Does S0189 require prior authorization?

No, S0189 does not require prior authorization (high confidence). Code is covered without prior authorization.

`S0189`, Testosterone pellet, 75 mg

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Before the start of testosterone therapy for primary or hypogonadotropic hypogonadism: at least two confirmed low morning testosterone levels according to current practice guidelines or the laboratory's standard reference values.
One fasting total serum testosterone level is sufficient for persons with severe deficiency (less than 150 ng/dL).
Testosterone levels should not be measured during acute or subacute illness.
Two consecutive low total (free plus protein-bound) fasting serum testosterone levels (below the testing laboratory's normal reference range or below 300 ng/dL) are required to determine medical necessity of testosterone replacement.

Covered ICD-10 diagnoses if selection criteria are met: E23.0 (Hypopituitarism [hypogonadotropic hypogonadism]), E29.1 (Testicular hypofunction [primary]), E30.0 (Delayed puberty), F64.0 - F64.9 (Gender identity disorders), Z87.890 (Personal history of sex reassignment)
Delayed male puberty
CPT/HCPCS: CPT 11980 (Subcutaneous hormone pellet implantation) is covered for testosterone only if selection criteria are met; HCPCS S0189 (Testosterone pellet, 75 mg) covered if selection criteria are met.
Gender dysphoria when all of the following are met: The member has a diagnosis of gender dysphoria; and The member is able to make an informed decision to engage in hormone therapy; and The member's comorbid conditions are reasonably controlled; and The member has been educated on any contraindications and side effects to therapy; and Before the start of therapy, the member has been informed of fertility preservation options; and For members less than 18 years of age, this medication will be pre [...]
Primary or hypogonadotropic hypogonadism, when the following criteria are met: Before the start of testosterone therapy, the member has at least two confirmed low morning testosterone levels according to current practice guidelines or your standard lab reference values
For continuation of testosterone therapy: before the member started testosterone therapy, the member had a confirmed low morning testosterone level according to current practice guidelines or your standard lab reference values

AETNA-CPB-0345, Implantable Hormone Pellets

AETNA-CPB-0457, Dry Eyes

RX501.007, Hormone Replacement Therapies (HRT) Using Implanted Pellets for Women and Delayed Puberty

BCBSIL-SUR717.001, Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

BCBSIL-RX501.007, Hormone Replacement Therapies (HRT) Using Implanted Pellets for Women and Delayed Puberty

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