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ICD-10-CM N94.5, Secondary dysmenorrhea | No Prior Auth

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`N94.5`, Secondary dysmenorrhea

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Documentation of prior treatments and rationale for EMDR (e.g., prior unsuccessful or inadequate trials of guideline-recommended therapies when applicable)
Evidence of therapist training / qualification in EMDR (background states training is considered mandatory for appropriate use) and competence to deliver EMDR protocol
For special-population uses (e.g., comorbid SUD, psychosis), documentation that inclusion/exclusion criteria and safety monitoring were considered (e.g., exclusion of acute suicidality, psychosis in some trials)
When EMDR is used as adjunctive therapy, documentation of concurrent 'treatment as usual' modalities and how EMDR integrates with ongoing care

Key Coverage Criteria

Rheumatoid arthritis pain (studied comparison vs guided imagery)
Primary dysmenorrhea (protocols exist to study EMDR effects)
Anxiety disorders (including general anxiety, specific phobia, panic)
Obsessive-compulsive disorder (EMDR vs CBT compared in RCTs)
Bipolar disorder — affective relapse prevention (trauma-focused EMDR study protocol)
Borderline personality disorder (case report of phase-oriented EMDR)

2 Active Policies

AETNA-CPB-0583, Eye Movement Desensitization and Reprocessing (EMDR) Therapy

REGENCE-SUR218, Hysterectomy

Related Codes

G89.29(2 policies)N94.6(2 policies)N94.4(2 policies)58180(1 policies)58267(1 policies)58270(1 policies)58262(1 policies)58275(1 policies)

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None specified in this document chunk; the text is a list of references and does not include required medical record, diagnostic, or clinical documentation instructions.

No other explicit documentation requirements are stated in the provided excerpt.