Currentculinary health fundPolicy N/A

Implantable testosterone hormone pellets (e.g., Testopel)

Defines medical necessity and prior authorization requirements for implantable testosterone pellets as replacement therapy in males with testosterone deficiency; governs reimbursement and documentation submission procedures for Culinary Health Fund members.

Policy Summary

Payerculinary health fund

PolicyImplantable testosterone hormone pellets (e.g., Testopel)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 15, 2012

Next Review DateN/A

Key ActionObtain prior authorization from American Health Holding, Inc. (AHH) and submit the completed pre-approval form with required documentation before services are rendered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

11980procedure code specifically referenced

S0189HCPCS code specifically referenced

invoice+10%reimbursement method

prior authauthorization requirement

Medical necessity — implantable testosterone pellets

Medical necessity — implantable testosterone pellets (initial coverage)

Implantable testosterone pellets are considered medically necessary as replacement therapy in males with testosterone deficiency when ALL of the following are met:

ALL of the following

ONE of the following diagnoses
- Congenital or acquired primary hypogonadism (e.g., testicular failure due to cryptorchidism, bilateral torsion, orchitis, vanishing testes syndrome or orchidectomy)
- Congenital or acquired hypogonadotrophic hypogonadism (e.g., idiopathic or gonadotropic LHRH deficiency, or pituitary–hypothalamic injury from tumors, trauma or radiation)
Failure or intolerance of topical/gels, transdermal patches, and injectable testosterone

Policy Summary

Payerculinary health fund

PolicyImplantable testosterone hormone pellets (e.g., Testopel)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 15, 2012

Next Review DateN/A

Key ActionObtain prior authorization from American Health Holding, Inc. (AHH) and submit the completed pre-approval form with required documentation before services are rendered.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Prior authorization, documentation, and claims

Prior Authorization

Prior authorization required

Prior authorization must be obtained from American Health Holding, Inc. (AHH) prior to services being rendered; failure to obtain prior authorization will result in denial of reimbursement.

CPT 11980
HCPCS S0189
Requests must be submitted to AHH via toll-free number (866) 330-2307 or website www.americanhealthholding.com

Documentation Required

Required documentation with prior authorization request

Submit the completed pre-approval form and all required documentation with the prior authorization request; lab reports are required to process requests.

Patient demographics (member name, member ID, age) and physician information
ICD-9 or ICD-10 diagnosis code(s)
Medication requested (e.g., Testopel) with dosing and frequency
Height and weight
Prior medication history: gels/topical, patch, injectable — include dates and outcomes
Lab reports: total testosterone, free testosterone, LH, FSH, or prolactin (lab reports are REQUIRED)

Documentation Required

Invoice attachment for claims

Attach the invoice to the claim submission for reimbursement calculation.

Reimbursement will be invoice cost plus 10%

Clinical and administrative context

Implantable testosterone pellets (e.g., Testopel) are a form of testosterone replacement therapy used to treat males with conditions causing deficiency or absence of endogenous testosterone, including primary hypogonadism (for example, testicular failure from cryptorchidism, bilateral torsion, orchitis, vanishing testes syndrome, or orchidectomy) and hypogonadotrophic hypogonadism (for example, idiopathic or gonadotropic LHRH deficiency or pituitary–hypothalamic injury from tumors, trauma, or radiation).

This policy limits coverage of implantable testosterone pellets to members who have experienced failure or intolerance of topical gels, transdermal patches, and injectable testosterone. Prior authorization must be obtained from Culinary Health Fund's utilization management vendor, American Health Holding, Inc. (AHH), before services are rendered; failure to obtain prior authorization will result in denial of reimbursement.

Requests for implantable pellets must include a completed preapproval form and documentation shown on the form: patient demographics, the requested medication with dosing/frequency, ICD-9/ICD-10 diagnosis code(s), prior medication history indicating use of gels/patches/injectable formulations with dates and outcomes, and required laboratory reports (including total testosterone, free testosterone, LH, FSH, or prolactin).

OpenPayer

Implantable testosterone hormone pellets (e.g., Testopel)

Medical necessity — implantable testosterone pellets

Procedure, HCPCS and diagnosis coding notes

Prior authorization, documentation, and claims

Clinical and administrative context

Defined terms

11980	Insertion of implantable hormone pellet (CPT) — referenced for implantable hormone pellets
S0189	HCPCS code for implantable testosterone pellets (Testopel) — referenced