Does J0725 require prior authorization?

Yes, J0725 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for J0725?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`J0725`, Injection, chorionic gonadotropin, per 1,000 usp units

HCPCS/CPT

Prior Authorization

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Refills based upon documentation in cycle sheets.
Benefit plan documentation: because "Some plans exclude infertility services for ovarian failure; please check benefit plan descriptions," documentation of plan-specific coverage determinations may be required.

Semen analysis documentation: severe semen quantity or quality deficits require documentation on 2 separate occasions at least 2 weeks apart.

For use of gonadotropin therapy in males (hypogonadotropic hypogonadism), documentation of normalization of serum testosterone levels is required prior to administration of recombinant follitropin for induction of spermatogenesis (policy text: "after normal serum testosterone levels are reached").

Documentation of prior responses to gonadotropin stimulation should be used to individualize initial dosing in subsequent cycles (policy text: initial dose in subsequent cycles is individualized based on prior response).

Check benefit plan descriptions for exclusions (plans may exclude infertility services for ovarian failure).

Key Coverage Criteria

N98.1: Hyperstimulation of ovaries
N99.83: Residual ovary syndrome
Benign neoplasm and neoplasm of uncertain behavior of pituitary gland and craniopharyngeal duct (D35.2 - D35.3; D44.3 - D44.4)
Neoplasm of uncertain behavior of female genital organs (D39.0 - D39.2)
Neoplasm of uncertain behavior of other and unspecified male genital organs (D40.8 - D40.9)
Iodine-deficiency related thyroid disorders and allied conditions (E01.8), subclinical iodine-deficiency hypothyroidism (E02), other hypothyroidism (E03.0 - E03.8)

10 Active Policies

BCBSMS-L-5-01-436-4BAA002687, Human Chorionic Gonadotropin

HEALTHPARTNERS-CC-ENTRY-202924, Chorionic gonadotropin (Novarel and Synarel) – Minnesota Health Care Programs

MULTI

PROVIDENCE-MP-MP410, Human Chorionic Gonadotropin

MULTI

PROVIDENCE-MP-MP411, Human Chorionic Gonadotropin

MULTI

BCBSNE-I-207-E2EAA79BB0, HUMAN CHORIONIC GONADOTROPIN

CAG-00372N__200__effda9a00c, Human Chorionic Gonadotropin (Addition of ICD-9-CM Code 158.9, Malignant Neoplasm of Peritoneum, Unspecified)

AETNA-CPB-0512, Premenstrual Syndrome and Premenstrual Dysphoric Disorder

AETNA-CPB-0039, Weight Reduction Programs and Devices

AETNA-CPB-0327, Infertility

NCD125, Human Chorionic Gonadotropin

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J0725, Injection, chorionic gonadotropin, per 1,000 usp units

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

10 Active Policies

Related Codes

Have a follow-up question?

`J0725`, Injection, chorionic gonadotropin, per 1,000 usp units