S0189 — Testosterone pellet, 75 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- 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.
Key Coverage Criteria
- 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
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