N95.1 — Menopausal and female climacteric states
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low 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 services are covered when they meet the clinical indications and medical necessity criteria specified in the related Local Coverage Determination L39268.
- NGS covers leuprolide acetate (LHRH analog) as palliative treatment of advanced breast carcinoma in premenopausal and perimenopausal women.
7 Active Policies
A52421 — Billing and Coding: Ibandronate Sodium
J06
L33394 — Drugs and Biologicals, Coverage of, for Label and Off-Label Uses
J06
AETNA-CPB-0135 — Acupuncture and Dry Needling
CIGNA-0398 — Transvaginal Ultrasound, Non-Obstetrical - (0398)
A59040 — Billing and Coding: Bone Mass Measurement
Related Codes
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