Implantable Hormone Pellets (CPB 0345, reviewed 2026-07-08)

IMMEDIATE (Effective 2026-07-08): Billing team must update authorization and billing workflows for all implantable hormone pellet procedures. (1) Update prior authorization system to DENY coverage for testosterone pellets (CPT 11980, HCPCS J1073) for age-related/late-onset hypogonadism, idiopathic hypogonadism, male menopause, cancer treatment, and pain management—these are now explicitly excluded. (2) For testosterone claims to be approved, require providers to document one of THREE qualifying indications: delayed puberty (E30.0), gender dysphoria (F64.0-F64.9) WITH full compliance to gender-affirming care criteria, or primary/hypogonadotropic hypogonadism (E23.0, E29.1) WITH two confirmed low morning testosterone lab results. (3) REJECT all estradiol pellet claims (CPT 11980 for estradiol only, or estradiol-only formulations)—these remain experimental/investigational. (4) For gender dysphoria claims involving members under 18, require documentation that prescriber is specialized in transgender youth care AND collaborating with mental health provider, AND member has reached Tanner stage 2+ of puberty. (5) For continuation of therapy authorizations, require re-verification that member STILL meets all initial approval criteria. (6) Update claim denial templates to reference CPB 0345 when rejecting non-qualifying indications. Providers and front-desk staff should flag any requisitions for age-related hypogonadism or estradiol pellets and route to billing for immediate rejection. Claims submitted without proper documentation will be denied and require resubmission.