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Printer Friendly Version Human Chorionic Gonadotropin (A.P.L®, Chorex-5®, Chorex-10®, Profasi®, Choron 10®, Gonic®, Pregnyl®)

Human Chorionic Gonadotropin (A.P.L®, Chorex-5®, Chorex-10®, Profasi®, Choron 10®, Gonic®, Pregnyl®)

DESCRIPTION

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

Cryptorchidism: For IM use only
Male hypogonadism
Ovulation induction

IDENTIFICATION

Generic Name: Human Chorionic Gonadotropin
Brand Name: A.P.L®., Chorex-5®, Chorex-10®, Profasi®, Choron 10®, Gonic®, Pregnyl®

POLICY

Human chorionic gonadotropin (HCG) is considered medically necessary for the following disease states:

Prepubertal cryptorchidism
Hypogonadism

POLICY EXCEPTIONS

None

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

POLICY HISTORY

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

SOURCE(S)

American Hospital Formulary Services 1998

Fact and Comparisons, October 1995

Micromedex, 1998, 2006

CODE REFERENCE

This is not intended to be a comprehensive list of codes. Some codes may be variable, and coverage will be based on the clinical indication for the service.

Covered Codes

Code Number	Description
CPT-4

ICD-9 Procedure
99.24	Injection of other hormone
ICD-9 Diagnosis
253.4	Other anterior pituitary disorders
256.39	Other ovarian failure
257.2	Other testicular hypofunction
752.51	Undescended testis (prepubertal)
HCPCS
J0725	Injection, chorionic gonadotropin, per 1,000 usp units

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