J1120 — Injection, acetazolamide sodium, up to 500 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- 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).
Key Coverage Criteria
- 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".
1 Active Policy
AETNA-CPB-0512 — Premenstrual Syndrome and Premenstrual Dysphoric Disorder
Related Codes
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