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Implantable Hormone Replacement Pellets

Section: Surgery
Effective Date: February 01, 2020
Revised Date: January 27, 2020
Last Reviewed: January 22, 2020

Description

Hormone replacement therapy (HRT) using formulas in subcutaneously implantable pellet form is an alternative to hormone therapy by injection or oral ingestion. Pellets are implanted in the physician’s office and release their contents over a period of months.

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.

Subcutaneous testosterone pellets may be considered medically necessary when there is documented failure or contraindication to other topical, oral, and injectable HRT and ONE of the following conditions:

  • Treatment of primary hypogonadism (congenital or acquired) due to testicular failure from conditions such as cryptorchidism, bilateral torsions, orchitis, vanishing testis syndrome, orchiectomy, Klinefelter syndrome, chemotherapy, or toxic damage from alcohol or heavy metals and who have documented testosterone deficiency as defined by ONE of the following:
    • A low total testosterone level, below the normal range as defined by the laboratory performing the test; or
    • A total testosterone level near the lower limit of the normal range and a low free testosterone level which is less than normal based upon the laboratory reference range; or
  • Treatment of hypogonadotropic hypogonadism (congenital or acquired) due to Idiopathic gonadotropin or luteinizing hormone-releasing hormone (LHRH) deficiency, pituitary-hypothalamic injury from tumors, trauma, radiation and who have documented testosterone deficiency as defined by ONE of the following:
    • A low total testosterone level, below the normal range as defined by the laboratory performing the test; or
    • A total testosterone level near the lower limit of the normal range and a low free testosterone level which is less than normal based upon the laboratory reference range; or
  • Delayed puberty in males greater than 14 years of age with either physical or laboratory evidence of hypogonadism as defined by ONE of the following:
    • A low total testosterone level, below the normal range as defined by the laboratory performing the test; or
    • A total testosterone level near the lower limit of the normal range and a low free testosterone level which is less than normal based upon the laboratory reference range.

Subcutaneous testosterone pellets as a treatment for menopausal symptoms and/or reduced libido or any other indications not listed above are considered experimental/investigational and therefore non-covered. Scientific evidence of safety and efficacy has not been proven.

Procedure Codes

11980S0189

Subcutaneous pellets composed of estradiol, estrogen, or estrogen in combination with testosterone are considered experimental/investigational and, therefore, non-covered. Scientific evidence of safety and efficacy has not been proven.

Procedure Codes

11980

Diagnosis Codes

Covered diagnosis codes for 11980 and S0189

E23.0E23.6E29.1E30.0E89.5

Professional Statements and Societal Positions Guidelines

NA

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