11976
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
1.74
Facility
$80.16
Non-Facility
$146.63
Documentation Required
- For Nexplanon insertion/removal: documentation that insertion and planned removal will follow labeled duration (removed by end of 3rd year) and adherence to label contraindications/warnings.
- For intramuscular 17-OHPC regimens: documentation of dosing schedule and gestational age at treatment initiation (policy/guideline references: 250 mg intramuscularly weekly, preferably starting at 16–20 weeks and continuing through 36 weeks).
- For contraceptive coverage (Depo-Provera, implants, IUDs): documentation that the member's plan covers contraceptive drugs/devices when required (policy text: Depo-Provera coverage limited to plans that specifically cover contraceptive drugs/devices).
- For implants (Implanon/Nexplanon) and IUDs: documentation of informed consent and screening for contraindications (pregnancy test when appropriate; history of breast cancer or other progestin-sensitive cancers; liver disease; undiagnosed abnormal genital bleeding).
Key Coverage Criteria
- Etonogestrel Subdermal Implant: "Aetna considers etonogestrel subdermal implant (Nexplanon) medically necessary for the prevention of pregnancy."
- Medroxyprogesterone Acetate Injection (Depo-Provera CI or generic formulation 150 mg/mL): "Aetna considers Depo-Provera CI or generic formulation 150 mg/mL medically necessary for the following indications: Prevention of pregnancy."
- Medroxyprogesterone Acetate Injection for Gender Dysphoria: "Gender dysphoria when all of the following are met: The member is able to make an informed decision to engage in hormone therapy; and The member has a diagnosis of gender dysphoria; and The member's comorbid conditions are reasonably controlled; and The member has been educated on any contraindications and side effects to therapy; and If the member is less than 18 years of age, the requested medication will be prescribed by or in consu [...]
- Depo-Provera 400 mg/mL: "Aetna considers Depo-Provera 400 mg/mL medically necessary as adjunctive therapy and palliative treatment of inoperable, recurrent, and metastatic endometrial or renal carcinoma."
- Implanon (etonogestrel implant) — single-rod progestogen-only contraceptive implant; long-acting (up to 3 years), reversible contraceptive method.
- Levonorgestrel-releasing intrauterine systems (examples: Mirena, Kyleena, Skyla, Liletta) — contraceptive devices indicated for prevention of pregnancy (durations vary by product: Mirena up to 5 years; Skyla up to 3 years; Liletta up to 3 years; Kyleena up to 5 years).
1 Active Policy
AETNA-CPB-0510 — Progestins
Related Codes
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