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DESCRIPTIONProgesterone is a female hormone that prepares the uterus to receive and sustain fertilized eggs. Progesterone is produced principally by the ovary after ovulation. Progesterone serves many purposes, but its principal function is to prepare the lining of the uterus (the endometrium) to allow a fertilized egg to implant and grow. Progesterone is sometimes not produced in adequate amounts or its effect on the lining of the uterus is inadequate. This problem is called luteal deficiency. It is more common in older women and in women with abnormal ovulation.
Men produce some amount of progesterone, but it probably has no normal function except to help produce other steroid hormones.
Progesterone plays a vital role in pregnancy. After an egg is released by the ovaries (ovulation), progesterone helps make the uterus ready for implantation of a fertilized egg. It prepares the womb (uterus) for pregnancy and the breasts for milk production.
Progesterone has characteristics that balance and counteract the adverse effects that estrogen can have. For example, some women produce too much estrogen, thus standing a risk of cancer of the uterus and breast. Supplemental progesterone has been known to aid in managing abnormal uterine bleeding, as well as recurrent pregnancy loss or premature labor.
POLICYMeasurement of progesterone is considered medically necessary in the evaluation of females with symptoms of adrenal or ovarian disease (See Policy Guidelines).
Measurement of progesterone is considered medically necessary to evaluate progesterone levels during pregnancy.
Measurement of progesterone is considered medically necessary to monitor progesterone levels in females receiving supplemental progesterone.
Measurement of progesterone 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.
Increased progesterone levels also are seen occasionally with:
Low levels of progesterone may be associated with:
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.
08/31/2015: Medical policy revised to add ICD-10 codes.
06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary definition.
09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: N83.00 - N83.02, N83.10 - N83.12, N83.201 - N83.209, N83.291 - N83.299, N93.1, O00.00 - O00.91, and Z33.3.
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.