Medical Policy Bulletin

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Section:	Visits
Number:	V-59
Topic:	Contraceptive Management
Effective Date:	January 1, 2009
Issued Date:	January 5, 2009
Date Last Reviewed:	12/2008

General Policy Guidelines

Indications and Limitations of Coverage

Contraceptive management refers to the use of contraceptive devices, implants, medications, injections, and related services (e.g., insertion/removal of an implant or IVD) for the prevention of pregnancy (i.e., birth control). Contraceptive management is determined according to specific individual or group customer benefits. When contraceptive management is not a benefit, a participating, preferred, or network provider can bill the member for the noncovered service.

There are some instances where a contraceptive device, implant, medication or injection may be used to treat a medical condition, (e.g., Depo-Provera for treatment of endometriosis, or an IUD for treatment of menorrhagia). When provided for treatment of medical conditions, and not solely for contraceptive puposes, contracept devices, implants, medicatons, injections and related services are covered in accordance with the member’s contractual benefits.

When a benefit, coverage for contraceptive devices, implants, medications, injections, and related services for non-contraceptive uses (i.e., medical uses) will be limited to the following medical conditions:

253.4    Other anterior pituitary disorders
256.1    Other ovarian hyperfunction
256.2    Postablative ovarian failure
256.31  Premature menopause
256.39  Other ovarian failure
256.4    Polycystic ovaries
256.8    Other ovarian dysfunction
617.0    Endometriosis of uterus
617.1    Endometriosis of ovary
617.2    Endometriosis of fallopian tube
617.3    Endometriosis of pelvic peritoneum
617.4    Endometriosis of rectovaginal septum and vagina
617.5    Endometriosis of intestine
617.6    Endometriosis in scar of skin
617.8    Endometriosis of other specified sites
617.9    Endometriosis, site unspecified
625.3    Dysmenorrhea
625.4    Premenstrual tension syndrome
625.5    Pelvic congestion syndrome
626.0    Absence of menstruation
626.1    Scanty or infrequent menstruation
626.2    Excessive or frequent menstruation
626.3    Puberty bleeding
626.4    Irregular menstrual cycle
626.5    Ovulation bleeding
626.6    Metrorrhagia
626.8    Other (dysfunctional or functional uterine hemorrhage NOS)
627.0    Premenopausal menorrhagia
627.1    Postmenopausal bleeding

When contraceptive devices, implants, medications, injections and related services are provided for medical conditions other than those listed above, a participating, preferred, or network provider can bill the member for the noncovered service.

Description

Contraceptive management refers to the use of contraceptive devices, implants, medications, injections and related services (i.e., insertion/removal of an implant or IUD) for the prevention of pregnancy (i.e., "birth control").

Sterilization and abortion procedures are not considered to be contraceptive management services.

Procedure Codes

11975	11976	11977	57170
58300	58301	A4261	A4266
J1055	J7300	J7302	J7303
J7304	J7306	J7307	S4981
S4989	S4993

Traditional Guidelines

Refer to General Policy Guidelines

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

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Table Attachment

Text Attachment

Procedure Code Attachment

11975 - Insertion, implantable contraceptive capsules

11976 - Removal, implantable contraceptive capsules

11977 - Removal with reinsertion, implantable contraceptive capsules

57170 - Diaphragm or cervical cap fitting with instructions

58300 - Insertion of intrauterine device (IUD)

58301 - Removal of intrauterine device (IUD)

A4261 - Cervical cap for contraceptive use

A4266 - Diaphragm for contraceptive use

J1055 - Injection, medroxyprogesterone acetate for contraceptive use, 150 mg.

J7300 - Intrauterine copper contraceptive

J7302 - Levnorgestrel-releasing intrauterine contraceptive system, 52 mg.

J7303 - Contraceptive supply, hormone containing vaginal ring, each

J7304 - Contraceptive supply, hormone containing patch, each

J7306 - Levnorgestrel (contraceptive) implant system, including implants and supplies

J7307 - Etonogestrel (contraceptive) implant system, including implant and supplies

S4981 - Insertion of levnorgestrel-releasing intrauterine system

S4989 - Contraceptive intrauterine device (e.g., progestacert IUD), including implants and supplies

S4993 - Contraceptive pills for birth control

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.