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.
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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 performi ng 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 not meeting the criteria as indicated in this policy are considered experimental/investigational.
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Procedure Codes
11980 S0189
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