N94.0 — Mittelschmerz
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- None specified in the CPB. (The document does not list explicit medical record, test result, or clinical documentation requirements for coverage or for investigational determinations.)
- For embryo transfer guidance: documentation that US guidance was used during embryo transfer and catheter type if relevant (policy notes trials that compared US-guided transfer with clinical touch and catheter type can affect outcomes).
- For cervical length screening: gestational age at measurement; measured cervical length and documentation of follow-up TV-US if cervical length is less than 25 mm (policy: "Women with cervical length less than 25 mm at 14 to 28 weeks should undergo a subsequent transvaginal ultrasound to confirm this finding").
- For monitoring hereditary risk of ovarian cancer: documentation of high-risk status (policy example: "Transvaginal ultrasound may be medically necessary for monitoring women with Lynch II syndrome (BRCA2 mutation) for ovarian cancer").
Key Coverage Criteria
- Endometriosis
- None explicitly listed as covered in this CPB. The policy identifies the following procedures as experimental and investigational (i.e., effectiveness not established and thus not supported by this policy): dorsal root ganglion stimulation; hypogastric plexus neurolysis for the treatment of chronic pelvic pain associated with endometriosis; peritoneal excision (stripping) for the treatment of endometriosis; uterine nerve ablation (UNA), laparoscopic uterine nerve ablation (LUNA) and presacral n [...]
- Other indications related to pelvic pain addressed by selected treatments (policy scope: selected treatments for chronic pelvic pain, endometriosis, and other indications)
- Evaluation of abnormal uterine bleeding;
- Evaluation of congenital uterine anomalies;
- Evaluation of infertility;
2 Active Policies
AETNA-CPB-0530 — Transvaginal Ultrasonography
AETNA-CPB-0754 — Chronic Pelvic Pain, Endometriosis, and Other Indications: Selected Treatments
Related Codes
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