N94.9 — Unspecified condition associated with female genital organs and menstrual cycle
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- No specific documentation requirements, prior authorization, or required medical records/test results are specified in this policy bulletin.
- Note: External guidance cited (NICE 2007) recommends use only in research settings (controlled trials, closely observed case series and/or contribution to a register), which would imply research documentation if used in that context, but Aetna's CPB itself does not list documentation requirements.
- 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.)
- Karyotype or chromosomal testing results on products of conception (POC) when cytogenetic evaluation is performed; for POC testing laboratories should document sample source and maternal cell contamination assessment when applicable (studies discuss MCC and methods to detect it).
Key Coverage Criteria
- None — Aetna considers Grenz ray therapy experimental and investigational for the treatment of dermatologic conditions because there is inadequate evidence in the published peer-reviewed medical literature regarding the effectiveness of Grenz ray therapy in the treatment of skin disorders.
- 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)
- H1299R Factor V (FV) variant (rs1800595): pooled analysis showed the variant was “slightly associated with RPL albeit without significance … demonstrated that there is no clear association between the FV H1299R variant and RPL.” (Capra et al, 2022) — indicating limited/uncertain utility of testing.
- Maternal ApoE genotyping: “ε4 allele was found to confer an increased risk of RPL compared to the ε3 allele … Subgroup analysis ... revealed that these associations were restricted to the Asian population.” (Cargnin et al, 2023) — suggesting possible relevance of ApoE genotyping in Asian women.
5 Active Policies
AMBETTER-CP.MP.97 — Testing for Select Genitourinary Conditions
AETNA-CPB-0231 — Grenz Ray Therapy for Skin Disorders
AETNA-CPB-0348 — Recurrent Pregnancy Loss
AETNA-CPB-0530 — Transvaginal Ultrasonography
AETNA-CPB-0754 — Chronic Pelvic Pain, Endometriosis, and Other Indications: Selected Treatments
Related Codes
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