Medical Policy Revision: Implantable Testosterone Pellets (Testopel® Pellets)

Effective December 24, 2015, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for implantable testosterone pellets, testosterone undecanoate injections, testosterone cypionate injections and testosterone enanthate injections.

According to the guidelines of our revised medical policy, Implantable Testosterone Pellets (Testopel® Pellets):

• Implantable testosterone pellets are considered medically necessary as testosterone replacement therapy in men for primary hypogonadism, hypogonadotropic hypogonadism and delayed male puberty when all criteria are met.
  
  Other uses of implantable testosterone pellets are considered investigational including, but not limited to, their use in the treatment of sexual dysfunction in both men (e.g., erectile dysfunction) and women (e.g., decreased libido), post-menopausal symptoms, depression and for the enhancement of athletic performance.
   
• Testosterone undecanoate injection is considered medically necessary as androgen replacement therapy in men ages 18 years or older for primary hypogonadism and hypogonadotropic hypogonadism (congenital or acquired), when all criteria are met.
  
  Other uses of testosterone undecanoate, depo-testosterone, testosterone cypionate and testosterone ethanthate are considered investigational including, but not limited to, their use in the treatment of pediatric patients, sexual dysfunction in both men (e.g., erectile dysfunction) and women (e.g., decreased libido), post-menopausal symptoms, depression and for the enhancement of athletic performance.
   
• Testosterone cypionate injection is considered medically necessary as testosterone replacement therapy in men for primary hypogonadism and hypogonadotropic hypogonadism, when all criteria are met.
  
  Use of testosterone therapy is considered medically necessary as off-label use for the treatment of breast cancer in women and the treatment of delayed puberty in males when all criteria are met.
  
  Other uses of testosterone cypionate are considered investigational including, but not limited to, their use in the treatment of pediatric patients, sexual dysfunction in both men (e.g., erectile dysfunction) and women (e.g., decreased libido), post-menopausal symptoms, depression, and for the enhancement of athletic performance.
   
• Testosterone enanthate injection is considered medically necessary as testosterone replacement therapy in men for primary hypogonadism, hypogonadotropic hypogonadism, treatment of delayed puberty and in women for metastatic mammary cancer, when all criteria are met.
  
  Other uses of testosterone enanthate are considered investigational including, but not limited to, their use in the treatment of pediatric patients, sexual dysfunction in both men (e.g., erectile dysfunction) and women (e.g., decreased libido), post-menopausal symptoms, depression and for the enhancement of athletic performance.

Based on the guidelines included in our revised medical policy, Implantable Testosterone Pellets (Testopel® Pellets), AND the submitted diagnosis or diagnoses code(s):

CPT® code 11980 and/or HCPCS code S0189

• Claims for services provided to male patients on and after December 24, 2015 that include CPT code 11980 and/or HCPCS code S0189 may pend while information required to determine medical necessity is requested and reviewed.
• CPT code 11980 and/or HCPCS code S0189 submitted on claims for services provided to male patients on and after December 24, 2015 may be denied as investigational services.
• CPT code 11980 and/or HCPCS code S0189 submitted on claims for services provided to female patients on and after December 24, 2015 will be denied as investigational services (regardless of the submitted diagnosis).

HCPCS code J3145

• Claims for services provided to male patients ages 18 years and older on and after December 24, 2015 that include HCPCS code J3145 may pend while information required to determine medical necessity is requested and reviewed.
• HCPCS code J3145 submitted on claims for services provided to male patients ages 18 years and older on and after December 24, 2015 may be denied as not medically necessary services.
• HCPCS codeJ3145 submitted on claims for services provided to male patients under 18 years of age and to female patients on and after December 24, 2015 will be denied as investigational services (regardless of the submitted diagnosis).

HCPCS codes J1071 and/or J3121

• HCPCS codes J1071 and/or J3121 submitted on claims for services provided to male patients ages 18 years and older on and after December 24, 2015 may be denied as investigational services.
• HCPCS codes J1071 and/or J3121 submitted on claims for services provided to male patients under 18 years of age on and after December 24, 2015 will be denied as investigational services (regardless of the submitted diagnosis).
• HCPCS codes J1071 and/or J3121 submitted on claims for services provided to female patients on and after December 24, 2015 may be denied as investigational services.

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 December 24, 2015.

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

CPT® is a registered trademark of the American Medical Association.