J7301 — Levonorgestrel-releasing intrauterine contraceptive system (skyla), 13.5 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
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage (refer to Medical Records Documentation Used for Reviews).
- For medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures, Hysteroscopy, Operative (for endometrial ablation) and InterQual® CP: Procedures, Uterine Artery Embolization (UAE).
- Recommendations prior to UFE treatment include an endometrial biopsy to rule out malignancy or hyperplasia.
- Preoperative evaluation should include risk stratification and use of imaging, cervical cancer screening, and endometrial tissue sampling to identify malignancy (per ACOG guidance).
Key Coverage Criteria
- Endometrial ablation is proven and medically necessary for treating abnormal uterine bleeding in premenopausal individuals.
- Levonorgestrel-releasing intrauterine devices (LNG-IUD) (e.g., Mirena®, Skyla®, Liletta™, Kyleena™) are proven and medically necessary for treating menorrhagia.
- Uterine artery embolization (UAE) is proven and medically necessary for treating symptomatic uterine fibroids, postpartum or post hysterectomy bleeding, or uterine arteriovenous malformation (AVM).
- Uterine fibroid embolization (UFE) is indicated for individuals with clinically documented fibroids and fibroid-related symptoms and is a viable alternative to hysterectomy surgery.
- Certain intrauterine devices are included in the preventive care services benefit (where applicable by plan document).
- LNG-IUD is covered when used for a non-contraceptive purpose, including treatment of abnormal uterine bleeding (in plans that exclude contraceptive use).
5 Active Policies
CIGNA-A004 — Preventive Care Services - (A004)
UHC-POL-abnormal-uterine-bleeding-uterine-fibroids — Abnormal Uterine Bleeding and Uterine Fibroids
AETNA-CPB-0510 — Progestins
UMR-POL-UMR-abnormal-uterine-bleeding-uterine-fibroids — Abnormal Uterine Bleeding and Uterine Fibroids
SUREST-POL-SUREST-abnormal-uterine-bleeding-uterine-fibroids
Related Codes
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