J1073 — Testosterone pellet, implant, 75 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
- Documentation of diagnosis of hypogonadism (or other documented condition associated with deficiency/absence of endogenous testosterone) and supporting clinical notes.
- For primary hypogonadism/hypogonadotropic hypogonadism: either two pre-treatment early morning serum total testosterone levels less than 300 ng/dL (<10.4 nmol/L) or less than the reference range for the lab, taken at separate times; OR when a condition that may alter sex-hormone binding globulin (SHBG) is present, one pre-treatment calculated free or bioavailable testosterone level less than 50 pg/mL (<5 ng/dL or <0.17 nmol/L) or less than the reference range for the lab.
- When patient is currently on testosterone therapy, documentation that one of the following is present: (a) Follow-up calculated free or bioavailable testosterone level, drawn within the past 6 months for patients new to testosterone therapy (on therapy <1 year), or within 12 months for patients continuing testosterone therapy (on therapy ≥1 year), is within or below the normal male limits of the reporting lab; OR (b) Follow-up calculated free or bioavailable testosterone level (same timing) is outside of upper male limits of normal for the reporting lab and the dose is adjusted.
Key Coverage Criteria
- 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.
- Replacement therapy for patients with panhypopituitarism.
- Replacement therapy for genetic disorders known to cause hypogonadism (e.g., congenital anorchia, Klinefelter's syndrome).
- Replacement therapy when documentation shows either: (a) two pre-treatment early morning serum total testosterone levels less than 300 ng/dL (<10.4 nmol/L) or less than the reference range for the lab, taken at separate times; OR (b) when SHBG‑altering condition present, one pre-treatment calculated free or bioavailable testosterone level less than 50 pg/mL (<5 ng/dL or <0.17 nmol/L) or less than the reference range for the lab.
3 Active Policies
UHC-POL-testosterone-replacement-supp-therapy — Testosterone Replacement or Supplementation Therapy
UMR-POL-UMR-testosterone-replacement-supp-therapy — Testosterone Replacement or Supplementation Therapy
SUREST-POL-SUREST-testosterone-replacement-supp-therapy — Testosterone Replacement or Supplementation Therapy
Related Codes
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