This policy version was replaced on March 28, 2022. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).
Approximately 12 percent of births in the United States are preterm, which is the leading cause of perinatal morbidity and mortality. A variety of measures to prevent preterm birth have been investigated including the use of progesterone in the form of 17 alpha-hydroxyprogesterone caproate (17P) administered by injection or vaginal suppository. 17P products are available through compounding pharmacies. Also, a synthetic hydroxyprogesterone caproate solution has been approved by the FDA. The product, Makena™, is indicated to reduce preterm birth in women with a singleton pregnancy who have a history of singleton spontaneous preterm birth. It is not intended for use in women with multiple gestations or in women with other risk factors for preterm birth. Makena™ is administered by either intramuscular or subcutaneous injection.
I. For women with a singleton pregnancy and prior history of spontaneous preterm birth before 37 weeks gestation, the following may be considered MEDICALLY NECESSARY AND APPROPRIATE:
II. For women with a singleton pregnancy and a short cervix (less than 20 mm) the following may be considered MEDICALLY NECESSARY AND APPROPRIATE:
III. Progesterone therapy as a technique to prevent preterm delivery is considered EXPERIMENTAL/INVESTIGATIVE in pregnant women with other risk factors for preterm delivery including but not limited to the following:
J1726 J1729 J2675 J3490
No additional statements.
Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.
Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.
Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites.
Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.
Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.
These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Acknowledgements:
CPT® codes copyright American Medical Association® 2022. All rights reserved.
CDT codes copyright American Dental Association® 2022. All rights reserved.
