Diagnosis Codes
Not applicable to this policy
Professional Statements and Societal Positions Guidelines
ND Committee Review
Internal Medical Policy Committee 9-21-2022 - Effective October 1, 2020
Internal Medical Policy Committee 9-21-2022 - Annual Review, no clinical content change
Internal Medical Policy Committee 3-23-2022 - Effective May 1, 2022
- Updated E/I statement
- Updated Professional Statements and Societal Positions Section
Internal Medical Policy Committee 3-23-2023 - Annual Review, no clinical content change
Internal Medical Policy Committee 5-23-2023 - Effective April 7, 2023
- Updated policy to make Makena (hydroxyprogesterone caproate) always experimental/investigational due to the FDA withdrawal of approval of Makena which occurred on April 6, 2023.
- Removed J1729 from the criteria
- Added Note concerning J1729