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Leuprolide Suspension: Lupron Depot®, Lupron Depot-Ped®, Eligard®, Fensolvi®, Camcevi™, Lutrate Depot™, Leuprolide Acetate Depot Ψ
Policy Number: PH-0080
Intramuscular/Subcutaneous
Last Review Date: 04/04/2024
Date of Origin: 11/28/2011
Dates Reviewed: 12/11, 03/2012, 06/2013, 09/2012, 12/2012, 03/2013, 06/2013, 09/2013, 12/2013, 03/2014, 06/2014, 09/2014, 12/2014, 03/2015, 05/2015, 08/2015, 11/2015, 02/2016, 5/2016, 8/2016, 11/2016, 2/2017, 5/2017, 8/2017, 11/2017, 02/2018, 05/2018, 04/2019, 04/2020, 06/2020, 04/2021, 07/2021, 08/2021, 03/2022, 10/2022, 01/2023, 04/2023, 05/2023, 04/2024
Precertification requirements do not apply for this policy. Pre-payment claim edits are applied to diagnosis criteria within this policy. |
FOR PEEHIP Members Only -Coverage excludes the provider-administered medication(s) outlined in this drug policy from being accessed through a specialty pharmacy. It must be obtained through buy and bill. |
- Length of Authorization
- Endometriosis:
- Coverage will be provided for 6 months and may be renewed one time only.
- Prevention/Management of Menstrual Bleeding:
- Coverage will be provided for 6 months and may NOT be renewed.
- Uterine Leiomyomata (fibroids):
- Coverage will be provided for 3 months and may NOT be renewed.
- Fertility Preservation:
- Coverage will be provided for 12 months and may be renewed while patient is receiving concomitant cytotoxic chemotherapy.
- All Other Indications: Coverage will be provided for 12 months and may be renewed.
- Dosing Limits
A. Quantity Limit (max daily dose) [NDC Unit]:
B. Max Units (per dose and over time) [HCPCS Unit]:
Drug Name |
Strength |
Quantity |
Days Supply |
Lupron Depot 1-Month |
3.75 mg |
1 injection |
28 days |
Lupron Depot 1-Month |
7.5 mg |
1 injection |
28 days |
Lupron Depot 3-Month |
11.25 mg |
1 injection |
84 days |
Lupron Depot 3-Month |
22.5 mg |
1 injection |
84 days |
Lupron Depot 4-Month |
30 mg |
1 injection |
112 days |
Lupron Depot 6-Month |
45 mg |
1 injection |
168 days |
Lupron Depot-Ped 1-month |
7.5 mg |
1 injection |
28 days |
Lupron Depot-Ped 1-month |
11.25 mg |
1 injection |
28 days |
Lupron Depot-Ped 3-Month |
11.25 mg |
1 injection |
84 days |
Lupron Depot-Ped 1-month |
15 mg |
1 injection |
28 days |
Lupron Depot-Ped 3-Month |
30 mg |
1 injection |
84 days |
Lupron Depot-Ped 6-Month |
45 mg |
1 injection |
168 days |
Eligard |
7.5 mg |
1 injection |
28 days |
Eligard |
22.5 mg |
1 injection |
84 days |
Eligard |
30 mg |
1 injection |
112 days |
Eligard |
45 mg |
1 injection |
168 days |
Fensolvi |
45 mg |
1 injection |
168 days |
Camcevi |
42 mg |
1 injection |
168 days |
Leuprolide Acetate Depot |
22.5 mg |
1 injection |
84 days |
Diagnosis |
HCPCS |
Product(s) |
Billable Units |
Days Supply |
Prostate/Breast/ Ovarian Cancer |
J9217
|
Lupron Depot 1-Month & Eligard 7.5 mg |
1 |
28 |
Lupron Depot 3-Month & Eligard 22.5 mg |
3 |
84 |
||
Lupron Depot 4-Month & Eligard 30 mg |
4 |
112 |
||
Lupron Depot 6-Month & Eligard 45 mg |
6 |
168 |
||
Head and Neck Cancer – Salivary Gland Tumors |
J9217 |
Lupron Depot 1-month & Eligard 7.5 mg |
1 |
28 |
Lupron Depot 3-Month & Eligard 22.5 mg |
3 |
84 |
||
Breast/Ovarian Cancer; Endometriosis; Uterine Fibroids |
J1950 |
Lupron Depot 1-Month 3.75 mg |
1 |
28 |
Lupron Depot 3-Month 11.25 mg |
3 |
84 |
||
Central Precocious Puberty |
J1950/ J1951 |
Lupron Depot-Ped 7.5 mg |
2 |
28 |
Lupron Depot-Ped 11.25 mg |
3 |
28 |
||
Lupron Depot-Ped 15 mg |
4 |
28 |
||
Lupron Depot-Ped 30 mg |
8 |
84 |
||
Lupron Depot-Ped 45 mg |
12 |
168 |
||
Fensolvi 45 mg Kit |
180 |
168 |
||
Prostate Cancer |
J1952 |
Camcevi 42 mg Kit |
42 |
168 |
Prostate Cancer |
J1954 |
Leuprolide Acetate Depot |
3 |
84 |
Fertility Preservation/ Prevention/Management of Menstrual Bleeding |
J1950 |
Lupron Depot 1-Month 3.75 mg |
1 |
28 |
Gender Dysphoria |
J1950/ J1951
|
Lupron Depot 1-Month 3.75 mg |
1 |
28 |
Lupron Depot 3-Month 11.25 mg |
3 |
84 |
||
Lupron Depot-Ped 11.25 mg |
3 |
28 |
||
Fensolvi 45 mg Kit |
180 |
168 |
- Initial Approval Criteria
Coverage is provided in the following conditions:
- Patient is at least 18 years of age (unless otherwise specified); AND
Central Precocious Puberty (CPP) 3,6,14,20-22 † Ф (J1950 and J1951)
- Patient is less than 13 years of age; AND
- Onset of secondary sexual characteristics earlier than age 8 for females and 9 for males associated with pubertal pituitary gonadotropin activation; AND
- Diagnosis is confirmed by pubertal gonadal sex steroid levels and a pubertal luteinizing hormone (LH) response to stimulation by native growth hormone-releasing hormone (GnRH); AND
- Bone age advanced greater than 2 standard deviations (SD) beyond chronological age; AND
- Tumor has been ruled out by lab tests such as diagnostic imaging of the brain (to rule out intracranial tumor), pelvic/testicular/adrenal ultrasound (to rule out steroid secreting tumors), and human chorionic gonadotropin levels (to rule out a chorionic gonadotropin secreting tumor); AND
- Will not be used in combination with growth hormone
Endometriosis 1,2,12 † (J1950)
- Patient’s diagnosis has been confirmed by a workup/evaluation (versus presumptive treatment)
Uterine Leiomyomata (fibroids) 1,2,13,36 † (J1950)
- Patient’s diagnosis has been confirmed by a workup/evaluation (versus presumptive treatment); AND
- Patient is receiving iron therapy
Breast Cancer 10,11,15,16 ‡ (J9217 and J1950)
- Patient has invasive or inflammatory disease; AND
- Patient is a premenopausal woman; AND
- Disease is hormone receptor-positive; AND
- Used in combination with adjuvant endocrine therapy; OR
- Used in combination with endocrine therapy for recurrent unresectable or metastatic disease
- Disease is hormone receptor-positive; AND
- Patient is a male (sex assigned at birth); AND
- Used in combination with aromatase inhibitor therapy
- Patient is a premenopausal woman; AND
Ovarian Cancer 10,11,18,19 ‡ (J9217 and J1950)
- Used as a single agent; AND
- Patient has a diagnosis of stage II-IV granulosa cell tumors of the ovary; AND
- Patient has relapsed disease; OR
- Patient has a diagnosis of Epithelial Ovarian Cancer/Fallopian Tube Cancer/Primary Peritoneal Cancer, Mucinous Carcinoma of the Ovary, Clear Cell Carcinoma of the Ovary, Carcinosarcoma (Malignant Mixed Müllerian Tumors), or Grade 1 Endometrioid Carcinoma; AND
- Patient has persistent or recurrent disease (excluding immediate treatment of biochemical relapse); OR
- Patient has a diagnosis of stage II-IV granulosa cell tumors of the ovary; AND
- Patient has a diagnosis of Low-Grade Serous Carcinoma; AND
- Patient has disease recurrence
Prostate Cancer 4,5,8-10,11,17 † ‡ (J9217, J1952, and J1954)
Head and Neck Cancer 10,11 ‡ (J9217)
- Patient has salivary gland tumors; AND
- Used as a single agent; AND
- Patient has androgen-receptor positive recurrent disease; AND
- Patient has distant metastases with a performance status score of 0-3; OR
- Patient has unresectable locoregional recurrence or second primary with prior radiation therapy
Prevention/Management of Menstrual Bleeding Associated with Hematopoietic Stem Cell Transplant (HCT) 24-27 ‡ (J1950)
- Patient is premenopausal; AND
- Patient will receive conditioning myeloablative treatment with cytotoxic chemotherapy; OR
- Patient has menorrhagia due to thrombocytopenia related to delayed platelet engraftment
Fertility Preservation Prior to Chemotherapy 24-27,37 ‡ (J1950)
- Patient is premenopausal; AND
- Patient is receiving treatment with cytotoxic chemotherapy with the potential to cause ovarian damage/toxicity (e.g., cyclophosphamide, melphalan, procarbazine vinblastine, imatinib, etc.); AND
- Patient has failed or is not a candidate for other fertility preservation methods (e.g., cryopreservation, etc.)
Gender Dysphoria (formerly Gender Identity Disorder) ‡ 28-30 (J1950 and J1951)
- Patient has experienced puberty development to at least Tanner stage 2; AND
- Patient has a diagnosis of gender dysphoria as confirmed by a qualified mental health professional (MHP)** OR the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) Criteria §; AND
- A qualified MHP** has confirmed all of the following:
- Patient has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed); AND
- Gender dysphoria worsened with the onset of puberty; AND
- 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; AND
- Patient has sufficient mental capacity to give informed consent to this (reversible) treatment; AND
- Patient has been informed of the effects and side effects of treatment (including potential loss of fertility if the individual subsequently continues with sex hormone treatment) and options to preserve fertility; AND
- Patient has given informed consent and (particularly when the adolescent has not reached the age of legal medical consent, depending on applicable legislation) the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process; AND
- A pediatric endocrinologist or other clinician experienced in pubertal assessment has confirmed all of the following:
- Agreement in the indication for treatment; AND
- There are no medical contraindications to treatment
** Definition of a qualified mental health professional 33 |
|
§ DSM-V Criteria for Gender Dysphoria 28,29 |
|
† FDA Approved Indication(s); ‡ Compendia Recommended Indication(s); Ф Orphan Drug
- Renewal Criteria
Coverage may be renewed based upon the following criteria:
- Patient continues to meet the indication-specific relevant criteria identified in section III; AND
- Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include: tumor flare, hyperglycemia/diabetes, cardiovascular disease (myocardial infarction, sudden cardiac death, stroke), QT/QTc prolongation, convulsions, severe cutaneous adverse reactions (e.g., Stevens-Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], drug reaction with eosinophilia and systemic symptoms [DRESS], acute generalized exanthematous pustulosis [AGEP]) etc.; AND
Prostate Cancer (J9217, J1952, and J1954); Head and Neck Cancer – Salivary Gland Tumors (J9217);
Breast and Ovarian Cancer (J9217 and J1950)
- Disease response with treatment as defined by stabilization of disease or decrease in size of tumor or tumor spread
Central Precocious Puberty (CPP) 3,6,14,20-22 (J1950 and J1951)
- Patient is less than 13 years of age; AND
- Disease response as indicated by lack of progression or stabilization of secondary sexual characteristics, decrease in height velocity, a decrease in the ratio of bone age to chronological age (BA:CA), and improvement in final height prediction; AND
- Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include: convulsions, development or worsening of psychiatric symptoms, pseudotumor cerebri (idiopathic intracranial hypertension), etc.; AND
- Will not be used in combination with growth hormone
Gender Dysphoria 28,29
- Patient has shown a beneficial response to treatment as evidenced by routine monitoring of clinical pubertal development and applicable laboratory parameters; AND
- Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include: convulsions, development or worsening of psychiatric symptoms, pseudotumor cerebri (idiopathic intracranial hypertension), etc.
Endometriosis (J1950) 1,2
- Patient has not received a total of 12 months of therapy of a GnRH-agonist (i.e., leuprolide acetate, etc.); AND
- Patient continues to have symptoms of endometriosis or symptoms recur after the initial 6-month course of therapy; AND
- Patient will have bone density assessment prior to retreatment; AND
- Extended GnRH-agonist treatment will be used in combination with norethindrone add-back therapy; AND
- Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include: significant loss of bone mineral density, hypersensitivity reactions, convulsions, new or worsening clinical depression, etc.
Uterine Leiomyomata (fibroids) (J1950)
- Coverage may NOT be renewed
Prevention/Management of Menstrual Bleeding Associated with HCT (J1950)
- Coverage may NOT be renewed
Fertility Preservation Prior to Chemotherapy (J1950)
- Patient is still receiving treatment with cytotoxic chemotherapy; AND
- Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include: significant loss of bone mineral density, hypersensitivity reactions, convulsions, new or worsening clinical depression, etc.
- Dosage/Administration 1-9,24,26-27,37
Indication |
Dose |
Endometriosis |
Administer 3.75 mg intramuscularly monthly or 11.25 mg intramuscularly every 3 months for a duration of 6 months only. |
Breast/Ovarian Cancer |
Administer, intramuscularly or subcutaneously, 3.75 mg every/7.5 mg monthly or 11.25 mg/22.5 mg every 3 months. |
Central Precocious Puberty (CPP) |
|
Uterine Leiomyomata (fibroids) |
Administer 3.75 mg intramuscularly monthly or 11.25 mg intramuscularly as a single dose*. *The recommended duration of therapy is 3 months or less; retreatment is dependent on the return of symptoms. |
Prostate Cancer |
|
Salivary Gland tumors of the Head and Neck |
Administer, intramuscularly or subcutaneously, 7.5 mg every 4 weeks, 22.5 mg every 12 weeks |
Prevention/Management of Menstrual Bleeding Associated with HCT |
Administer 3.75 mg intramuscularly once every 4 weeks up to 6 months Therapy should be started 4-5 weeks prior to conditioning chemotherapy and continued as required until platelets are >50,000 post HCT) |
Fertility Preservation Prior to Chemotherapy |
Administer 3.75 mg intramuscularly every 4 weeks |
Gender Dysphoria |
|
Note:
|
- Billing Code/Availability Information
Drug Name |
Strength |
HCPCS* |
NDC |
Lupron Depot 1-Month |
3.75 mg |
J1950 |
00074-3641-xx |
Lupron Depot 1-Month |
7.5 mg |
J9217 |
00074-3642-xx |
Lupron Depot 3-Month |
11.25 mg |
J1950 |
00074-3663-xx |
Lupron Depot 3-Month |
22.5 mg |
J9217 |
00074-3346-xx |
Lupron Depot 4-Month |
30 mg |
J9217 |
00074-3683-xx |
Lupron Depot 6-Month |
45 mg |
J9217 |
00074-3473-xx |
Lupron Depot-Ped 1-Month |
7.5 mg |
J1950 |
00074-2108-xx |
Lupron Depot-Ped 1-Month |
11.25 mg |
J1950 |
00074-2282-xx |
Lupron Depot-Ped 3-Month |
11.25 mg |
J1950 |
00074-3779-xx |
Lupron Depot-Ped 1-Month |
15 mg |
J1950 |
00074-2440-xx |
Lupron Depot-Ped 3-Month |
30 mg |
J1950 |
00074-9694-xx |
Lupron Depot-Ped 6-Month |
45 mg |
J1950 |
00074-3575-xx |
Eligard |
7.5 mg |
J9217 |
62935-0753-xx 62935-0756-xx |
Eligard |
22.5 mg |
J9217 |
62935-0223-xx 62935-0227-xx |
Eligard |
30 mg |
J9217 |
62935-0303-xx 62935-0306-xx |
Eligard |
45 mg |
J9217 |
62935-0453-xx 62935-0461-xx |
Fensolvi |
45 mg |
J1951 |
62935-0153-xx |
Camcevi |
42 mg |
J1952 |
69448-0014-xx 69448-0023-xx |
Leuprolide Acetate Depot (Cipla) Ψ |
22.5 mg |
J1954 |
69097-0909-xx |
|
Approved Drug Products with Therapeutic Equivalence Evaluations | Orange Book | FDA |
- References
- Lupron Depot GYN 3 Month 11.25 mg [package insert]. North Chicago, IL; Abbvie Inc.; October 2023. Accessed March 2024.
- Lupron Depot GYN 3.75 mg and 3 Month 11.25 mg [package insert]. North Chicago, IL; Abbvie Inc.; October 2023. Accessed March 2024.
- Lupron Depot-Ped [package insert]. North Chicago, IL; Abbvie Inc.; April 2023. Accessed March 2024.
- Lupron Depot URO [package insert.]. North Chicago, IL; Abbvie Inc.; December 2023. Accessed March 2024.
- Eligard [package insert]. Fort Collins, CO; Tolmar Therapeutics, Inc; January 2024. Accessed March 2024.
- Fensolvi [package insert]. Fort Collins, CO; Tolmar Therapeutics, Inc; April 2023. Accessed March 2024.
- Camcevi [package insert]. Taipei City, Taiwan; Foresee Pharmaceuticals Co., Ltd.; March 2024. Accessed March 2024.
- Lutrate Depot [package insert]. Sant Quintí de Mediona, Spain; GP-PHARM, S.A..; February 2023. Accessed March 2023.
- Leuprolide Acetate Depot (Cipla) [package insert]. Sant Quintí de Mediona, Spain; GP-PHARM, S.A..; November 2023. Accessed March 2024.
- Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) Leuprolide acetate. National Comprehensive Cancer Network, 2024. The NCCN Compendium® is a derivative work of the NCCN Guidelines®. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed March 2024.
- Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) Leuprolide acetate for depot suspension. National Comprehensive Cancer Network, 2024. The NCCN Compendium® is a derivative work of the NCCN Guidelines®. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed March 2024.
- Dlugi AM, Miller JD, Knittle J, et al: Lupron depot (leuprolide acetate for depot suspension) in the treatment of endometriosis: a randomized, placebo-controlled, double-blind study. Fertil Steril 1990; 54:419-427.
- Friedman AJ, Barbieri RL, Doubilet PM, et al: A randomized, double-blind trial of a gonadotropin-releasing hormone agonist (leuprolide) with or without medroxyprogesterone acetate in the treatment of leiomyomata uteri. Obstet Gynecol Surv 1988; 43:484-485.
- Lee PA & Page JG: The Leuprolide Study Group: Effects of leuprolide in the treatment of central precocious puberty. J Pediatr 1989; 114:321-324.
- Harvey HA, Lipton A, Max DT, et al: Medical castration produced by the GnRH analogue leuprolide to treat metastatic breast cancer. J Clin Oncol 1985; 3:1068-1072.
- Boccardo F, Rubagotti A, Amoroso D, et al, “Endocrinological and Clinical Evaluation of Two Depot Formulations of Leuprolide Acetate in Pre- and Perimenopausal Breast Cancer Patients,” Cancer Chemother Pharmacol, 1999, 43(6):461-6.
- National Collaborating Centre for Cancer. Prostate cancer: diagnosis and treatment. London (UK): National Institute for Health and Clinical Excellence (NICE); 2008 Feb. 146 p. (NICE clinical guideline; no. 58)
- 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.
- Kavanagh JJ, Roberts W, Townsend P, et al: Leuprolide acetate in the treatment of refractory or persistent epithelial ovarian cancer. J Clin Oncol 1989; 7:115-118.
- Beccuti G, Ghizzoni L. Normal and Abnormal Puberty. Endotext. De Groot LJ, Chrousos G, Dungan K, et al., editors, South Dartmouth (MA): MDText.com, Inc.; 2000-. Accessed at: https://www.ncbi.nlm.nih.gov/books/NBK279024/.
- Brito VN, Spinola-Castro AM, Kochi C, et al. Central precocious puberty: revisiting the diagnosis and therapeutic management. Arch Endocrinol Metab. 2016 Apr;60(2):163-72
- Carel JC, Eugster E, Rogol A, et al. Consensus statement on the use of gonadotropin-releasing hormone analogs in children. Pediatrics. 2009 Apr;123(4):e752-62. doi: 10.1542/peds.2008-1783. Epub 2009 Mar 30.
- Shore N, Mincik I, DeGuenther M, et al. A phase 3, open-label, multicenter study of a 6-month pre-mixed depot formulation of leuprolide mesylate in advanced prostate cancer patients. World J Urol. 2020 Jan;38(1):111-119. doi: 10.1007/s00345-019-02741-7.
- Amsterdam A, et al. Management of menorrhagia. Treatment of menorrhagia in women undergoing hematopoietic stem cell transplantation. Bone Marrow Transplantation 2004; 34:363-66.
- Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Adolescent and Young Adult (AYA) Oncology Version 2.2024. National Comprehensive Cancer Network, 2024. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Guidelines, go online to NCCN.org. Accessed March 2024.
- Options for Prevention and Management of Menstrual Bleeding in Adolescent Patients Undergoing Cancer Treatment: ACOG Committee Opinion, Number 817. Obstet Gynecol. 2021 Jan 1;137(1):e7-e15. doi: 10.1097/AOG.0000000000004209.
- Ghalie, R., et al. Prevention of Hypermenorrhea with Leuprolide in Premenopausal Women Undergoing Bone Marrow Transplantation, American Journal of Hematology. 1993;42: 350-353.
- Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2017; 102:3869
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association Publishing.
- The World Professional Association for Transgender Health (WPATH), Standards of Care for the Health of Transsexual, and Gender Nonconforming People. Seventh Version. July 2012. Available at: https://www.wpath.org/media/cms/Documents/SOC%20v7/SOC%20V7_English2012.pdf?_t=1613669341
- Hembree WC, Cohen-Kettenis PT, Gooren L, et al; Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2017; 102(11):3869-3903.
- Gava G, Cerpolini S, Martelli V, et al; Cyproterone acetate vs leuprolide acetate in combination with transdermal oestradiol in transwomen: a comparison of safety and effectiveness. Clin Endocrinol (Oxf) 2016; 85(2):239-246.
- Coleman E, Radix AE, Bouman WP, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgend Health. 2022 Sep 6;23(Suppl 1):S1-S259. doi: 10.1080/26895269.2022.2100644.
- Lee PA, Neely EK, Fuqua J, et al. Efficacy of Leuprolide Acetate 1-Month Depot for Central Precocious Puberty (CPP): Growth Outcomes During a Prospective, Longitudinal Study. Int J Pediatr Endocrinol. 2011;2011(1):7. doi: 10.1186/1687-9856-2011-7. Epub 2011 Jul 12.
- Lee PA, Klein K, Mauras N, et al. 36-month treatment experience of two doses of leuprolide acetate 3-month depot for children with central precocious puberty. J Clin Endocrinol Metab. 2014 Sep;99(9):3153-9. doi: 10.1210/jc.2013-4471.
- Stewart EA, Laughlin-Tommaso SK. (2023) Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history. In: Barbieri R, Chakrabarti A (Eds). UpToDate. Last update: Nov 03, 2023. Accessed March 5, 2024. Available from: https://www.uptodate.com/contents/uterine-fibroids-leiomyomas-epidemiology-clinical-features-diagnosis-and-natural-history.
- Clowse ME, Behera MA, Anders CK, et al. Ovarian preservation by GnRH agonists during chemotherapy: a meta-analysis. J Womens Health (Larchmt). 2009 Mar;18(3):311-9. doi: 10.1089/jwh.2008.0857. PMID: 19281314; PMCID: PMC2858300.
- Klein KO, Mauras N, Nayak S, et al. Efficacy and Safety of Leuprolide Acetate 6-Month Depot for the Treatment of Central Precocious Puberty: A Phase 3 Study. J Endocr Soc. 2023 Jun 1;7(7):bvad071. doi: 10.1210/jendso/bvad071. PMID: 37334213; PMCID: PMC10274571.
- National Government Services, Inc. Local Coverage Article: Billing and Coding: Luteinizing Hormone-Releasing Hormone (LHRH) Analogs (A52453). Centers for Medicare & Medicaid Services, Inc. Updated on 11/11/2023 with effective date 01/01/2023. Accessed March 2024.
- Palmetto GBA. Local Coverage Article: Billing and Coding: Luteinizing Hormone-Releasing Hormone (LHRH) Analogs (A59160). Centers for Medicare & Medicaid Services, Inc. Updated on 02/07/2024 with effective date 03/15/2024 Accessed March 2024.
Appendix 1 – Covered Diagnosis Codes
J1950
ICD-10 |
ICD-10 Description |
C48.1 |
Malignant neoplasm of specified parts of peritoneum |
C48.2 |
Malignant neoplasm of peritoneum, unspecified |
C48.8 |
Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum |
C50.011 |
Malignant neoplasm of nipple and areola, right female breast |
C50.012 |
Malignant neoplasm of nipple and areola, left female breast |
C50.019 |
Malignant neoplasm of nipple and areola, unspecified female breast |
C50.021 |
Malignant neoplasm of nipple and areola, right female breast |
C50.022 |
Malignant neoplasm of nipple and areola, left female breast |
C50.029 |
Malignant neoplasm of nipple and areola, unspecified female breast |
C50.111 |
Malignant neoplasm of central portion of right female breast |
C50.112 |
Malignant neoplasm of central portion of left female breast |
C50.119 |
Malignant neoplasm of central portion of unspecified female breast |
C50.121 |
Malignant neoplasm of central portion of right male breast |
C50.122 |
Malignant neoplasm of central portion of left male breast |
C50.129 |
Malignant neoplasm of central portion of unspecified male breast |
C50.211 |
Malignant neoplasm of upper-inner quadrant of right female breast |
C50.212 |
Malignant neoplasm of upper-inner quadrant of left female breast |
C50.219 |
Malignant neoplasm of upper-inner quadrant of unspecified female breast |
C50.221 |
Malignant neoplasm of upper-inner quadrant of right male breast |
C50.222 |
Malignant neoplasm of upper-inner quadrant of left male breast |
C50.229 |
Malignant neoplasm of upper-inner quadrant of unspecified male breast |
C50.311 |
Malignant neoplasm of lower-inner quadrant of right female breast |
C50.312 |
Malignant neoplasm of lower-inner quadrant of left female breast |
C50.319 |
Malignant neoplasm of lower-inner quadrant of unspecified female breast |
C50.321 |
Malignant neoplasm of lower-inner quadrant of right male breast |
C50.322 |
Malignant neoplasm of lower-inner quadrant of left male breast |
C50.329 |
Malignant neoplasm of lower-inner quadrant of unspecified male breast |
C50.411 |
Malignant neoplasm of upper-outer quadrant of right female breast |
C50.412 |
Malignant neoplasm of upper-outer quadrant of left female breast |
C50.419 |
Malignant neoplasm of upper-outer quadrant of unspecified female breast |
C50.421 |
Malignant neoplasm of upper-outer quadrant of right male breast |
C50.422 |
Malignant neoplasm of upper-outer quadrant of left male breast |
C50.429 |
Malignant neoplasm of upper-outer quadrant of unspecified male breast |
C50.511 |
Malignant neoplasm of lower-outer quadrant of right female breast |
C50.512 |
Malignant neoplasm of lower-outer quadrant of left female breast |
C50.519 |
Malignant neoplasm of lower-outer quadrant of unspecified female breast |
C50.521 |
Malignant neoplasm of lower-outer quadrant of right male breast |
C50.522 |
Malignant neoplasm of lower-outer quadrant of left male breast |
C50.529 |
Malignant neoplasm of lower-outer quadrant of unspecified male breast |
C50.611 |
Malignant neoplasm of axillary tail of right female breast |
C50.612 |
Malignant neoplasm of axillary tail of left female breast |
C50.619 |
Malignant neoplasm of axillary tail of unspecified female breast |
C50.621 |
Malignant neoplasm of axillary tail of right male breast |
C50.622 |
Malignant neoplasm of axillary tail of left male breast |
C50.629 |
Malignant neoplasm of axillary tail of unspecified male breast |
C50.811 |
Malignant neoplasm of overlapping sites of right female breast |
C50.812 |
Malignant neoplasm of overlapping sites of left female breast |
C50.819 |
Malignant neoplasm of overlapping sites of unspecified female breast |
C50.821 |
Malignant neoplasm of overlapping sites of right male breast |
C50.822 |
Malignant neoplasm of overlapping sites of left male breast |
C50.829 |
Malignant neoplasm of overlapping sites of unspecified male breast |
C50.911 |
Malignant neoplasm of unspecified site of right female breast |
C50.912 |
Malignant neoplasm of unspecified site of left female breast |
C50.919 |
Malignant neoplasm of unspecified site of unspecified female breast |
C50.921 |
Malignant neoplasm of unspecified site of right male breast |
C50.922 |
Malignant neoplasm of unspecified site of left male breast |
C50.929 |
Malignant neoplasm of unspecified site of unspecified male breast |
C56.1 |
Malignant neoplasm of right ovary |
C56.2 |
Malignant neoplasm of left ovary |
C56.3 |
Malignant neoplasm of bilateral ovaries |
C56.9 |
Malignant neoplasm of unspecified ovary |
C57.00 |
Malignant neoplasm of unspecified fallopian tube |
C57.01 |
Malignant neoplasm of right fallopian tube |
C57.02 |
Malignant neoplasm of left fallopian tube |
C57.10 |
Malignant neoplasm of unspecified broad ligament |
C57.11 |
Malignant neoplasm of right broad ligament |
C57.12 |
Malignant neoplasm of left broad ligament |
C57.20 |
Malignant neoplasm of unspecified round ligament |
C57.21 |
Malignant neoplasm of right round ligament |
C57.22 |
Malignant neoplasm of left round ligament |
C57.3 |
Malignant neoplasm of parametrium |
C57.4 |
Malignant neoplasm of uterine adnexa, unspecified |
C57.7 |
Malignant neoplasm of other specified female genital organs |
C57.8 |
Malignant neoplasm of overlapping sites of female genital organs |
C57.9 |
Malignant neoplasm of female genital organ, unspecified |
D25.0 |
Submucous leiomyoma of uterus |
D25.1 |
Intramural leiomyoma of uterus |
D25.2 |
Subserosal leiomyoma of uterus |
D25.9 |
Leiomyoma of uterus, unspecified |
E30.1 |
Precocious puberty |
E30.8 |
Other disorders of puberty |
F64.0 |
Transsexualism |
F64.1 |
Dual role transvestism |
F64.2 |
Gender identity disorder of childhood |
F64.8 |
Other gender identity disorders |
F64.9 |
Gender identity disorder, unspecified |
N80.00 |
Endometriosis of the uterus, unspecified |
N80.01 |
Superficial endometriosis of the uterus |
N80.02 |
Deep endometriosis of the uterus |
N80.03 |
Adenomyosis of the uterus |
N80.101 |
Endometriosis of right ovary, unspecified depth |
N80.102 |
Endometriosis of left ovary, unspecified depth |
N80.103 |
Endometriosis of bilateral ovaries, unspecified depth |
N80.109 |
Endometriosis of ovary, unspecified side, unspecified depth |
N80.111 |
Superficial endometriosis of right ovary |
N80.112 |
Superficial endometriosis of left ovary |
N80.113 |
Superficial endometriosis of bilateral ovaries |
N80.119 |
Superficial endometriosis of ovary, unspecified ovary |
N80.121 |
Deep endometriosis of right ovary |
N80.122 |
Deep endometriosis of left ovary |
N80.123 |
Deep endometriosis of bilateral ovaries |
N80.129 |
Deep endometriosis of ovary, unspecified ovary |
N80.201 |
Endometriosis of right fallopian tube, unspecified depth |
N80.202 |
Endometriosis of left fallopian tube, unspecified depth |
N80.203 |
Endometriosis of bilateral fallopian tubes, unspecified depth |
N80.209 |
Endometriosis of unspecified fallopian tube, unspecified depth |
N80.211 |
Superficial endometriosis of right fallopian tube |
N80.212 |
Superficial endometriosis of left fallopian tube |
N80.213 |
Superficial endometriosis of bilateral fallopian tubes |
N80.219 |
Superficial endometriosis of unspecified fallopian tube |
N80.221 |
Deep endometriosis of right fallopian tube |
N80.222 |
Deep endometriosis of left fallopian tube |
N80.223 |
Deep endometriosis of bilateral fallopian tubes |
N80.229 |
Deep endometriosis of unspecified fallopian tube |
N80.30 |
Endometriosis of pelvic peritoneum, unspecified |
N80.311 |
Superficial endometriosis of the anterior cul-de-sac |
N80.312 |
Deep endometriosis of the anterior cul-de-sac |
N80.319 |
Endometriosis of the anterior cul-de-sac, unspecified depth |
N80.321 |
Superficial endometriosis of the posterior cul-de-sac |
N80.322 |
Deep endometriosis of the posterior cul-de-sac |
N80.329 |
Endometriosis of the posterior cul-de-sac, unspecified depth |
N80.331 |
Superficial endometriosis of the right pelvic sidewall |
N80.332 |
Superficial endometriosis of the left pelvic sidewall |
N80.333 |
Superficial endometriosis of bilateral pelvic sidewall |
N80.339 |
Superficial endometriosis of pelvic sidewall, unspecified side |
N80.341 |
Deep endometriosis of the right pelvic sidewall |
N80.342 |
Deep endometriosis of the left pelvic sidewall |
N80.343 |
Deep endometriosis of the bilateral pelvic sidewall |
N80.349 |
Deep endometriosis of the pelvic sidewall, unspecified side |
N80.351 |
Endometriosis of the right pelvic sidewall, unspecified depth |
N80.352 |
Endometriosis of the left pelvic sidewall, unspecified depth |
N80.353 |
Endometriosis of bilateral pelvic sidewall, unspecified depth |
N80.359 |
Endometriosis of pelvic sidewall, unspecified side, unspecified depth |
N80.361 |
Superficial endometriosis of the right pelvic brim |
N80.362 |
Superficial endometriosis of the left pelvic brim |
N80.363 |
Superficial endometriosis of bilateral pelvic brim |
N80.369 |
Superficial endometriosis of the pelvic brim, unspecified side |
N80.371 |
Deep endometriosis of the right pelvic brim |
N80.372 |
Deep endometriosis of the left pelvic brim |
N80.373 |
Deep endometriosis of bilateral pelvic brim |
N80.379 |
Deep endometriosis of the pelvic brim, unspecified side |
N80.381 |
Endometriosis of the right pelvic brim, unspecified depth |
N80.382 |
Endometriosis of the left pelvic brim, unspecified depth |
N80.383 |
Endometriosis of bilateral pelvic brim, unspecified depth |
N80.389 |
Endometriosis of the pelvic brim, unspecified side, unspecified depth |
N80.3A1 |
Superficial endometriosis of the right uterosacral ligament |
N80.3A2 |
Superficial endometriosis of the left uterosacral ligament |
N80.3A3 |
Superficial endometriosis of the bilateral uterosacral ligament(s) |
N80.3A9 |
Superficial endometriosis of the uterosacral ligament(s), unspecified side |
N80.3B1 |
Deep endometriosis of the right uterosacral ligament |
N80.3B2 |
Deep endometriosis of the left uterosacral ligament |
N80.3B3 |
Deep endometriosis of bilateral uterosacral ligament(s) |
N80.3B9 |
Deep endometriosis of the uterosacral ligament(s), unspecified side |
N80.3C1 |
Endometriosis of the right uterosacral ligament, unspecified depth |
N80.3C2 |
Endometriosis of the left uterosacral ligament, unspecified depth |
N80.3C3 |
Endometriosis of bilateral uterosacral ligament(s), unspecified depth |
N80.3C9 |
Endometriosis of the uterosacral ligament(s), unspecified side, unspecified depth |
N80.391 |
Superficial endometriosis of the pelvic peritoneum, other specified sites |
N80.392 |
Deep endometriosis of the pelvic peritoneum, other specified sites |
N80.399 |
Endometriosis of the pelvic peritoneum, other specified sites, unspecified depth |
N80.40 |
Endometriosis of rectovaginal septum, unspecified involvement of vagina |
N80.41 |
Endometriosis of rectovaginal septum without involvement of vagina |
N80.42 |
Endometriosis of rectovaginal septum with involvement of vagina |
N80.50 |
Endometriosis of intestine, unspecified |
N80.511 |
Superficial endometriosis of the rectum |
N80.512 |
Deep endometriosis of the rectum |
N80.519 |
Endometriosis of the rectum, unspecified depth |
N80.521 |
Superficial endometriosis of the sigmoid colon |
N80.522 |
Deep endometriosis of the sigmoid colon |
N80.529 |
Endometriosis of the sigmoid colon, unspecified depth |
N80.531 |
Superficial endometriosis of the cecum |
N80.532 |
Deep endometriosis of the cecum |
N80.539 |
Endometriosis of the cecum, unspecified depth |
N80.541 |
Superficial endometriosis of the appendix |
N80.542 |
Deep endometriosis of the appendix |
N80.549 |
Endometriosis of the appendix, unspecified depth |
N80.551 |
Superficial endometriosis of other parts of the colon |
N80.552 |
Deep endometriosis of other parts of the colon |
N80.559 |
Endometriosis of other parts of the colon, unspecified depth |
N80.561 |
Superficial endometriosis of the small intestine |
N80.562 |
Deep endometriosis of the small intestine |
N80.569 |
Endometriosis of the small intestine, unspecified depth |
N80.A0 |
Endometriosis in cutaneous scar |
N80.A1 |
Endometriosis of bladder, unspecified depth |
N80.A2 |
Superficial endometriosis of bladder |
N80.A41 |
Deep endometriosis of bladder |
N80.A42 |
Superficial endometriosis of right ureter |
N80.A43 |
Superficial endometriosis of left ureter |
N80.A49 |
Superficial endometriosis of bilateral ureters |
N80.A51 |
Superficial endometriosis of unspecified ureter |
N80.A52 |
Deep endometriosis of right ureter |
N80.A53 |
Deep endometriosis of left ureter |
N80.A59 |
Deep endometriosis of bilateral ureters |
N80.A61 |
Deep endometriosis of unspecified ureter |
N80.A62 |
Endometriosis of right ureter, unspecified depth |
N80.A63 |
Endometriosis of left ureter, unspecified depth |
N80.A69 |
Endometriosis of bilateral ureters, unspecified depth |
N80.B1 |
Endometriosis of unspecified ureter, unspecified depth |
N80.B2 |
Endometriosis of pleura |
N80.B31 |
Endometriosis of lung |
N80.B32 |
Superficial endometriosis of diaphragm |
N80.B39 |
Deep endometriosis of diaphragm |
N80.B4 |
Endometriosis of diaphragm, unspecified depth |
N80.B5 |
Endometriosis of the pericardial space |
N80.B6 |
Endometriosis of the mediastinal space |
N80.C0 |
Endometriosis of cardiothoracic space |
N80.C10 |
Endometriosis of the abdomen, unspecified |
N80.C11 |
Endometriosis of the anterior abdominal wall, subcutaneous tissue |
N80.C19 |
Endometriosis of the anterior abdominal wall, fascia and muscular layers |
N80.C2 |
Endometriosis of the anterior abdominal wall, unspecified depth |
N80.C3 |
Endometriosis of the umbilicus |
N80.C4 |
Endometriosis of the inguinal canal |
N80.C9 |
Endometriosis of extra-pelvic abdominal peritoneum |
N80.D0 |
Endometriosis of other site of abdomen |
N80.D1 |
Endometriosis of the pelvic nerves, unspecified |
N80.D2 |
Endometriosis of the sacral splanchnic nerves |
N80.D3 |
Endometriosis of the sacral nerve roots |
N80.D4 |
Endometriosis of the obturator nerve |
N80.D5 |
Endometriosis of the sciatic nerve |
N80.D6 |
Endometriosis of the pudendal nerve |
N80.D9 |
Endometriosis of the femoral nerve |
N80.9 |
Endometriosis, unspecified |
N93.8 |
Other specified abnormal uterine and vaginal bleeding |
N94.89 |
Other specified conditions associated with female genital organs and menstrual cycle
|
T86.09 |
Other complications of bone marrow transplant |
Z31.84 |
Encounter for fertility preservation procedure |
Z85.3 |
Personal history of malignant neoplasm of breast |
Z85.43 |
Personal history of malignant neoplasm of ovary |
J9217
ICD-10 |
ICD-10 Description |
C06.9 |
Malignant neoplasm of mouth, unspecified |
C07 |
Malignant neoplasm of parotid gland |
C08.0 |
Malignant neoplasm of submandibular gland |
C08.1 |
Malignant neoplasm of sublingual gland |
C08.9 |
Malignant neoplasm of major salivary gland, unspecified |
C48.1 |
Malignant neoplasm of specified parts of peritoneum |
C48.2 |
Malignant neoplasm of peritoneum, unspecified |
C48.8 |
Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum |
C50.011 |
Malignant neoplasm of nipple and areola, right female breast |
C50.012 |
Malignant neoplasm of nipple and areola, left female breast |
C50.019 |
Malignant neoplasm of nipple and areola, unspecified female breast |
C50.021 |
Malignant neoplasm of nipple and areola, right female breast |
C50.022 |
Malignant neoplasm of nipple and areola, left female breast |
C50.029 |
Malignant neoplasm of nipple and areola, unspecified female breast |
C50.111 |
Malignant neoplasm of central portion of right female breast |
C50.112 |
Malignant neoplasm of central portion of left female breast |
C50.119 |
Malignant neoplasm of central portion of unspecified female breast |
C50.121 |
Malignant neoplasm of central portion of right male breast |
C50.122 |
Malignant neoplasm of central portion of left male breast |
C50.129 |
Malignant neoplasm of central portion of unspecified male breast |
C50.211 |
Malignant neoplasm of upper-inner quadrant of right female breast |
C50.212 |
Malignant neoplasm of upper-inner quadrant of left female breast |
C50.219 |
Malignant neoplasm of upper-inner quadrant of unspecified female breast |
C50.221 |
Malignant neoplasm of upper-inner quadrant of right male breast |
C50.222 |
Malignant neoplasm of upper-inner quadrant of left male breast |
C50.229 |
Malignant neoplasm of upper-inner quadrant of unspecified male breast |
C50.311 |
Malignant neoplasm of lower-inner quadrant of right female breast |
C50.312 |
Malignant neoplasm of lower-inner quadrant of left female breast |
C50.319 |
Malignant neoplasm of lower-inner quadrant of unspecified female breast |
C50.321 |
Malignant neoplasm of lower-inner quadrant of right male breast |
C50.322 |
Malignant neoplasm of lower-inner quadrant of left male breast |
C50.329 |
Malignant neoplasm of lower-inner quadrant of unspecified male breast |
C50.411 |
Malignant neoplasm of upper-outer quadrant of right female breast |
C50.412 |
Malignant neoplasm of upper-outer quadrant of left female breast |
C50.419 |
Malignant neoplasm of upper-outer quadrant of unspecified female breast |
C50.421 |
Malignant neoplasm of upper-outer quadrant of right male breast |
C50.422 |
Malignant neoplasm of upper-outer quadrant of left male breast |
C50.429 |
Malignant neoplasm of upper-outer quadrant of unspecified male breast |
C50.511 |
Malignant neoplasm of lower-outer quadrant of right female breast |
C50.512 |
Malignant neoplasm of lower-outer quadrant of left female breast |
C50.519 |
Malignant neoplasm of lower-outer quadrant of unspecified female breast |
C50.521 |
Malignant neoplasm of lower-outer quadrant of right male breast |
C50.522 |
Malignant neoplasm of lower-outer quadrant of left male breast |
C50.529 |
Malignant neoplasm of lower-outer quadrant of unspecified male breast |
C50.611 |
Malignant neoplasm of axillary tail of right female breast |
C50.612 |
Malignant neoplasm of axillary tail of left female breast |
C50.619 |
Malignant neoplasm of axillary tail of unspecified female breast |
C50.621 |
Malignant neoplasm of axillary tail of right male breast |
C50.622 |
Malignant neoplasm of axillary tail of left male breast |
C50.629 |
Malignant neoplasm of axillary tail of unspecified male breast |
C50.811 |
Malignant neoplasm of overlapping sites of right female breast |
C50.812 |
Malignant neoplasm of overlapping sites of left female breast |
C50.819 |
Malignant neoplasm of overlapping sites of unspecified female breast |
C50.821 |
Malignant neoplasm of overlapping sites of right male breast |
C50.822 |
Malignant neoplasm of overlapping sites of left male breast |
C50.829 |
Malignant neoplasm of overlapping sites of unspecified male breast |
C50.911 |
Malignant neoplasm of unspecified site of right female breast |
C50.912 |
Malignant neoplasm of unspecified site of left female breast |
C50.919 |
Malignant neoplasm of unspecified site of unspecified female breast |
C50.921 |
Malignant neoplasm of unspecified site of right male breast |
C50.922 |
Malignant neoplasm of unspecified site of left male breast |
C50.929 |
Malignant neoplasm of unspecified site of unspecified male breast |
C56.1 |
Malignant neoplasm of right ovary |
C56.2 |
Malignant neoplasm of left ovary |
C56.3 |
Malignant neoplasm of bilateral ovaries |
C56.9 |
Malignant neoplasm of unspecified ovary |
C57.00 |
Malignant neoplasm of unspecified fallopian tube |
C57.01 |
Malignant neoplasm of right fallopian tube |
C57.02 |
Malignant neoplasm of left fallopian tube |
C57.10 |
Malignant neoplasm of unspecified broad ligament |
C57.11 |
Malignant neoplasm of right broad ligament |
C57.12 |
Malignant neoplasm of left broad ligament |
C57.20 |
Malignant neoplasm of unspecified round ligament |
C57.21 |
Malignant neoplasm of right round ligament |
C57.22 |
Malignant neoplasm of left round ligament |
C57.3 |
Malignant neoplasm of parametrium |
C57.4 |
Malignant neoplasm of uterine adnexa, unspecified |
C57.7 |
Malignant neoplasm of other specified female genital organs |
C57.8 |
Malignant neoplasm of overlapping sites of female genital organs |
C57.9 |
Malignant neoplasm of female genital organ, unspecified |
C61 |
Malignant neoplasm of prostate |
Z85.3 |
Personal history of malignant neoplasm of breast |
Z85.43 |
Personal history of malignant neoplasm of ovary |
Z85.46 |
Personal history of malignant neoplasm of prostate |
J1951
ICD-10 |
ICD-10 Description |
E30.1 |
Precocious puberty |
E30.8 |
Other disorders of puberty |
F64.0 |
Transsexualism |
F64.1 |
Dual role transvestism |
F64.2 |
Gender identity disorder of childhood |
F64.8 |
Other gender identity disorders |
F64.9 |
Gender identity disorder, unspecified |
J1952 and J1954
ICD-10 |
ICD-10 Description |
C61 |
Malignant neoplasm of prostate |
Z85.46 |
Personal history of malignant neoplasm of prostate |
Appendix 2 – Centers for Medicare and Medicaid Services (CMS)
The preceding information is intended for non-Medicare coverage determinations. Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs) may exist and compliance with these policies is required where applicable. Local Coverage Articles (LCAs) may also exist for claims payment purposes or to clarify benefit eligibility under Part B for drugs which may be self-administered. The following link may be used to search for NCD, LCD, or LCA documents: https://www.cms.gov/medicare-coverage-database/search.aspx. Additional indications, including any preceding information, may be applied at the discretion of the health plan.
(J1950, J9217, J1952 and J1954)
Medicare Part B Covered Diagnosis Codes |
||
Jurisdiction |
NCD/LCA/LCD Document (s) |
Contractor |
6, K |
A52453 |
National Government Services, Inc |
J, M |
A59160 |
Palmetto GBA |
Medicare Part B Administrative Contractor (MAC) Jurisdictions |
||
Jurisdiction |
Applicable State/US Territory |
Contractor |
E (1) |
CA, HI, NV, AS, GU, CNMI |
Noridian Healthcare Solutions, LLC |
F (2 & 3) |
AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ |
Noridian Healthcare Solutions, LLC |
5 |
KS, NE, IA, MO |
Wisconsin Physicians Service Insurance Corp (WPS) |
6 |
MN, WI, IL |
National Government Services, Inc. (NGS) |
H (4 & 7) |
LA, AR, MS, TX, OK, CO, NM |
Novitas Solutions, Inc. |
8 |
MI, IN |
Wisconsin Physicians Service Insurance Corp (WPS) |
N (9) |
FL, PR, VI |
First Coast Service Options, Inc. |
J (10) |
TN, GA, AL |
Palmetto GBA |
M (11) |
NC, SC, WV, VA (excluding below) |
Palmetto GBA |
L (12) |
DE, MD, PA, NJ, DC (includes Arlington & Fairfax counties and the city of Alexandria in VA) |
Novitas Solutions, Inc. |
K (13 & 14) |
NY, CT, MA, RI, VT, ME, NH |
National Government Services, Inc. (NGS) |
15 |
KY, OH |
CGS Administrators, LLC |
LEUPROLIDE SUSP (Lupron Depot®, Lupron Depot-Ped®, Eligard®, Fensolvi®, Leuprolide Acetate Depot) Prior Auth Criteria |
|