Download Gonadotropin-Releasing Hormone Agonists

MEDICAL POLICY
POLICY TITLE
GONADOTROPIN-RELEASING HORMONE AGONISTS AND
ANTAGONISTS
POLICY NUMBER
MP-2.107
Original Issue Date (Created):
July 1, 2002
Most Recent Review Date (Revised):
August 30, 2011
Effective Date:
June 1, 2012- RETIRED
I.
POLICY
GnRH Agonist Therapy
GnRH agonist therapy (e.g. leuprolide acetate, goserelin acetate, histrelin, triptorelin
pamoate) may be considered medically necessary for any one of the following diagnoses:
 Breast cancer, advanced; or
 Central precocious puberty; or
 Endometriosis; or
 Excessive uterine bleeding (e.g. menorrhagia, metrorrhagia and menometrorrhagia),
including treatment of excessive bleeding related to fibroids; or
 Dysmenorrhea, including treatment of pain related to fibroids; or
 Prostate cancer.
Implantable forms of GnRH agonists (e. g. Zoladex®, Viadur™, Vantas™)
for the palliative treatment of advanced prostate cancer may be considered medically
necessary when the following conditions are met:
 A urologist or oncologist is prescribing the treatment;
 Documentation of an initial trial of at least three (3) months of GnRH injections (e.g.
leuprolide acetate, goserelin acetate, and triptorelin pamoate) were effective and well
tolerated.
Histrelin acetate subcutaneous implant (Supprelin LA) may be considered medically
necessary for the treatment of children with central precocious puberty.
The use of GnRh agonists (injectable or implantable) for the treatment of a diagnosis other
than those listed in the policy criteria is considered not medically necessary.
GnRH Antagonist Therapy
GnRH antagonist therapy (e.g. degarelix [Firmagon®]) may be considered medically
necessary for treatment of advanced prostate cancer.
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MEDICAL POLICY
POLICY TITLE
GONADOTROPIN-RELEASING HORMONE AGONISTS AND
ANTAGONISTS
POLICY NUMBER
MP-2.107
II. PRODUCT VARIATIONS
[N] = No product variation, policy applies as stated
[Y] = Standard product coverage varies from application of this policy, see below
[N] Capital Cares 4 Kids
[N] Indemnity
[N] PPO
[N] SpecialCare
[N] HMO
[N] POS
[Y] SeniorBlue HMO*
[Y] FEP PPO**
[Y] SeniorBlue PPO*
* Refer to Highmark Medicare Services Local Coverage Determination (LCD), L27500, Luteinizing
Hormone-Releasing Hormone (LHRH) Analogs, as prescribing provider is not required to be a
urologist or oncologist. Also, documentation of an initial three month trial of GnRH injections is
not required prior to coverage of implantable forms of GnRH agonists.
** The FEP program dictates that all drugs, devices or biological products approved by the U.S. Food
and Drug Administration (FDA) may not be considered investigational. Therefore, FDA-approved
drugs, devices or biological products may be assessed on the basis of medical necessity.
III. DESCRIPTION/BACKGROUND
Gonadotropin releasing hormone (GnRH) is released by the hypothalamus. GnRH is also
known as lutenizing hormone releasing hormone (LHRH). GnRH stimulates the pituitary
gland to release gonadotropins (lutenizing hormone [LH] and follicular stimulating
hormone [FSH]). In females, FSH and LH play a key role in ovulation and estrogen
production. In males, LH stimulates testosterone production.
GnRH Agonists
GnRH agonists (also known as LHRH agonists) are synthetic analogs of gonadotropin
releasing hormones. GnRH agonists block the action of GnRH, thus preventing the release
of LH. Conditions treated by GnRH agonists include estrogen dependent conditions (e.g.
endometriosis, fibroids), precocious puberty and hormonally sensitive cancers (e.g. breast,
prostate). GnRH agonists are also used for the off-label treatment of excessive uterine
bleeding (e.g. menorrhagia, metrorrhagia and menometrorrhagia) and dysmenorrhea in
women who have contraindications to other medical therapy. GnRH agonists are available
as injectables or long-acting implants and include leuprolide acetate (Lupron®, Eligard®,
Viadur™), goserelin acetate (Zoladex®), histrelin (Vantas™) and triptorelin pamoate
(Trelstar™).
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MEDICAL POLICY
POLICY TITLE
GONADOTROPIN-RELEASING HORMONE AGONISTS AND
ANTAGONISTS
POLICY NUMBER
MP-2.107
Goserelin acetate (Zoladex®) is available as a monthly and a 3-month implant that is
administered by subcutaneous injection into the anterior abdominal wall.
Leuprolide acetate is available as an injectable suspension (Eligard®) that may be given
subcutaneously monthly, every three months, every four months or every six months, and
as a long-acting depot formulation (Lupron® Depot) that is administered intramuscularly
on a monthly, every three months, or every four months basis. The leuprolide acetate
implant (Viadur™) is a once-yearly implant for the palliative treatment of advanced
prostate cancer. It is a drug-filled, miniature titanium implant that is placed under the skin
in the inner aspect of the upper arm via an in-office surgical procedure.
Vantas™, (histrelin acetate) is a once-yearly diffusion-controlled reservoir drug delivery
system implant for the palliative treatment of advanced prostate cancer Histrelin implant
can be inserted into the inner aspect of the upper arm within the physician’s office setting.
Supprelin LA (histrelin acetate) is a once yearly subcutaneous implant for the treatment
of central precocious puberty (CPP). CCP develops when the hypothalamus releases
GnRH and activates the hypothalamic-pituitary gonadal (HPG) axis (or puberty) early.
Triptorelin pamoate (Trelstar™ Depot, Trelstar™ LA) is a long-acting formula for the
palliative treatment of advanced prostate cancer administered every four (Depot) or twelve
weeks (LA) as a single intramuscular injection.
When given to males, GnRH agonists produce “chemical castration”, with a drop in
testosterone production. Since prostate tumors require testosterone to grow, reducing the
testosterone level helps prevent further growth and spread of the cancer. When initially
treating prostate cancer, GnRH agonists can be given in conjunction with an oral
antiandrogen (e.g. flutamide [Eulexin], bicalutamide [Casodex] and nilutamide
[Nilandron]). Antiandrogens prevent disease flare-ups, which are characterized by tumor
growth or an increase in pain related to bone metastases.
GnRH Antagonists
Gonadotropin-releasing hormone (GnRH) antagonists block GnRH receptors located on the
surfaces of gonadotroph cells in the anterior pituitary, thereby reducing secretion of
luteinizing hormone (LH) by pituitary gonadotroph cells and so decreasing testosterone
production by interstitial (Leydig) cells in the testes. Testosterone levels do not exhibit an
initial surge, or flare, as is typical with GnRH agonists.
Degarelix (Firmagon®) is a GnRH antagonist approved by the FDA for the treatment of
advanced prostate cancer. The recommended dosing schedule is an initial loading dose of
240 mg and maintenance dosing of 80 mg every 28 days. It is administered subcutaneously
by a healthcare professional.
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MEDICAL POLICY
POLICY TITLE
GONADOTROPIN-RELEASING HORMONE AGONISTS AND
ANTAGONISTS
POLICY NUMBER
MP-2.107
IV. DEFINITIONS
AGONIST refers to a drug that has affinity for and stimulates physiologic activity at cell
receptors normally stimulated by naturally occurring substances.
ANDROGEN is the general term for any male sex hormone.
ANTAGONIST refers to a drug that binds to a cell receptor without eliciting a biological
response.
DYSMENORRHEA refers to pain associated with menstruation.
ENDOMETRIOSIS is an abnormal gynecologic condition characterized by ectopic growth
and function of endometrial tissue.
FOLLICLE-STIMULATING HORMONE (FSH) is a gonadotropin that stimulates the growth
and maturation of graafian follicles in the ovary and promotes spermatogenesis in the male.
It is secreted by the anterior pituitary gland.
GONADOTROPIN is a hormone capable of promoting gonadal (i.e. ovarian or testicular)
growth and function.
LUTEINIZING HORMONE (LH) is a glycoprotein hormone produced by the anterior
pituitary gland. It stimulates the secretion of the sex hormones by the ovary and the testes
and is involved in the maturation of spermatozoa and ova.
MENOMETRORRHAGIA is excessive bleeding during and between menstrual periods.
MENORRHAGIA is menstrual bleeding that is excessive in number of days or amount of
blood, or both.
METRORRHAGIA is intermenstrual bleeding.
PRECOCIOUS PUBERTY is an abnormally early development of sexual maturity. It is
usually marked by early breast development and ovulation in girls before eight (8) years of
age and the production of mature sperm in boys before ten (10) years of age.
V. BENEFIT VARIATIONS
The existence of this medical policy does not mean that this service is a covered benefit
under the member’s contract. Benefit determinations should be based in all cases on the
applicable contract language. Medical policies do not constitute a description of benefits.
A member’s individual or group customer benefits govern which services are covered,
which are excluded, and which are subject to benefit limits and which require
preauthorization. Members and providers should consult the member’s benefit information
or contact Capital for benefit information.
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MEDICAL POLICY
POLICY TITLE
GONADOTROPIN-RELEASING HORMONE AGONISTS AND
ANTAGONISTS
POLICY NUMBER
MP-2.107
VI. DISCLAIMER
Capital’s medical policies are developed to assist in administering a member’s benefits, do not
constitute medical advice and are subject to change. Treating providers are solely responsible for
medical advice and treatment of members. Members should discuss any medical policy related to
their coverage or condition with their provider and consult their benefit information to determine if
the service is covered. If there is a discrepancy between this medical policy and a member’s benefit
information, the benefit information will govern. Capital considers the information contained in
this medical policy to be proprietary and it may only be disseminated as permitted by law.
VII. REFERENCES
Abraham J. Degarelix, a new GnRH antagonist, in prostate cancer. Commun Oncol 2009;6:197201.
Bulun S. Endometriosis. N Engl J Med 2009; 360:268-79.
CenterWatch Clinical Trials Listing Service. Drugs Approved by the FDA: Supprelin LA (histrelin
acetate). Updated May 17, 2007. [Website]:
http://www.centerwatch.com/patient/drugs/dru950.html. Accessed June 1, 2011.
Cuzick J, Ambroisine L, Davidson N, et al. Use of luteinising-hormone-releasing hormone agonists
as adjuvant treatment in premenopausal patients with hormone-receptor-positive breast cancer:
Ameta-analysis of individual patient data from randomised adjuvant trials. Lancet. 2007;369:17111723.
Dawson N. Overview of treatment for advanced prostate cancer. In: UpToDate Online Journal
[serial online]. Waltham, MA: UpToDate; updated July 30, 2009. [Website]: www.uptodate.com.
Accessed March 30, 2010.
D'Amico A. Global update on defining and treating high-risk localized prostate cancer with
leuprorelin: a USA perspective--identifying men at diagnosis who are at high risk of prostate
cancer death after surgery or radiation therapy. BJU International 2007;99 Suppl 1:13-6;
discussion 17-8.
ECRI Forecast. First new prostate cancer drug in years approved by FDA. 1/15/2009.
Ellis M, Hayes D, Naughton M. Endocrine therapy of metastatic breast cancer. In: UpToDate
Online Journal [serial online]. Waltham, MA: UpToDate; updated February 17, 2011. [Website] :
www.uptodate.com . Accessed June 1, 2011.
Engel JB, Schally AV. Drug Insight: clinical use of agonists and antagonists of luteinizinghormone-releasing hormone. Nature Clinical Practice. Endocrinology & Metabolism
2007;3(2):157-67.
Eusgter EA, Clark W, et al. Efficacy and Safety of Hisrtrelin Subdermal Implant in children with
Central Precocious Puberty: A Multicenter Trial. J Clin Endocrin Metabolism. 2007
May;92(5):1697-704.
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MEDICAL POLICY
POLICY TITLE
GONADOTROPIN-RELEASING HORMONE AGONISTS AND
ANTAGONISTS
POLICY NUMBER
MP-2.107
Firmagon prescribing information. Firmagon [Website]: http://www.firmagon.us/us/us-homeg/pclhomeg/accessser/0/261/0/default.html. Accessed June 1, 2011.French L. Dysmenorrhea. Am Fam
Physician. 2005 Jan 15;71(2):285-91.
Highmark Medicare Services Local Coverage Determination (LCD), L27500, Luteinizing
Hormone-Releasing Hormone (LHRH) Analogs Effective 02/21/11. [Website]:
https://www.highmarkmedicareservices.com/policy/mac-ab/l27500-r6.html
Accessed June 1, 2011.
Hirsch HJ, Gillis D, Strich D, et al. The histrelin implant: A novel treatment for central precocious
puberty. Pediatrics. 2005;116(6):e798-e802.
Hompes PG, Mijatovic V. Endometriosis: the way forward. Gynecological Endocrinology
2007;23(1):5-12.
Hornstein M, Gibbons W. Gonadotropin releasing hormone agonists for long term treatment of
endometriosis. In: UpToDate Online Journal [serial online]. Waltham, MA: UpToDate; updated
January 6, 2011. [Website]: www.uptodate.com. Accessed June 1, 2011.
Kaufmann M, et al. A randomised trial of goserelin versus control after adjuvant, risk-adapted
chemotherapy in premenopausal patients with primary breast cancer - GABG-IV B-93. European
Journal of Cancer 2007;43(16):2351-8.
Klotz L, Boccon-Gibod L, Shore ND, et al. The efficacy and safety of degarelix: a 12-month,
comparative, randomized, open-label, parallel-group phase III study in patients with prostate
cancer.BJU Int. 2008 Dec;102(11):1531-8.
Lee R, Smith M. Initial hormone therapy for metastatic prostate cancer. In: UpToDate Online
Journal [serial online]. Waltham, MA: UpToDate; updated September 20, 2010. [Website]:
www.uptodate.com. Accessed June 1, 2011.
Lu-Yao G, Moore DF, Oleynick JU, DiPaola RS, Yao SL. Population based study of hormonal
therapy and survival in men with metastatic prostate cancer. Journal of Urology 2007;177(2):5359.
Mosby’s Medical, Nursing, & Allied Health Dictionary, 6th edition.
Nanda A, Chen MH, Moran BJ, et al. Total androgen blockade versus a luteinizing hormonereleasing hormone agonist alone in men with high-risk prostate cancer treated with radiotherapy.
Int J Radiat Oncol Biol Phys. 2010 Apr;76(5):1439-44.
National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology.
Prostate Cancer. V.1.2010. [Website]: www.nccn.org. Accessed June 1, 2011.
National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology.
Breast Cancer. V.2.2010. [Website]: www.nccn.org. Accessed June 1, 2011.
National Institute for Health and Clinical Excellence (NICE): National Collaborating Centre for
Women’s and Children’s Health. Heavy menstrual bleeding. Clinical Guideline CG44. London,
UK: NICE; January 2007. [Website]:
http://www.nice.org.uk/nicemedia/pdf/CG44FullGuideline.pdf Accessed June 1, 2011.
Pilepich MV, Winter K, Lawton CA, Krisch RE, Wolkov HB et al. Androgen suppression adjuvant
to definitive radiotherapy in prostate carcinoma-–long term results of phase III RTOG 85-31. Int J
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MEDICAL POLICY
POLICY TITLE
GONADOTROPIN-RELEASING HORMONE AGONISTS AND
ANTAGONISTS
POLICY NUMBER
MP-2.107
Radiat Oncol Biol Phys 2005; 61 (5): 1285-90.Roach M, et al. Short-term neoadjuvant androgen
deprivation therapy and external-beam radiotherapy for locally advanced prostate cancer: longterm results of RTOG 8610. Journal of Clinical Oncology 2008;26(4):585-91.
Saenger P. Overview of precocious puberty. In: UpToDate Online Journal [serial online].
Waltham, MA: UpToDate; updated October 5, 2011[Website] : www.uptodate.com . Accessed
June 1, 2011.
Sesti F, et al. Hormonal suppression treatment or dietary therapy versus placebo in the control of
painful symptoms after conservative surgery for endometriosis stage III-IV. A randomized
comparative trial. Fertility and Sterility 2007;88(6):1541-7.
Supprelin LA prescribing information. Supprelin LA [Website]:
http://www.supprelinla.com/endocrinologists/index.html Accessed June 1, 2011.
Taber’s Cyclopedic Medical Dictionary, 20th edition.
U.S. National Institutes of Health. National Cancer Institutes (NCI) Drug Dictionary. [Website]:
http://www.cancer.gov/drugdictionary/ Accessed June 1, 2011.
Van Voorhis B. A 41-Year-Old Woman With Menorrhagia, Anemia, and Fibroids: Review of
Treatment of Uterine Fibroids. JAMA. 2009;301(1):82-93.
Welt C. Physiology of gonadotropin-releasing hormone. In: UpToDate Online Journal [serial
online]. Waltham, MA: UpToDate; updated February 11, 2011. [Website]: www.uptodate.com .
Accessed April 2, 2010.
Wilson AC, Meethal SV, Bowen RL, Atwood CS. Leuprolide acetate: a drug of diverse clinical
applications. Expert Opinion on Investigational Drugs 2007;16(11):1851-63.
Zacur H. Chronic menorrhagia or anovulatory bleeding. In: UpToDate Online Journal [serial
online]. Waltham, MA: UpToDate; updated September 27, 2010. [Website] : www.uptodate.com .
Accessed June 1, 2011.
VIII. CODING INFORMATION
Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The
identification of a code in this section does not denote coverage as coverage is determined
by the terms of member benefit information. In addition, not all covered services are
eligible for separate reimbursement.
Covered when medically necessary:
CPT Codes ®
11981
11982
11983
Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved.
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MEDICAL POLICY
POLICY TITLE
GONADOTROPIN-RELEASING HORMONE AGONISTS AND
ANTAGONISTS
POLICY NUMBER
MP-2.107
HCPCS
Code
Description
J1675
J1950
J3315
J9155
J9202
INJECTION, HISTRELIN ACETATE, 10 MCG
INJECTION, LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), PER 3.75 MG
INJECTION, TRIPTORELIN PAMOATE, 3.75 MG
INJECTION, DEGARELIX, 1 MG
GOSERELIN ACETATE IMPLANT, PER 3.6 MG
J9217
J9218
J9219
J9225
J9226
S9560
LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG
LEUPROLIDE ACETATE, PER 1 MG
LEUPROLIDE ACETATE IMPLANT, 65 MG
HISTRELIN IMPLANT (VANTAS), 50 MG
HISTRELIN IMPLANT (SUPPRELIN LA), 50 MG
HOME INJECTABLE THERAPY; HORMONAL THERAPY DIEM
ICD-9-CM
Diagnosis
Code*
Description
174.0 – 174.9
185.
189.3
198.1
198.5
MALIGNANT NEOPLASM OF FEMALE BREAST
MALIGNANT NEOPLASM OF PROSTATE
MALIGNANT NEOPLASM OF URETHRA
SECONDARY MALIGNANT NEOPLASM OF OTHER URINARY ORGANS
SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW
198.81
198.82
218.0
218.1
218.2
218.9
SECONDARY MALIGNANT NEOPLASM OF BREAST
SECONDARY MALIGNANT NEOPLASM OF GENITAL ORGANS
SUBMUCOUS LEIOMYOMA OF UTERUS
INTRAMURAL LEIOMYOMA OF UTERUS
SUBSEROUS LEIOMYOMA OF UTERUS
LEIOMYOMA OF UTERUS, UNSPECIFIED
233.4
255.2
259.1
617.0 – 617.9
625.3
626.2
CARCINOMA IN SITU OF PROSTATE
ADRENOGENITAL DISORDERS
PRECOCIOUS SEXUAL DEVELOPMENT AND PUBERTY, NOT ELSEWHERE CLASSIFIED
ENDOMETRIOSIS
DYSMENORRHEA
EXCESSIVE OR FREQUENT MENSTRUATION
626.3
626.6
PUBERTY BLEEDING
METRORRHAGIA
OTHER DISORDER OF MENSTRUATION AND OTHER ABNORMAL BLEEDING FROM
FEMALE GENITAL TRACT
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626.8
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MEDICAL POLICY
POLICY TITLE
GONADOTROPIN-RELEASING HORMONE AGONISTS AND
ANTAGONISTS
POLICY NUMBER
MP-2.107
ICD-9-CM
Diagnosis
Code*
Description
627.0
V10.3
PREMENOPAUSAL MENORRHAGIA
PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BREAST
V10.46
PERSONAL HISTORY OF MALIGNANT NEOPLASM OF PROSTATE
*If applicable, please see Medicare LCD or NCD for additional covered diagnoses.
The following ICD-10 diagnosis codes will be effective October 1, 2013:
ICD-10-CM
Diagnosis
Code*
Description
C50.012
C50.011
C50.019
C50.112
C50.111
C50.119
C50.212
C50.211
C50.219
C50.312
C50.311
C50.319
C50.412
C50.411
C50.419
C50.512
C50.511
C50.519
C50.612
C50.611
C50.619
C50.812
C50.811
C50.819
C50.912
C50.911
Malignant neoplasm of nipple and areola, left female breast
Malignant neoplasm of nipple and areola, right female breast
Malignant neoplasm of nipple and areola, unspecified female breast
Malignant neoplasm of central portion of left female breast
Malignant neoplasm of central portion of right female breast
Malignant neoplasm of central portion of unspecified
Malignant neoplasm of upper-inner quadrant of left female breast
Malignant neoplasm of upper-inner quadrant of right female breast
Malignant neoplasm of upper-inner quadrant of unspecified
Malignant neoplasm of lower-inner quadrant of left female breast
Malignant neoplasm of lower-inner quadrant of right female breast
Malignant neoplasm of lower-inner quadrant of unspecified female breast
Malignant neoplasm of upper-outer quadrant of left female breast
Malignant neoplasm of upper-outer quadrant of right female breast
Malignant neoplasm of upper-outer quadrant of unspecified female breast
Malignant neoplasm of lower-outer quadrant of left female breast
Malignant neoplasm of lower-outer quadrant of right
Malignant neoplasm of lower-outer quadrant of unspecified female breast
Malignant neoplasm of axillary tail of left female breast
Malignant neoplasm of axillary tail of right female breast
Malignant neoplasm of axillary tail of unspecified female breast
Malignant neoplasm of overlapping sites of left female breast
Malignant neoplasm of overlapping sites of right female breast
Malignant neoplasm of overlapping sites of unspecified female breast
Malignant neoplasm of unspecified site of left female breast
Malignant neoplasm of unspecified site of right female breast
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MEDICAL POLICY
POLICY TITLE
GONADOTROPIN-RELEASING HORMONE AGONISTS AND
ANTAGONISTS
POLICY NUMBER
MP-2.107
ICD-10-CM
Diagnosis
Code*
Description
C50.919
C61
C68.0
C79.11
C79.19
C79.10
C79.51
C79.52
C79.81
C79.82
D25.0
D25.1
D25.2
D25.9
D07.5
E25.9
E25.0
E25.8
E30.8
E30.1
N80.0
N80.1
N80.2
N80.3
N80.4
N80.5
N80.6
N80.8
N80.9
N94.6
N94.4
N94.5
N92.0
N92.2
N92.1
N89.7
N93.8
N92.5
Malignant neoplasm of unspecified site of unspecified female breast
Malignant neoplasm of prostate
Malignant neoplasm of urethra
Secondary malignant neoplasm of bladder
Secondary malignant neoplasm of other urinary organs
Secondary malignant neoplasm of unspecified urinary organs
Secondary malignant neoplasm of bone
Secondary malignant neoplasm of bone marrow
Secondary malignant neoplasm of breast
Secondary malignant neoplasm of genital organs
Submucous leiomyoma of uterus
Intramural leiomyoma of uterus
Subserosal leiomyoma of uterus
Leiomyoma of uterus, unspecified
Carcinoma in situ of prostate
Adrenogenital disorder, unspecified
Congenital adrenogenital disorders associated with enzyme deficiency
Other adrenogenital disorders
Other disorders of puberty
Precocious puberty
Endometriosis of uterus
Endometriosis of ovary
Endometriosis of fallopian tube
Endometriosis of pelvic peritoneum
Endometriosis of rectovaginal septum and vagina
Endometriosis of intestine
Endometriosis in cutaneous scar
Other endometriosis
Endometriosis, unspecified
Dysmenorrhea, unspecified
Primary dysmenorrhea
Secondary dysmenorrhea
Excessive and frequent menstruation with regular cycle
Excessive menstruation at puberty
Excessive and frequent menstruation with irregular cycle
Hematocolpos
Other specified abnormal uterine and vaginal bleeding
Other specified irregular menstruation
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MEDICAL POLICY
POLICY TITLE
GONADOTROPIN-RELEASING HORMONE AGONISTS AND
ANTAGONISTS
POLICY NUMBER
MP-2.107
ICD-10-CM
Diagnosis
Code*
Description
N92.4
Z85.3
Z85.46
Excessive bleeding in the premenopausal period
Personal history of malignant
Personal history of malignant neoplasm of prostate
*If applicable, please see Medicare LCD or NCD for additional covered diagnoses.
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MEDICAL POLICY
POLICY TITLE
GONADOTROPIN-RELEASING HORMONE AGONISTS AND
ANTAGONISTS
POLICY NUMBER
MP-2.107
IX. POLICY HISTORY
MP 2.107
CAC 6/29/04
CAC 10/26/04
CAC 3/29/05
CAC 8/30/05
CAC 6/27/06
CAC 3/27/07
CAC 7/29/08
J12 MAC 12/12/08
CAC 3/31/09
CAC 5/25/10 Added medical necessity criteria for GnRH antagonists (degarelix).
Removed policy criteria for androgen blockade. Retitled policy.
CAC 7/26/11 Consensus
Policy approved for retirement effective 6/1/2012.
Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance
Company® and Keystone Health Plan® Central. Independent licensees of the Blue Cross and Blue Shield Association.
Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all
companies.
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