Coverage Denial for Vyleesi

Vyleesi (bremelanotide) requests will be denied for all indications. Prior authorization will not result in coverage except where an individual contract exception applies.

• All indications, including treatment of premenopausal women with acquired, generalized HSDD
• Denial applies due to limited clinical benefit, high cost, and increased risk of nausea

Benefit Determinations and Verification

Benefit determinations are based on the member's contract in effect at the time services are rendered. Verify individual member benefits, exclusions, limitations, and exceptions prior to rendering services. Wellmark (Blue Cross Blue Shield - Iowa) determines medical necessity only when the benefit exists and no contract exclusions apply. This policy may not apply to FEP members.

• Verify member eligibility and benefits prior to submitting requests or billing
• Coverage decisions follow contract terms, exclusions, and any applicable Federal Employee Program rules

Prior Authorization and Denial Guidance

Requests for Vyleesi will be denied for all indications; do not submit prior authorization expecting coverage unless a specific contract exception is documented and applicable.

• Prior authorization will be processed only to document the request but will not overturn the not-covered determination absent a contract exception
• If a contract exception is claimed, include supporting contract documentation with the request

Billing and Reporting Guidance

Use appropriate CPT, HCPCS, Revenue, and ICD-10 codes when reporting services. Ensure billing reflects the coverage determination (not covered) and document attempts to verify benefits and any contract exceptions.

• Report services with applicable CPT/HCPCS/Revenue/ICD-10 codes
• Do not bill the plan for Vyleesi when denied — follow member liability rules per contract