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L.2.04.414
Progesterone 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.
Measurement 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).
None
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:
Some ovarian cysts
Non-viable pregnancies known as molar pregnancies
A rare form of ovarian cancer
Overproduction of progesterone by the adrenal glands
Congenital adrenal hyperplasia (CAH)
Low levels of progesterone may be associated with:
Toxemia late in pregnancy
Decreased function of ovaries
Lack of menstruation (amenorrhea)
Benefits will not be provided for the following contract exclusions:
Services and supplies related to infertility, artificial insemination, intrauterine insemination and in-vitro fertilization regardless of any claim of Medical Necessity.
For treatment related to sex transformations, sexual function, sexual dysfunctions or inadequacies regardless of Medical Necessity.
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 Mental Health Disorders, 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 medical necessity, “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 L.2.04.414 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.
09/29/2017: Code Reference section updated to revise description for ICD-10 diagnosis code Z79.890.
09/29/2022: Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity." Code Reference section updated to add new ICD-10 diagnosis codes N80.00, N80.01, N80.02, N80.03, N80.101, N80.102, N80.103, N80.109, N80.111, N80.112, N80.113, N80.119, N80.121, N80.122, N80.123, N80.129, N80.201, N80.202, N80.203, N80.209, N80.211, N80.212, N80.213, N80.219, N80.221, N80.222, N80.223, N80.229, N80.30, N80.311, N80.312, N80.319, N80.321, N80.322, N80.329, N80.331, N80.332, N80.333, N80.339, N80.341, N80.342, N80.343, N80.349, N80.351, N80.352, N80.353, N80.359, N80.361, N80.362, N80.363, N80.369, N80.371, N80.372, N80.373, N80.379, N80.381, N80.382, N80.383, N80.389, N80.391, N80.392, N80.399, N80.3A1, N80.3A2, N80.3A3, N80.3A9, N80.3B1, N80.3B2, N80.3B3, N80.3B9, N80.3C1, N80.3C2, N80.3C3, N80.3C9, N80.40, N80.41, N80.42, N80.50, N80.511, N80.512, N80.519, N80.521, N80.522, N80.529, N80.531, N80.532, N80.539, N80.541, N80.542, N80.549, N80.551, N80.552, N80.559, N80.561, N80.562, N80.569, N80.A0, N80.A1, N80.A2, N80.A41, N80.A42, N80.A43, N80.A49, N80.A51, N80.A52, N80.A53, N80.A59, N80.A61, N80.A62, N80.A63, N80.A69, N80.B1, N80.B2, N80.B31, N80.B32, N80.B39, N80.B4, N80.B5, N80.B6, N80.C0, N80.C10, N80.C11, N80.C19, N80.C2, N80.C3, N80.C4, N80.C9, N80.D0, N80.D1, N80.D2, N80.D3, N80.D4, N80.D5, N80.D6, and N80.D9, effective 10/01/2022. Removed deleted ICD-10 diagnosis codes N83.0, N83.1, N83.20-N83.29, and O00.0-O00.9. Removed related ICD-9 diagnosis codes 620.0, 620.1, 620.2, and 633.00-633.91.
01/18/2023: Policy reviewed; no changes.
02/15/2024: Policy reviewed. Policy statements unchanged. Code Reference section updated to remove deleted ICD-10 diagnosis codes N80.0, N80.1, N80.2, N80.3, N80.4, and N80.5.
03/13/2025: Policy reviewed; no changes.
Endocrine Physician Advisory Committee
Progesterone, American Society for Reproductive American
Serum progesterone -
http://labtestsonline.org/understanding/analytes/progesterone/tab/test
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.
Code Number | Description | ||
CPT-4 | |||
84144 | Progesterone | ||
HCPCS | |||
ICD-9 Procedure | ICD-10 Procedure | ||
ICD-9 Diagnosis | ICD-10 Diagnosis | ||
183.0 | Malignant neoplasm of ovary | C56.1 - C56.9 | Malignant neoplasm of ovary |
194.0 - 194.9 | Malignant neoplasm of other endocrine glands and related structures | C74.00 - C74.92 | Malignant neoplasm of adrenal gland |
C75.0 - C75.9 | Malignant neoplasm of other endocrine glands and related structures | ||
220 | Benign neoplasm of ovary | D27.0 - D27.9 | Benign neoplasm of ovary |
227.0 - 227.9 | Benign neoplasm of other endocrine glands and related structures | D35.00 - D35.9 | Benign neoplasm of other and unspecified endocrine glands |
236.2 | Neoplasm of uncertain behavior of ovary | D39.10 - D39.12 | Neoplasm of uncertain behavior of ovary |
253.2 | Panhypopituitarism | E23.0 | Hypopituitarism (Panhypopituitarism) |
253.4 | Other anterior pituitary disorders | E23.6 | Other disorders of pituitary gland |
253.7 | Iatrogenic pituitary disorders | E23.1 | Drug-induced hypopituitarism |
255.2 | Adrenogenital disorders | E25.0 - E25.9 | Adrenogenital disorders |
256.31 | Premature menopause | E28.310 - E28.319 | Other ovarian failure |
256.39 | Other ovarian failure | E28.39 | Other primary ovarian failure |
256.4 | Polycystic ovaries | E28.2 | Polycystic ovarian syndrome |
611.4 | Atrophy of breast | N64.2 | Atrophy of breast |
617.0 - 617.9 | Endometriosis | N80.00 | Endometriosis of the uterus, unspecified |
N80.01 | Superficial endometriosis of the uterus | ||
N80.02 | Deep endometriosis of the uterus | ||
N80.03 | Adenomyosis of the uterus | ||
N80.101 | Endometriosis of right ovary, unspecified depth | ||
N80.102 | Endometriosis of left ovary, unspecified depth | ||
N80.103 | Endometriosis of bilateral ovaries, unspecified depth | ||
N80.109 | Endometriosis of ovary, unspecified side, unspecified depth | ||
N80.111 | Superficial endometriosis of right ovary | ||
N80.112 | Superficial endometriosis of left ovary | ||
N80.113 | Superficial endometriosis of bilateral ovaries | ||
N80.119 | Superficial endometriosis of ovary, unspecified ovary | ||
N80.121 | Deep endometriosis of right ovary | ||
N80.122 | Deep endometriosis of left ovary | ||
N80.123 | Deep endometriosis of bilateral ovaries | ||
N80.129 | Deep endometriosis of ovary, unspecified ovary | ||
N80.201 | Endometriosis of right fallopian tube, unspecified depth | ||
N80.202 | Endometriosis of left fallopian tube, unspecified depth | ||
N80.203 | Endometriosis of bilateral fallopian tubes, unspecified depth | ||
N80.209 | Endometriosis of unspecified fallopian tube, unspecified depth | ||
N80.211 | Superficial endometriosis of right fallopian tube | ||
N80.212 | Superficial endometriosis of left fallopian tube | ||
N80.213 | Superficial endometriosis of bilateral fallopian tubes | ||
N80.219 | Superficial endometriosis of unspecified fallopian tube | ||
N80.221 | Deep endometriosis of right fallopian tube | ||
N80.222 | Deep endometriosis of left fallopian tube | ||
N80.223 | Deep endometriosis of bilateral fallopian tubes | ||
N80.229 | Deep endometriosis of unspecified fallopian tube | ||
N80.30 | Endometriosis of pelvic peritoneum, unspecified | ||
N80.311 | Superficial endometriosis of the anterior cul-de-sac | ||
N80.312 | Deep endometriosis of the anterior cul-de-sac | ||
N80.319 | Endometriosis of the anterior cul-de-sac, unspecified depth | ||
N80.321 | Superficial endometriosis of the posterior cul-de-sac | ||
N80.322 | Deep endometriosis of the posterior cul-de-sac | ||
N80.329 | Endometriosis of the posterior cul-de-sac, unspecified depth | ||
N80.331 | Superficial endometriosis of the right pelvic sidewall | ||
N80.332 | Superficial endometriosis of the left pelvic sidewall | ||
N80.333 | Superficial endometriosis of bilateral pelvic sidewall | ||
N80.339 | Superficial endometriosis of pelvic sidewall, unspecified side | ||
N80.341 | Deep endometriosis of the right pelvic sidewall | ||
N80.342 | Deep endometriosis of the left pelvic sidewall | ||
N80.343 | Deep endometriosis of the bilateral pelvic sidewall | ||
N80.349 | Deep endometriosis of the pelvic sidewall, unspecified side | ||
N80.351 | Endometriosis of the right pelvic sidewall, unspecified depth | ||
N80.352 | Endometriosis of the left pelvic sidewall, unspecified depth | ||
N80.353 | Endometriosis of bilateral pelvic sidewall, unspecified depth | ||
N80.359 | Endometriosis of pelvic sidewall, unspecified side, unspecified depth | ||
N80.361 | Superficial endometriosis of the right pelvic brim | ||
N80.362 | Superficial endometriosis of the left pelvic brim | ||
N80.363 | Superficial endometriosis of bilateral pelvic brim | ||
N80.369 | Superficial endometriosis of the pelvic brim, unspecified side | ||
N80.371 | Deep endometriosis of the right pelvic brim | ||
N80.372 | Deep endometriosis of the left pelvic brim | ||
N80.373 | Deep endometriosis of bilateral pelvic brim | ||
N80.379 | Deep endometriosis of the pelvic brim, unspecified side | ||
N80.381 | Endometriosis of the right pelvic brim, unspecified depth | ||
N80.382 | Endometriosis of the left pelvic brim, unspecified depth | ||
N80.383 | Endometriosis of bilateral pelvic brim, unspecified depth | ||
N80.389 | Endometriosis of the pelvic brim, unspecified side, unspecified depth | ||
N80.391 | Superficial endometriosis of the pelvic peritoneum, other specified sites | ||
N80.392 | Deep endometriosis of the pelvic peritoneum, other specified sites | ||
N80.399 | Endometriosis of the pelvic peritoneum, other specified sites, unspecified depth | ||
N80.3A1 | Superficial endometriosis of the right uterosacral ligament | ||
N80.3A2 | Superficial endometriosis of the left uterosacral ligament | ||
N80.3A3 | Superficial endometriosis of the bilateral uterosacral ligament(s) | ||
N80.3A9 | Superficial endometriosis of the uterosacral ligament(s), unspecified side | ||
N80.3B1 | Deep endometriosis of the right uterosacral ligament | ||
N80.3B2 | Deep endometriosis of the left uterosacral ligament | ||
N80.3B3 | Deep endometriosis of bilateral uterosacral ligament(s) | ||
N80.3B9 | Deep endometriosis of the uterosacral ligament(s), unspecified side | ||
N80.3C1 | Endometriosis of the right uterosacral ligament, unspecified depth | ||
N80.3C2 | Endometriosis of the left uterosacral ligament, unspecified depth | ||
N80.3C3 | Endometriosis of bilateral uterosacral ligament(s), unspecified depth | ||
N80.3C9 | Endometriosis of the uterosacral ligament(s), unspecified side, unspecified depth | ||
N80.40 | Endometriosis of rectovaginal septum, unspecified involvement of vagina | ||
N80.41 | Endometriosis of rectovaginal septum without involvement of vagina | ||
N80.42 | Endometriosis of rectovaginal septum with involvement of vagina | ||
N80.50 | Endometriosis of intestine, unspecified | ||
N80.511 | Superficial endometriosis of the rectum | ||
N80.512 | Deep endometriosis of the rectum | ||
N80.519 | Endometriosis of the rectum, unspecified depth | ||
N80.521 | Superficial endometriosis of the sigmoid colon | ||
N80.522 | Deep endometriosis of the sigmoid colon | ||
N80.529 | Endometriosis of the sigmoid colon, unspecified depth | ||
N80.531 | Superficial endometriosis of the cecum | ||
N80.532 | Deep endometriosis of the cecum | ||
N80.539 | Endometriosis of the cecum, unspecified depth | ||
N80.541 | Superficial endometriosis of the appendix | ||
N80.542 | Deep endometriosis of the appendix | ||
N80.549 | Endometriosis of the appendix, unspecified depth | ||
N80.551 | Superficial endometriosis of other parts of the colon | ||
N80.552 | Deep endometriosis of other parts of the colon | ||
N80.559 | Endometriosis of other parts of the colon, unspecified depth | ||
N80.561 | Superficial endometriosis of the small intestine | ||
N80.562 | Deep endometriosis of the small intestine | ||
N80.569 | Endometriosis of the small intestine, unspecified depth | ||
N80.6 | Endometriosis in cutaneous scar | ||
N80.8 | Other endometriosis | ||
N80.9 | Endometriosis, unspecified | ||
N80.A0 | Endometriosis of bladder, unspecified depth | ||
N80.A1 | Superficial endometriosis of bladder | ||
N80.A2 | Deep endometriosis of bladder | ||
N80.A41 | Superficial endometriosis of right ureter | ||
N80.A42 | Superficial endometriosis of left ureter | ||
N80.A43 | Superficial endometriosis of bilateral ureters | ||
N80.A49 | Superficial endometriosis of unspecified ureter | ||
N80.A51 | Deep endometriosis of right ureter | ||
N80.A52 | Deep endometriosis of left ureter | ||
N80.A53 | Deep endometriosis of bilateral ureters | ||
N80.A59 | Deep endometriosis of unspecified ureter | ||
N80.A61 | Endometriosis of right ureter, unspecified depth | ||
N80.A62 | Endometriosis of left ureter, unspecified depth | ||
N80.A63 | Endometriosis of bilateral ureters, unspecified depth | ||
N80.A69 | Endometriosis of unspecified ureter, unspecified depth | ||
N80.B1 | Endometriosis of pleura | ||
N80.B2 | Endometriosis of lung | ||
N80.B31 | Superficial endometriosis of diaphragm | ||
N80.B32 | Deep endometriosis of diaphragm | ||
N80.B39 | Endometriosis of diaphragm, unspecified depth | ||
N80.B4 | Endometriosis of the pericardial space | ||
N80.B5 | Endometriosis of the mediastinal space | ||
N80.B6 | Endometriosis of cardiothoracic space | ||
N80.C0 | Endometriosis of the abdomen, unspecified | ||
N80.C10 | Endometriosis of the anterior abdominal wall, subcutaneous tissue | ||
N80.C11 | Endometriosis of the anterior abdominal wall, fascia and muscular layers | ||
N80.C19 | Endometriosis of the anterior abdominal wall, unspecified depth | ||
N80.C2 | Endometriosis of the umbilicus | ||
N80.C3 | Endometriosis of the inguinal canal | ||
N80.C4 | Endometriosis of extra-pelvic abdominal peritoneum | ||
N80.C9 | Endometriosis of other site of abdomen | ||
N80.D0 | Endometriosis of the pelvic nerves, unspecified | ||
N80.D1 | Endometriosis of the sacral splanchnic nerves | ||
N80.D2 | Endometriosis of the sacral nerve roots | ||
N80.D3 | Endometriosis of the obturator nerve | ||
N80.D4 | Endometriosis of the sciatic nerve | ||
N80.D5 | Endometriosis of the pudendal nerve | ||
N80.D6 | Endometriosis of the femoral nerve | ||
N80.D9 | Endometriosis of other pelvic nerve | ||
N83.00 - N83.02, N83.10 - N83.12, N83.201 - N83.209, N83.291 - N83.299 | Noninflammatory disorders of ovary, fallopian tube and broad ligament | ||
621.2 | Hypertrophy of uterus | N85.2 | Hypertrophy of uterus |
624.2 | Hypertrophy of clitoris | N90.89 | Other specified noninflammatory disorders of vulva and perineum |
626.0 | Absence of menstruation | N91.0 | Primary amenorrhea |
N91.1 | Secondary amenorrhea | ||
N91.2 | Amenorrhea, unspecified | ||
626.1 | Scanty or infrequent menstruation | N91.3 | Primary oligomenorrhea |
N91.4 | Secondary oligomenorrhea | ||
N91.5 | Oligomenorrhea, unspecified | ||
626.2 | Excessive or frequent menstruation | N92.0 | Excessive and frequent menstruation with regular cycle |
626.4 | Irregular menstrual cycle | N92.5 | Other specified irregular menstruation |
N92.6 | Irregular menstruation, unspecified | ||
626.6 | Metrorrhagia | N92.1 | Excessive and frequent menstruation with irregular cycle |
N93.1 | Pre-pubertal vaginal bleeding | ||
626.8 | Other disorder of menstruation and other abnormal bleeding from female genital tract | N89.7 | Hematocolpos |
N92.5 | Other specified irregular menstruation | ||
N93.8 | Other specified abnormal uterine and vaginal bleeding | ||
627.0 | Premenopausal menorrhagia | N92.4 | Excessive bleeding in the premenopausal period |
627.1 | Postmenopausal bleeding | N95.0 | Postmenopausal bleeding |
627.2 | Symptomatic menopausal or female climacteric states | N95.1 | Menopausal and female climacteric states |
627.3 | Postmenopausal atrophic vaginitis | N95.2 | Postmenopausal atrophic vaginitis |
627.4 | Symptomatic states associated with artificial menopause | N95.8 | Other specified menopausal and perimenopausal disorders |
O00.00 - O00.91 | Ectopic pregnancy | ||
640.00 - 640.03 | Threatened abortion | O20.0 | Threatened abortion |
704.00 | Alopecia, unspecified [Male pattern baldness in female] | L64.9 | Androgenic alopecia, unspecified |
704.1 | Hirsutism | L68.0 | Hirsutism |
706.1 | Other acne | L70.0 | Acne vulgaris |
L70.1 | Acne conglobata | ||
L70.3 | Acne varioliformis, acne necrotica miliaris | ||
L70.5 | Acne tropica | ||
L70.8 | Other acne | ||
706.3 | Seborrhea | L21.9 | Seborrheic dermatitis, unspecified |
758.6 | Gonadal dysgenesis | Q96.0 - Q96.9 | Turner's syndrome code range |
780.8 | Generalized hyperhidrosis | R61 | Generalized hyperhidrosis |
782.62 | Flushing | R23.2 | Flushing |
799.81 | Decreased libido | R68.82 | Decreased libido |
V07.4 | Hormone replacement therapy (postmenopausal) | Z79.890 | Hormone replacement therapy |
Z33.3 | Pregnant state, gestational carrier | ||
V22.0 - V22.2 | Normal pregnancy | Z33.1 | Pregnant state, incidental |
Z34.00 - Z34.93 | Encounter for supervision of normal pregnancy | ||
V23.0 - V23.9 | Supervision of high-risk pregnancy | O09.00 – O09.93 | Supervision of high risk pregnancy |
O36.80X0 - O36.80X9 | Pregnancy with inconclusive fetal viability | ||
V58.69 | Long-term (current) use of other medications | Z79.899 | Other long term (current) drug therapy |
V72.42 | Pregnancy examination or test, positive result | Z32.01 | Encounter for pregnancy test, result positive |
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