MP-15 Long Acting Reversible Contraception Form

Long Acting Reversible Contraception

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           Medical   Policy

Current Effective Date: 10/01/2017
Original Effective Date: 10/01/2017
Next Review/Revision Date: 10/01/2018
Plans: QUEST Integration (Medicaid)

I. Definition

Long Acting Reversible Contraception (LARC) methods are effective birth control methods to prevent pregnancy. These methods include contraceptive implant, contraceptive injection, intrauterine device, intrauterine system, and combined injectable contraceptive.

Contraceptive implant is a small flexible rod which is put under the skin of upper arm. It releases the hormone progestogen. It stops ovulation, thickens cervical mucus to stop sperm reaching an egg. It also thins the lining of the uterus to prevent a fertilized egg implanting. It may last for three years.

Contraceptive injection releases the hormone progestogen. The function is the same with Contraceptive implant. However, it lasts for 12 weeks.

Intrauterine device (IUD) is a small plastic and copper device which is put into the uterus. It stops sperm reaching an egg, and may also stop a fertilized egg implanting in the uterus. It may last for 10 years.

Intrauterine system (IUS) is a small, T‐shaped plastic device which releases the hormone progestogen. It is put into the uterus, too. It thins the lining of the uterus to prevent a fertilized egg implanting, thickens cervical mucus to prevent sperm reaching and egg, and may stop ovulation. There is one type which may last for three years. Another type may last for five years.

Combined injectable contraceptive (CIC) is an injection of progestin and a synthetic estrogen taken to suppress fertility.

II. Criteria
LARC is covered any time during a member’s menstrual cycle, postpartum period, or Intentional
Termination of Pregnancy (ITOP).
A. IUD and IUS is contraindicated for members with any of the following complications, including but not limited to:

Long Acting Reversible Contraception

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           Medical   Policy

• Current Pelvic inflammatory disease (PID)
• Current Purulent cervicitis
• Current unexplained bleeding

• Current endometritis
• Certain uterine anomalies
• Currently pregnant
• Existing IUD in place
• Gynecologic cancers
• Peripartum chorioamnionitis
• Puerperal sepsis
B. The hormone based IUS is not covered for members with any active hepatic disease, tumor or progestogen sensitive breast cancer.
C. The copper IUD is not covered for members with any allergy to copper or Wilson’s disease.
D. The contraception implants and injections are not covered for patients with thrombophlebitis and venous thromboembolism (VTE).

III. Guidelines
A. Prior Authorization is not required.
B. The payment for LARC devices, insertion and removal during the postpartum period is not included in global reimbursement bundled with pregnancy/delivery.

IV. Coding Information
The following medical codes are relevant codes for diagnosis and procedures for LARC and for informational purposes only. All the medical codes listed in this policy do not constitute or imply benefit coverage or provider reimbursement.
ICD‐10
Description
Z30.013
Encounter for initial prescription of injectable contraceptive
Z30.014
Encounter for initial prescription of intrauterine contraceptive device
Z30.018
Encounter for initial prescription of other contraceptives
Z30.2
Encounter for sterilization
Z30.430
Encounter for insertion of intrauterine contraceptive device

Long Acting Reversible Contraception

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           Medical   Policy

Z30.432
Encounter for removal of intrauterine contraceptive device
Z30.433
Encounter for removal and reinsertion of intrauterine contraceptive device
Z30.49
Encounter for surveillance of other contraceptives

CPT
Description
11981
Insertion, non‐biodegradable drug delivery implant
11982
Removal, non‐biodegradable drug delivery implant
11983
Removal with reinsertion, non‐biodegradable drug delivery implant
58300
Insertion of intrauterine device (IUD)
58301
Removal of intrauterine device (IUD)

HCPCS
Description
J7300
Intrauterine copper contraceptive
J7301
Levonorgestrel‐releasing intrauterine contraceptive system, 13.5 mg
J7302
Levonorgestrel‐releasing intrauterine contraceptive system, 52 mg
J7306
Levonorgestrel (contraceptive) implant system, including implants and supplies
J3707
Etonogestrel (contraceptive) implant system, including implant and supplies

V. References/Resources
Document Name
Effective
Source/Link
Date
Choosing a Birth Control
06/2014
Association of Reproductive Health Professionals
method
http://www.arhp.org/Publications‐and‐Resources/Quick‐ Reference‐Guide‐for‐Clinicians/choosing/Combined‐ HormonalContraception
Long Acting Reversible
10/23/2013
San Francisco General Hospital
Contraception
http://www.ucsfcme.com/2014/MOB14001/slides/04KernsLong ActingReversableContraception.pdf
Effectiveness of Long‐Acting
05/24/2012
The New England Journal of Medicine.

Long Acting Reversible Contraception

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           Medical   Policy

Reversible Contraception
http://www.nejm.org/doi/full/10.1056/NEJMoa1110855#t=articl e
Adolescents and Long‐ 10/2012
American College of Obstetricians and Gynecologists (ACOG)
Acting Reversible
https://www.acog.org/Resources‐And‐Publications/CommitteeContraception: Implants

Opinions/Committee‐on‐Adolescent‐Health‐Care/Adolescentsand Intrauterine Devices
and‐ Long‐Acting‐Reversible‐Contraception
Coding for Long‐Acting
2012
American College of Obstetricians and Gynecologists (ACOG)
Reversible Contraception
https://www.acog.org/About%20ACOG/404.aspx CDC Updates Guidelines for 2011 The US Centers or Diseases Control and Prevention Postpartum Contraceptive

http://www.medscape.com/viewarticle/746177

Review/Revision History
10/01/2018 - Retired