Premenstrual Syndrome/Premenstrual Dysphoric Disorder — CPB 0512 | AETNA Coverage Update

Aetna modified CPB 0512 covering PMS and PMDD diagnosis and treatment, effective September 26, 2025. Here's what billing teams need to do.

Aetna, a CVS Health company, updated its coverage policy for premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) under CPB 0512 Aetna's clinical policy bulletin system. This update affects a wide range of codes — from surgical procedures like CPT 58661 (laparoscopic removal of adnexal structures) and CPT 58940 (oophorectomy) to diagnostic codes like CPT 84443 (thyroid stimulating hormone) and psychiatric evaluation codes CPT 90791 and 90792. If your practice bills any of these for Aetna members, the September 26, 2025 effective date is the line in the sand.

Quick-Reference Table

Aetna PMS and PMDD Coverage Criteria and Medical Necessity Requirements 2025

The core framework of the Aetna PMS and PMDD coverage policy is that services are covered when they are medically necessary for the diagnosis or treatment of PMS or PMDD. That sounds straightforward. It isn't.

The phrase "if selection criteria are met" appears across the majority of the covered code groups in CPB 0512. Aetna does not cover these services on diagnosis alone. Aetna requires that selection criteria be met for covered codes — the specific criteria are defined in the full CPB 0512 policy text. Verify the current criteria directly at the policy source before finalizing documentation templates.

For surgical interventions like CPT 58661 (laparoscopic adnexal structure removal) or CPT 58940 (oophorectomy), the documentation bar is high. For laboratory work like CPT 84436 (thyroxine total), CPT 84439 (free thyroxine), and CPT 84443 (TSH), document the clinical rationale for ordering per CPB 0512 requirements.

The psychiatric and psychological evaluation codes — CPT 90791, 90792, 96130, 96131, 96136, 96137, 96138, 96139, and 96146 — fall under the same selection criteria requirement. Providers ordering these for PMDD workups need to document why the evaluation was clinically indicated and how it supports the diagnosis or treatment plan.

Prior authorization requirements for this policy are not explicitly detailed in the modified CPB 0512 summary. For surgical procedures in particular — especially oophorectomy and hysterectomy — assume prior auth is required and verify with Aetna before scheduling. A missed prior authorization on a CPT 58940 or CPT 58570 claim is a predictable claim denial that documentation alone won't fix.

Aetna PMS and PMDD Exclusions and Non-Covered Indications

The policy groups certain codes — including open hysterectomy codes (CPT 58150 through 58210 and CPT 58260) and laparoscopic hysterectomy codes (CPT 58570 through 58573) — under a group labeled with references to vestibular stimulation, plasma leptin, and measurement of serum. This is where the policy gets confusing.

These codes appear in a separate group within CPB 0512. The policy source data does not define what this grouping means for coverage status. Verify directly with Aetna and review the full policy text before billing these codes for PMS/PMDD indications.

The real issue here is that the group label is ambiguous. If your practice performs hysterectomies for PMDD, talk to your compliance officer before the effective date. You need a clear read on whether Aetna will consider these covered under CPB 0512 — and that conversation shouldn't happen after a denial.

Coverage Indications at a Glance

Aetna PMS and PMDD Billing Guidelines and Action Items 2025

The modified CPB 0512 affects a wide swath of specialties. OB/GYN, psychiatry, behavioral health, and lab all have skin in this game. Here's what to do before September 26, 2025.

CPT, HCPCS, and ICD-10 Codes for PMS/PMDD Under CPB 0512

Covered CPT Codes (When Selection Criteria Are Met)

Descriptions for CPT 96130, 96131, 96136, and 96137 are drawn from AMA CPT conventions. The source policy data contains truncated descriptions for these codes. Verify the complete descriptions against the AMA CPT code set and the CPB 0512 policy source before billing.

Codes in Separate Policy Group (Coverage Status Unconfirmed — Verify Before Billing)

These codes appear in CPB 0512 under a separate group. The policy source data does not define what this grouping means for coverage status. Verify directly with Aetna and review the full policy text before billing these codes for PMS/PMDD indications.

Note: The open hysterectomy codes present in the policy data run CPT 58150 through 58210 and CPT 58260. These are not a continuous range through 58260. Verify each specific code against Aetna's provider portal for current coverage status under CPB 0512.

HCPCS Codes

CPB 0512 includes 19 HCPCS codes. Code details were not available in the policy summary data — verify the complete HCPCS code list directly at the CPB 0512 policy source before billing.

Key ICD-10-CM Diagnosis Codes

The policy data lists two ICD-10-CM codes. Aetna did not provide descriptions for these codes in the policy data. Confirm the specific codes directly at the CPB 0512 policy source and map them to your charge capture before September 26, 2025.