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DESCRIPTIONBoth men and women produce estrogen hormones. Estrogens are responsible for female sexual development and function, such as breast development and the menstrual cycle. In women, estrogens are produced mainly in the ovaries and in the placenta during pregnancy. Small amounts are also produced by the adrenal glands. In men, small amounts of estrogens are produced by the adrenal glands and testicles.
The two major naturally occurring estrogens are estrone (E1) and estradiol (E2).
Estradiol levels are used in evaluating ovarian function. Estradiol levels may be increased in cases of early (precocious) puberty in girls and gynecomastia in men. In males, it may help in the diagnosis of the cause of gynecomastia or in the detection of estrogen-producing tumors. Its main use has been in the differential diagnosis of amenorrhea – for example, to determine whether the cause is menopause, pregnancy, or a medical problem. Estradiol is also sometimes used to monitor menopausal hormone replacement therapy.
Increased levels of estrogens are seen in the following:
Decreased levels of estrogen are seen in the following:
POLICYMeasurement of estrogen hormones is considered medically necessary to evaluate ovarian function in females with symptoms of hypoestrogenism or hyperestrogenism.
Measurement of estrogen hormones is considered medically necessary to diagnosis hyperestrogenism in symptomatic males.
Measurement of estrogen hormones is considered medically necessary for monitoring hormone replacement therapy in postmenopausal females.
Measurement of estrogen hormones is considered medically necessary for monitoring antiestrogen therapy.
Measurement of estrogen hormones is considered not medically necessary when performed for screening purposes in asymptomatic patients (absence of signs, symptoms, or disease).
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:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
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.
10/01/2013: New policy added.
08/28/2015: Medical policy revised to add ICD-10 codes.
06/07/2016: Policy number L.2.04.404 added. Policy Guidelines updated to add medically necessary definition.
09/30/2016: Code Reference section updated to add the following new ICD-10 diagnosis codes: N83.00 - N83.299 and N93.1.
CODE REFERENCEThis 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.
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