Clinical UM Guideline


Subject:  Gonadotropin Releasing Hormone (GnRH) Analogs
Guideline #:  CG-DRUG-15Current Effective Date:  05/11/2015
Status:RevisedLast Review Date:  05/07/2015

Description

Gonadotropin releasing hormone (GnRH) analogs are synthetic analogs of naturally occurring GnRH.   

The following agents are addressed in this document: 

Note: This document does not address infertility treatment. Please see the following document for additional information:

Clinical Indications

I.   Breast Cancer–Goserelin acetate or leuprolide acetate

Medically Necessary: 

Goserelin acetate or leuprolide acetate is considered medically necessary for the treatment of men and pre- or peri-menopausal women with hormone receptor positive breast cancer. 

Not Medically Necessary: 

Goserelin acetate or leuprolide acetate is considered not medically necessary for the treatment of breast cancer when the criteria above are not met.

II.   Ovarian Cancer (including fallopian tube cancer and primary peritoneal cancer)–Leuprolide acetate 

Medically Necessary: 

Leuprolide acetate is considered medically necessary for ovarian cancer when any of the following are met:

Not Medically Necessary: 

Leuprolide acetate is considered not medically necessary for ovarian cancer when the criteria above are not met.

III.   Prostate Cancer-Degarelix, goserelin acetate, histrelin acetate (Vantas), leuprolide acetate, or triptorelin pamoate 

Medically Necessary: 

  1. Degarelix, goserelin acetate, histrelin acetate (Vantas), leuprolide acetate, or triptorelin pamoate is considered medically necessary for the treatment of prostate cancer when any of the following indications are met:
    • Clinically localized disease* with intermediate (T2b to T2c cancer, Gleason score of 7, or prostate specific antigen (PSA) value of 10-20 ng/mL) or higher risk of recurrence as neoadjuvant therapy with radiation therapy or cryosurgery; or
    • Following radical prostatectomy as adjuvant therapy when lymph node metastases are present; or
    • Locally advanced disease*; or
    • Other advanced*, recurrent, or metastatic* disease.

*See definition section below for description of term.

Not Medically Necessary: 

Degarelix, goserelin acetate, histrelin acetate (Vantas), leuprolide acetate, or triptorelin pamoate is considered not medically necessary for treatment of prostate cancer when the criteria above are not met. 

IV.   Central Precocious Puberty- Leuprolide acetate (Lupron Depot-Ped), nafarelin acetate, or histrelin acetate subcutaneous implant (Supprelin LA) 

Medically Necessary: 

Leuprolide acetate (Lupron Depot-Ped), nafarelin acetate or histrelin acetate subcutaneous implant (Supprelin LA) is considered medically necessary for the treatment of children known to have central precocious puberty (defined as the beginning of secondary sexual characteristics before age 8 in girls and 9 in boys)*.

*See discussion section below for additional information. 

Not Medically Necessary: 

Leuprolide acetate (Lupron Depot-Ped), nafarelin acetate or Supprelin LA (histrelin acetate subcutaneous implant) is considered not medically necessary for the treatment of central precocious puberty when the criteria above are not met. 

V.   Gynecology Uses-Goserelin acetate, leuprolide acetate, leuprolide acetate for depot suspension and norethindrone (Lupaneta Pack), or nafarelin acetate 

Medically Necessary: 

  1. Goserelin acetate, leuprolide acetate or nafarelin acetate is considered medically necessary when any of the following indications are met:
    • Chronic pelvic pain (noncyclical pain lasting 6 or more months that localizes to the anatomic pelvis, anterior abdominal wall at or below the umbilicus, the lumbosacral back, or the buttocks, and is of sufficient severity to cause functional disability or lead to medical care [ACOG, 2004])-not to continue beyond 3 months if there is no symptomatic relief; or
    • To induce amenorrhea in women in certain populations, including menstruating women diagnosed with severe thrombocytopenia or aplastic anemia.
  2. Goserelin acetate is considered medically necessary for any of the following additional indications:
    • Endometriosis (duration of treatment limited to 6 months); or
    • Dysfunctional uterine bleeding; or
    • Endometrial thinning prior to endometrial ablation for dysfunctional uterine bleeding (3.6 mg implant only).
  3. Leuprolide acetate is considered medically necessary for any of the following additional indications:
    • Initial treatment of endometriosis (duration of treatment limited to 6 months); or
    • Retreatment of endometriosis (duration of treatment limited to 6 months); or
    • Preoperative treatment as adjunct to surgical treatment of uterine fibroids (leiomyoma uteri). May be used to reduce size of fibroids to allow for a vaginal procedure; or
    • Prior to surgical treatment (myomectomy or hysterectomy) in individuals with documented anemia.
  4. Leuprolide acetate for depot suspension and norethindrone acetate tablets (Lupaneta Pack) is considered medically necessary for any of the following indications:
    • Initial treatment of endometriosis (duration of treatment limited to 6 months); or
    • Retreatment of endometriosis (duration of treatment limited to 6 months).
  5. Nafarelin acetate is considered medically necessary for the following additional indication:
    • Endometriosis (duration of treatment limited to 6 months).

Not Medically Necessary: 

Goserelin acetate, leuprolide acetate, leuprolide acetate for depot suspension and norethindrone acetate tablets or nafarelin acetate is considered not medically necessary for gynecological uses when the criteria above are not met. 

VI.   Ovarian Preservation for Fertility during Chemotherapy

Medically Necessary: 

GnRH analogs are considered medically necessary for preservation of fertility in pre-menopausal women that will receive chemotherapy with curative intent.

Not Medically Necessary:

GnRH analogs are considered not medically necessary for preservation of fertility when the criteria above are not met.

VII.  Gender Dysphoria in Adolescents 

Medically Necessary: 

GnRH analogs are considered medically necessary for adolescents with gender dysphoria when all of the following criteria are met:

Not Medically Necessary:

GnRH analogs are considered not medically necessary for adolescents with gender dysphoria when the criteria above are not met.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

HCPCS 
J1675Injection, histrelin acetate, 10 micrograms
J1950Injection, leuprolide acetate (for depot suspension), per 3.75 mg [Lupron Depot, Lupron Depot-Ped]
J3315Injection, triptorelin pamoate, 3.75 mg [Trelstar, Trelstar Depot, Trelstar LA]
J9155Injection, degarelix, 1 mg [Firmagon]
J9202Goserelin acetate implant, per 3.6 mg [Zoladex]
J9217Leuprolide acetate (for depot suspension), 7.5 mg [Eligard, Lupron Depot, Lupron Depot-Ped]
J9218Leuprolide acetate, per 1 mg [Lupron, Eligard]
J9225Histrelin implant (Vantas), 50 mg 
J9226Histrelin implant (Supprelin LA), 50 mg 
S9560Home injectable therapy; hormonal therapy (e.g.; Leuprolide, Goserelin), including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
 No code for Nafarelin acetate [Synarel Nasal Spray]
 No code for Leuprolide acetate for depot suspension and norethindrone acetate tablets [Lupaneta Pack]
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
 All diagnoses
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
 All diagnoses
  
Discussion/General Information

GnRH analogs are a group of hormonal drugs consisting of GnRH agonists and antagonists, both of which suppress pituitary hormones. GnRH agonists typically act over several days and GnRH antagonists act quickly within several hours. Affecting the pituitary gland in the brain, GnRH analogs suppress function of the ovaries and testes, blocking the production of testosterone in males and estrogen in females. Repeated administration of these drugs will cause gonadal hormone dependent tissues/organs to reduce or cease activity, such as the normal prostate gland that is dependent on testosterone for growth and function. This effect is reversible on discontinuation of the drug therapy.

Drugs classified as GnRH analogs include, but are not limited to: degarelix (Firmagon®), goserelin acetate (Zoladex®), histrelin acetate (Vantas® 12 month implant; Supprelin® LA 12 month implant), leuprolide acetate (Lupron Depot®, Lupron Depot-Ped®, Eligard®), nafarelin acetate (Synarel Nasal Spray®), and triptorelin pamoate (Trelstar ®, Trelstar LA®, Trelstar Depot®). Currently, the brand Lupron (leuprolide acetate) is not being marketed in the United States; however, the brands Lupron Depot, Lupron Depot-Ped and Eligard remain available. There are both U.S. Food and Drug Administration (FDA) approved and non-FDA approved indications for these drugs. The non-FDA approved indications listed in this document are based on drug compendia (National Comprehensive Cancer Network® NCCN Drugs & Biologic Compendium, DrugPoints® Compendium, and the American Hospital Formulary Service®) and published peer reviewed literature as detailed in CG-DRUG-01 Off-Label Drug and Approved Orphan Drug Use.

Although GnRH products may differ in specific labeled indications and dosing requirements, clinical evidence does not support differential effectiveness of one product over the other for FDA approved clinical indications. 

Breast Cancer

Breast cancer is the most common cancer diagnosed in women today with the exception of skin cancer. Suppression of ovarian function with the use of goserelin acetate or leuprolide acetate has been shown to be effective in the treatment of hormone receptor positive breast cancer in pre- or peri-menopausal women. Two clinical studies (Jakesz, 2002; Jonat, 2002) compared ovarian suppression hormones, such as GnRH analogs to conventional chemotherapeutic agents, such as a combination of cyclophosphamide, methotrexate, and 5-fluorouracil (CMF). CMF induced significantly better disease free survival and overall survival when subjects were converted from an estrogen receptor positive to negative state.

Breast cancer in men is a relatively rare disease. Due to this rarity, studies are limited in number and size. However, several authors (Giordano, 2002; Hotko, 2013) demonstrate that additive hormonal therapy has been shown to have substantial response rates in metastatic breast carcinoma in men. In addition, NCCN (2014) recommends that men with breast cancer be treated similarly to postmenopausal women, except that use of an aromatase inhibitor is ineffective without concomitant suppression of testicular steroidogenesis.

Ovarian Cancer

There are several small studies in the peer-reviewed published literature assessing the role of leuprolide acetate as a treatment for ovarian cancer. Fishman (1996) evaluated 6 women with recurrent or persistent ovarian granulosa cell tumor who were treated with monthly leuprolide acetate injections. Cessation of disease progression was noted in 5 subjects. The 6th subject remained disease free since her primary cytoreductive surgery while on adjuvant therapy with leuprolide acetate for 24 months. There were no major side effects noted and the treatment was well tolerated. The authors concluded that a reasonable disease progression-free interval occurred and leuprolide treatment should be considered for further trials of therapy. Balbi (2004) reported on a study in which 12 women with advanced ovarian cancer previously treated with paclitaxel were administered leuprolide on days 1, 8, and 28. Progression free survival was 6 months and the treatment was well tolerated. The authors noted: "the high tolerability and the results obtained with leuprolide versus platinum in second-line therapy might permit a better use of the analogs for advanced ovarian cancer."

Prostate Cancer

Prostate cancer is the most common form of cancer, other than skin cancer, among men. Wilt and colleagues (2008) report that approximately 90% of men with prostate cancer have disease confined to the prostate gland (clinically localized disease). GnRH analogs are commonly used in the treatment of prostate cancer under specific conditions.

Men with prostate cancer are categorized according to their recurrence risk into those with clinically localized disease at low, intermediate and high risk of recurrence, or those with locally advanced disease at very high risk of recurrence, or those with metastatic disease. The 2015 NCCN Prostate Cancer Guideline includes the following additional information defining prostate cancer recurrence risk categories:

Low risk category includes men with tumors stage T1-T2a, low Gleason score (less than or equal to 6), and serum PSA level below 10 ng/ml.

Intermediate risk category includes men with any T2b to T2c cancer, Gleason score of 7, or PSA value of 10-20 ng/ mL. Those with multiple adverse factors may be shifted into the high risk category.

Men with prostate cancer that is clinically localized Stage T3a or Gleason score 8-10 or preoperative PSA level greater than 20 ng/mL are categorized by the NCCN Guideline Panel as high risk for recurrence after definitive therapy, and those at very high risk of recurrence have Stage T3b to T4 (locally advanced) disease.

Neoadjuvant androgen deprivation therapy (ADT) (which includes GnRH analogs) may be used to shrink the prostate to an acceptable size prior to brachytherapy, however increased toxicity would be expected from ADT and prostate size may not decline (NCCN Clinical Practice Guideline for Prostate Cancer, V1.2015). The American Academy of Urology (2008) indicates that there is evidence of benefit from hormone therapy prior to cryosurgery for downsizing purposes.

Central Precocious Puberty

Central precocious puberty (CPP) refers to premature activation of the hypothalamic-pituitary-gonadal axis (Eugster, 2007; Phillip, 2005). Carel and colleagues (2009), on behalf of members of the European Society for Pediatric Endocrinology, indicated that precocious puberty is the development of secondary sexual characteristics before 8 years of age in girls and 9 years of age in boys. Treatment may be initiated following the establishment of a clinical diagnosis of CPP; however, the condition may not be detected or evaluated at onset and treatment can sometimes be started after age 8 or 9. Discontinuation of therapy is a clinical decision and there is insufficient evidence to rely on any one clinical variable to make that decision. In studies examined, wishes of the individual receiving treatment, family and the physician's decision were stated as deciding factors for cessation of treatment. However, discontinuation guidance is provided in the product label. For example, the Supprelin LA product label indicates that discontinuation "should be considered at the discretion of the physician and at the appropriate time point for the onset of puberty (approximately 11 years for females and 12 years for males)."

Gynecology Uses

Guidelines from the Royal College of Obstetricians and Gynaecologists (2005) state women with cyclical pelvic pain should be offered a therapeutic trial, using the combined oral contraceptive pill or a GnRH agonist for a period of 3-6 months before having a diagnostic laparoscopy.

The American College of Obstetrics and Gynecology (ACOG) (2004; reaffirmed 2008) practice bulletin for chronic pelvic pain includes the following Level A recommendation and conclusion which is stated to be based on good and consistent scientific evidence:

Level B recommendations which are based on limited or inconsistent scientific evidence include the following:

The ACOG (2010) practice bulletin for the management of endometriosis includes the following Level A recommendations and conclusions:

Level B recommendations include the following:

FDA approved labels for goserelin acetate, leuprolide acetate, leuprolide acetate for depot suspension and norethindrone (Lupaneta Pack), and nafarelin acetate all specify a time limit for duration of treatment for endometriosis. Leuprolide acetate and leuprolide acetate for depot suspension with norethindrone (Lupaneta Pack) are approved for an initial 6 month course and a 6 month course of retreatment if necessary. Goserelin acetate and nafarelin acetate are limited to a 6 month duration of treatment.

The Ling (1999) study is a small, short-term, randomized controlled trial (RCT) used for support of empiric therapy for management of chronic pelvic pain

Ovarian Preservation for Fertility during Chemotherapy 

The effect of GnRH analogs on fertility preservation during chemotherapy has been investigated in multiple randomized clinical trials. Del Mastro and colleagues (2011) reported that the use of triptorelin to induce temporary ovarian suppression during chemotherapy in premenopausal women with early-stage breast cancer reduced the occurrence of chemotherapy-induced early menopause. In another study, Gerber and colleagues (2011) concluded that premenopausal women with breast cancer receiving goserelin acetate during chemotherapy did not experience statistically significantly less amenorrhea 6 months after end of chemotherapy compared with those receiving chemotherapy alone. Although the resumption of menses was more favorable in the triptorelin study, the actual number of live births between both groups was not significantly different.

Several recent meta-analyses reported on randomized trials which used GnRH for the prevention of chemotherapy induced ovarian failure. Vitek and colleagues (2014) analyzed the use of GnRH agonists for the preservation of ovarian function in women with breast cancer who did not use tamoxifen after chemotherapy. Four randomized studies were analyzed (Del Mastro, 2011; Elgnidy, 2013; Gerber, 2011; Sverrisdottir, 2009). The authors concluded that concurrent GnRH agonists with chemotherapy may not preserve ovarian function in women with breast cancer.

However, Del Mastro and colleagues (2014) analyzed nine randomized studies, including four from the Vitek meta-analysis and concluded that temporary ovarian suppression induced by GnRH reduced the risk of chemotherapy induced primary ovarian failure in young women with cancer. In addition to the studies previously addressed in the Vitek meta-analysis, Del Mastro included other randomized trials for breast cancer (Badawy, 2009; Munster, 2012), as well as ovarian cancer (article not published in U.S.) and Hodgkin's or non-Hodgkin's lymphoma (Behringer, 2010; Demeestere, 2013).

In 2015, Moore and colleagues published results of the international phase III POEMS trial of GnRH analog during chemotherapy to reduce ovarian failure in early-stage, hormone receptor-negative breast cancer. A total of 257 premenopausal women with operable hormone-receptor negative breast cancer were randomly assigned to receive either standard chemotherapy consisting of goserelin acetate (goserelin group) or standard chemotherapy without goserelin (chemotherapy alone group). The primary end point of the study was rate of ovarian dysfunction at 2 years. Ovarian failure was defined as the absence of menses in the preceding 6 months and levels of follicle-stimulating hormone (FSH) in the postmenopausal range. Secondary end points included pregnancy outcomes and disease-free and overall survival. The median time of follow-up was 4.1 years for those that remained alive at the time of end-point study analysis. Menstrual status and FSH levels were available for 135 of the 218 women who could be evaluated for primary end point data. Of the 135 women with complete primary end-point data, the ovarian failure rate was 8% in the goserelin group and 22% in the chemotherapy-alone group (odds ratio, 0.30; 95% confidence interval, 0.09 to 0.97; two-sided P=0.04). Sensitivity analyses were performed due to missing primary end-point data and results were consistent with the main findings. Among the 218 women evaluated, pregnancy occurred more in the goserelin group than in the chemotherapy-alone group (21% vs. 11%, P=0.03). Women in the goserelin group also had improved disease-free survival (P=0.04) and overall survival (P=0.05).

In a clinical practice guideline on fertility preservation for individuals with cancer, American Society of Clinical Oncology 2013 stated:

Currently, there is insufficient evidence regarding the effectiveness of GnRHa and other means of ovarian suppression in fertility preservation. GnRHa should not be relied upon as a fertility preservation method. However, GnRHa may have other medical benefits such as a reduction of vaginal bleeding when patients have low platelet counts as a result of chemotherapy. This benefit must be weighed against other possible risks such as bone loss, hot flashes, and potential interference with response to chemotherapy in estrogen-sensitive cancers. Women interested in this method should participate in clinical trials, because current data do not support it. In a true emergency or rare or extreme circumstances where proven options are not available, providers may consider GnRHa an option, preferably as part of a clinical trial.

NCCN oncology guidelines for adolescents and young adults (V2.2015) report that randomized trials have shown conflicting results regarding GnRH agonists and ovarian preservation. NCCN breast cancer guidelines V2.2015) indicate randomized trials have shown that ovarian suppression with GnRH agonist therapy given during adjuvant chemotherapy in premenopausal women with ER-negative tumors may preserve ovarian function. Additionally noted is that smaller historical experiences in women with ER-positive breast cancer have reported conflicting results regarding the protective effect of GnRH agonist on fertility.

Gender Dysphoria in Adolescents

Gender dysphoria is a condition wherein an individual's experienced gender is the opposite of his or her natal gender (usually assigned at birth based on anatomic sex). This can result in distress associated with persistent feelings such as being "trapped in the wrong body." Gender dysphoria is distinct from cross dressing (transvestitism), inability to accept homosexual orientation, psychotic delusions or personality disorders. Most individuals who express gender dysphoria in adolescence and later are thought to sustain the experienced gender.

Endocrine Society Clinical Practice Guidelines for endocrine treatment of transsexual persons (Hembree, 2009) state that adolescents are eligible and ready for GnRH treatment if they:

  1. Fulfill DSM IV-TR or ICD-10 criteria for GID or transsexualism.
  2. Have experienced puberty to at least Tanner stage 2.
  3. Have (early) pubertal changes that have resulted in an increase of their gender dysphoria.
  4. Do not suffer from psychiatric comorbidity that interferes with the diagnostic work-up or treatment.
  5. Have adequate psychological and social support during treatment, AND
  6. Demonstrate knowledge and understanding of the expected outcomes of GnRH analog treatment, cross-sex hormone treatment, and sex reassignment surgery, as well as the medical and the social risks and benefits of sex reassignment.

World Professional Association for Transgender Health (WPATH) (2012) recommendations include the following regarding puberty suppression:

For puberty suppression, adolescents with male genitalia should be treated with GnRH analogues, which stop luteinizing hormone secretion and therefore testosterone secretion. Alternatively, they may be treated with progestins (such as medroxyprogesterone) or with other medications that block testosterone secretion and/or neutralize testosterone action. Adolescents with female genitalia should be treated with GnRH analogues, which stop the production of estrogens and progesterone. No large scale data to support these recommendations but short term data exists.

WPATH 2012 Criteria for Puberty-Suppressing Hormones state:

In order for adolescents to receive puberty-suppressing hormones, the following minimum criteria must be met:

  1. The adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed);
  2. Gender dysphoria emerged or worsened with the onset of puberty;
  3. Any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent's situation and functioning are stable enough to start treatment;
  4. The adolescent has given informed consent and, particularly when the adolescent has not reached the age of medical consent, the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process.

In May 2013, the American Psychiatric Association published an update to their Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5). This update included a significant change to the nomenclature of conditions related to gender psychology. Specifically, the term "Gender Identify Disorder (GID)" was replaced with "Gender Dysphoria". Additionally, the DSM-5 provided updated diagnostic criteria for gender dysphoria for both children and adults. The new criteria are as follows:

Gender dysphoria in Children*

  1. A marked incongruence between one's experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least six of the following (one of which must be Criterion A1):
    1. A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender, different from one's assigned gender).
    2. In boys (assigned gender), a strong preference for cross dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to wearing of typical feminine clothing.
    3. A strong preference for cross-gender roles in make-believe play of fantasy play.
    4. A strong preference for toys, games, or activities stereotypically used or engaged in by the other gender.
    5. A strong preference for playmates of the other gender.
    6. In boys (assigned gender), a strong rejection of typically masculine toys, games and activities and a strong avoidance of rough and tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games and activities.
    7. A strong dislike of one's sexual anatomy.
    8. A strong desire for the primary and/or secondary sex characteristics that match one's experienced gender.
  2. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.

Specify if:

With a disorder of sex development (e.g., a congenital adrenogenital disorder such as 2.55.2 [E25.0] congenital adrenal hyperplasia or 259.0 [E34.50] androgen insensitivity syndrome)
Coding note: Code the disorder of sex development as well as gender dysphoria.

Gender dysphoria in Adolescents and Adults*

  1. A marked incongruence between one's experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least two of the following:
    1. A marked incongruence between one's experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics).
    2. A strong desire to be rid of one's primary and/or secondary sex characteristics because of a marked incongruence with one's experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).
    3. A strong desire for the primary and /or secondary sex characteristics of the other gender.
    4. A strong desire to be of the other gender (or some alternative gender different from one's assigned gender).
    5. A strong desire to be treated as the other gender (or some alternative gender different from one's assigned gender).
    6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one's assigned gender).
  2. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:

With a disorder of sex development (e.g., a congenital adrenogenital disorder such as 2.55.2 [E25.0] congenital adrenal hyperplasia or 259.0 [E34.50] androgen insensitivity syndrome)
Coding note: Code the disorder of sex development as well as gender dysphoria.

Specify if:

Post transition: The individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one cross-sex medical procedure or treatment regimen- namely regular cross-sex treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in a natal male; mastectomy or phalloplasty in the natal female).

* From: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. DSM-5. American Psychiatric Association. Washington, DC.  May 2013. Page 451-459.

Conclusion

The uses of GnRH analogs considered to be medically necessary in this document have sufficient published evidence available to support them. However, there is a lack of scientific evidence found from which conclusions could be made concerning the safety and efficacy of treating various other indications, including, but not limited to: premenstrual syndrome, menopause or mood related disorders, cancer of the endometrium, cancer of the liver, benign prostatic hypertrophy, and to stop pubertal development in order to maximize growth for children of short stature on growth hormones.

Definitions

Adjuvant therapy: Treatment given after the primary treatment to increase the chances of a cure; may include chemotherapy, radiation, hormone, or biological therapy.

Advanced prostate cancer: Disease that has spread beyond the prostate to surrounding tissues or distant organs.

Androgen deprivation therapy (also known as androgen ablation or androgen suppression): Treatment to suppress or block the production or action of male hormones. This is done by having the testicles removed, by taking female sex hormones, or by taking drugs called antiandrogens or GnRH analogs.

Brachytherapy (also known as internal radiation): A type of radiation treatment used to stop the growth of cancer cells by implanting radioactive material directly into the tumor or into the surrounding tissues.

Cancer staging: The process of determining how much cancer there is in the body and where it is located; describes the extent or severity of an individual's cancer based on the extent of the original (primary) tumor and the extent of spread in the body.

Central precocious puberty: The beginning of secondary sexual characteristics before age 8 in girls and age 9 in boys.

Chronic pelvic pain: Noncyclical pain lasting 6 or more months that localizes to the anatomic pelvis, anterior abdominal wall at or below the umbilicus, the lumbosacral back, or the buttocks, and is of sufficient severity to cause functional disability or lead to medical care (ACOG, 2004).

Clinically localized prostate cancer: Cancer presumed to be confined within the prostate based on pre-treatment findings such as physical exam, imaging, and biopsy findings.

Cryosurgery (also called cryotherapy or cryosurgical ablation): Is the use of extreme cold produced by liquid nitrogen (or argon gas) to destroy abnormal tissue. Cryosurgery may be used to treat tumors on the skin (external tumors), such as basal cell carcinoma, or tumors inside the body (internal tumors), such as prostate cancer.    

External beam radiation therapy (EBRT) (also known as teletherapy): A form of therapy using radiation to stop the growth of cancer cells. A linear accelerator directs a photon or electron beam from outside the body through normal body tissue to reach the cancer and the radiation is given 5 days per week for a period of 3 to 8 weeks.

Gleason Grading System: A prostate cancer grading system based on a number range from one to five; the lower the number, the lower the grade, and the slower the cancer growth.

Gleason score: Represents the sum of the two most common Gleason grades observed by the pathologist on a specimen, the first number is the most frequent grade seen.

Locally advanced disease (prostate cancer): Cancer that has spread from where it started to nearby tissue or lymph nodes. 

Metastatic: The spread of cancer from one part of the body to another; a metastatic tumor contains cells that are like those in the original (primary) tumor and have spread.

Risk of recurrence (prostate cancer):

References

Peer Reviewed Publications: 

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  2. Balbi G, Piano LD, Cardone A, Cirelli G. Second-line therapy of advanced ovarian cancer with GnRH analogs. Int J Gynecol Cancer. 2004; 14(5):799-803.
  3. Behringer K, Wildt L, Mueller H, et al.; German Hodgkin Study Group. No protection of the ovarian follicle pool with the use of GnRH-analogues or oral contraceptives in young women treated with escalated BEACOPP for advanced-stage Hodgkin lymphoma. Final results of a phase II trial from the German Hodgkin Study Group. Ann Oncol. 2010; 21(10):2052-2060.
  4. Carel JC. Can we increase adolescent growth? Eur J Endocrin. 2004; 151 Suppl 3:U101-U108.
  5. Carel JC. Management of short stature with GnRH agonist and co-treatment with growth hormone: a controversial issue. Mol Cell Endocrinol. 2006; 254-255:226-233.
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  8. Del Mastro L, Boni L, Michelotti A, et al. Effect of the gonadotropin-releasing hormone analogue triptorelin on the occurrence of chemotherapy-induced early menopause in premenopausal women with breast cancer: a randomized trial. JAMA. 2011; 306(3):269-276.
  9. Del Mastro L, Ceppi M, Poggio F, et al. Gonadotropin-releasing hormone analogues for the prevention of chemotherapy-induced premature ovarian failure in cancer women: systematic review and meta-analysis of randomized trials. Cancer Treat Rev. 2014; 40(5):675-683.
  10. Demeestere I, Brice P, Peccatori FA, et al. Gonadotropin-releasing hormone agonist for the prevention of chemotherapy-induced ovarian failure in patients with lymphoma: 1-year follow-up of a prospective randomized trial. J Clin Oncol. 2013; 31(7):903-909.
  11. Donnez J, Vilos G, Gannon MJ, et al. Goserelin acetate (Zoladex) plus endometrial ablation for dysfunctional uterine bleeding: a large, randomized double-blind study. Fertil Steril. 1997; 68(1):29-36.
  12. Elgindy EA, El-Haieg DO, Khorshid OM, et al. Gonadatrophin suppression to prevent chemotherapy-induced ovarian damage: a randomized controlled trial. Obstet Gynecol. 2013; 121(1):78-86.
  13. Eugster EA, Clarke W, Kletter GB, et al. Efficacy and safety of histrelin subdermal implant in children with central precocious puberty: a multicenter trial. J Clin Endocrinol Metab. 2007; 92(5):1697-1704.  
  14. Fishman A, Kudelka AP, Tresukosol D, et al. Leuprolide acetate for treating refractory or persistent ovarian granulosa cell tumor. J Reprod Med. 1996; 41(6):393-396.
  15. Franke HR, van de Weijer PH, Pennings TM, van der Mooren MJ. Gonadotropin-releasing hormone agonist plus "add-back" hormone replacement therapy for treatment of endometriosis: a prospective, randomized, placebo-controlled, double-blind trial. Fertil Steril. 2000; 74(3):534-539.
  16. Gerber B, von Minckwitz G, Stehle H, et al.; German Breast Group Investigators. Effect of luteinizing hormone-releasing hormone agonist on ovarian function after modern adjuvant breast cancer chemotherapy: the GBG 37 ZORO study. J Clin Oncol. 2011; 29(17):2334-2341.
  17. Giordano SH, Buzdar AU, Hortobagyi GN. Breast cancer in men. Ann Intern Med. 2002; 137(8):678-687.
  18. Hembree WC. Guidelines for pubertal suspension and gender reassignment for transgender adolescents. Child Adolesc Psychiatr Clin N Am. 2011; 20(4):725-732.
  19. Hembree WC, Cohen-Kettenis P, et al; Endocrine Society. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-3154.
  20. Hotko YS. Male breast cancer: clinical presentation, diagnosis, treatment. Exp Oncol. 2013; 35(4):303-310.
  21. Jakesz R, Hausmaninger H, Kubista E, et al.; Austrian Breast and Colorectal Cancer Study Group Trial 5. Randomized adjuvant trial of tamoxifen and goserelin versus cyclophosphamide, methotrexate, and fluorouracil: evidence for the superiority of treatment with endocrine blockade in premenopausal patients with hormone-responsive breast cancer--Austrian Breast and Colorectal Cancer Study Group Trial 5. J Clin Oncol. 2002; 20(24):4621-4627.
  22. Jonat W, Kaufmann M, Sauerbrei W, et al. Zoladex Early Breast Cancer Research Association Study. Goserelin versus cyclophosphamide, methotrexate, and fluorouracil as adjuvant therapy in premenopausal patients with node-positive breast cancer: The Zoladex Early Breast Cancer Research Association Study. J Clin Oncol. 2002; 20(24):4628-4635.
  23. Ling, FW. Randomized controlled trial of depot leuprolide in patients with chronic pelvic pain and clinically suspected endometriosis. Obstet Gynecol. 1999; 93(1):51-58.
  24. Meirow D, Rabinovici J, Katz D, et al. Prevention of severe menorrhagia in oncology patients with treatment-induced thrombocytopenia by luteinizing hormone-releasing hormone agonist and depo-medroxyprogesterone acetate. Cancer. 2006; 107(7):1634-1641.
  25. Messing EM, Manola J, Sarosdy M, et al. Immediate hormonal therapy compared with observation after radical prostatectomy and pelvic lymphadenectomy in men with node positive prostate cancer. N Engl J Med. 1999; 341(24):1781-1788.
  26. Moore HC, Unger JM, Phillips KA, et al; POEMS/S0230 Investigators. Goserelin for ovarian protection during breast-cancer adjuvant chemotherapy. N Engl J Med. 2015; 372(10):923-932.
  27. Munster PN, Moore AP, Ismail-Khan R, et al. Randomized trial using gonadotropin-releasing hormone agonist triptorelin for the preservation of ovarian function during (neo)adjuvant chemotherapy for breast cancer. J Clin Oncol. 2012; 30(5):533-538.
  28. Phillip M, Lazar L. Precocious puberty: growth and genetics. Horm Res. 2005; 64 Suppl 2:56-61.
  29. Pilepich MV, Winter K, Lawton CA, et al. Androgen suppression adjuvant to definitive radiotherapy in prostate carcinoma- long-term results of phase III RTOG 85-31. Int J Radiat Oncol Biol Phys. 2005; 61(5):1285-1290.
  30. Quaas AM, Ginsburg ES. Prevention and treatment of uterine bleeding in hematologic malignancy. Eur J Obstet Gynecol Reprod Biol. 2007; 134(1):3-8.
  31. Roach M III, deSilvio M, Lawton C, et al. Phase III trial comparing whole-pelvic versus prostate-only radiotherapy and neoadjuvant versus adjuvant combined androgen suppression: Radiation Therapy Oncology Group 9413. J Clin Oncol. 2003; 21(10):1904-1911.
  32. Seidenfeld J, Samson DJ, Hasselblad V, et al. Single-therapy androgen suppression in men with advanced prostate cancer. a systematic review and meta-analysis. Ann Internal Med. 2000; 132(7):566-577.
  33. Sverrisdottir A, Nystedt M, Johansson H, Fornander T. Adjuvant goserelin and ovarian preservation in chemotherapy treated patients with early breast cancer: results from a randomized trial. Breast Cancer Res Treat. 2009; 117(3):561-570.
  34. Thompson I, Thrasher JB, Aus G, et al.; AUA Prostate Cancer Clinical Guideline Update Panel. Guideline for the management of clinically localized prostate cancer: 2007 update. J Urol. 2007; 177(6):2106-2131.
  35. van Gool SA, Kamp GA, Visser-van Balen H, et al. Final height outcome after three years of growth hormone and gonadotropic-releasing hormone agonist treatment in short adolescents with relatively early puberty.  J Clin Endocrinol Metab. 2007; 92(4):1402-1408.
  36. Vitek WS, Shayne M, Hoeger K, et al. Gonadotropin-releasing hormone agonists for the preservation of ovarian function among women with breast cancer who did not use tamoxifen after chemotherapy: a systematic review and meta-analysis. Fertil Steril. 2014; 102(3):808-815.
  37. Wheeler JM, Knittle JD, Miller JD. The Lupron Endometriosis Study Group. Depot leuprolide acetate versus danazol in treatment of women with symptomatic endometriosis: a multicenter, double-blind, randomized clinical trial II. Assessment of safety. Am J Gynecol Obstet. 1993; 169(1):26-33.
  38. Wilt TJ, MacDonald R, Rutks I, et al. Systematic review: comparative effectiveness and harms of treatments for clinically localized prostate cancer. Ann Intern Med. 2008; 148(6):435-448.
  39. Wit JM, Visser-van Balen H, Kamp GA, Oostdijk W. Benefit of postponing normal puberty for improving final height. Eur J Endocrin. 2004; 151:S41-S45.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American College of Obstetrics and Gynecology Committee on Practice Bulletins -- Gynecology. ACOG Practice Bulletin No. 51. Chronic pelvic pain. Obstet Gynecol. 2004 (reaffirmed 2008); 103(3):589-605.
  2. American College of Obstetrics and Gynecology Committee on Practice Bulletins -- Gynecology. ACOG Practice bulletin no. 114: management of endometriosis. Obstet Gynecol. 2010; 116(1):223-236.
  3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 2013. Washington, DC. Pages 451-459.
  4. Babaian RJ, Donnelly B, Bahn D, et al. Best practice statement on cryosurgery for the treatment of localized prostate cancer. J Urol. 2008; 180(5):1993-2004.
  5. Degarelix Acetate. In: DrugPoints® System [electronic version]. Truven Health Analytics, Greenwood Village, CO. Last Modified: April 3, 2015. Available at: http://www.micromedexsolutions.com. Accessed on April  17, 2015.
  6. Eligard [Product Information], Fort Collins, CO. Tolmar Pharmaceuticals, Inc.; May 2014. Available at: http://www.eligard.com/Docs/Pdf/TOLMAR%20Pharmaceuticals_Web_PI_05-07-14.pdf. Accessed on April 22, 2015.
  7. Firmagon [Product Information], Parsippany, NJ. Ferring Pharmaceuticals Inc.: March 2015. Available at:  http://www.firmagon.us/assets/full_pi-2cf8bc4f2d7216ec431b83f29b875150.pdf. Accessed on April 22, 2015.
  8. Goserelin acetate Monograph. Lexicomp® Online, American Hospital Formulary Service® (AHFS®) Online, Hudson, Ohio. Lexi-Comp., Inc. Last revised February 7, 2012. Accessed on April 23, 2015.
  9. Goserelin acetate (Zoladex®). In: DrugPoints® System [electronic version]. Truven Health Analytics, Greenwood Village, CO. Last modified April 3, 2015. Available at: http://www.micromedexsolutions.com. Accessed on April 17, 2015.
  10. Histrelin acetate (Vantas®, Supprelin®, Supprelin® LA). In: DrugPoints® System [electronic version]. Truven Health Analytics, Greenwood Village, CO. Last modified April 3, 2015. Available at: http://www.micromedexsolutions.com. Accessed on April 20, 2015.
  11. Lee SJ, Schover LR, Partridge A, et al. American Society of Clinical Oncology Recommendations on fertility preservation in cancer patients. J Clin Oncol. 2006; 24(18):2917-2931.
  12. Lethaby A, Vollenhoven B, Sowter M. Pre-operative GnRH analogue therapy before hysterectomy or myomectomy for uterine fibroids. Cochrane Database Syst Rev. 2001; (2):CD000547.
  13. Leuprolide acetate Monograph. Lexicomp® Online, American Hospital Formulary Service® (AHFS®) Online, Hudson, Ohio. Lexi-Comp., Inc. Last revised February 2, 2012. Accessed on April 23, 2015.
  14. Leuprolide acetate (Lupron®, Lupron Depot®, Lupron Depot-Ped®, Eligard®). In: DrugPoints® System [electronic version]. Truven Health Analytics, Greenwood Village, CO. Last modified April 16, 2015. Available at: http://www.micromedexsolutions.com. Accessed on April 20, 2015.
  15. Leuprolide Acetate/Norethindrone Acetate (Lupaneta Pack). In: DrugPoints® System [electronic version]. Truven Health Analytics, Greenwood Village, CO. Last modified April 3, 2015. Available at: http://www.micromedexsolutions.com. Accessed on April 20, 2015.
  16. Loblaw DA, Virgo KS, Nam R, et al.; American Society of Clinical Oncology. Initial hormonal management of androgen-sensitive metastatic, recurrent, or progressive prostate cancer: 2006 update of an American Society of Clinical Oncology practice guideline. J Clin Oncol. 2007; 25(12):1596-1605.
  17. Loren AW, Mangu PB, Beck LN, et al.; American Society of Clinical Oncology. Fertility preservation for patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2013; 31(19):2500-2510.
  18. Lupaneta Pack [Product Information], North Chicago, IL. AbbVie Inc.; October 2013. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2013/203696s001lbl.pdf. Accessed on April 22, 2015.
  19. Lupron Depot [Product Information], North Chicago, IL. AbbVie Inc.; June 2014. Available at: http://www.rxabbvie.com/pdf/lupron3_4_6month.pdf. Accessed on April 22, 2015.
  20. Lupron Depot-Ped [Product Information], North Chicago, IL. AbbVie Inc.; June 2013. Available at: http://www.rxabbott.com/pdf/lupronpediatric.pdf. Accessed on April 22, 2015.
  21. Nafarelin acetate Monograph. Lexicomp® Online, American Hospital Formulary Service® (AHFS®) Online, Hudson, Ohio. Lexi-Comp., Inc. Last revised February 8, 2012. Accessed on April 23, 2015.
  22. Nafarelin acetate (Synarel Nasal Spray®). In: DrugPoints® System [electronic version]. Truven Health Analytics, Greenwood Village, CO. Last modified April 3, 2015. Available at: http://www.micromedexsolutions.com. Accessed on April 20, 2015.
  23. National Comprehensive Cancer Network®. NCCN Drugs & Biologic Compendium (electronic version). 2015. For additional information visit the NCCN website: http://www.nccn.org. Accessed on April 23, 2015.
    • Degarelix
    • Goserelin acetate
    • Histrelin acetate
    • Leuprolide acetate
    • Leuprolide acetate for depot suspension
    • Triptorelin pamoate
  24. National Comprehensive Cancer Network® (NCCN). Clinical Practice Guidelines in Oncology. 2015. For additional information visit the NCCN website: http://www.nccn.org/index.asp. Accessed on April 23, 2015.
    • Adolescent and Young Adult Oncology (V.2.2015). Revised September 18, 2014.
    • Breast Cancer (V.2.2015). Revised March 11, 2015.
    • Ovarian Cancer (V.1.2015). Revised February 25, 2015.
    • Prostate Cancer (V.1.2015). Revised October 24, 2014.
  25. Royal College of Obstetricians and Gynaecologists (RCOG). The initial management of chronic pelvic pain. RCOG Guideline No. 41. London, UK: RCOG; April 2005.
  26. Sagsveen M, Farmer JE, Prentice A, Breeze A. Gonadotropin-releasing hormone analogues for endometriosis: bone mineral density. Cochrane Database Syst Rev. 2003; (4):CD001297.
  27. Sowter MC, Lethaby A, Singla AA. Pre-operative endometrial thinning agents before endometrial destruction for heavy menstrual bleeding. Cochrane Database Syst Rev. 2002; (3):CD001124.
  28. Supprelin LA [Product Information], Chadds Ford, PA. Endo Pharmaceuticals, Inc.; April 2013. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2013/022058s011lbl.pdf. Accessed on April 22, 2015.
  29. Synarel [Product Information], New York, NY. GD Searle LLC.; November 2014. Available at: http://labeling.pfizer.com/ShowLabeling.aspx?id=515. Accessed on April 22, 2015.
  30. Trelstar [Product Information], Parsippany, NJ. Watson Pharma, Inc.; February 2013. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2013/020715s030,021288s027,022437s007lbl.pdf. Accessed on April 22, 2015.
  31. Triptorelin pamoate Monograph. Lexicomp® Online, American Hospital Formulary Service® (AHFS®) Online, Hudson, Ohio. Lexi-Comp., Inc. Last revised February 7, 2012. Accessed on April 22, 2015.
  32. Triptorelin pamoate (Trelstar®, Trelstar LA®, Trelstar Depot®). In: DrugPoints® System [electronic version]. Truven Health Analytics, Greenwood Village, CO. Last modified September 12, 2014. Available at: http://www.micromedexsolutions.com. Accessed on April 20, 2015.
  33. Vantas (histrelin) Implant [Product Information], Malvern, PA. Endo Pharmaceuticals, Inc.; July 2014. Available at: http://www.endo.com/File%20Library/Products/Prescribing%20Information/Vantas_prescribing_information.html. Accessed on April 22, 2015.
  34. World Professional Association for Transgender Health. The Harry Benjamin International Gender Dysphoria Association's standards of care for gender identity disorders. Version 7. Minneapolis (MN): WPATH; 2012. Available at: http://admin.associationsonline.com/uploaded_files/140/files/Standards%20of%20Care,%20V7%20Full%20Book.pdf. Accessed on April 17, 2015.
  35. Zoladex (goserelin acetate) Implant 3.6 mg. [Product Information], Wilmington, DE. AstraZeneca; June 2013. Available at: http://www1.astrazeneca-us.com/pi/zoladex3_6.pdf. Accessed on April 22, 2015.
  36. Zoladex (gosarelin acetate) Implant 10.8 mg. [Product Information], Wilmington, DE. AstraZeneca; June 2013. Available at: http://www1.astrazeneca-us.com/pi/zoladex10_8.pdf. Accessed on April 22, 2015.
Websites for Additional Information
  1. American Cancer Society. Prostate Cancer. Hormone (androgen deprivation) therapy. Last Revised: 03/12/2015. Available at: http://www.cancer.org/Cancer/ProstateCancer/DetailedGuide/prostate-cancer-treating-hormone-therapy. Accessed on April 22, 2015.
  2. American Cancer Society. Breast Cancer in Men. Last revised 01/31/2013. Available at: http://www.cancer.org/cancer/breastcancerinmen/detailedguide/breast-cancer-in-men-what-is-breast-cancer-in-men. Accessed on April 22, 2015.
Index

Breast Cancer
Central Precocious Puberty (CPP)
Chronic Pelvic Pain
Degarelix
Dysfunctional Uterine Bleeding
Eligard
Endometrial Thinning
Endometriosis
Firmagon
Gonadotropin Releasing Hormone (GnRH) Analogs
Goserelin Acetate
Histrelin Acetate
Leuprolide Acetate
Lupaneta Pack
Lupron Depot
Lupron Depot-Ped
Nafarelin Acetate
Ovarian Cancer
Prostate Cancer
Supprelin LA
Synarel Nasal Spray
Trelstar
Trelstar Depot
Trelstar LA
Triptorelin Pamoate
Uterine Fibroids
Vantas
Zoladex

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Document History
StatusDateAction
Revised05/07/2015Medical Policy & Technology Assessment Committee (MPTAC) review.
Revised05/06/2015Hematology/Oncology Subcommittee review. Position statement for ovarian protection added.
Revised11/13/2014MPTAC review.
Revised11/12/2014Hematology/Oncology Subcommittee review. Medically necessary statements for prostate cancer clarified. Discussion and Reference sections updated.
Revised05/15/2014MPTAC review.
Revised05/14/2014Hematology/Oncology Subcommittee review. Medically necessary statement for leuprolide acetate for depot suspension and norethindrone acetate tablets (Lupaneta Pack) added. Limits for treatment duration of endometriosis added. Medically necessary statement in breast cancer section of position statement updated to include breast cancer in men. Description, Discussion, Reference and Index sections updated.
Reviewed05/09/2013Medical Policy & Technology Assessment Committee (MPTAC) review. Discussion and Reference sections updated.
Reviewed05/08/2013Hematology/Oncology Subcommittee review. Discussion and Reference sections updated.
Revised05/10/2012MPTAC review. Medically necessary statement for central precocious puberty clarified. Added "or" between medically necessary statements for prostate cancer. Discussion and Reference sections updated.
Revised11/17/2011MPTAC review.
Revised11/16/2011Hematology/Oncology Subcommittee review. Added medically necessary statements to the prostate cancer indications for use in combination with antiandrogen (flutamide or bicalutamide) and to shrink an enlarged prostate to an acceptable size prior to brachytherapy, cryosurgery or external beam radiation therapy. Discussion, Definitions and Reference sections updated.
Revised11/18/2010MPTAC review.
Revised11/17/2010Hematology/Oncology Subcommittee review. Clarified the not medically necessary statements for ovarian cancer, prostate cancer and gynecological uses by removing the words "any of". "Intermediate risk of recurrence" defined in prostate cancer medically necessary statement. Clarified prostate cancer clinical indication statements by adding the brand name of Vantas. Note added below prostate cancer medically necessary statement referring reader to definition section for description of terms. Clarified the precocious puberty clinical indication statement by adding the brand name Lupron Depot-Ped. Description, Discussion, Definitions, and References updated. Index added.
 10/01/2010Updated Coding section with 10/01/2010 ICD-9 changes.
Revised05/13/2010MPTAC review.
Revised05/12/2010Hematology/Oncology Subcommittee review. Reformatted the clinical indication section by adding specific GnRH analogs for each indication. Added degarelix to the GnRH analogs considered medically necessary for prostate cancer. Removed infertility treatment indications and added a note in the description section referring to CG-DRUG-11 Oral and Injectable Infertility Drugs. Removed a note in the description section stating this document does not address the combined use of gonadotropin releasing hormone (GnRH) analogs and anti-androgens. Removed Viadur® from description section. Removed the medically necessary indication for GnRH analogs and breast cancer which stated: "Breast cancer patients who are not on concurrent aromatase inhibitor therapy for: Treatment of advanced or metastatic breast cancer in premenopausal and perimenopausal women; or Treatment in premenopausal women with hormone receptor positive disease with or without concurrent tamoxifen for ovarian suppression" and replaced with "Goserelin acetate or leuprolide acetate is considered medically necessary for the treatment of hormone receptor positive breast cancer in pre- or peri-menopausal women." Added medically and not medically necessary statements for the use of leuprolide acetate for ovarian cancer. Removed prostate cancer indications for "palliative treatment of advanced or metastatic prostate cancer and neoadjuvant or adjuvant therapy with radiation therapy in the management of localized prostate cancer in men" and replaced with "when any of the following indications are met: clinically localized disease with intermediate or higher risk of recurrence; or locally advanced disease; or other advanced, recurrent, or metastatic disease." Added a medically necessary statement for goserelin acetate stating it is considered medically necessary for the treatment of prostate cancer in combination with flutamide for locally confined stage T2b-T4 (stage B2-C) disease. Added a medically necessary statement for goserelin acetate and dysfunctional uterine bleeding. Wording of "precocious puberty" in medically necessary statements updated to "central precocious puberty" and removed the precocious puberty requirement stating "tumor has been ruled out by lab tests, CT, MRI, or ultrasound". Updated definition of precocious puberty by changing age limit from before age 10 to before age 9 in boys. Description, Discussion, Coding and References updated. Definition section added.
 11/11/2009Removed the table of FDA-approved indications.
Reviewed05/21/2009MPTAC review. No change to clinical indications. Removed the additional table of FDA approved drugs with dosing and labeling information. Updated Reference section.
 10/01/2008Updated Coding section with 10/01/2008 ICD-9 changes.
Reviewed05/15/2008MPTAC review. Added Supprelin® LA (histrelin acetate) to the GnRH agents considered medically necessary for precocious puberty. References were updated including the change from USP DI reference information to DrugPoints® and the American Hospital Formulary Service (AHFS).
 01/01/2008Updated Coding section with 01/01/2008 HCPCS changes.
Revised05/17/2007MPTAC review. Document was revised to delete delayed puberty as a medically necessary indication for GnRH therapy. References and coding were also updated. 

Reviewed

 

03/08/2007MPTAC review. No change to clinical indications. Removed dosage table. References and coding were updated (updated coding; removed HCPCS S0133 deleted 03/31/2006).
New03/23/2006MPTAC initial guideline development.
Pre-Merger OrganizationsLast Review
Date
Document
Number
Title
Anthem, Inc.  No document
Anthem BCBS  No document
WellPoint Health Networks, Inc.10/03/2005Pharmacology ToolkitGoserelin (Zoladex ®)
 10/03/2005Pharmacology ToolkitLeuprolide acetate (Lupron®, Lupron depot®)