01/02/2024
| This version of the policy will become effective 01/02/2024. The following policy criteria have been added to this policy:
- The noncontraceptive use of a levonorgestrel-releasing intrauterine system (LNG-IUS) (Liletta) for the treatment of heavy menstrual bleeding for up to 5 years in individuals who chose intrauterine contraception as their method of contraception
- LNG-IUS (Liletta) as an alternative delivery system to protect against endometrial intraepithelial
neoplasia (endometrial
hyperplasia) in women who are under 65 years of age and currently
receiving menopausal estrogen therapy
- The use of LNG-IUS (Mirena, Liletta) as second-line treatment for endometriosis
The following section was removed from the policy: Discussion of indications for removal of the LNG-IUS
The following ICD-10 codes have been added to this policy: N80.00, N80.01, N80.02, N80.03, N80.101, N80.102, N80.103, N80.109, N80.111, N80.112, N80.113, N80.119, N80.12, N80.121, N80.122, N80.123, N80.129, N80.201, N80.202, N80.203, N80.209, N80.211, N80.212, N80.213, N80.219, N80.22, N80.221, N80.222, N80.223, N80.229, N80.30, N80.311, N80.312, N80.319, N80.321, N80.322, N80.329, N80.331, N80.332, N80.333, N80.339, N80.341, N80.342, N80.343, N80.349, N80.351, N80.352, N80.353, N80.359, N80.361, N80.362, N80.363, N80.369, N80.371, N80.372, N80.373, N80.379, N80.381, N80.382, N80.383, N80.389, N80.391, N80.392, N80.399, N80.3A1, N80.3A2, N80.3A3, N80.3A9, N80.3B1, N80.3B2, N80.3B3, N80.3B9, N80.3C1, N80.3C2, N80.3C3, N80.3C9, N80.40, N80.41, N80.42, N80.50, N80.511, N80.512, N80.519, N80.521, N80.522, N80.529, N80.531, N80.532, N80.539, N80.541, N80.542, N80.549, N80.551, N80.552, N80.559, N80.561, N80.562, N80.569, N80.6, N80.8, N80.9
The following ICD-10 codes have been removed from this policy: T83.31XA, T83.31XD, T83.31XS, T83.32XA, T83.32XD, T83.32XS, T83.39XA, T83.39XD, T83.39XS, T83.69XA, T83.69XD, T83.69XS, T83.79XA, T83.79XD, T83.79XS, T83.81XA, T83.81XD, T83.81XS, T83.82XA, T83.82XD, T83.82XS, T83.83XA, T83.83XD, T83.83XS, T83.84XA, T83.84XD, T83.84XS, T83.86XA, T83.86XD, T83.86XS, T83.89XA, T83.89XD, T83.89XS, T83.9XXA, and Z33.1
|