Payer PolicyActive
Chronic Pelvic Pain, Endometriosis, and Other Indications: Selected Treatments
AETNA-CPB-0754
Aetna
Effective: October 5, 2023
Updated: December 6, 2025
created · Dec 2, 2025
Policy Summary
Aetna considers dorsal root ganglion stimulation; hypogastric plexus neurolysis for endometriosis; peritoneal excision (stripping) for endometriosis; and uterine nerve ablation (UNA), laparoscopic UNA (LUNA), and presacral neurectomy (PSN) experimental/investigational and therefore not covered because effectiveness has not been established. The bulletin lists no covered indications and notes there are no specific CPT codes for UNA/LUNA/PSN.
Coverage Criteria Preview
Key requirements from the full policy
"Endometriosis"
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