Naltrexone Implantable Pellets
Defines coverage stance and clinical coding guidance for extended-release, implantable naltrexone pellets used to treat alcohol and opioid use disorders under the medical benefit.
Clarified ICD-10 Diagnosis statement to indicate naltrexone pellets may not be approved for the following diagnoses.
Removed CPT 22999 and 49999 from coding list.
Coverage Criteria — Implantable Naltrexone Pellets
Medical necessity for implantable naltrexone pellets
Covered when ALL of the following are met
Implants are compounded from bulk powder and are not FDA-approved; clinical review (including prior authorization) will be used to determine medical necessity.
This policy addresses extended‑release, implantable naltrexone pellets. These implantable pellets and the bulk powder used to compound them are not approved by the FDA. The scope of this document is limited to implantable pellet formulations; it does not address injectable extended‑release naltrexone (Vivitrol) or oral naltrexone (Revia). As such, coverage determinations and clinical review described here apply only to implantable pellets and not to Vivitrol or oral formulations.
Use of extended‑release naltrexone implants/pellets for the treatment of alcohol‑related disorders or opioid‑related disorders may not be approved. Relevant diagnosis ranges referenced in this document include F10.10–F10.99 for alcohol‑related disorders and F11.10–F11.99 for opioid‑related disorders. Clinical review and medical necessity determinations will consider these diagnoses when evaluating requests for implantable naltrexone.
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