RetiredUnitedHealthcarePolicy CSLA2026D0078H

Subcutaneous Implantable Naltrexone Pellets (for Louisiana Only)

UnitedHealthcare Medical Benefit Drug Policy for compounded implantable naltrexone pellets applicable only to Louisiana; declares compounded naltrexone pellets unapproved by FDA and not medically necessary for any indication, and states policy retirement effective April 1, 2026.

Policy Summary

PayerUnitedHealthcare

PolicySubcutaneous Implantable Naltrexone Pellets (for Louisiana Only)

Policy CodePolicy CSLA2026D0078H

Change TypeRetired / Code exclusion added

Effective DateJan 1, 2026

Next Review Date

Key ActionProviders should not expect coverage or reimbursement for compounded implantable naltrexone pellets in Louisiana as they are designated not medically necessary and not FDA approved; benefit coverage must follow federal, state, or contractual requirements.

SourceLink

POLICY UPDATE CHANGES

Retired policy; Louisiana plan membership disenrolled on Apr. 1, 2026.

Added notation that the policy does not apply to HCPCS code J2315 (Vivitrol).

0Covered Indications

1States applicable

2026-04-01Retirement date

Coverage Determination

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Coverage determination for compounded implantable naltrexone pellets

Compounded implantable naltrexone pellets

Coverage determination

Regulatory status: Compounded drugs, including compounded naltrexone pellets, are not FDA approved
Source states compounded naltrexone pellets are not FDA approved.
Medical necessity: Compounded drug pellets, including but not limited to compounded naltrexone, are not proven nor medically necessary for any indication
Policy declares compounded naltrexone pellets not proven or medically necessary.

Applicable Codes

Referenced CPT codesCPT

11981	Insertion, drug-delivery implant (i.e., bioresorbable, biodegradable, non-biodegradable)
11982	Removal, non-biodegradable drug delivery implant
11983	Removal with reinsertion, non-biodegradable drug delivery implant

Referenced HCPCS / J-codes (not applicable: FDA-approved Vivitrol excluded from this policy)HCPCS

J2315	Vivitrol (naltrexone powder for suspension for injection, extended-release) - this policy does not apply to J2315
J3490	Unclassified drugs
J7999	Compounded drug, not otherwise classified

Provider Actions & Billing Guidance

Documentation Required

Do not cover compounded naltrexone pellets

Providers should not expect coverage or reimbursement for compounded implantable naltrexone pellets in Louisiana as they are designated not medically necessary and not FDA approved; benefit coverage must follow federal, state, or contractual requirements.

J3490
J7999
11981
11982
11983

Billing Rule

Policy exclusion vs Vivitrol

This policy explicitly does not apply to HCPCS code J2315 (Vivitrol); claims for J2315 should be adjudicated under applicable coverage rules for that product.

J2315
Claims for J2315 should follow applicable coverage rules for Vivitrol