Medical Policy Revision: Implantable Testosterone Pellets

Effective June 22, 2015, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for implantable testosterone pellets.

Based on the guidelines of our revised medical policy, Implantable Testosterone Pellets (Testopel® pellets):

• HCPCS code J3145 submitted on claims for services provided on and after June 22, 2015 and after to female patients of any age and to male patients under 18 years of age will be denied as an investigational service.
• Claims for services provided on and after June 22, 2015 and after to male patients 18 years of age and older that include HCPCS code J3145 and one or more of the ICD-9 or ICD-10 diagnosis codes listed below will pend while information required to determine medical appropriateness is requested and reviewed.
  
  ICD-9 diagnosis codes: 253.2, 253.4, 253.7, 257.1, 257.2, 259.0, 259.50, 259.51, 259.52, 604.0, 604.90, 604.91, 604.99, 608.20, 608.21, 608.22, 608.23, 608.24, 608.3, 752.51, 752.52, 759.81, 990, V10.47
  
  ICD-10 diagnosis codes: E23.0, E23.6, E23.1, E89.3, E89.5, E29.1, E30.0, E34.50, E34.51, E34.52, N45.4, N45.2, N45.3, N51, N45.2, N45.3, N44.00, N44.01, N44.02, N50.0, Q53.00, Q53.01, Q53.02, Q53.10, Q53.11, Q53.12, Q53.20, Q53.21, Q53.22, Q53.9, Q55.22, Q87.1, T66.XXXA, Z85.47
• HCPCS code J3145 submitted on claims for services provided on and after June 22, 2015 to male patients 18 years of age and older that DO NOT also include one of the ICD-9 or ICD-10 diagnosis codes listed above will be denied as an investigational/experimental service.

Review this revised policy in our online Medical Policy Manual.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after June 22, 2015.

TESTOPEL® is a registered trademark of Auxilium Pharmaceuticals, Inc.