacral neurectomy (PSN) involves cutting or removing the presacral nerve to interrupt pain signals from the pelvis. Laparoscopic uterosacral nerve ablation (LUNA) destroys the uterosacral ligament nerve fibers via laparoscopy. Both treat chronic pelvic pain, and Cigna treats them identically in terms of coverage status — both are considered medically necessary when the applicable criteria in MM 0368 are met.
Cigna's specific medical necessity criteria are defined within MM 0368 — refer to the full policy document for the complete criteria language. Do not rely on secondary sources or prior policy versions to determine what documentation Cigna requires for either procedure.
Because both procedures bill under unlisted CPT codes — 58578 for LUNA and 64999 for PSN — there is no standard fee schedule rate you can look up. Unlisted CPT codes generally do not have fixed reimbursement values, which means the clinical documentation you submit with the claim carries significant weight. A weak operative report is a weak claim.
While MM 0368 does not specify prior authorization requirements, billing teams should verify PA requirements directly with the applicable Cigna plan before scheduling either procedure. Commercial Cigna plans, Cigna-administered self-insured plans, and Cigna Medicare Advantage products may have different prior authorization pathways.
Cigna Pelvic Denervation Exclusions and Non-Covered Indications
The source policy does not enumerate specific exclusions. Refer to the full MM 0368 policy document for non-covered indications.
What the policy does state is that both CPT 58578 and CPT 64999 are considered medically necessary when the criteria in MM 0368 are met. Claims that don't satisfy those criteria — whatever they specify — are at risk for denial.
The real issue here is that unlisted codes invite manual review by definition. There is no automated adjudication path for CPT 58578 or 64999. Strong, complete documentation is your primary defense on both codes equally.
Coverage Indications at a Glance
| Indication | Procedure | Status | Relevant Codes | Notes |
|---|---|---|---|---|
| Chronic pelvic pain | Presacral Neurectomy (PSN) | Covered when criteria met | CPT 64999 | Medical necessity criteria defined in MM 0368; verify PA requirements with the applicable Cigna plan |
| Chronic pelvic pain | Laparoscopic Uterosacral Nerve Ablation (LUNA) | Covered when criteria met | CPT 58578 | Medical necessity criteria defined in MM 0368; verify PA requirements with the applicable Cigna plan |
Cigna Pelvic Denervation Billing Guidelines and Action Items 2025
Unlisted codes require more from your billing team than standard CPT codes. Here's what to do before and after the September 26, 2025 effective date.
| # | Action Item |
|---|---|
| 1 | Pull all open and pending claims for CPT 58578 and 64999 now. Compare your documentation against the updated MM 0368 criteria. If a claim is pending and the documentation is thin, add a cover letter or medical records before Cigna's reviewer touches it. |
| 2 | Update your charge capture templates for both CPT 58578 and 64999. Flag these codes in your practice management system as requiring additional documentation at the time of charge entry. Don't let them slip through without a documentation check. |
| 3 | Verify prior authorization requirements with each Cigna plan before scheduling. MM 0368 does not specify PA requirements, but PA is common for surgical procedures at this level. Call or use Cigna's provider portal. Do not assume that a prior auth for one Cigna product covers another. Commercial, ASO (administrative services only), and Cigna Medicare Advantage plans may have separate workflows. |
| 4 | Standardize your operative report template for PSN and LUNA. The report must fully support medical necessity as defined in MM 0368. Review the full policy document to confirm exactly what clinical elements Cigna requires. This is the entire basis for reimbursement on an unlisted code. |
| 5 | Separate your PSN and LUNA claims review workflows. PSN (CPT 64999) and LUNA (CPT 58578) are distinct procedures. Track denials for each code separately so you can identify which is generating more claim denial volume and address it at the documentation level. |
| 6 | Loop in your compliance officer if your practice performs high volumes of either procedure. The shift in MM 0368 and the unlisted-code billing structure create real audit exposure. If you're not sure how this coverage policy applies to your payer mix, talk to your compliance officer or billing consultant before September 26, 2025. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Pelvic Denervation Under MM 0368
Covered CPT Codes (When Medical Necessity Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 58578 | CPT | Unlisted laparoscopy procedure, uterus — used for LUNA (laparoscopic uterosacral nerve ablation) |
| 64999 | CPT | Unlisted procedure, nervous system — used for PSN (presacral neurectomy) |
Both codes are considered medically necessary by Cigna when the applicable criteria in MM 0368 are met. Unlisted CPT codes generally do not carry standard fee schedule rates — reimbursement is determined on a case-by-case basis.
No HCPCS Level II codes are listed in this policy.
No ICD-10-CM codes are listed in this policy. Diagnosis code selection should reflect the underlying indication — chronic pelvic pain — using the appropriate ICD-10-CM codes for your patient's documented condition. Work with your clinical team to align diagnosis coding with the medical necessity language in MM 0368.
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