Testosterone pellets are a type of treatment that helps people with low testosterone levels. They’re small implants that release a steady dose of testosterone over several months, which can help with symptoms like low libido and fatigue.
Does Blue Cross Blue Shield cover testosterone pellets? Coverage for testosterone pellets by Blue Cross Blue Shield (BCBS) is subject to specific criteria and conditions. The following details outline the relevant policies, medical necessity requirements, and documentation needed for approval.
Criteria and Conditions for Coverage:
Diagnosis of Hypogonadism: Does Blue Cross Blue Shield cover testosterone pellets?
Yes, when there is an established diagnosis of hypogonadism with androgen deficiency. This diagnosis must be confirmed by persistently low testosterone levels, as demonstrated by:
A baseline, early morning, serum total testosterone level below the testing laboratory’s lower limit of the normal range.
A baseline, early morning, free serum testosterone level below the testing laboratory’s lower limit of the normal range.
A second, early morning, level (either free serum or total testosterone) drawn on a subsequent day to confirm the diagnosis.
Symptoms of Hypogonadism: Does Blue Cross Blue Shield cover testosterone pellets? Yes, if there are symptoms of hypogonadism, including at least one of the following:
Incomplete or delayed sexual development.
Decreased libido.
Decreased spontaneous erections.
Breast discomfort or gynecomastia.
Loss of axillar and/or pubic body hair.
Very small (< 5 mL) or shrinking testes.
Infertility due to low sperm count.
Height loss due to vertebral fractures, low trauma fractures, low bone density.
Hot flushes or sweats.
Trial and Failure of Other Therapies: Does Blue Cross Blue Shield cover testosterone pellets?
Yes, when there is documented failure, contraindication, or intolerance to other topical, oral, and injectable hormone replacement therapies (HRT). This includes:
Trial and failure, contraindication, or intolerance to either generic Depo®-testosterone or generic Delatestryl®.
Specific Conditions: Does Blue Cross Blue Shield cover testosterone pellets? Yes, for specific conditions such as:
Primary hypogonadism (congenital or acquired) due to testicular failure from conditions like cryptorchidism, bilateral torsions, orchitis, vanishing testis syndrome, orchiectomy, Klinefelter syndrome, chemotherapy, or toxic damage from alcohol or heavy metals.
Hypogonadotropic hypogonadism (congenital or acquired) due to idiopathic gonadotropin or luteinizing hormone-releasing hormone (LHRH) deficiency, pituitary-hypothalamic injury from tumors, trauma, or radiation.
Documentation Needed for Approval:
Medical Records: Does Blue Cross Blue Shield cover testosterone pellets?
Yes, with the submission of medical records documenting the diagnosis and symptoms of hypogonadism.
Laboratory Test Results: Does Blue Cross Blue Shield cover testosterone pellets? Yes, with the submission of laboratory test results showing persistently low testosterone levels.
Chart Notes: Does Blue Cross Blue Shield cover testosterone pellets? Yes, with the submission of chart notes and patient-specific documentation supporting the request.
Authorization and Renewal Criteria:
Quantity Limits: Does Blue Cross Blue Shield cover testosterone pellets?
Yes, with quantity limits aligning with FDA-recommended dosing, such as 6 pellets (450 mg) every 3 months.
Authorization Period: Does Blue Cross Blue Shield cover testosterone pellets? Yes, typically for one year at a time.
Renewal Criteria: Does Blue Cross Blue Shield cover testosterone pellets? Yes, with clinical documentation confirming that current criteria are met and that the medication is providing clinical
Blue Cross Blue Shield (BCBS) covers testosterone pellets as a treatment option for individuals with low testosterone levels, but only under specific criteria and conditions.
To be eligible for coverage, patients must have an established diagnosis of hypogonadism with androgen deficiency, confirmed by persistently low testosterone levels and symptoms such as decreased libido, fatigue, or other related issues.
Additionally, patients must have tried and failed other hormone replacement therapies (HRT) or have a contraindication or intolerance to them. Specific conditions like primary or hypogonadotropic hypogonadism may also qualify for coverage.
To obtain approval, patients need to submit medical records documenting their diagnosis and symptoms, laboratory test results showing low testosterone levels, and chart notes supporting the request.
Quantity limits are typically set at 6 pellets (450 mg) every 3 months, and authorization is usually granted for one year at a time, with renewal criteria requiring clinical documentation confirming ongoing eligibility.
In summary, Blue Cross Blue Shield does cover testosterone pellets as a treatment option for individuals meeting specific criteria and conditions, but it’s essential to consult the specific insurance plan for detailed coverage information.