| Printer Friendly Version |
| Section: | Visits |
| Number: | V-59 |
| Topic: | Contraceptive Management |
| Effective Date: | August 2, 2010 |
| Issued Date: | January 17, 2011 |
| Date Last Reviewed: |
Indications and Limitations of Coverage
Contraceptive management refers to the use of reversible methods of contraception such as contraceptive devices, implants, medications, injections, and related services (e.g., insertion/removal of an implant or IUD) for the prevention of pregnancy. Services related to contraceptive management are determined according to specific individual or group customer benefits. When the member does not have coverage for the contraceptive device, implant, medication, injection, or related service, a participating, preferred or network provider can bill the member for the non-covered 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 purposes, contraceptive devices, implants, medications, 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 those medical conditions listed in the "Diagnosis Codes" section. When contraceptive devices, implants, medications, injections and related services are provided for medical conditions other than those listed in the "Diagnosis Codes" section of this policy, a participating, preferred, or network provider can bill the member for the non-covered service. Description Contraceptive management refers to the use of reversible methods of contraception such as contraceptive devices, implants, medications, injections, and related services (e.g., insertion/removal of an implant or IUD) for the prevention of pregnancy. Sterilization and abortion procedures are not considered to be contraceptive management services. |
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| 11975 | 11976 | 11977 | 57170 |
| 58300 | 58301 | A4261 | A4266 |
| J1055 | J7300 | J7302 | J7303 |
| J7304 | J7306 | J7307 | S4981 |
| S4989 | S4993 |
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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. |
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| [Version 004 of V-59] |
| [Version 003 of V-59] |
| [Version 002 of V-59] |
| [Version 001 of V-59] |
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| 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 |
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| 253.4 | 256.1 | 256.2 | 256.31 |
| 256.39 | 256.4 | 256.8 | 617.0 |
| 617.1 | 617.2 | 617.3 | 617.4 |
| 617.5 | 617.6 | 617.8 | 617.9 |
| 625.3 | 625.4 | 625.5 | 626.0 |
| 626.1 | 626.2 | 626.3 | 626.4 |
| 626.5 | 626.6 | 626.8 | 627.0 |
| 627.1 |
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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 Highmark West Virginia 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.
Highmark West Virginia retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark West Virginia. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
