J1072, Injection, testosterone cypionate (azmiro), 1 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- The patient's medical record must document medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
- A claim submitted without a valid ICD‑10‑CM diagnosis code that best describes the condition will be returned as an incomplete claim under §1833(e) of the Social Security Act.
- For diagnostic tests, report the test result if known on the claim; if result is not known, report the symptoms that prompted the test.
Key Coverage Criteria
- Medicare may cover injectable testosterone pellets (Testopel) for males when used for an FDA‑approved indication and when the service meets Medicare coverage requirements in CMS Medicare Benefit Policy Manual, Chapter 15, §50.4.3.
- Injectable testosterone pellet therapy may be used when alternative accepted routes (transdermal, oral, nasal, intramuscular) are clinically inappropriate or insufficient and medical necessity is documented.
- Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
- Injectable testosterone and Testopel (testosterone pellets) are proven for replacement therapy in conditions associated with a deficiency or absence of endogenous testosterone, including primary hypogonadism (congenital or acquired) and hypogonadotropic hypogonadism (congenital or acquired).
- Injectable testosterone and Testopel (testosterone pellets) are medically necessary for replacement therapy in conditions associated with a deficiency or absence of endogenous testosterone, including primary hypogonadism (congenital or acquired) and hypogonadotropic hypogonadism (congenital or acquired), when the following criteria are met (see policy for detailed criteria).
- Replacement therapy following bilateral orchiectomy.
12 Active Policies
PALMETTO-JJ-L39086, Treatment of Males with Low Testosterone
JJ
PALMETTO-JM-L39086, Treatment of Males with Low Testosterone
JM
UHC-POL-testosterone-replacement-supp-therapy, Testosterone Replacement or Supplementation Therapy
BCBSIL-RX501.076, Testosterone Replacement Therapies
BCBSMT-RX501.076
Related Codes
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