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Date Printed: October 23, 2017: 02:18 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

09-J0000-60

Original Effective Date: 06/15/00

Reviewed: 08/14/13

Revised: 07/01/17

Subject: Contraceptive Drugs

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Contraception, or birth control, is the means by which the male or female can utilize methods that will prevent pregnancy. Such methods include oral contraceptives and medroxyprogesterone containing agents (i.e., Depo-Provera®) that are injected. Oral contraceptives (birth control pills) are medications that prevent pregnancy. They are one method of birth control. Oral contraceptives are hormonal preparations that may contain combinations of the hormones estrogen and progestin or progestin alone. Combinations of estrogen and progestin prevent pregnancy by inhibiting the release of the hormones luteinizing hormone (LH) and follicle stimulating hormone (FSH) from the pituitary gland in the brain. LH and FSH play key roles in the development of the egg and preparation of the lining of the uterus for implantation of the embryo. Progestin also makes the uterine mucus that surrounds the egg more difficult for sperm to penetrate and, therefore, for fertilization to take place. In some women, progestin inhibits ovulation (release of the egg).

DEPO-PROVERA Contraceptive Injection (CI) contains medroxyprogesterone acetate, a derivative of progesterone, as its active ingredient. Depo-Provera®, when administered at the recommended dose to women every 3 months, inhibits the secretion of gonadotropins which, in turn, prevents follicular maturation and ovulation and results in endometrial thinning. These actions produce its contraceptive effect.

POSITION STATEMENT:

Benefits vary by contract. Some contracts may exclude benefits for all or some methods of birth control.

Contraceptive drugs may be eligible for coverage when used for treatment of the following medical conditions:

Medroxyprogesterone acetate meets the definition of medical necessity when administered for the following Orphan Drug Indication (http://www.fda.gov/orphan/designat/list.htm):

PRECAUTIONS:

Contraindications

Levonorgestrel contraceptive injection

Medroxyprogesterone acetate contraceptive injection:

Oral contraceptives should not be used in women who currently have the following conditions.

Warnings:

Levonorgestrel contraceptive injection

Medroxyprogesterone acetate contraceptive injection:

Oral Contraceptives:

BILLING/CODING INFORMATION:

HCPCS Coding:

J2675

Injection, progesterone, per 50 mg

J3490

Unclassified drug (for Depo-Provera, Depo-SubQ Provera ONLY)

Q9984

Levonorgestrel-releasing intrauterine contraceptive system (Kyleena), 19.5 mg

S4993

Contraceptive pills for birth control

ICD-10 Diagnoses Codes That Support Medical Necessity for contraceptives used for non-contraceptive indications:

D39.0

Neoplasm of uncertain behavior of uterus

D69.3

Immune thrombocytopenic purpura

D69.42

Congenital and hereditary thrombocytopenia purpura

E28.2

Polycystic ovarian syndrome

E28.8

Other ovarian dysfunction

L85.0

Acquired ichthyosis

L85.1

Acquired keratosis [keratoderma] palmaris et plantaris

L87.0

Keratosis follicularis et parafollicularis in cutem penetrans

M81.0

Age-related osteoporosis without current pathological fracture

N80.0

Endometriosis of uterus

N80.1

Endometriosis of ovary

N80.2

Endometriosis of fallopian tube

N80.3

Endometriosis of pelvic peritoneum

N80.4

Endometriosis of rectovaginal septum and vagina

N80.5

Endometriosis of intestine

N80.6

Endometriosis in cutaneous scar

N80.8

Other endometriosis

N80.9

Endometriosis, unspecified

N83.0

Follicular cyst of ovary

N83.00

Follicular cyst of ovary, unspecified side

N83.01

Follicular cyst of right ovary

N83.02

Follicular cyst of left ovary

N91.2

Amenorrhea, unspecified

N91.5

Oligomenorrhea, unspecified

N92.0

Excessive and frequent menstruation with regular cycle

N92.2

Excessive menstruation at puberty

N92.3

Ovulation bleeding

N92.4

Excessive bleeding in the premenopausal period

N92.5

Other specified irregular menstruation

N93.8

Other specified abnormal uterine and vaginal bleeding

N94.6

Dysmenorrhea, unspecified

N95.0

Postmenopausal bleeding

N95.1

Menopausal and female climacteric states

Q55.4

Other congenital malformations of vas deferens, epididymis, seminal vesicles and prostate

Q96.9

Turner's syndrome, unspecified

Y04.8XXA

Assault by other bodily force, initial encounter

REIMBURSEMENT INFORMATION:

Refer to the section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products: No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline revised date.

Medicare Part D: Florida Blue has delegated to Prime Therapeutics authority to make coverage determinations for the Medicare Part D services referenced in this guideline.

DEFINITIONS:

Amenorrhea: absence of menstruation or stoppage of the menses; also called amenia.

Dysmenorrhea: painful menstruation.

Endometriosis: benign condition where endometrial tissue is present outside the uterine cavity.

Hirsutism: abnormal hair-growth, especially an adult male pattern of hair distribution in women.

Menorrhagia: excessive menstrual bleeding.

Polycystic ovary syndrome (PCOS): a mild hormone imbalance that can cause irregular periods, unwanted hair growth, and acne. This is a common condition that begins during the teenage years.

Postcoital: following sexual intercourse between a male and female.

Subcutaneous: beneath the skin.

Turner's syndrome: an endocrine disorder in which amenorrhea is an indication in girls.

RELATED GUIDELINES:

None applicable.

OTHER:

None applicable.

REFERENCES:

  1. American College of Obstetricians and Gynecologists, News Release, Contraception-A Basic Health Necessity: Affordable Access Needed for All Women, 05/08/07.
  2. Arowojulu AO, Gallo MF, Lopez LM et al. Combined oral contraceptives pills for treatment of acne. Cochrane Database System Review 2009:CD004425.
  3. Kyleena (levonorgestrel-releasing intrauterine system). Prescribing information. Accessed 9/19/16.
  4. Clinical Pharmacology. Copyright® 2013 Elsevier. Accessed 07/11/13.
  5. Depo-Provera CI prescribing information. Revised 4/2012.
  6. Diagnosis and management of polycystic ovarian syndrome. National Guideline Clearinghouse. Accessed October 2011.
  7. DrugDex®, (Accessed 07/11/13).
  8. Facts & Comparisons® E Answers. Accessed 09/30/11.
  9. Grimes, David A MD, et al. The Contraception Report Volume 14, No. 4, 02/04.
  10. Ingenex, HCPCS Level II Coding, 2013 Expert.
  11. Ingenex, ICD-9-CM for Physicians-Volumes 1 & 2, Expert 2013
  12. Kaunitz AM. Oral contraceptive use in perimenopause. Am J Obstet Gynecol. 2001 Aug;185(2 Suppl):S32-7.
  13. NCCN Drugs and Biologics Compendium (NCCN Compendium®). Accessed 07/11/13.
  14. Van Vliet HAAM, Grimes DA, Helmerhorst FM, Schulz KF. Biphasic versus monophasic oral contraceptives for contraception. Art. No.: CD002032. DOI: 10.2002/14651858.CD002032.pub2. 05/15/06.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Pharmacy Policy Committee on 10/11/16.

GUIDELINE UPDATE INFORMATION:

06/15/00

New Medical Coverage Guideline.

04/01/02

Quarterly HCPCS code update.

06/15/02

Reviewed; added information regarding Mirena® contraceptive systems; revise name of policy.

07/15/02

Additional procedure codes added.

01/01/03

HCPCS coding update.

02/15/03

Description section revised to include “contraceptive patches”.

06/15/04

Scheduled review; no change in coverage statement. Additional related procedure codes added.

01/01/06

HCPCS update, deleted A4260, added new code J7306.

07/01/06

Updated MCG number from 09-A9140-09 to 09-J0000-60.

09/15/06

Biennial review, updated references.

12/15/06

Revised: added new implantable rod called Implanon® and added new HCPCS code S0180.

07/15/07

Reviewed guideline: Reformatted guideline, maintain current coverage and limitations, added the word “medical” to conditions that may be covered, updated links and updated references.

01/01/08

Annual coding update. Added HCPCS code J7307 and removed S0180.

08/15/09

Review and revision to guideline; consisting of review of literature, added menorrhagia as a covered diagnosis and definition, updated description section, removal of devices and changed name of guideline.

12/15/10

Review and revision to guideline; consisting of updating coding, update references and added Acne, recalcitrant (resistant to treatment) and Perimenopausal symptoms as covered diagnoses.

12/15/11

Review and revision to guideline; consisting of updating references.

12/15/12

Review and revision to guideline; consisting of revising position statement to include premenstrual dysphoric disorder, updating references.

01/01/13

Annual HCPCS Update; added HCPCS code J1050, removed J1055 and J1056

09/15/13

Review and revision to guideline; consisting of updating position statement, precautions, references, program exceptions, and coding.

11/01/15

Revision: ICD-9 Codes deleted.

11/15/16

Revision to guideline; consisting of revising contraindications, precautions/warnings, coding.

07/01/17

Addition of HCPCS code Q9984.

Date Printed: October 23, 2017: 02:18 AM