Does S9560 require prior authorization?

No, S9560 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for S9560?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`S9560`, Home injectable therapy; hormonal therapy (e.g.; leuprolide, goserelin),

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Daily prospective symptom charting for at least 2 menstrual cycles to confirm luteal-phase confinement of symptoms: "daily symptom charting for at least 2 menstrual cycles (2 periods are studied because of variability between cycles)."
Use of validated rating tools in trials / diagnosis: e.g., Daily Record of Severity of Problems (DRSP) for prospective confirmatory ratings (PMDD trials used 2 consecutive months of DRSP), and symptom scales such as the Zung, Hamilton Depression and Anxiety Rating Scales, Clinical Global Impressions Scale in studies.

Diagnosis confirmation: "An accurate diagnosis of PMS can only be made by confirming that symptoms are confined to the luteal phase of the menstrual cycle."

Diagnostic criteria: PMDD diagnosed per DSM criteria (DSM-IV-TR referenced in studies) and exclusion of current psychiatric comorbidity when appropriate (some studies used the MINI to exclude comorbid conditions).

Documentation of failure of conservative therapy prior to pharmacologic therapy: "Women with PMDD or PMS, who have failed to adequately respond to 2 to 3 months of first-line treatments, may be prescribed medications."

Relevant laboratory tests as clinically indicated: thyroid function measures (e.g., TSH, thyroxine) may be useful to rule out thyroid dysfunction; no routine hormone measurements are recommended for PMS diagnosis.

Key Coverage Criteria

Diagnosis and treatment of pre-menstrual syndrome (PMS) and pre-menstrual dysphoric disorder (PMDD).
Assessment services considered medically necessary for PMS/PMDD: "Gynecological consultation".
Assessment services considered medically necessary for PMS/PMDD: "Medical evaluation (complete medical history and physical examination)".
Assessment services considered medically necessary for PMS/PMDD: "Psychiatric/psychological consultation and testing if the member exhibits mental/nervous symptoms".
Assessment services considered medically necessary for PMS/PMDD: "Thyroid function tests (e.g., thyroid stimulating hormone, thyroxine)".
Treatment services considered medically necessary for PMS/PMDD: "Bilateral oophorectomy for members with severe symptoms when all medical therapy has either failed or produced unacceptable side effects".

7 Active Policies

ANTHEM-CG-MED-23, Home Health

AETNA-CPB-0512, Premenstrual Syndrome and Premenstrual Dysphoric Disorder

AMBETTER-CP.MP.91, Obstetrical Home Care Programs

BCBSIL-RX501.041, Gonadotropin-Releasing Hormone (GnRH) Agonists and Antagonists

BCBSMT-RX501.041, Gonadotropin-Releasing Hormone (GnRH) Agonists and Antagonists

BCBSNM-RX501.041, Gonadotropin-Releasing Hormone (GnRH) Agonists and Antagonists

BCBSOK-RX501.041, Gonadotropin-Releasing Hormone (GnRH) Agonists and Antagonists

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S9560, Home injectable therapy; hormonal therapy (e.g.; leuprolide, goserelin),