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Contraceptive Management

Section: Visits
Effective Date: May 15, 2019
Revised Date: May 08, 2019

Description

Contraceptive management refers to the use of reversible methods of contraception such as contraceptive devices, implants, medications, injections, and related services (e.g., insertion/removal of an implant or IUD) for the prevention of pregnancy. Sterilization and abortion procedures are not considered to be contraceptive management services. 

Criteria

Coverage is subject to the specific terms of the member's benefit plan. 

Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website. 

When contraceptive management services are provided solely for contraceptive purposes, eligibility is determined according to specific individual or group customer benefits. 

There are some instances where a contraceptive device, implant, medication or injection may be used to treat a medical condition, (e.g., Depo-Provera for treatment of endometriosis, or an IUD for treatment of menorrhagia). When provided for treatment of medical conditions, and not solely for contraceptive purposes, contraceptive devices, implants, medications, injections and related services are covered in accordance with the member's contractual benefits. 

When a benefit, coverage for contraceptive devices, implants, medications, injections, and related services for non-contraceptive uses (i.e., medical uses) will be limited to those medical conditions listed in the "Diagnosis Codes" section. 

When contraceptive devices, implants, medications, injections and related services are provided for medical conditions other than those listed in the "Diagnosis Codes" section of this policy, it is considered as a non-covered service. 

Procedure Codes

11976 11981 11982 11983 57170
58300 58301 A4261 A4266 J1050
J7296 J7297 J7298 J7300 J7301
J7303 J7304 J7306 J7307 S4981
S4989 S4993

Diagnosis Codes 

E23.6 E28.1 E28.2 E28.8 E28.39
E28.310 E28.319 E89.40 E89.41 N80.0
N80.1 N80.2 N80.3 N80.4 N80.5
N80.6 N80.8 N80.9 N83.00 N83.01
N83.02 N83.10 N83.11 N83.12 N83.201
N83.202 N83.209 N83.291 N83.292 N83.299
N89.7 N91.0 N91.1 N91.2 N91.3
N91.4  N91.5 N92.0 N92.1 N92.2
N92.3 N92.4 N92.5 N92.6 N93.8
N94.3 N94.4 N94.5 N94.6 N94.89
N95.0 N98.1

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