J9226 — Histrelin implant (supprelin la), 50 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Central Precocious Puberty (initial): Documentation of diagnosis of central precocious puberty (idiopathic or neurogenic); documentation of onset of secondary sexual characteristics by age (females 64; 8 yrs; males 64; 9 yrs); confirmation of diagnosis by one of the following: pubertal basal LH (based on lab reference ranges), a pubertal LH response to a GnRH stimulation test, or bone age advanced one year beyond chronological age.
- Central Precocious Puberty (continuation): Documentation patient is currently receiving therapy for CPP; documentation of positive clinical response to therapy; documentation patient is currently younger than the appropriate time point for onset of puberty (females <11 yrs; males <12 yrs).
- Endometriosis (initial): Documentation of diagnosis or suspected endometriosis; documentation of contraindication/intolerance/failure of BOTH oral contraceptives or depot medroxyprogesterone AND NSAIDs, OR documentation patient had surgical ablation to prevent recurrence; plan stating intended course (initial course limited to 6 months).
Key Coverage Criteria
- Central Precocious Puberty (Fensolvi, Lupron Depot-Ped, Supprelin LA, Triptodur): treatment of central precocious puberty (idiopathic or neurogenic) when criteria are met (see diagnosis/age/confirmation requirements).
- Endometriosis (Lupron Depot, Zoladex): treatment of endometriosis or suspected endometriosis when criteria are met (see prior therapy or surgical ablation requirements).
- Endometrial Thinning/Dysfunctional Uterine Bleeding (Zoladex): endometrial thinning prior to endometrial ablation when criteria are met.
- Fertility Preservation: use of GnRH analogs for fertility preservation in pre-menopausal women receiving a cytotoxic agent associated with causing primary ovarian insufficiency.
- Uterine Leiomyomata (Fibroids) (Lupron Depot): preoperative hematologic improvement for leiomyomata-related anemia unresponsive to iron therapy and/or preoperative size reduction to facilitate surgical procedure.
- Gender Dysphoria in Adolescents: GnRH analogs may be covered for treatment of gender dysphoria in adolescents when comprehensive diagnostic, prescriber, laboratory, psychosocial support, and documentation criteria are met.
4 Active Policies
AETNA-CPB-0079 — Benign Prostatic Hyperplasia
UHC-POL-gonadotropin-releasing-hormone-analogs — Gonadotropin Releasing Hormone Analogs
UMR-POL-UMR-gonadotropin-releasing-hormone-analogs — Gonadotropin Releasing Hormone Analogs
SUREST-POL-SUREST-gonadotropin-releasing-hormone-analogs — Gonadotropin Releasing Hormone Analogs
Related Codes
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