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Human chorionic gonadotropin (HCG) is a hormone produced by the human placenta. HCG's action is virtually identical to pituitary LHs, although HCG appears to have a small degree of FSH activity as well. It stimulates production of gonadal steroid hormones by stimulating interstitial cells of testis to produce androgens, and the corpus luteum of the ovary to produce progesterone. Androgen stimulation in males leads to development of secondary sex characteristics and may stimulate testicular descent when no anatomical impediment is present. During the normal menstrual cycle, LH participates with FSH in development and maturation of the normal ovarian follicle, and the mid-cycle LH surge triggers ovulation; HCG can substitute for LH in this function. During a normal pregnancy, HCG secreted by the placenta maintains the corpus luteum after LH secretion decreases, supporting continued estrogen and progesterone secretion and preventing menstruation.
FDA approved indications for HCG are as follows:
Human chorionic gonadotropin (HCG) is considered medically necessary for the following disease states:
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Benefits will not be provided for the following contract exclusions:
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
5/1999: Approved by Pharmacy & Therapeutics (P & T)
1/30/2002: Prior authorization deleted
4/24/2002: Type of Service and Place of Service deleted. Code Reference section completed, CPT code 80414, 83001, 83002, 84403, 84702, 84703, 90782 added covered codes, ICD-9 procedure code 99.24, 99.29 added covered codes, ICD-9 diagnosis code 176.0-176.9, 253.4, 256.39, 257.2, 752.51 added covered codes, HCPCS J0725 added covered codes, ICD-9 diagnosis code 607.84, 783.21 added non-covered codes
11/19/2004: Code Reference section updated, CPT code 80414, 83001, 83002, 84403, 84702, 84703, 90782 deleted covered codes, ICD-9 procedure code 99.29 deleted covered codes, ICD-9 diagnosis code range 176.0-176.9 listed separately, non-covered table deleted, ICD-9 diagnosis code 607.84, 783.21 deleted non-covered codes
10/29/2006: Dosing and off-label information removed
11/2/2006: Code Reference section updated. ICD-9 Diagnosis codes 176.0-176.5, 176.8, 176.9 deleted from policy
04/01/2014: Policy title changed from "Human Chorionic Gonadotropin (A.P.L®, Chorex-5®, Chorex-10®, Profasi®, Choron 10®, Gonic®, Pregnyl®)" to "Human Chorionic Gonadotropin." Policy description updated to include brand names "Novarel® and Ovidrel®." Policy statement updated to add "secondary to a pituitary deficiency" to the medically necessary statement.
08/27/2015: Policy guidelines updated to add contract exclusion language and the definition of medical necessary. Code Reference section updated to add ICD-10 codes and to remove ICD-9 diagnosis code 256.39.
American Hospital Formulary Services 1998
Fact and Comparisons, October 1995
Micromedex, 1998, 2006
Novarel® Prescribing Information
Pregnyl® Prescribing Information
Ovidrel® Prescribing Information
This may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.