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ICD-10-CM N94.810, Vulvar vestibulitis | No Prior Auth

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`N94.810`, Vulvar vestibulitis

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Chronic sialorrhea — documentation member is refractory to pharmacotherapy (e.g., anticholinergics).
Anal fissures — documentation of failure to first-line therapy such as topical calcium channel blockers or topical nitrates.
Hirschsprung disease with internal sphincter achalasia — documentation that treatment is after endorectal pull-through and refractory to laxative therapy.
Services are covered 'if selection criteria are met' — documentation should demonstrate that the applicable selection criteria (as referenced in the policy) are met for the specific product and indication.

Key Coverage Criteria

OnabotulinumtoxinA (Botox) medically necessary indications (initial approval): Achalasia — Treatment of achalasia when the member has tried and failed or is a poor candidate for conventional therapy such as pneumatic dilation and surgical myotomy.
Botulinum toxin type A has become 1st-line therapy for Frey's syndrome.
Botulinum toxin type A therapy for blepharospasm
Botulinum toxin for chronic low back pain
Botulinum toxin for Raynaud's phenomenon / ischemic digits
Botulinum toxin for temporomandibular disorders

3 Active Policies

AETNA-CPB-0113, Botulinum Toxin

AETNA-CPB-0735, Pulsed Radiofrequency

AETNA-CPB-0759, Vulvodynia and Vulvar Vestibulitis Treatments

Related Codes

N94.819(3 policies)M72.2(2 policies)L74.510(2 policies)M54.2(2 policies)M54.6(2 policies)M54.81(2 policies)M53.3(2 policies)M54.59(2 policies)

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Precertification: Providers must obtain precertification for botulinum toxin; call (866) 752-7021 or fax (888) 267-3277; use Statement of Medical Necessity (SMN) precertification forms (Specialty Pharmacy Precertification).

Prior therapy and trial documentation required where specified: e.g., chronic migraine — documentation of headaches 15+ days/month with 4+ hour duration on ≥8 days/month; documentation of an adequate trial (or contraindication) of two oral migraine preventative therapies from at least 2 classes with a trial of each medication at least 60 days in duration; documentation of benefit (reduction in monthly headache frequency) for continuation.