Does 58940 require prior authorization?

No, 58940 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 58940?

Medicare facility rate: $515.38. Non-facility rate: $515.38. Work RVU: 8.01.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

8.01

Facility

$515.38

Non-Facility

$515.38

Daily prospective symptom charting for at least 2 menstrual cycles to confirm luteal-phase confinement of symptoms: "daily symptom charting for at least 2 menstrual cycles (2 periods are studied because of variability between cycles)."
Use of validated rating tools in trials / diagnosis: e.g., Daily Record of Severity of Problems (DRSP) for prospective confirmatory ratings (PMDD trials used 2 consecutive months of DRSP), and symptom scales such as the Zung, Hamilton Depression and Anxiety Rating Scales, Clinical Global Impressions Scale in studies.
Diagnosis confirmation: "An accurate diagnosis of PMS can only be made by confirming that symptoms are confined to the luteal phase of the menstrual cycle."
Diagnostic criteria: PMDD diagnosed per DSM criteria (DSM-IV-TR referenced in studies) and exclusion of current psychiatric comorbidity when appropriate (some studies used the MINI to exclude comorbid conditions).

Diagnosis and treatment of pre-menstrual syndrome (PMS) and pre-menstrual dysphoric disorder (PMDD).
Assessment services considered medically necessary for PMS/PMDD: "Gynecological consultation".
Assessment services considered medically necessary for PMS/PMDD: "Medical evaluation (complete medical history and physical examination)".
Assessment services considered medically necessary for PMS/PMDD: "Psychiatric/psychological consultation and testing if the member exhibits mental/nervous symptoms".
Assessment services considered medically necessary for PMS/PMDD: "Thyroid function tests (e.g., thyroid stimulating hormone, thyroxine)".
Treatment services considered medically necessary for PMS/PMDD: "Bilateral oophorectomy for members with severe symptoms when all medical therapy has either failed or produced unacceptable side effects".

AMBETTER-CP.MP.95 — Gender-Affirming Procedures

AETNA-CPB-0512 — Premenstrual Syndrome and Premenstrual Dysphoric Disorder

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