E28.310 — Symptomatic premature menopause
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical record documentation must demonstrate that the patient cannot tolerate oral bisphosphonates or that oral bisphosphonates are medically contraindicated (including documentation of severe esophagitis when applicable).
- If inability to tolerate oral ibandronate is claimed, include appropriate intolerance/interaction codes (T50.995A-T50.995S, Y63.8, Z91.89, or Z92.89) in the documentation and claims as applicable.
- For hypercalcemia of malignancy (E83.52), document the clinical rationale for ibandronate use and the specific related malignancy in the patient record.
- For osteoporosis as a transplant complication, include the related transplant complication code plus T50.995A-T50.995S or Z87.19 to justify intravenous therapy.
Key Coverage Criteria
- Intravenous ibandronate sodium is reasonable and necessary only for patients for whom bisphosphonate therapy (including oral ibandronate) is medically indicated and who cannot tolerate oral therapy or have a medical contraindication to oral bisphosphonates.
- Use for osteoporosis (including senile or other osteoporosis) is covered when oral bisphosphonate therapy is indicated but cannot be used due to intolerance or contraindication.
- Ibandronate sodium may be used for management of hypercalcemia of malignancy when the medical record documents the rationale for use and the related malignancy.
- Ibandronate sodium may be used for osteoporosis that is a complication of transplant when the claim includes the related complication-of-transplant code and documentation of inability to tolerate oral bisphosphonates.
- Bone mass measurement tests are covered when ordered by the treating physician or a qualified non-physician practitioner authorized by state law.
- An initial bone mass measurement is covered (Medicare reimbursement for an initial bone mass measurement may be allowed only once, regardless of sites studied).
14 Active Policies
L33394 — Drugs and Biologicals, Coverage of, for Label and Off-Label Uses
J06
A52421 — Billing and Coding: Ibandronate Sodium
J06
AETNA-CPB-0608 — Salivary Tests
AETNA-CPB-0763 — Homocysteine Testing
AETNA-CPB-0787 — Comparative Genomic Hybridization (CGH)
Related Codes
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