Contraceptive Management

Policy ID: I-9059-009

Effective Date: May 15, 2019

Revised Date: March 06, 2025

Revision Effective Date: April 01, 2025

Last Reviewed: March 11, 2025

Applies To: Commercial Only

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.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Criteria

Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.

When contraceptive management services are provided solely for contraceptive purposes, eligibility is determined according to specific individual or group customer benefits.

When provided for treatment of medical conditions, and not solely for contraceptive purposes, contraceptive devices, implants, medications, injections and related services may be considered medically necessary, including but not limited to:

Acne
Adenomyosis of the uterus
Amenorrhea
- Primary
- Secondary
Androgen excess
Bleeding
- Abnormal uterine and vaginal bleeding
- Due to Fibroids or Polyps
- Excessive bleeding in the premenopausal period
- Ovulation bleeding
- Post-menopausal
Conditions requiring withdrawal bleeding
Corpus luteum cyst of ovary
Dysmenorrhea
- Primary
- Secondary
Endometrial cancer prevention
Endometriosis in cutaneous scar
Endometriosis (including extrapelvic endometriosis)
Follicular cyst of ovary
Hematocolpos
Hirsutism
Hyperlactation
Menstruation
- Excessive and frequent menstruation with irregular cycle
- Excessive and frequent menstruation with regular cycle
- Excessive menstruation at puberty
- Irregular menstruation
Menstrual Migraine
Oligomenorrhea
- Primary
- Secondary
Ovarian cancer prevention
Ovarian conditions
- Hyper-stimulation of ovaries
- Ovarian dysfunction
- Ovarian cyst
- Polycystic ovarian syndrome
- Primary ovarian failure
Pituitary gland disorders
Post-procedural ovarian failure
- Asymptomatic
- Symptomatic
Premature menopause
- Asymptomatic
- Symptomatic
Premenstrual dysphoric disorder
Premenstrual tension syndrome
The individual requires therapy with a contraceptive in conjunction with a drug that is contraindicated in pregnancy in FDA labeling.

When a contraceptive device, implant, medication, injection, or related service is provided for medical conditions other than those listed above, it is considered a non-covered service.

Procedure Codes

11976

11981

11982

11983

57170

58300

58301

A4261

A4266

J1050

J7294

J7295

J7296

J7297

J7298

J7300

J7301

J7304

J7306

J7307

S4981

S4989

S4993

Diagnosis Codes

E236

E281

E282

E28310

E28319

E2839

E288

E289

E301

E8940

E8941

F3281

G43821

G43829

G43831

G43839

L680

L700

L701

L702

L703

L704

L705

L708

L709

N8000

N8001

N8002

N8003

N80101

N80102

N80103

N80109

N80111

N80112

N80113

N80119

N80121

N80122

N80123

N80129

N80201

N80202

N80203

N80209

N80211

N80212

N80213

N80219

N80221

N80222

N80223

N80229

N8030

N80311

N80312

N80319

N80321

N80322

N80329

N80331

N80332

N80333

N80339

N80341

N80342

N80343

N80349

N80351

N80352

N80353

N80359

N80361

N80362

N80363

N80369

N80371

N80372

N80373

N80379

N80381

N80382

N80383

N80389

N80391

N80392

N80399

N803A1

N803A2

N803A3

N803A9

N803B1

N803B2

N803B3

N803B9

N803C1

N803C2

N803C3

N803C9

N8040

N8041

N8042

N8050

N80511

N80512

N80519

N80521

N80522

N80529

N80531

N80532

N80539

N80541

N80542

N80549

N80551

N80552

N80559

N80561

N80562

N80569

N806

N808

N809

N80A0

N80A1

N80A2

N80A41

N80A42

N80A43

N80A49

N80A51

N80A52

N80A53

N80A59

N80A61

N80A62

N80A63

N80A69

N80B1

N80B2

N80B31

N80B32

N80B39

N80B4

N80B5

N80B6

N80C0

N80C10

N80C11

N80C19

N80C2

N80C3

N80C4

N80C9

N80D0

N80D1

N80D2

N80D3

N80D4

N80D5

N80D6

N80D9

N8300

N8301

N8302

N8310

N8311

N8312

N83201

N83202

N83209

N83291

N83292

N83299

N840

N897

N910

N911

N912

N913

N914

N915

N920

N921

N922

N923

N924

N925

N926

N938

N939

N940

N943

N944

N945

N946

N9489

N950

N981

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 5-19-2020 Annual review, update to criteria

Internal Medical Policy Committee 7-22-20

Added Additional criteria and
Added Diagnosis codes

Internal Medical Policy Committee 11-19-2020

Updated pregnancy criteria

Internal Medical Policy Committee 9-21-2021

Added new codes J7294 and J7295 to the policy and
Removed code J7303

Internal Medical Policy Committee 1-20-2022

Minor wording change 'When a contraceptive device, implant, medication, injection, or related service is provided for medical conditions other than those listed above, it is considered as a non-covered service.'

Internal Medical Policy Committee 5-24-2022

Added two additional medical conditions to the policy: endometrial cancer prevention, ovarian cancer prevention

Internal Medical Policy Committee 9-28-2022 - Effective October 01, 2022

Removed Diagnosis codes N80.0, N80.1, N80.2 N80.3, N80.4 and N80.5 and
Added Diagnosis codes N80.00, N80.01, N80.02, N80.101, N80.102, N80.103, N80.109, N80.111, N80.112, N80.113, N80.119, N80.121, N80.122, N80.123, N80.129, N80.201, N80.202, N80.203, N80.209, N80.211, N80.212, N80.213, N80.219, N80.221, N80.222, N80.223, N80.229, N80.30, N80.311, N80.312, N80.319, N80.321, N80.322, N80.329, N80.331, N80.332, N80.333, N80.339, N80.341, N80.342, N80.343, N80.349, N80.351, N80.352, N80.353, N80.359, N80.361, N80.362, N80.363, N80.369, N80.371, N80.372, N80.373, N80.379, N80.381, ,N80.382, N80.383, N80.389, N80.391, N80.392, N80.399, N80.3A1, N80.3A2, N80.3A3, N80.3A9, N80.3B1, N80.3B2, N80.3B3, N80.3B9, N80.3C1, N80.3C2, N80.3C3, N80.3C9, N80.40, N80.41, N80.42, N80.50, N80.511, N80.512, N80.519, N80.521, N80.522, N80.529, N80.531, N80.532, N80.539, N80.541, N80.542, N80.549, N80.551, N80.552, N80.559, N80.561, N80.562, N80.569, N80.A0, N80.A1, N80.A2, N80.A41, N80.A42, N80.A43, N80.A49, N80.A51, N80.A52, N80.A53, N80.A59, N80.A61, N80.A62, N80.A63, and N80.A69

Internal Medical Policy Committee 9-12-2023 Annual review, no clinical content change

Internal Medical Policy Committee 5-14-2024 Effective July 01, 2024

Added hyperlactation to criteria list

Internal Medical Policy Committee 03-11-2025 Effective April 01, 2025

Added Adenomyosis of the uterus to criteria list
Added Diagnosis codes

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: I-9059-008

Effective Date: May 15, 2019

Revised Date: May 08, 2024

Revision Effective Date: July 01, 2024

Last Reviewed: May 14, 2024

Archived Date: March 31, 2025

Applies To: Commercial Only

Description

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

When contraceptive management services are provided solely for contraceptive purposes, eligibility is determined according to specific individual or group customer benefits.

Acne
Amenorrhea
- Primary
- Secondary
Androgen excess
Bleeding
- Abnormal uterine and vaginal bleeding
- Due to Fibroids or Polyps
- Excessive bleeding in the premenopausal period
- Ovulation bleeding
- Post-menopausal
Conditions requiring withdrawal bleeding
Corpus luteum cyst of ovary
Dysmenorrhea
- Primary
- Secondary
Endometrial cancer prevention
Endometriosis in cutaneous scar
Endometriosis of:
- Fallopian Tube
- Intestine
- Ovary
- Pelvic peritoneum
- Rectovaginal septum and vagina
- Uterus
Follicular cyst of ovary
Hematocolpos
Hirsutism
Hyperlactation
Menstruation
- Excessive and frequent menstruation with irregular cycle
- Excessive and frequent menstruation with regular cycle
- Excessive menstruation at puberty
- Irregular menstruation
Menstrual Migraine
Oligomenorrhea
- Primary
- Secondary
Ovarian cancer prevention
Ovarian conditions
- Hyper-stimulation of ovaries
- Ovarian dysfunction
- Ovarian cyst
- Polycystic ovarian syndrome
- Primary ovarian failure
Pituitary gland disorders
Post-procedural ovarian failure
- Asymptomatic
- Symptomatic
Premature menopause
- Asymptomatic
- Symptomatic
Premenstrual dysphoric disorder
Premenstrual tension syndrome
The individual requires therapy with a contraceptive in conjunction with a drug that is contraindicated in pregnancy in FDA labeling.

When a contraceptive device, implant, medication, injection, or related service is provided for medical conditions other than those listed above, it is considered a non-covered service.

Procedure Codes

11976

11981

11982

11983

57170

58300

58301

A4261

A4266

J1050

J7294

J7295

J7296

J7297

J7298

J7300

J7301

J7304

J7306

J7307

S4981

S4989

S4993

Diagnosis Codes

E23.6

E28.1

E28.2

E28.310

E28.319

E28.39

E28.8

E28.9

E30.1

E89.40

E89.41

F32.81

G43.821

G43.829

G43.831

G43.839

L68.0

L70.0

L70.1

L70.2

L70.3

L70.4

L70.5

L70.8

L70.9

N80.00

N80.01

N80.02

N80.101

N80.102

N80.103

N80.109

N80.111

N80.112

N80.113

N80.119

N80.121

N80.122

N80.123

N80.129

N80.201

N80.202

N80.203

N80.209

N80.211

N80.212

N80.213

N80.219

N80.221

N80.222

N80.223

N80.229

N80.30

N80.311

N80.312

N80.319

N80.321

N80.322

N80.329

N80.331

N80.332

N80.333

N80.339

N80.341

N80.342

N80.343

N80.349

N80.351

N80.352

N80.353

N80.359

N80.361

N80.362

N80.363

N80.369

N80.371

N80.372

N80.373

N80.379

N80.381

N80.382

N80.383

N80.389

N80.391

N80.392

N80.399

N80.3A1

N80.3A2

N80.3A3

N80.3A9

N80.3B1

N80.3B2

N80.3B3

N80.3B9

N80.3C1

N80.3C2

N80.3C3

N80.3C9

N80.40

N80.41

N80.42

N80.50

N80.511

N80.512

N80.519

N80.521

N80.522

N80.529

N80.531

N80.532

N80.539

N80.541

N80.542

N80.549

N80.551

N80.552

N80.559

N80.561

N80.562

N80.569

N80.6

N80.8

N80.A0

N80.A1

N80.A2

N80.A41

N80.A42

N80.A43

N80.A49

N80.A51

N80.A52

N80.A53

N80.A59

N80.A61

N80.A62

N80.A63

N80.A69

N83.00

N83.01

N83.02

N83.10

N83.11

N83.12

N83.201

N83.202

N83.209

N83.291

N83.292

N83.299

N84.0

N89.7

N91.0

N91.1

N91.2

N91.3

N91.4

N91.5

N92.0

N92.1

N92.2

N92.3

N92.4

N92.5

N92.6

N93.8

N93.9

N94.0

N94.3

N94.4

N94.5

N94.6

N94.89

N95.0

N98.1

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 5-19-2020 Annual review, update to criteria

Internal Medical Policy Committee 7-22-20

Added Additional criteria and
Added Diagnosis codes

Internal Medical Policy Committee 11-19-2020

Updated pregnancy criteria

Internal Medical Policy Committee 9-21-2021

Added new codes J7294 and J7295 to the policy and
Removed code J7303

Internal Medical Policy Committee 1-20-2022

Minor wording change 'When a contraceptive device, implant, medication, injection, or related service is provided for medical conditions other than those listed above, it is considered as a non-covered service.'

Internal Medical Policy Committee 5-24-2022

Added two additional medical conditions to the policy: endometrial cancer prevention, ovarian cancer prevention

Internal Medical Policy Committee 9-28-2022 - Effective October 01, 2022

Removed Diagnosis codes N80.0, N80.1, N80.2 N80.3, N80.4 and N80.5 and
Added Diagnosis codes N80.00, N80.01, N80.02, N80.101, N80.102, N80.103, N80.109, N80.111, N80.112, N80.113, N80.119, N80.121, N80.122, N80.123, N80.129, N80.201, N80.202, N80.203, N80.209, N80.211, N80.212, N80.213, N80.219, N80.221, N80.222, N80.223, N80.229, N80.30, N80.311, N80.312, N80.319, N80.321, N80.322, N80.329, N80.331, N80.332, N80.333, N80.339, N80.341, N80.342, N80.343, N80.349, N80.351, N80.352, N80.353, N80.359, N80.361, N80.362, N80.363, N80.369, N80.371, N80.372, N80.373, N80.379, N80.381, ,N80.382, N80.383, N80.389, N80.391, N80.392, N80.399, N80.3A1, N80.3A2, N80.3A3, N80.3A9, N80.3B1, N80.3B2, N80.3B3, N80.3B9, N80.3C1, N80.3C2, N80.3C3, N80.3C9, N80.40, N80.41, N80.42, N80.50, N80.511, N80.512, N80.519, N80.521, N80.522, N80.529, N80.531, N80.532, N80.539, N80.541, N80.542, N80.549, N80.551, N80.552, N80.559, N80.561, N80.562, N80.569, N80.A0, N80.A1, N80.A2, N80.A41, N80.A42, N80.A43, N80.A49, N80.A51, N80.A52, N80.A53, N80.A59, N80.A61, N80.A62, N80.A63, and N80.A69

Internal Medical Policy Committee 9-12-2023 Annual review, no clinical content change

Internal Medical Policy Committee 5-14-2024 Effective July 01, 2024

Added hyperlactation to criteria list

Medical Policies Quick Search

Contraceptive Management

Description

Policy Application

Criteria

Procedure Codes

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer

Description

Policy Application

Criteria

Procedure Codes

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer