Prep your pasta: Bring a large pot of salted water to a boil. Cook pasta according to package directions until al dente. Reserve ½ cup of pasta water before draining.
Brown the sausage: While the pasta cooks, heat olive oil in a large skillet over medium-high heat. Add sliced sausage and cook until browned on both sides, about 5-7 minutes. If using raw Italian sausage, remove from casings first and break into chunks while browning.
Add aromatics: Reduce heat to medium and add diced onion to the skillet with the sausage. Cook until onion becomes translucent, about 3-4 minutes. Add minced garlic and red pepper flakes, and cook for another 30 seconds until fragrant.
Make the sauce: Add butter to the skillet and let it melt. Pour in the heavy cream, stirring constantly, and bring to a gentle simmer. Let it cook for 3-4 minutes until it starts to thicken slightly.
Add the cheese: Reduce heat to low and gradually stir in the Parmesan cheese until melted and smooth. Add the mozzarella and stir until incorporated. Season with black pepper and salt to taste.
Combine elements: Add the drained pasta to the sauce, tossing to coat evenly. If the sauce is too thick, add a splash of the reserved pasta water. If adding optional vegetables like spinach or cherry tomatoes, toss them in now and let cook for 1-2 minutes until just wilted or warmed through.
Finish and serve: Garnish with chopped parsley and serve immediately for a stovetop version.