J3145, Injection, testosterone undecanoate, 1 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Documentation Required
- This billing and coding guidance must be used in conjunction with the associated Local Coverage Determination (LCD).
- 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.
- Medical record documentation supporting services within the related LCD must be available to Medicare upon request.
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.
- 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.
17 Active Policies
NORIDIAN-L36538, Treatment of Males with Low Testosterone
JF
PALMETTO-JJ-L39086, Treatment of Males with Low Testosterone
JJ
PALMETTO-JM-L39086, Treatment of Males with Low Testosterone
JM
AETNA-CPB-0788, Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments
BCBSIL-SUR717.001, Gender Assignment Surgery and Gender Reassignment Surgery with Related Services
BCBSIL-RX501.076, Testosterone Replacement Therapies
BCBSMT-SUR717.001, Gender Assignment Surgery and Gender Reassignment Surgery with Related Services
BCBSMT-RX501.076, Testosterone Replacement Therapies
BCBSNM-SUR717.001, Gender Assignment Surgery and Gender Reassignment Surgery with Related Services
BCBSNM-RX501.076, Testosterone Replacement Therapies
BCBSOK-RX501.076, Testosterone Replacement Therapies
UMR-POL-UMR-testosterone-replacement-supp-therapy, Testosterone Replacement or Supplementation Therapy
SUREST-POL-SUREST-testosterone-replacement-supp-therapy, Testosterone Replacement or Supplementation Therapy
A57615, Billing and Coding: Treatment of Males with Low Testosterone
BCBSOK-SUR717.001, Gender Assignment Surgery and Gender Reassignment Surgery with Related Services
A58828, Billing and Coding: Treatment of Males with Low Testosterone
UHC-POL-testosterone-replacement-supp-therapy, Testosterone Replacement or Supplementation Therapy
Related Codes
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