Archived Policies - Prescription Drugs


Gonadotropin-Releasing Hormone (GnRH) Agonists and Antagonists

Number:RX501.041

Effective Date:07-01-2015

End Date:10-14-2016

Coverage:

Medical policies are a set of written guidelines that support current standards of practice. They are based on current peer-reviewed scientific literature. A requested therapy must be proven effective for the relevant diagnosis or procedure. For drug therapy, the proposed dose, frequency and duration of therapy must be consistent with recommendations in at least one authoritative source. This medical policy is supported by FDA-approved labeling and nationally recognized authoritative references. These references include, but are not limited to:  MCG care guidelines, Hayes, DrugDex (IIb level of evidence or higher), NCCN Guidelines (IIb level of evidence or higher), NCCN Compendia (IIb level of evidence or higher), professional society guidelines, and CMS coverage policy.

This policy addresses the singular use of gonadotropin-releasing hormone (GnRH) agonists and antagonists. It does not address the combined use of luteinizing hormone-releasing hormone (LHRH) agonists AND anti-androgens, for which there is no corresponding medical document.

This is not an all-inclusive listing of all GnRH preparations. Refer to the U.S. Food and Drug Administration (FDA) for all labeled indications of those GnRH preparations not listed in this policy.

Special Comment: Check contract or legislative provisions which may mandate benefits.

ALERT: All self-injectable medications are administered under the pharmacy benefit.

Gonadotropin-releasing hormone (GnRH) agonists and antagonists are addressed individually by generic and brand names (refer to Indications Table below) and may be considered medically necessary when:

There are FDA approved label indications; or

The FDA has granted an “Orphan Drug Designation” to the drug; or

There is an off-label listing within a standard reference compendia (such as the United States Pharmacopoeia Drug Information [USPDI] or the Thompson Micromedex Drug Dex Compendium (Drug Dex).

INDICATIONS TABLE

If the drug therapy is:

Then the medically necessary indications may include:

Abarelix Depot (Plenaxis™),

For the palliative treatment of men with advanced symptomatic prostate cancer in whom luteinizing-hormone-releasing hormone (LHRH) agonist therapy is not appropriate, and who refuse surgical castration, and have one or more of the following:

Risk of neurological compromise due to metastases; and/or

Ureteral or bladder outlet obstruction due to local encroachment or metastatic disease; and/or

Severe, persistent bone pain from skeletal metastases that is unrelieved by narcotic analgesia.

Cetrorelix Acetate (Cetrotide®),

For the following indications:

In vitro fertilization to inhibit premature luteinizing hormone (LH) surges to control ovarian stimulation/induction and/or final maturation of human embryos (check member benefit contracts for coverage); or

In the treatment of uterine leiomyomas, including preoperative hematologic improvement for anemia, in premenopausal women.

Degarelix Acetate (Firmagon®),

For advanced prostate cancer treatment, including metastasis, when other hormone therapies are intolerable, surgical castration is not an option, and there are no other alternative therapies available.

Ganirelix Acetate (Antagon®),

For in vitro fertilization to inhibit premature luteinizing hormone (LH) surges to control ovarian stimulation/induction and/or final maturation of human embryos (check member benefit contracts for coverage)

Goseralin Acetate (Zoladex®),

For the following indications:

A. Oncology uses:

Prostate cancer patients:

1. Palliative treatment of advanced prostate cancer, including metastasis, as an alternative to surgery or estrogen administration; or

2. Advanced prostate cancer, including metastasis, when other hormone therapies are intolerable, surgical castration is not an option, and there are no other alternative therapies available; or

3. Prostate cancer treatment; Stage B2 through C locally confined.

Breast cancer patients:

1. Palliative treatment of breast cancer in pre- or post-menopausal women; or

2. Adjuvant treatment of hormone receptor-positive, axillary lymph node-positive disease in premenopausal women.

B. Gynecology uses:

Endometriosis for pain relief and reduction of lesions for up to six-months of treatment; or

Endometriosis for pain relief and reduction of lesions for duration of therapy (the management of chronic pelvic pain) for up to 6-months of treatment; or

Dysfunctional uterine bleeding; or

Endometrial thinning (hypoplasia) prior to endometrial ablation for dysfunctional uterine bleeding.

C. Endocrine uses: Central precocious puberty (CPP), gonadotropin-dependent, with onset of secondary sexual characteristics earlier than 9-years for males and 8-years for females.

D. In vitro fertilization uses: Infertility treatment to desensitize the pituitary gland prior to ovarian stimulation (check member benefit contracts for coverage).

Histrelin Acetate (Supprelin LA®),

For endocrine treatment, including CPP, gonadotropin-dependent, with onset of secondary sexual characteristics earlier than 9-years for males and 8-years for females.

Histrelin Acetate (Vantas®),

For the following indications:

A. Oncology uses:

Prostate cancer patients:

1. Palliative treatment of advanced prostate cancer, including metastasis, as an alternative to surgery or estrogen administration; or

2. Advanced prostate cancer, including metastasis, when other hormone therapies are intolerable, surgical castration is no longer an option, and there are no other alternative therapies available.

Leuprolide Acetate (Eligard®, Lupron® and Viadur®),

For the following indications:

A. Oncology uses:

Prostate cancer patients:

  1. Palliative treatment of advanced prostate cancer, including metastasis, as an alternative to surgery or estrogen administration; or
  2. Advanced prostate cancer, including metastasis, when other hormone therapies are intolerable, surgical castration is not an option, and there are no alternate therapies available; or
  3. Prostate cancer neoadjuvant treatment; Stage B2 through C locally confined.

Breast cancer patients who are not on concurrent aromatase inhibitor therapy for:

  1. Treatment of advanced or metastatic breast cancer in premenopausal and peri menopausal women; or
  2. Treatment in premenopausal women with hormone receptor positive disease with or without concurrent tamoxifen or ovarian suppression.

Ovarian cancer patients for treatment of ovarian stromal tumors, relapsing granulosa cell tumors of the ovary, recurrent epithelial ovarian cancers, primary peritoneal cancer, and/or fallopian tube cancer.

B. Gynecology uses:

Endometriosis for pain relief and reduction of lesions for duration of therapy (management of chronic pelvic pain); or

Premenstrual syndrome; or

In the treatment of uterine leiomyomas, including preoperative hematologic improvement for anemia, in premenopausal women.

C. Endocrine uses:

CPP, gonadotropin-dependent, with onset of secondary sexual characteristics earlier than 9-years for males and 8-years for females; or

Endometrial thinning (hypoplasia) prior to endometrial ablation for dysfunctional uterine bleeding.

D. In vitro fertilization uses: Infertility treatment to inhibit premature luteinizing hormone (LH) surges to control ovarian stimulation/induction and/or final maturation of human embryos (check member benefit contracts for coverage).

Nafarelin Acetate (Synarel®),

For the following indications:

A. Gynecology uses:

Endometriosis for pain relief and reduction of lesions for up to 6-months of treatment; or

Endometriosis for pain relief and reduction of lesions for duration of therapy (the management of chronic pelvic pain) for up to 6-months of treatment.

B. Endocrine uses:

CPP, gonadotropin-dependent, with onset of secondary sexual characteristics earlier than 9-years for males and 8-years for females; or

Hirsutism due to ovarian androgen hypersecretion.

Triptorelin Pamoate (Trelstar®),

For the following indications:

A. Oncology uses:

Palliative treatment of advanced prostate cancer, including metastasis, as an alternative to surgery or estrogen administration; or

Advanced prostate cancer, including metastasis, when other hormone therapies are intolerable, surgical castration is no longer an option, and there are no other alternative therapies available.

B. Non-oncology uses: Benign fibrocystic mastopathy (fibrocystic disease of the breast) for up to 3-months.

C. Gynecology uses:

Endometriosis for pain relief and reduction of lesions for up to 6--months of treatment; or

Endometriosis for pain relief and reduction of lesions for duration of therapy (the management of chronic pelvic pain) for up to 6-months of treatment; or

Hyperplastic endometrium; or

In the treatment of uterine leiomyomas, including preoperative hematologic improvement for anemia, in premenopausal women.

D. Endocrine uses: CPP, gonadotropin-dependent, with onset of secondary sexual characteristics earlier than 9-years for males and 8-years for females.

E. In vitro fertilization uses: Infertility treatment to inhibit premature luteinizing hormone (LH) surges to control ovarian stimulation/induction and/or final maturation of human embryos (check member benefit contracts for coverage).

An off-label indication for an FDA approved drug that is not addressed in the coverage table below is considered not medically necessary when:

The FDA has determined its use to be contraindicated for a specific condition; or

The off-label use cannot be validated by standard reference compendia or peer reviewed literature.

All Other Indications

In addition to the table above, administration of GnRH analogs, hormones and antagonists are considered not medically necessary for all other indications, including but not limited to:

Anovulation with or without accompanying polycystic ovarian disease; or

Benign prostate hypertrophy (BPH); or

Chemically induced male castration; or

Cryopreservation of oocytes, spermatozoa, and/or human embryos (including ovarian or testicular tissue) before or during chemotherapy; or

Delayed puberty; or

Endometrial cancer; or

Hypogonadism; or

Irritable bowel syndrome; or

Liver cancer; or

Male contraceptive agents or oligospermia; or

Menopause; or

Menstrual cycle regulation with or without amenorrhea; or

Menstrually related mood disorder; or

Non-specific chronic intestinal diseases (such as, pseudo obstruction, functional disease; or hollow visceral neuropathy);

Obesity; or

Polycystic ovarian disease; or

Premature ovarian failure; or

Skin conditions (such as itching; redness; dryness; wrinkling; or roughness); or

Testicular cancer.

NOTE: The following discontinued preparations are no longer on the medical policy and references to them have been removed from the coverage and description sections of this medical policy:

Gonadorelin Acetate (Lutrepulse®/Lutrepulse Kit® or Factrel®), and

Histrelin Acetate (Supprelin® only, not Supprelin LA® or Vantas®).

NOTE: Abarelix Depot (Plenaxis™), the brand named version has been discontinued; but, generic preparations may still be available and in use. Discussion within the coverage and description sections remains on the medical policy.

Special Comment: Check contract or legislative provisions which may mandate benefits.

Description:

Acting on the pituitary gland in the brain, gonadotropin-releasing hormone (GnRH), also known as luteinizing hormone-releasing hormone (LHRH), stimulates the function of the testes and ovaries. GnRH analogs are synthetic peptide drugs modeled after the human hypothalamic GnRH. Two types of analogs have been distinguished – GnRH agonists and GnRH antagonist. GnRH agonists drugs interacts with GnRH receptors to elicit its biologic response, the release of pituitary gland hormones – follicle-stimulating hormones (FSH) and luteinizing hormone (LH). GnRH antagonist drugs competitively and reversibly binds to the GnRH receptors in the pituitary gland, blocking or suppressing the release of FSH and LH. In men, the reduction of LH subsequently leads to rapid suppression of testosterone release from the testes. In women, the reduction leads to suppression of estrogen release from the ovaries.

Repeated monthly injections of these drugs cause gonadal hormone dependent tissues or 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.

Although GnRH products may differ in specific labeled indications and dosing requirements, clinical evidence may not support differential effectiveness of one product over the other for U.S. Food and Drug Administration (FDA) approved clinical indications.

Abarelix (Plenaxis™) has been approved, as an injectable form of a GnRH antagonist, for marketing under a voluntary risk management program (RMP) to patients with advanced prostate cancer. RMP is a strict “Prescribing Program”, part of an expedited drug approval pathway, to reserve specific pharmaceuticals to patients where the medical benefits outweigh the risks. RMP requirements generally include all of the following:

  • Restricted dispensing of the medication directly to the physician, and
  • Completed educational programs by the physician and patient, and
  • Maintenance of physician and patient registries.

NOTE: Plenaxis™ was originally approved November 25, 2003, but was withdrawn from the market in May 2005. Patients who were on Plenaxis™ before it was withdrawn were “grandfathered”; currently, Plenaxis™ is only available to patients who have continued on it since being “grandfathered”. The FDA mentions the brand name is not available, but generic preparations may still be in use.

Cetrorelix Acetate (Cetrotide®) is a synthetic injectable decapeptide analog of GnRH, a GnRH antagonist. It is used as a component of infertility regimens (recombinant FSH or human menopausal gonadotropin [hMG], Cetrorelix®, and human chorionic gonadotropin [hCG]) to inhibit premature LH surges in women undergoing controlled ovarian stimulation (COS).

Degarelix Acetate (Firmagon®) is a GnRH antagonist injectable for the treatment of adult male patients with advanced hormone-dependent prostate cancer and is administered by subcutaneous injection. Firmagon® reduces levels of prostate specific antigen (PSA) by blocking the GnRH receptors in the pituitary gland. Blocking these receptors suppresses the luteinizing hormone, which decreases production of testosterone by the testicles. Since prostate cancer is dependent on testosterone for growth, the growth of prostate cancer slows down.

Ganirelix Acetate (Antagon®) injection is a synthetic decapeptide analog of GnRH, like cetrorelix acetate, and a GnRH antagonist. This drug is used for infertility treatment to inhibit LH surges.

Goseralin Acetate (Zoladex®) is a GnRH analog, which is indicated in certain conditions requiring suppression of estrogen or testosterone secretion. At this time, Zolodex® is available as a long acting, continuous releasing subcutaneous implant for a period of 28 days.

Histrelin Acetate (Supprelin LA® or Vantas®) is a GnRH antagonist that lowers the male hormone testosterone in blood. Both Supprelin LA® and Vantas® are available as subcutaneous implants for continuous release of the drug. Supprelin LA® is utilized for treatment of children with central precious puberty, whereas Vantas® is indicated in the palliative treatment of advanced prostate cancer.

NOTE: In 2007, Supprelin® (not Supprelin LA®) marketing has been discontinued, no longer available.

Leuprolide Acetate (Eligard®, Lupron®, or Viadur®) is a synthetic analog of naturally occurring GnRH or LHRH and an antagonist. The analog possesses greater potency than the natural hormone. Because of its inhibitory effect on gonadotropin secretion and androgen or estrogen synthesis, leuprolide inhibits growth of hormone-dependent tumors. Leuprolide has reduced the size of the prostate gland and has inhibited prostatic tumor growth. There is also evidence to suggest that leuprolide inhibits the growth of estrogen-dependent mammary tumors mainly by inhibiting ovarian function and estrogen synthesis. Eligard® and Lupron® are available as injectables, whereas Viadur® is an implant.

Nafarelin Acetate (Synarel®), a metered nasal spray, is used in the palliative treatment of endometriosis. This drug like other GnRH analogs produces reversible hypo estrogenic state, which is thought to be principally responsible for the beneficial effects observed in endometriosis. A 6-month course of therapy can provide symptomatic relief and a reduction in endometrial lesions. Synarel® is also used for the treatment of central (via activation of the hypothalamic-pituitary-gonadal axis) precocious puberty (true precocious puberty GnRH-dependent precocious puberty, complete isosexual precocity) in children of both sexes and has been designated an orphan drug by the FDA for use in this condition. Precocious puberty is generally defined as the onset of sexual characteristics in girls or boys younger than eight or nine years of age respectively. The principle goals of therapy with GnRH analogs in this condition are to halt the premature development of secondary sexual characteristics and achieve a near normal adult height by slowing linear growth and skeletal maturation.

Triptorelin Pamoate (Trelstar®) injection is indicated in the palliative treatment of advanced prostate cancer. It offers an alternative treatment for prostate cancer when orchiectomy or estrogen administration is either not indicated or unacceptable to the patient.

Rationale:

This policy was created in 1990 and based on U.S. Food and Drug Administration (FDA) –approved labeled indications and routinely updated with literature searches, particularly for off-labeled use, with the most recent update including searches in the MedLine database and standard reference compendium through December 2014. The following includes a summary of each gonadotropin releasing hormone (GnRH) agonist and antagonist.

Gonadotropin Releasing Hormone (GnRH) for Breast Cancer

Coverage for treatment of breast cancer beyond the approved FDA–approved labeled indications has been based on two clinical studies, over a two year period, comparing ovarian suppression hormones, such as GnRH analogs to conventional chemotherapeutic agents, such as a combination of cyclophosphamide, methotrexate, and 5-fluorouracil (CMF). Five years after the completion of one study, no difference between goserelin (Zoladex®) and CMF was established in the final outcome review. Converting patients from an estrogen receptor (ER) positive to negative state, CMF induces significantly better disease free survival and overall survival. (1, 6, 7)

GnRH for Chronic Pelvic Pain

The 2004 American College of Obstetrics and Gynecology (ACOG) recommended the use of gonadotropin-releasing hormone agonists as a treatment option for chronic pelvic pain since they have been demonstrated to relieve endometriosis-associated pelvic pain. (2) Guidelines from the 2005 Royal College of Obstetricians and Gynecologists 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- to 6-months before having a diagnostic laparoscopy. (3) The 1999 Ling et al study represents the one small short-term randomized controlled trial used for support of empiric therapy for management of chronic pelvic pain. (4)

GnRH for Advanced Prostate Cancer

GnRH receptor blockers are the latest addition to the hormonal therapy armamentarium for patients with advanced prostate cancer. In contrast to GnRH agonists, GnRH blockers have an immediate onset of action and do not cause a surge in testosterone levels that can lead to a flare in patients with advanced disease. (6, 7)

On December 29, 2008, the FDA approved degarelix acetate (Firmagon®), a GnRH receptor blocker for the treatment of hormone-sensitive advanced prostate cancer. (6, 7) The effectiveness of degarelix was established in a 12-month, comparative, randomized, open-label, parallel-group phase III 2008 clinical trial by Klotz et al in which a total of 610 patients with cancer of the prostate [median prostate-specific antigen (PSA) level 19.0] were randomized and received treatment with degarelix (starting dose of 240 mg for one-month followed by maintenance doses of either 80 mg or 160 mg monthly) or leuprolide (7.5mg monthly). (5) After 3 days of treatment, testosterone levels were equal to or lesser than 0.5 ng/ml in 96.l% and 95.5% of patients of the degarelix 240/80 mg and 240/160 mg groups, respectively. The median PSA levels at 14- and 28-days were significantly lower in the degarelix groups than in the leuprolide group. The authors concluded that degarelix was not inferior to leuprolide at maintaining low testosterone levels over a 1-year treatment period; however, degarelix induced testosterone and PSA suppression significantly faster than leuprolide, which was maintained throughout the study. Furthermore, there was no need for anti-androgen supplements to prevent the possibility of a clinical flare.

GnRH for Cryopreservation

According to the Practice Committee of the American Society for Reproductive Medicine (ASRM) in 2013, over 100,000 patients less than 45 years of age are diagnosed with cancer in the U.S. (8) Advancements of cancer treatments, including chemotherapy regimens, have led to improved outcomes and survival. However, gonadotoxicity is a concern, with a growing interest in expanding fertility options and treatments. Success rates using cryopreserved embryos and mature oocytes have been discussed and should be discussed with each patient with or without a committed partner. There is concern if chemotherapeutic agents affect the reproductive tissue, particularly when cancer treatments were started emergently and concerns about the well-being of future children had not been addressed. Due to the strategy of fertility treatments, such as ovarian stimulation, there is added concern if cryopreservation would interfere or result in unpredictable outcomes when combined with the chemotherapy regimen. Cryopreservation may also result in a lower yield of oocytes in particular, especially when there is an attempt to begin a second or more cycle. There are no human studies that have specifically examined the quality of oocytes or embryos that result following a prior chemotherapy course, as well as concerns regarding the outcomes following cervical, endometrial, or ovarian surgical treatment. (8, 9)

Summary

The FDA approves drugs for specific indications that are included in the drug's labeling. When a drug is used for an indication other than those specifically included in the labeling, it is referred to as an off-label, unlabeled use, or grant supported orphan drug use with marketing approval. When coverage is allowed for GnRH therapies, it is done based solely on the FDA–approved label indications as well as supporting literature from standard reference compendium for off-labeled indications. (6, 7)

As a result of the searches, there is a lack of peer reviewed scientific literature from which conclusions could be made concerning the safety and efficacy of treatment of various other indications mentioned which were not FDA–approved label indications, including, but not limited to: premenstrual syndrome; menopause or mood related disorders; chronic intestinal disease; cancer of the endometrium, ovary, testicles, or liver; benign prostatic hypertrophy; menstrual cycle regulation; non-oncological ovarian conditions, obesity, and male castration. (6, 7)

Several preparations have been discontinued from marketing based on diminished market demand and costs of manufacturing. Those preparations have been removed from the medically necessary indications of this medical policy. One preparation may still be available in generic form and available for utilization.

Contract:

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coding:

CODING:

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

CPT/HCPCS/ICD-9/ICD-10 Codes

The following codes may be applicable to this Medical policy and may not be all inclusive.

CPT Codes

None

HCPCS Codes

J1620, J1675, J1950, J3315, J9155, J9202, J9217, J9218, J9219, J9225, J9226, S0132, S9560

ICD-9 Diagnosis Codes

Refer to the ICD-9-CM manual

ICD-9 Procedure Codes

Refer to the ICD-9-CM manual

ICD-10 Diagnosis Codes

Refer to the ICD-10-CM manual

ICD-10 Procedure Codes

Refer to the ICD-10-CM manual


Medicare Coverage:

The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.

The Centers for Medicare and Medicaid Services (CMS) does not have a national Medicare coverage position. Coverage may be subject to local carrier discretion.

A national coverage position for Medicare may have been developed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.

References:

1. Robertson, J.F., and R.W. Blamey. The use of gonadotrophin-releasing hormone (GnRH) agonists in early and advanced breast cancer in pre- and perimenopausal women. European Journal of Cancer (2003 May) 39(7):861-9.

2. Chronic Pelvic Pain – Position paper. Washington, D.C.: ACOG Practice Bulletin (2004 March) (51):1-16.

3. McEvoy, G.K., Miller, J., eds., et al. American Society of Health-System Pharmacists, American Chronic Pelvic Pain – Position paper. Washington, D.C.: ACOG Practice Bulletin (2004 March) (51):1-16.

4. Ling, F.W. Randomized controlled trial of depot leuprolide in patients with chronic pelvic pain and clinically suspected endometriosis. Obstetrics and Gynecology (1999 January) 93(1):51-8.

5. Klotz, L., Boccon-Gibod, L., et al. The efficacy and safety of degarelix: a 12-month, comparative randomized, open-label, parallel-group phase III study in patients with prostate cancer. BJU International (2008 December) 102(11):1531-8.

6. FDA – Drugs @ FDA (FDA Approved Drug Products and Label Information for Plenaxis™, Cetrotide®, Firmagon®, Antagon®, Zoladex®, Suppralin LA®, Vantas®, Eligard®, Lupron®, Viadur®, Synarel®, and Trelstar®). Available at <http://www.accessdata.fda.gov> (accessed on 2015 February 2).

7. MICROMEDEX 2.0 [Health Care Series]) Drug Information for the Health Care Professional – Non-FDA Labeled Indications for cetrorelix acetate, goserelin acetate, leuprolide acetate, nafarelin acetate, and triptorelin pamoate. Available at <http://www.micromedex.com> (accessed on 2015 February 2).

8. The Practice Committee of the American Society for Reproductive Medicine. Fertility preservation in patients undergoing gonadotoxic therapy or gonadectomy: a committee opinion. Fertility and Sterility (2013 November) 100(5):1214-22.

9. Rabah, D.M., El-Nimer, N., et al. Fertility cryopreservation for female cancer patients: attitudes and clinical practices of oncologist in Riyadh, Saudi Arabia. Journal of Reproductive Medicine (2012 September-October) (9-10):431-4.

Policy History:

Date Reason
7/1/2015 Document updated with literature review. The following was added to the coverage section: 1) For in vitro fertilization, clarification to control ovarian stimulation/induction and/or final maturation of human embryos; 2) For Zoladex®, dysfunctional uterine bleeding may be considered medically necessary; 3) For Eligard®, Lupron®, and Viadur®, premenstrual syndrome may be considered medically necessary; and 4) For uterine leiomyomas in premenopausal women, clarification to improve preoperative anemia. The following indications were added to experimental, investigational and/or unproven listing; cryopreservation of oocytes, spermatozoa, and/or human embryos (including ovarian or testicular tissue) before or during chemotherapy; endometrial cancer; irritable bowel syndrome, obesity, polycystic ovarian disease, premature ovarian failure; and testicular cancer.
7/1/2012 Document updated with literature review. Coverage completely revised, with new indications, and all covered indications categorized as first-line therapy or second-line therapy in a table. Entire policy was completely revised. Document title changed from “Gonadotropin-Releasing Hormone (GnRH) Analogs, Hormones, Antagonists and Receptor Blockers.”
11/6/2009 Codes Added
3/1/2009 Codes Revised/Added/Deleted
7/15/2008 Coverage Revised
4/15/2008 Revised/Updated Entire Document
7/15/2007 Coverage Revised
11/15/2006 Revised/Updated Entire Document
1/1/2006 Coverage Revised
7/1/2005 Codes Revised/Added/Deleted
3/29/2005 Coverage Revised
10/1/2004 Revised/Updated Entire Document
6/1/2001 Codes Revised/Added/Deleted
9/1/1996 Revised/Updated Entire Document
5/1/1996 Document number change
7/1/1995 Revised/Updated Entire Document
10/1/1994 Revised/Updated Entire Document
7/1/1993 Revised/Updated Entire Document
7/1/1992 Revised/Updated Entire Document
4/1/1992 Revised/Updated Entire Document
5/1/1990 New Medical Document

Archived Document(s):

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