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AetnaAll Plans · Coverage · Medical Policy · OB-GYN, PsychiatryMedium impact

Premenstrual Syndrome and Premenstrual Dysphoric Disorder (CPB 0512, reviewed 2026-08-05)

Effective date
Not stated in the notice
Identified
Aug 13, 2026

Summary

Aetna's Clinical Policy Bulletin 0512 considers gynecological consultation, a medical evaluation with complete medical history and physical examination, thyroid function tests, cognitive behavioral therapy and bilateral oophorectomy medically necessary for premenstrual syndrome and premenstrual dysphoric disorder, with oophorectomy reserved for severe symptoms when all medical therapy has failed or produced unacceptable side effects. Psychiatric or psychological consultation and testing are medically necessary when the member exhibits mental or nervous symptoms. The policy lists acupuncture, aromatherapy, light therapy, intravenous magnesium, intravenous vitamin B6 and vitamin E, reflexology, vestibular stimulation, endometrial ablation, and several laboratory and neuroimaging tests as experimental, investigational or unproven.

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What to do

Action · 8 steps
01Before billing PMS or PMDD services, document the symptom pattern, since the policy says an accurate diagnosis can only be made by confirming that symptoms are confined to the luteal phase of the menstrual cycle, and daily symptom charting for at least two menstrual cycles can aid this.
02Psychiatric and psychological consultation and testing are not necessary unless the patient exhibits mental or nervous symptoms, so bill those services only when that documentation is present.
03Use ICD-10 F32.81 for premenstrual dysphoric disorder or N94.3 for premenstrual tension syndrome, since these are the codes the policy lists as covered if selection criteria are met.
04Bill oophorectomy (CPT 58940, or 58661 for partial or total oophorectomy) only for members with severe symptoms when all medical therapy has either failed or produced unacceptable side effects.
05Psychotherapy codes 90832 through 90838 and psychological testing codes 96130 through 96146 are listed as covered if selection criteria are met.
06Do not bill the services the policy lists as experimental, investigational or unproven as medically necessary, including acupuncture, aromatherapy, light therapy, intravenous magnesium, intravenous vitamin B6 or vitamin E, vestibular stimulation, reflexology, endometrial ablation, neuroimaging, and the listed laboratory tests.
07HCPCS codes A4633 and E0691 through E0694 are not covered for the indications in this policy, and J3415 and J3475 are listed as not covered.
08For self-administered medications such as diuretics, oral contraceptives and selective serotonin reuptake inhibitors, refer to the member's pharmacy benefit plan.

Codes mentioned

586615894084436844398444390791907929083290833908349083690837908389613096131961369613796138961399614658353583565856370554705558218082306823108253082533826078260882652826778267982725827268274682747835408373584100841058420784252842558442584446845908459184597846308815595923969009781097814S9560A4633E0691E0692E0693E0694J3415J3475F32.81N94.3

Original notice

Premenstrual Syndrome and Premenstrual Dysphoric Disorder (CPB 0512, reviewed 2026-08-05)
aetna.com · Always check the source before changing claims.
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Related policy hubs

Aetna policiesOB-GYNPsychiatryCode 58661Code 58940Code 84436Code 84439Code 84443Code 90791Code 90792Code 90832Code 90833Code 90834Code 90836Code 90837Code 90838Code 96130Code 96131Code 96136Code 96137Code 96138Code 96139Code 96146Code 58353Code 58356Code 58563Code 70554Code 70555Code 82180Code 82306Code 82310Code 82530Code 82533Code 82607Code 82608Code 82652Code 82677Code 82679Code 82725Code 82726Code 82746Code 82747Code 83540Code 83735Code 84100Code 84105Code 84207Code 84252Code 84255Code 84425Code 84446Code 84590Code 84591Code 84597Code 84630Code 88155Code 95923Code 96900Code 97810Code 97814Code S9560Code A4633Code E0691Code E0692Code E0693Code E0694Code J3415Code J3475Code F32.81Code N94.3

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