Highmark Commercial Medical Policy - Pennsylvania

Medical Policy: I-160-005
Topic: Buprenorphine (Probuphine®) Implant for Treatment of Opioid Dependence
Section: Injections
Effective Date: July 1, 2018
Issue Date: July 2, 2018
Last Reviewed: March 2017

Buprenorphine is a partial μ-opioid agonist used with or without naloxone, an opioid antagonist, via transmucosal delivery to treat patients with opioid dependence (or a moderate-to-severe opioid use disorder). Buprenorphine (Probuphine) is an implant to provide sustained delivery of buprenorphine for up to six (6) months when four (4) rods are inserted subdermally. It is intended as a maintenance treatment for a selected subgroup of opioid-dependent patients who are clinically stable on a low dose of transmucosal buprenorphine (less than or equal to 8 mg/d).

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

Buprenorphine implants may be considered medically necessary for the treatment of opioid dependence when an individual is greater than or equal to 16 years of age and has met ALL of the following criteria:

* Food and Drug Administration indications specify that maintenance doses should not be tapered to a lower dose for the sole purpose of transitioning to buprenorphine implants.

Initial treatment  consist of inserting up to four (4) buprenorphine implants may be considered medically necessary for six (6) months. Implants must be removed at the end of the six (6) months following insertion.

If indicated, a second set of buprenorphine implants may be considered medically necessary and placed in the contralateral arm when the criteria above are met.  The second set of implants must be removed at the end of the second six (6) month treatment period.

Retreatment with buprenorphine implant after a prior 12-month treatment period is considered experimental/investigational and therefore, non-covered. Scientific evidence does not support the use of buprenorphine implant after a 12-month treatment period.

Individuals can be transitioned back to transmucosal buprenorphine-containing medications for continued treatment after 12 months as needed.

Buprenorphine implants are considered experimental/investigational and ,therefore, non-covered for all other indications. Scientific evidence does not support the use of buprenorphine implant for any other indication.

Procedure Codes
11981, 11982, 11983, G0516, J0570, Q9991, Q9992

NOTE: Dosage recommendations per the FDA label. 

Refer to medical policy I-92 Naltrexone for Treatment of Alcohol and Opioid Dependence for further information.

Refer to medical policy L-102 Drug Testing in Pain Management and Substance Abuse Treatment for further information.

Refer to medical policy Y-22 Opioid dependence Therapy for further information.

Refer to pharmacy policy J-331 Opioid Dependence Therapy for further information.

Place of Service: Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Buprenorphine (Probuphine) implant for treatment of opioid dependence is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business

Denial Statements

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.


Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer: If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.