Peptide Therapy & Insurance Billing: A Fun, Fearless Guide for Providers
If you've ever prescribed BPC-157, Semax, or Thymosin Beta-4 and thought, "Patients love this—why doesn't insurance cover it?" you're not alone. The peptide world is booming, but billing rules haven't caught up. The good news? Depending on the peptide, diagnosis, documentation, and payer, some therapies can be billed—legally, ethically, and successfully.
Let's turn confusion into confidence.
First, A Reality Check
Insurance companies are not impressed by patient testimonials. They care about medical necessity, FDA approval, diagnosis alignment, documentation, and coding accuracy. Some peptides already have established billing pathways. Others belong strictly in the cash-pay world. Knowing which is which protects your practice.
Peptides Commonly Covered (or Partially Covered)
These have FDA-approved indications, meaning payers have written coverage policies. Approval is not guaranteed, but it's possible.
- Semaglutide: Type 2 diabetes, obesity
- Tirzepatide: Type 2 diabetes
- Pramlintide: Diabetes
- Testosterone + Gonadorelin: Hypogonadism
- Growth Hormone (Norditropin/Omnitrope): Pediatric GH deficiency, wasting syndromes
- Vitamin D3 injections: Deficiency
- Iron infusions: Anemia
Peptides Almost Never Covered
(Not due to lack of clinical potential—just lack of FDA approval)
- BPC-157
- TB-500
- Epitalon
- Selank
- Semax
- ARA-290
- KPV
- LL-37
- GHK-Cu
These should remain clear, transparent cash-pay offerings. Avoid forcing them through insurance—auditors will notice.
The Golden Rule of Billing Peptides
Bill the diagnosis, not the peptide.
Insurance reimburses based on:
- Why treatment is needed
- What condition exists
- How it affects function, safety, or disease progression
Example ICD-10s:
- E11.9 — Type 2 diabetes, without complications
- E66.01 — Morbid obesity
- E29.1 — Testicular hypofunction
- D50.9 — Iron deficiency anemia
When diagnosis and treatment align, billing becomes far more predictable.
Documentation That Gets Claims Approved
Think like a claims reviewer evaluating medical necessity.
Include:
- Chief complaint
- Relevant history and failed therapies
- Objective data (labs, vitals, imaging, BMI trends)
- Clinical reasoning and treatment justification
- Medication, dosage, route, frequency
- Consent discussion and risks
- Follow-up plan and monitoring
Insurance wants proof that treatment is necessary, evidence-supported, and not elective or experimental.
CPT Codes Commonly Used with Peptide-Related Visits
Choose based on what actually occurred, not based on reimbursement amount.
- Office visit: 99202–99215
- Therapeutic injection (non-chemo): 96372
- IV infusion: 96365–96367
- Therapeutic, prophylactic, diagnostic injection: 96374
- Telehealth follow-up: 99212–99214
Billing Compounded Peptides
If the peptide is compounded, not FDA-approved, or not commercially manufactured:
- Coverage is unlikely
- Expect denials
- Use cash-pay agreements or ABNs
- Document informed consent
Compounding is not a pathway to bypass coverage restrictions.
Prior Authorization Tips That Work
Strengthen approval chances with:
- Lab results
- Documentation of failed therapies
- Specialist notes
- Comorbidity risk factors
- Pharmacy benefit appeal letters
- Weight trend charts for obesity drugs
- Peer-reviewed evidence attached to PA
Provide new information, not just resubmitted claims.
When a Claim Gets Denied
Successful appeals clearly state medical necessity and risk of non-treatment. Include:
- Progress notes
- Diagnostic data
- Medication history
- Updated ICD-10 codes
- Rationale for treatment selection
Appeal only when documentation supports it—insurance rarely reverses without evidence.
A Smart Clinic Strategy
Offer both:
Insurance-billable peptides and therapies:
- Semaglutide for diabetes
- Tirzepatide for diabetes
- Testosterone for hypogonadism
- Iron infusions for anemia
Cash-pay peptides:
- BPC-157
- TB-500
- Epitalon
- Selank
This keeps billing clean, compliant, and profitable—without staff confusion or payer pushback.
Compliance Reminders
- Do not bill off-label use as on-label
- Do not alter ICD-10 codes for coverage
- Do not bill compounded peptides through insurance
- Do not routinely waive copays
- Follow payer medical policies and state laws
Compliance protects your license, your practice, and your patients.
Final Thoughts
Peptide therapy is one of the fastest-growing areas in functional and regenerative medicine. Insurance billing doesn't have to be intimidating. When providers understand coverage criteria, document intentionally, code accurately, and use insurance only when appropriate, peptide therapy can be delivered responsibly and sustainably.
Bill smarter, communicate transparently, and continue advancing patient-centered care.