Does J3121 require prior authorization?

Yes, J3121 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for J3121?

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

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`J3121`, Injection, testosterone enanthate, 1 mg

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

This billing and coding guidance must be used in conjunction with the associated Local Coverage Determination (LCD).
The patient's medical record must document medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
A claim submitted without a valid ICD‑10‑CM diagnosis code that best describes the condition will be returned as an incomplete claim under §1833(e) of the Social Security Act.
For diagnostic tests, report the test result if known on the claim; if result is not known, report the symptoms that prompted the test.
Medical record documentation supporting services within the related LCD must be available to Medicare upon request.

Key Coverage Criteria

Medicare may cover injectable testosterone pellets (Testopel) for males when used for an FDA‑approved indication and when the service meets Medicare coverage requirements in CMS Medicare Benefit Policy Manual, Chapter 15, §50.4.3.
Injectable testosterone pellet therapy may be used when alternative accepted routes (transdermal, oral, nasal, intramuscular) are clinically inappropriate or insufficient and medical necessity is documented.
Injectable testosterone and Testopel (testosterone pellets) are proven for replacement therapy in conditions associated with a deficiency or absence of endogenous testosterone, including primary hypogonadism (congenital or acquired) and hypogonadotropic hypogonadism (congenital or acquired).
Injectable testosterone and Testopel (testosterone pellets) are medically necessary for replacement therapy in conditions associated with a deficiency or absence of endogenous testosterone, including primary hypogonadism (congenital or acquired) and hypogonadotropic hypogonadism (congenital or acquired), when the following criteria are met (see policy for detailed criteria).
Replacement therapy following bilateral orchiectomy.
Replacement therapy for patients with panhypopituitarism.

20 Active Policies

FIRST_COAST-L40314, Trigger Point Injections

FIRST_COAST-L33912, Trigger Point Injections

NORIDIAN-JE-L36538, Treatment of Males with Low Testosterone

NORIDIAN-JF-L36538, Treatment of Males with Low Testosterone

NOVITAS-JH-L40310, Trigger Point Injections

NOVITAS-JH-L35010, Trigger Point Injections

PALMETTO-JJ-L39086, Treatment of Males with Low Testosterone

NOVITAS-JL-L40310, Trigger Point Injections

NOVITAS-JL-L35010, Trigger Point Injections

PALMETTO-JM-L39086, Treatment of Males with Low Testosterone

BCBSNJ-DRUGS-090-9FA123334C, Testosterone [Implantable Testosterone Pellets (Testopel Pellets), Testosterone Undecanoate (Aveed)], Testosterone Cypionate (Depo-Testosterone), or Testosterone Enanthate (Delatestryl)]

BCBSOK-RX501.076, Testosterone Replacement Therapies

UMR-POL-UMR-testosterone-replacement-supp-therapy, Testosterone Replacement or Supplementation Therapy

SUREST-POL-SUREST-testosterone-replacement-supp-therapy, Testosterone Replacement or Supplementation Therapy

BCBSOK-SUR717.001, Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

A57615, Billing and Coding: Treatment of Males with Low Testosterone

A58828, Billing and Coding: Treatment of Males with Low Testosterone

UHC-POL-testosterone-replacement-supp-therapy, Testosterone Replacement or Supplementation Therapy

AETNA-CPB-0788, Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments

BCBSIL-SUR717.001, Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

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J3121, Injection, testosterone enanthate, 1 mg