Does N95.0 require prior authorization?

No, N95.0 does not require prior authorization (high confidence). Covered without prior authorization.

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`N95.0`, Postmenopausal bleeding

ICD-10-CM

Prior Authorization

No Prior Auth Required

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 [...]

9 Active Policies

ANTHEM-CG-LAB-21, Serum Iron Testing

AETNA-CPB-0091, Endometrial Ablation

AETNA-CPB-0304, Fibroid Treatment

AETNA-CPB-0327, Infertility

AETNA-CPB-0345, Implantable Hormone Pellets

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N95.0, Postmenopausal bleeding