Mountain State Medical Policy Bulletin
Section: Injections
Number: I-17
Topic: Terbutaline Therapy (Subcutaneous) for Preterm Labor
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 07/2005

General Policy Guidelines

Indications and Limitations of Coverage

Traditional options for management of patients experiencing preterm labor (644.0, 644.00, 644.03) include: (1) long term intravenous tocolytic therapy in the hospital, and (2) the administration of oral tocolytics at home, usually ritodrine or terbutaline. However, some patients may either fail to respond to the medications given orally, or require the medication more frequently than every four hours. For these patients, physicians may prescribe tocolytic therapy to be delivered by a portable infusion pump for at-home use.

Tocolytic therapy (J3105), delivered subcutaneously by a portable infusion pump for at-home use in the management of preterm labor is experimental/investigational. This therapy does not have FDA approval and scientific evidence does not demonstrate that safety and efficacy have been proven. Therefore, it is not eligible for payment.

NOTE:
See Medical Policy Bulletin E-17 for guidelines on the portable external infusion pump.

NOTE:
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.

Procedure Codes

J3105     

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Effective January 1, 2004, Tocolytic Therapy will be covered under Maternity Care Benefits. Tocolytic Therapy and related services are covered if administered through IV or subcutaneous infusion. The services must be provided and billed by a Home Infusion or Home Health Care provider and are subject to the visit maximum.

Note: Oral Tocolytic Therapy is not a covered service.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

PRN References

02/1998, Terbutaline therapy coverage limited

References

Terbutaline Sulfate, USPDI-Vol. I, Edition 21, 2001, Micromedex, Inc.

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Glossary




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.