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December 2016 Texas Medicaid Provider Procedures Manual

Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook : 3 Obstetric Services : 3.1 *Services, Benefits, Limitations, and Prior Authorization : 3.1.11 Hydroxyprogesterone Caproate

The following procedure codes may be submitted for hydroxyprogesterone caproate:
The following documentation supporting medical necessity for administration of a hydroxyprogesterone caproate injection must be maintained in the client’s medical record:
Hydroxyprogesterone caproate is limited to a maximum of 21 doses per pregnancy.
Prior authorization is not required for either the compounded or trademarked versions of hydroxyprogesterone caproate for injection (procedure codes J1725 and J1725 U1).
Requests for initiation of the client’s treatment after 20 weeks, 6 days gestation but not beyond 24 weeks gestation will be considered on a case-by-case basis. A prior authorization request must be submitted by the physician to the Special Medical Prior Authorization (SMPA) department with documentation to support the medical necessity of starting treatment at this stage of gestation, and must be approved by the Medical Director.
Procedure code J1725 with and without modifier U1 is restricted to the following payable diagnosis:
Hydroxyprogesterone caproate must be submitted with an NDC. Hydroxyprogesterone caproate is administered intramuscularly at a dose of 250mg once weekly (every 7 days).

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