Does N94.6 require prior authorization?

No, N94.6 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`N94.6`, Dysmenorrhea, unspecified

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

Documentation that the patient's diagnosis meets one of the covered indications (e.g., chronic neck pain or chronic headache with minimum 12 weeks duration where applicable).
Documentation of duration of symptoms when chronicity is required (policy explicitly requires minimum 12 weeks duration for chronic neck pain and chronic headache).
Documentation of clinical response: if no clinical benefit after four weeks of acupuncture, the treatment plan should be reevaluated; further treatment is not medically necessary if the member does not demonstrate meaningful improvement in symptoms.
Provider credentialing/license documentation showing the acupuncture is administered by a health care provider practicing within the scope of his/her license (and, where applicable by specific plans, documentation that provider is a legally qualified physician practicing within scope of license).

Key Coverage Criteria

Plantar Fasciitis
Peptic Ulcer
Post-Operative Ileus
Post-Prandial Distress Syndrome
Post-Stroke Shoulder Pain
Premature Ejaculation

8 Active Policies

CIGNA-0013, Endometrial Ablation

ANTHEM-CG-LAB-20, Thyroid Testing

AETNA-CPB-0107, Chiropractic Services

AETNA-CPB-0135, Acupuncture and Dry Needling

AETNA-CPB-0345, Implantable Hormone Pellets

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N94.6, Dysmenorrhea, unspecified