Naltrexone Implants (CPB 0878, reviewed 2025-12-22)
Aetna considers naltrexone implants experimental, investigational, or unproven for alcohol addiction, amphetamine use, autism spectrum disorders, buprenorphine dependence, fentanyl-induced respiratory depression, impulse control disorders in Parkinson disease, narcotic addiction, prolactinoma (prolactin-secreting pituitary tumor), and trichotillomania, because of insufficient evidence in the peer-reviewed published medical literature and because their safety and effectiveness have not been established. The policy does not apply to Vivitrol injections or other commercially available naltrexone formulations that are not implants. Naltrexone implants have no specific HCPCS code, and the not-covered ICD-10 codes include alcohol dependence (F10.20 to F10.29), opioid use disorder codes (F11), stimulant abuse (F15), pervasive developmental disorders (F84.0 to F84.9), Parkinson disease impulse control disorder (G20.A1 to G21.9), and benign pituitary neoplasm (D35.2).