N95.0 — Postmenopausal bleeding
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Precertification/authorization documentation including Statement of Medical Necessity (SMN) forms as required by Aetna (contact precertification at phone (866) 752-7021 or fax (888) 267-3277).
- For suspected secondary (hypogonadotropic) hypogonadism: documentation of LH and FSH levels and any additional laboratory tests and/or imaging performed to evaluate etiology (e.g., pituitary imaging, hyperprolactinemia workup, hemochromatosis evaluation) as appropriate.
- For primary hypogonadism of unknown etiology: documentation of karyotype when indicated to rule out Klinefelter's syndrome.
- Monitoring documentation as clinically indicated and per product labeling (PSA, hemoglobin, hematocrit, lipids, assessment for signs of VTE, cardiac/renal/hepatic status, sleep apnea risk).
Key Coverage Criteria
- Primary hypogonadism (congenital or acquired) or hypogonadotropic hypogonadism (congenital or acquired) when ALL of the following criteria are met: member is a biological male or a person that self-identifies as male; member is at least 18 years of age; and member has at least two confirmed low morning serum total testosterone concentrations based on the reference laboratory range or current practice guidelines.
- Gender dysphoria in adults when ALL of the following are met: member has a diagnosis of gender dysphoria; member is able to make an informed decision to engage in hormone therapy; member's comorbid conditions are reasonably controlled; member has been educated on any contraindications and side effects to therapy; and member has been informed of fertility preservation options.
- Gender dysphoria in an adolescent when ALL of the following are met: member has a diagnosis of gender dysphoria; member is able to make an informed decision to engage in hormone therapy; member has reached Tanner stage 2 of puberty or greater; member’s comorbid conditions are reasonably controlled; member has been educated on any contraindications and side effects to therapy; and member has been informed of fertility preservation options.
- Continuation/reauthorization for primary hypogonadism or hypogonadotropic hypogonadism when ALL of the following are met: member is a biological male or self-identifies as male; member is at least 18 years of age; and before the start of therapy the member had at least two confirmed low morning serum total testosterone concentrations based on the reference laboratory range or current practice guidelines.
- Continuation/reauthorization for gender dysphoria in adults when ALL of the following are met: member has a diagnosis of gender dysphoria; member is able to make an informed decision to engage in hormone therapy; member’s comorbid conditions are reasonably controlled; member has been educated on contraindications and side effects; and before the start of therapy the member has been informed of fertility preservation options.
- Continuation/reauthorization for gender dysphoria in adolescent members when ALL of the following are met: member has a diagnosis of gender dysphoria; member is able to make an informed decision to engage in hormone therapy; member has previously reached Tanner stage 2 of puberty or greater; member’s comorbid conditions are reasonably controlled; member has been educated on contraindications and side effects; and before the start of therapy the member has been informed of fertility preservation [...]
8 Active Policies
AETNA-CPB-0091 — Endometrial Ablation
AETNA-CPB-0304 — Fibroid Treatment
AETNA-CPB-0327 — Infertility
AETNA-CPB-0345 — Implantable Hormone Pellets
AETNA-CPB-0528 — Testosterone Undecanoate Injection (Aveed)
Related Codes
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