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Medical Policy: 02.04.05
Original Effective Date: May 1998
Reviewed: May 2012
Revised:
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Salivary hormone tests measure the biologically active fraction of female hormones in the blood stream. Many proponents use this test to identify female hormone levels in perimenopausal women to initiate hormone replacement therapy. Baseline measurements of hormone levels in saliva may provide an assessment of climacteric changes for the peri- and post-menopausal woman. This test was designed to monitor the titration of individual hormone dosage.
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Prior Approval:
Not applicable
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Policy:
Salivary tests for management of hormone replacement therapy are considered investigational. The available evidence does not support the test's clinical efficacy.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- S3650 Saliva test, hormone level; during menopause.
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Selected References:
- Lewis, J.G., McGill, H., Patton, V.M., Elder, P.A. Caution on the use of saliva measurements to monitor absorption of progesterone from transdermal creams in postmenopausal women. Maturitas 2002; 41:1-6.
- Wren, B.G., McFarland, K., Edwards, L., O’Shea, P., Sufi, S., Gross, B., Eden, J.A. Effect of sequential transdermal progesterone cream on endometrium bleeding pattern, and plasma progesterone and salivary progesterone levels in postmenopausal women. Climactric 2000; 3:155-160.
- O’Leary, P., Feddema, P., Chan, K., Taranto, M., Sith, M., Evans, S. Salivary, but not serum or urinary levels of progesterone are elevated after topical application of progesterone cream to pre-and postmenopausal women. Clinical Endocrinology 2000; 53:615-620.
- Griscgek, M., Wagner, R., Tauh, M., Dorr, H.G. Stability of salivary steroids: the influences of storage, food and dental care. Steroids 2001; 66:737-741.
- Kaufman E, Lamster IB. The diagnostic applications of saliva--a review. Crit Rev Oral Biol Med. 2002;13(2):197-212.
- Warren MP, Stanczyk FZ. Custom-compounded hormone therapy: Is there science to support the claims? Council on Hormone Education, University of Wisconsin Medical School, Newsletter 2004, Vol. 2 No. 4.
- Institute for Clinical Systems Improvement (ICSI). Menopause and hormone therapy (HT): collaborative decision-making and management. 2006 Oct.
- AACE Menopause Guidelines Revision Task Force. Medical guidelines for clinical practice for the diagnosis and management of menopause. American Association of Clinical Endocrinologists. Endocrine Practice 2006; 12(3).
- ACOG Committee on Gynecologic Practice. ACOG Committee Opinion #322: Compounded bioidentical hormones. Obstet Gynecol. 2005 Nov;106(5 Pt 1):1139-40.
- ECRI Institute. Accuracy of Salivary Hormone Tests Compared to Serum Hormone Tests. Plymouth Meeting (PA): ECRI Institute; 2009 Sept 29. 10p. [ECRI hotline response]. Also available: http://www.ecri.org.
- ECRI. Salivary Hormone Tests for Menopause and Aging in Adult Women. Plymouth Meeting (PA): ECRI Health Technology Assessment Information Service; 2011 July 25. [Hotline Response]. Also available: http://www.ecri.org.
- ECRI. Accuracy of Salivary Hormone Tests Compared to Serum Hormone Tests. Plymouth Meeting (PA): ECRI Health Technology Assessment Information Service; 2011 July 25. [Hotline Response]. Also available: http://www.ecri.org.
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Policy History:
Date Reason Action
June 2011 Annual review Policy renewed
May 2012 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.
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