About this policy
Jurisdiction: JM Part B. States: North Carolina, South Carolina, Virginia, West Virginia. Type: Active LCD
Coverage indications
Luteinizing Hormone-Releasing Hormone (LHRH) Analogs are synthetic analogs of the naturally occurring gonadotropin releasing hormone (GnRH) with greater potency than the naturally occurring hormone, that when given inhibits pituitary gonadotropin secretion and suppresses testicular and ovarian steroidogenesis. Leuprolide acetate (Lupron Depot ® ) , goserelin acetate (Zoladex ® ) , triptorelin pamoate (Trelstar ® ) , histrelin acetate (Vantas ® ) are synthetic LHRH agonists, analogs of the naturally occurring GnRH, and leuprolide mesylate (Camcevi ® ) . They will be covered for Food and Drug Administration (FDA) approved indications. The dose and frequency of administration should be consistent with the FDA approved labeling. Covered Indications Leuprolide Acetate is covered for endometriosis, uterine fibroids, advanced prostate cancer, head and neck cancer (salivary gland tumors), ovarian cancer/fallopian tube cancer/primary peritoneal cancer, premenopausal breast cancer, male breast cancer, central precocious puberty (CPP) and palliative treatment of advanced prostate cancer. 1 Leuprolide mesylate is covered for advanced prostate cancer. 12 The National Comprehensive Cancer Network ® (NCCN) Clinical Practice Guidelines in Oncology for Breast Cancer ® 14 , the NCCN Clinical Practice Guidelines in Oncology for Head and Neck Cancers ® 15 , the NCCN Clinical Practice Guidelines in Oncology for Ovarian Cancer ®16 , and the NCCN Clinical Practice Guidelines in Oncology for Prostate Cancer ®17 are referenced for recommendations for coverage across each of these disease settings. Goserelin implant is covered for locally confined prostate cancer in combination with flutamide; for stage T2b-T4 (stage B2-C) flutamide is recommended only with radiation in this disease setting. Goserelin implant is covered for advanced breast cancer in premenopausal and perimenopausal women, endometriosis, to thin the endometrial lining of the uterus prior to endometrial ablation for dysfunctional uterine bleeding, and palliative treatment of advanced prostate cancer. 2 The NCCN Clinical Practice Guidelines in Oncology for Breast Cancer ® is cited to nationally recognized guidelines to accommodate specific clinical scenarios. 14 The NCCN Clinical Practice Guidelines in Oncology for Prostate Cancer ® is cited to nationally recognized guidelines to accommodate specific clinical scenarios for “advanced prostate cancer.” 17 Triptorelin pamoate is covered for palliative treatment of advanced prostate cancer. 3 The NCCN Clinical Practice Guidelines in Oncology for Prostate Cancer ® is cited to nationally recognized guidelines to accommodate specific clinical scenarios for “advanced prostate cancer.” 17 Histrelin acetate implant is covered for CPP. Note : The NCCN Clinical Practice Guidelines in Oncology for Prostate Cancer ® is cited to nationally recognized guidelines to accommodate specific clinical scenarios for “advanced prostate cancer.” 17 Limitations Services that are not reasonable and necessary cannot be covered by Medicare in the following: The dose and frequency of administration is not consistent with the FDA approved labeling. Doses and frequencies that exceed the FDA recommended dosage/frequency as per the prescribing information, are considered not reasonable and necessary and not covered by Medicare. It is contraindicated to administer these products if you have experienced any type of allergic reaction to these drugs or to any of its ingredients.
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.