CurrentAetnaPolicy 0501

Gonadotropin-Releasing Hormone Analogs and Antagonists

Aetna clinical policy bulletin for commercial medical plans addressing medical necessity, precertification, initial and continuation approval criteria, and prescriber specialty requirements for multiple GnRH agonists and antagonists (e.g., cetrorelix, ganirelix, degarelix, goserelin, histrelin, leuprolide formulations).

Policy Summary

PayerAetna

PolicyGonadotropin-Releasing Hormone Analogs and Antagonists

Policy CodePolicy 0501

Change TypeNo material changes

Effective DateApr 27, 2001

Next Review DateJan 25, 2024

Key ActionPrecertification is required for listed GnRH products; call (866) 752-7021 or fax (888) 267-3277 and use SMN precertification forms as applicable.

SourceLink

POLICY UPDATE CHANGES

No material changes — this policy part reports no material clinical or coverage changes.

MultipleProducts covered with criteria

SeveralIndications with gender dysphoria criteria

(866) 752-7021Precertification phone contact

ManyIndications considered experimental

MultipleCovered ICD-10 ranges listed

Coverage Summary

This CPB covers multiple GnRH agonists and antagonists as medically necessary when the product-specific selection criteria are met; the overall coverage stance is covered with criteria.

Precertification is required for listed products (examples: cetrorelix, degarelix, ganirelix, goserelin, leuprolide formulations including Eligard, Lupron Depot, Camcevi/Fensolvi, and triptorelin); providers must use the SMN precertification process and contact the phone/fax numbers in the policy.

Indications not listed in the agent-specific criteria are considered experimental/investigational and will not be approved under this policy.

For Medicare Part B criteria reference a separate CMS resource as noted in the policy (Medicare Part B Criteria).

Initial Therapy Criteria (agent-specific)

General Precertification Note

Precertification is required for listed agents. For continuation, initial criteria must be met unless otherwise specified.

ALL of the following

General Precertification Note: Precertification of cetrorelix acetate (Cetrotide), degarelix (Firmagon), ganirelix acetate (Ganirelix AC), goserelin acetate implant (Zoladex), leuprolide acetate (Eligard), leuprolide acetate, 7.5 mg (Lupron Depot), leuprolide mesylate (Camcevi), and triptorelin (Trelstar) is required of all Aetna participating providers and members in applicable plan designs. For precertification call (866) 752-7021 or fax (888) 267-3277. For Statement of Medical Necessity (SMN) precertification forms, see Specialty Pharmacy Precertification.
Coverage by indication: Brand selection rules apply. Camcevi, Firmagon, Lupron Depot, Trelstar, and Zoladex are considered medically necessary for prostate cancer only when member has contraindication, intolerance, or ineffective response to Eligard (leuprolide acetate).

Goserelin (Zoladex) - Initial Approval Indications

Agent-specific initial approval and continuation criteria.

ALL of the following

Cetrorelix Acetate (Cetrotide) and Ganirelix Acetate - Initial Approval
- Indication: Inhibition of premature luteinizing hormone (LH) surges in members undergoing ovulation induction or assisted reproductive technology (ART).
- Plans: Coverage limited to plans that cover advanced reproductive technologies; check benefit descriptions.
Cetrorelix Acetate (Cetrotide) and Ganirelix Acetate - Continuation
- Continuation: Medically necessary for members (including new members) requesting authorization for continuation who meet all initial authorization criteria.

ALL of the following

Histrelin (Supprelin LA) - Initial Approval Indications

ALL of the following

Histrelin (Supprelin LA) - Continuation
- Continuation for CPP or gender dysphoria: Members requesting reauthorization must meet initial authorization criteria and demonstrate clinical benefit and no unacceptable toxicity.

Leuprolide Acetate (Subcutaneous Injection) - Initial Approval

ALL of the following

Leuprolide Acetate (Subcutaneous Injection) - Initial Approval
- Indications: treatment of prostate cancer, central precocious puberty, endometriosis, uterine leiomyomata, gender dysphoria (pubertal suppression or gender transition) and other FDA-approved or compendial uses as specified in policy.
Leuprolide Acetate (Subcutaneous Injection) - Continuation
- Continuation: Medically necessary for members requesting reauthorization who meet initial authorization criteria and are experiencing clinical benefit and have not experienced unacceptable toxicity (e.g., for prostate cancer testosterone suppression thresholds apply).

Leuprolide Acetate (Eligard) - Initial Approval

ALL of the following

Leuprolide Acetate (Eligard) - Initial Approval
- Indications: treatment of prostate cancer and other FDA-approved indications; subject to brand selection rules for prostate cancer (Eligard preferred).
Leuprolide Acetate (Eligard) - Continuation
- Continuation: Medically necessary for members requesting reauthorization who meet initial authorization criteria and demonstrate clinical benefit and no unacceptable toxicity.

Leuprolide Acetate (Fensolvi) - Initial Approval

ALL of the following

Leuprolide Acetate (Fensolvi) - Initial Approval
- Indications: per FDA-approved labeling and compendial uses (e.g., prostate cancer, central precocious puberty, endometriosis, gender dysphoria) as described in policy.
Leuprolide Acetate (Fensolvi) - Continuation
- Continuation: Medically necessary for members requesting reauthorization who meet initial authorization criteria and demonstrate clinical benefit and no unacceptable toxicity.

Lupron Depot (various) - Initial Approval

ALL of the following

Lupron Depot (various) - Initial Approval
- Includes 1-month, 3-month, 4-month, 6-month and other depot formulations (e.g., Lupron Depot 3.75 mg, 11.25 mg, 7.5 mg). Indications: prostate cancer, central precocious puberty (pediatric formulations), endometriosis, uterine leiomyomata, and other FDA-approved indications per product labeling.
Leuprolide Acetate for Depot Suspension (Lupron Depot 3.75 mg, 11.25 mg) - Prescribing Information
- Refer to product labeling for dosing, administration intervals, and indications (including adult and pediatric formulations).
Lupron Depot (3.75 mg, 11.25 mg) - Continuation
- Continuation: Medically necessary for members requesting reauthorization who meet initial authorization criteria and demonstrate clinical benefit and no unacceptable toxicity.

Lupron Depot-PED - Initial Approval for Gender Dysphoria

ALL of the following

Lupron Depot-PED - Prescriber Specialties
- For gender dysphoria: must be prescribed by or in consultation with provider specialized in care of transgender youth (eg, pediatric endocrinologist, family or internal medicine physician, obstetrician-gynecologist) with collaborative mental health provider for members < 18 years.
Lupron Depot-PED - Initial Approval for Gender Dysphoria
- Pubertal hormonal suppression in adolescent member when ALL criteria met:
- Diagnosis of gender dysphoria.
- Member able to make an informed decision to engage in treatment.

Camcevi - Initial

ALL of the following

Camcevi (Leuprolide Mesylate) - Initial
- Initial: Medically necessary for FDA-approved indications; for prostate cancer subject to brand selection rules — Camcevi is covered only when member has contraindication, intolerance, or ineffective response to Eligard.
Leuprolide Mesylate (Camcevi) - Continuation
- Continuation: Medically necessary for members requesting reauthorization who meet initial authorization criteria and demonstrate clinical benefit and have not experienced unacceptable toxicity.

Triptorelin (Trelstar/Triptodur) - Initial Approval Indications

ALL of the following

Triptorelin (Trelstar/Triptodur) - Prescriber Specialty Requirement
- For gender dysphoria: Trelstar/Triptodur must be prescribed by or in consultation with a provider specialized in care of transgender youth with collaborative mental health care for members < 18 years.
Triptorelin (Trelstar) - Initial Approval Indications
- Indications per product labeling: prostate cancer, central precocious puberty (when applicable formulations), and other FDA-approved uses as described in policy.
- Gender dysphoria indications follow same shared decision/Tanner stage criteria as other agents (diagnosis, informed consent, Tanner stage >=2 for suppression, comorbid control, education on risks, fertility preservation discussion).
Triptorelin (Trelstar) - Continuation of Therapy

FDA-Approved Indications and Safety

Agent-specific FDA-approved indications, compendial uses, and safety considerations summarized below.

ALL of the following

Coverage by Indication (agent-specific)
- Agents covered for prostate cancer: leuprolide acetate (Eligard preferred), degarelix, goserelin, triptorelin, leuprolide depot formulations, Camcevi (only if Eligard contraindicated/intolerant/ineffective).
- Agents covered for central precocious puberty: approved pediatric formulations of leuprolide (Lupron Depot-PED), histrelin (Supprelin LA), triptorelin where indicated.
- Agents covered for assisted reproduction: cetrorelix and ganirelix for inhibition of premature LH surge in ART when plan covers advanced reproductive technologies.
FDA-Approved Indications and Compendial Uses (agent-specific summaries)

Continuation Therapy Criteria (agent-specific)

Continuation / Reauthorization Criteria per Agent

Render continuation / reauthorization logic per agent including clinical benefit thresholds (e.g., serum testosterone <50 ng/dL), age continuation cutoffs, treatment‑benefit and toxicity requirements, and duration limits.

Cetrorelix/Ganirelix - Continuation: Continuation medically necessary for all members (including new members) requesting authorization for continuation who meet all initial authorization criteria. Coverage limited to plans that cover advanced reproductive technologies.

Degarelix - Continuation: Continuation medically necessary for members requesting reauthorization who are experiencing clinical benefit to therapy (e.g., serum testosterone less than 50 ng/dL) and who have not experienced an unacceptable toxicity.Serum testosterone <50 ng/dL (example of clinical benefit)

Contraindicated in members with hypersensitivity to degarelix

Goserelin - Continuation:

Prescriber Specialty & Documentation Requirements

Prescriber specialty and provider consultation requirements for specific agents (goserelin, histrelin, leuprolide, triptorelin) and required consultations for gender dysphoria and porphyria.

ALL of the following

Goserelin (Zoladex): Prescribing Specialties - For gender dysphoria, must be prescribed by or in consultation with a provider specialized in care of transgender youth (e.g., pediatric endocrinologist, family or internal medicine physician, obstetrician-gynecologist) who has collaborated care with a mental health provider for members < 18 years of age.
Goserelin (Zoladex): Prescribing Specialties - For prevention of recurrent menstrual related attacks in acute porphyria, must be prescribed by or in consultation with a provider experienced in management of porphyrias.
Histrelin (Supprelin LA): Prescribing Specialties - For gender dysphoria, must be prescribed by or in consultation with a provider specialized in care of transgender youth (e.g., pediatric endocrinologist, family or internal medicine physician, obstetrician-gynecologist) that has collaborated care with a mental health provider for members < 18 years of age.

Provider Actions — Prior Authorization, Billing, Monitoring

Prior Authorization

Continuation and prior authorization triggers; investigational exclusions

Continuation requests require evidence of clinical benefit and absence of unacceptable toxicity; prior authorization is required when selection criteria apply. Examples: clinical benefit for prostate cancer may be shown by serum testosterone < 50 ng/dL. Requests for indications not listed in the policy are considered experimental/investigational and will not be approved.

Continuation: demonstrate clinical benefit (e.g., serum testosterone < 50 ng/dL) and no unacceptable toxicity
Prior authorization required when selection criteria for the specific agent/indication apply
Non‑listed indications are experimental/investigational and are not approved

Billing Rule

Agent administration and billing rules (examples)

Applicable Codes

Products requiring precertification (examples listed in policy text)mixed

	Cetrorelix acetate (Cetrotide)
	Degarelix (Firmagon)
	Ganirelix acetate (Ganirelix AC)
	Goserelin acetate implant (Zoladex)
	Leuprolide acetate (Eligard)
	Leuprolide acetate 7.5 mg (Lupron Depot)
	Leuprolide mesylate (Camcevi)
	Triptorelin (Trelstar)

Therapeutic injection CPTCPT

96372

Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular.

Leuprolide HCPCS (covered if selection criteria met)HCPCSCovered

J9218	Leuprolide acetate, per 1 mg.
J9219	Leuprolide acetate implant, 65 mg.
J1950	Injection, leuprolide acetate (for depot suspension), per 3.75 mg.
J1954	Injection, leuprolide acetate for depot suspension (lutrate), 7.5 mg.
J9217	Leuprolide acetate (for depot suspension), 7.5 mg.

Lupron Depot-PED HCPCS (covered if selection criteria met)HCPCSCovered

J1950

Injection, leuprolide acetate (for depot suspension), per 3.75 mg.

Goserelin (Zoladex) HCPCS (covered if selection criteria met)HCPCSCovered

J9202

Goserelin acetate implant, per 3.6 mg.

Supprelin LA HCPCS (covered if selection criteria met)HCPCSCovered

J9226

Histrelin implant (Supprelin LA), 50 mg.

Triptorelin/related CPT (procedures)CPT

58353	Endometrial ablation, thermal, without hysteroscopic guidance.
58356	Endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed.
58563	Hysteroscopy, surgical; with endometrial ablation.
11980	Subcutaneous hormone pellet implantation.

Testosterone laboratory CPT (related monitoring)CPT

84402	Testosterone; free.
84403	Testosterone; total.

ICD-10 codes covered if selection criteria are metICD-10Covered

C61	Malignant neoplasm of prostate.
E22.8	Other hyperfunction of pituitary gland [central precocious puberty].
E30.1-E30.8	Precocious puberty and other disorders of puberty.
F64.0-F64.9	Gender identity disorders.
C50.011-C50.929	Malignant neoplasm of breast (listed for some agents).
C54.0-C54.9	Malignant neoplasm of corpus uteri.
C56.1-C56.9	Malignant neoplasm of ovary.
D25.0-D25.9	Leiomyoma of uterus (selected coverage for some agents).
Z51.11	Encounter for antineoplastic chemotherapy (when used for prevention of heavy uterine bleeding during chemotherapy).
Z87.890	Personal history of sex reassignment.

1–10 of 12

1/2

ICD-10 codes not covered / experimental (examples listed)ICD-10Not Covered

C07	Malignant neoplasm of parotid gland.
C49.0-C49.9	Malignant neoplasm of other connective and soft tissue [borderline leiomyosarcoma].
C53.0-C53.9	Malignant neoplasm of cervix uteri.
C55	Malignant neoplasm of uterus, part unspecified.
C62.00-C62.92	Malignant neoplasm of testis.
C90.00-C90.02	Multiple myeloma.
D48.1	Neoplasm of uncertain behavior of connective and other soft tissue [angiomyxoma].
E28.310-E28.319	Primary ovarian failure [premature ovarian failure].
D57.00-D57.819	Sickle-cell disorders.
G35	Multiple sclerosis.

1–10 of 11

1/2

Covered HCPCSHCPCSCovered

J9226	Histrelin implant (Supprelin LA), 50 mg
J3315	Injection, triptorelin pamoate, 3.75 mg
J3316	Injection, triptorelin, extended-release, 3.75 mg
J9155	Injection, degarelix, 1 mg
J1951	Injection, leuprolide acetate for depot suspension (fensolvi), 0.25 mg
J1952	Leuprolide injectable, camcevi, 1 mg
S0132	Injection, ganirelix acetate, 250 mcg

Related CPT codesCPT

11980	Subcutaneous hormone pellet implantation
96372	Therapeutic, prophylactic, or diagnostic injection; SC/IM
96401	Chemotherapy administration, SC/IM; non-hormonal anti-neoplastic
58970	Follicle puncture for oocyte retrieval, any method
58974	Embryo transfer, intrauterine
58976	Gamete, zygote, or embryo intrafallopian transfer, any method

Covered ICD-10 diagnoses (examples listed)ICD-10Covered

E22.8	Other hyperfunction of pituitary gland [central precocious puberty]
E30.1 - E30.8	Precocious puberty and other disorders of puberty
F64.0 - F64.9	Gender identity disorders
C50.011 - C50.929	Malignant neoplasm of breast
C61	Malignant neoplasm of prostate
N80.00 - N80.03, N80.A0 - N80.D9	Endometriosis
N85.01	Benign endometrial hyperplasia
N97.0 - N97.9	Female infertility (inhibition of premature LH surges in ART)
Z51.11	Encounter for antineoplastic chemotherapy (e.g., prevention of heavy uterine bleeding during chemotherapy)
Z87.890	Personal history of sex reassignment

ICD-10 codes NOT covered for CPB-listed indications (examples)ICD-10Not Covered

E25.0 - E25.9	Hyperaldosteronism [precocious puberty due to adrenal hyperplasia]
E27.8	Other specified disorders of adrenal glands
E35	Disorders of endocrine glands in diseases classified elsewhere
C18.0 - C18.9	Malignant neoplasm of colon
C81.00 - C81.99	Hodgkin lymphoma [for suppression of ovarian function]
N60.11 - N60.19	Diffuse cystic mastopathy [fibrocystic breast disease]
N46.021 - N46.9	Male infertility (not covered for cetrorelix/ganirelix indications)
N40.0 - N40.1	Enlarged prostate without/with lower urinary tract symptoms (not covered for degarelix)
T50.995A - T50.995S	Adverse effect of other drugs [contraindicated and considered not medically necessary for persons with hypersensitivity to degarelix]
Z31.83	Encounter for assisted reproductive fertility procedure cycle [in-vitro fertilization] (not covered for degarelix)

Laboratory codes referencedCPT

84402	Testosterone; free
84403	Testosterone; total

No explicit procedure or billing codes listed in this partmixed

No codes listed

No explicit procedure/CPT/HCPCS codes listed in this partmixed

No codes listed

Clinical Evidence and Limitations

-17%PROMISE‑GIM6: absolute reduction in early menopause with triptorelin during chemo (25.9% → 8.9%) = -17%

Key randomized controlled trial outcomes: degarelix trials showed rapid and durable testosterone suppression versus leuprolide with faster PSA decline and, in subgroup analyses, lower risk of PSA progression or death in some patients (Klotz et al; Tombal et al).

In oncology/fertility preservation RCTs, triptorelin (PROMISE-GIM6) reduced chemotherapy-induced early menopause (absolute difference −17%, p<0.001); the SOFT trial found no overall DFS benefit adding ovarian suppression to tamoxifen in the entire cohort but suggested benefit in women who remained premenopausal after chemotherapy.

Single-arm and pivotal trials for pediatric CPP (Fensolvi) achieved the primary LH suppression endpoint in ~87% at 6 months with sex-steroid suppression in most patients.

Systematic reviews and meta-analyses of GnRHa for ovarian protection report mixed results: some meta-analyses show reduced rates of premature ovarian failure or improved resumption of menses, while other RCTs and pooled analyses are inconsistent for ovarian reserve markers and pregnancy rates; significant heterogeneity and variable trial quality were noted.

Guideline positions and reviews (ASCO, UpToDate, Endocrine Society) caution limited or low-quality evidence for some off-label fertility-preservation uses and recommend that ovarian suppression for fertility preservation be considered investigational or used in clinical trials; UpToDate supports selective use (e.g., to induce amenorrhea or to prevent luteal-phase porphyria attacks).

Limitations include heterogeneity of study designs, mixed-quality evidence, small sample sizes, variable endpoints (menstrual resumption vs ovarian reserve vs pregnancy), and inconsistent long-term fertility outcomes—all of which temper broad coverage beyond listed, evidence-supported indications.

Background & Compendial / Off-Label Uses

Background: GnRH agonists and antagonists suppress gonadotropin secretion to control sex-steroid–dependent conditions; products vary by formulation, indication, and monitoring requirements.

Common compendial/off-label uses discussed include: infertility protocols (suppression of premature LH surge and oocyte maturation/triggering in ART); preservation of ovarian function during chemotherapy; pubertal suppression for gender dysphoria (pubertal blockade and gender transition); and prevention of recurrent menstrual-related attacks in acute porphyria.

Other off-label or compendial uses noted in the background include treatment of certain gynecologic tumors, uterine leiomyomata as preoperative adjunct, and rare uses such as porphyria and aggressive angiomyxoma; the policy emphasizes many of these uses have limited evidence and some are considered investigational per the policy.

Compendial / Off-Label Uses Discussed

Compendial and off‑label uses discussed in the document and any conditional criteria described (e.g., ovarian preservation, porphyria prevention, fertility preservation counseling).

Fertility/ART related off‑label uses: GnRH antagonists/agonists (cetrorelix, ganirelix, leuprolide, degarelix) are discussed for inhibition of premature LH surges in ART, stimulation testing, oocyte maturation/ovulation trigger, and dual‑trigger strategies in IVF; some uses limited by plan ART coverage and evidence; continuation requires meeting initial ART criteria.

Safety, Contraindications & Monitoring

Product label warnings and precautions across GnRH agonists/antagonists include an initial hormone surge with potential tumor flare (worsening bone pain, obstruction, or neurologic compromise), particularly in androgen-sensitive tumors.

Metabolic and cardiovascular risks are noted: reports of hyperglycemia/diabetes and increased risk of myocardial infarction, sudden cardiac death, and stroke with androgen-deprivation therapy; consider risks/benefits.

Labels warn about potential QT/QTc prolongation with androgen-deprivation therapy and recommend caution with concomitant QT-prolonging drugs.

Serious neurological and psychiatric events have been reported: convulsions/seizures, psychiatric events (emotional lability, depression), and pseudotumor cerebri/idiopathic intracranial hypertension in pediatric patients; monitor and counsel accordingly.

Chronic use can decrease bone mineral density; specific duration limits apply for some products (e.g., Lupaneta Pack initial 6 months with single retreatment ≤6 months; total use not recommended beyond 12 months), and bone density monitoring is recommended.

Other labeled adverse effects include implant/injection-site reactions (common with implants) and contraindications for use in pregnancy.

Definitions

Definitions (short pairs):

SMN: Statement of Medical Necessity precertification form used for prior authorization of listed GnRH products.

CPP: Central precocious puberty—onset of secondary sexual characteristics before age 8 in females and before age 9 in males, requiring diagnostic confirmation.

Tanner stage 2: Clinical staging of puberty used as the threshold for initiating pubertal suppression for gender dysphoria (policy requires Tanner stage ≥2).

GnRH agonist / antagonist: GnRH agonist/analog — initially stimulates then suppresses pituitary gonadotropin release with continuous administration; GnRH antagonist — directly blocks GnRH receptor producing rapid suppression without flare.

Medical castration: Serum testosterone suppression to ≤ 50 ng/dL, used as a clinical benefit threshold for prostate cancer therapy.

CPB: Clinical Policy Bulletin describing selection criteria determining medical necessity for agents.

POF: Premature ovarian failure (term noted in definitions/background).

Revision History

2001-04-27effective

Policy effective date (Clinical Policy Bulletin 0501).

2023-07-14last_review

Policy last review date.

2024-01-25next_reviewLatest

Planned next review date.

Policy Summary

PayerAetna

PolicyGonadotropin-Releasing Hormone Analogs and Antagonists

Policy CodePolicy 0501

Change TypeNo material changes

Effective DateApr 27, 2001

Next Review DateJan 25, 2024

Key ActionPrecertification is required for listed GnRH products; call (866) 752-7021 or fax (888) 267-3277 and use SMN precertification forms as applicable.

SourceLink

On This Page

Degarelix (Firmagon) - Initial Approval

Indication: Treatment of prostate cancer.

Degarelix (Firmagon) - Continuation

Continuation: Medically necessary in members requesting reauthorization who are experiencing clinical benefit (e.g., serum testosterone < 50 ng/dL) and who have not experienced unacceptable toxicity.< 50 ng/dL

ALL of the following

Lupron Depot (1-Month 7.5 mg, 3-Month 22.5 mg, 4-Month 30 mg, 6-Month 45 mg) - Prescribing Information
- Refer to product labeling for dosing and pediatric use (Lupron Depot-PED) for central precocious puberty and gender dysphoria pubertal suppression indications.
Lupron Depot (1- & multi-dose) - Continuation
- Continuation: Medically necessary for members requesting reauthorization who meet initial authorization criteria and demonstrate clinical benefit and no unacceptable toxicity.

Member has reached Tanner stage 2 of puberty or greater.Tanner stage >= 2

Comorbid conditions reasonably controlled.

Member educated on contraindications and side effects to therapy.

Member informed of fertility preservation options before therapy start.

Leuprolide Acetate for Depot Suspension-Pediatric (Lupron Depot-PED) - Initial Approval for Gender Dysphoria

Gender transition when ALL criteria met: diagnosis of gender dysphoria; member informed and able to decide; will receive Lupron Depot concomitantly with gender-affirming hormones; comorbid conditions reasonably controlled; education on contraindications/side effects; informed of fertility preservation options.

Leuprolide Depot-PED - Initial Approval for Gender Transition

As above for gender transition criteria; prescribing specialty requirements apply.

Lupron Depot-PED - Continuation of Therapy for Central Precocious Puberty (CPP)

Continuation: Members requesting reauthorization must meet initial authorization criteria, demonstrate clinical benefit (suppression of pubertal progression), and have no unacceptable toxicity.

Lupron Depot-PED - Continuation of Therapy for Gender Dysphoria (pubertal suppression)

Continuation: Members requesting reauthorization must meet initial authorization criteria and ongoing monitoring requirements and have not experienced unacceptable toxicity.

Lupron Depot-PED - Continuation of Therapy for Gender Transition

Continuation: Members requesting reauthorization must meet initial authorization criteria, be receiving gender-affirming hormones as indicated, and have no unacceptable toxicity.

Continuation: Medically necessary for members requesting reauthorization who meet initial authorization criteria, demonstrate clinical benefit (eg, testosterone suppression for prostate cancer), and have not experienced unacceptable toxicity.

Triptodur (extended-release triptorelin) - Prescriber Specialties and Initial Approval

Prescriber specialties: For gender dysphoria, prescribing by or in consultation with specialized provider plus collaborative mental health care for members < 18 years required.
Initial approval: per product labeling and shared decision/Tanner-stage criteria for pubertal suppression and gender transition indications.

Triptodur - Continuation of Therapy

Continuation: Medically necessary for members requesting reauthorization who meet initial authorization criteria, demonstrate clinical benefit, and have not experienced unacceptable toxicity.

Summaries: Follow FDA labeling for each product for approved indications, dosing, contraindications, and monitoring. Compendial uses as referenced in policy may be considered where supported by evidence.

FDA-Approved Indications (product-specific)

Refer to individual product labeling (Cetrotide, Ganirelix, Firmagon, Zoladex, Supprelin LA, Lupron Depot products, Eligard, Camcevi, Trelstar/Triptodur) for full lists of FDA-approved indications.

Safety, Contraindications, Warnings

Safety: All agents carry risks of hypoestrogenism or androgen deprivation effects (eg, bone loss, hot flashes, sexual dysfunction), injection site reactions, and other product-specific warnings; follow product labeling.
Contraindications and warnings: Refer to each product’s prescribing information for contraindications (eg, pregnancy for some agents), warnings (eg, pituitary apoplexy, tumor flare with agonists), and monitoring recommendations.

Continuation medically necessary when members requesting reauthorization meet any of: breast cancer (clinical benefit, no unacceptable toxicity); prostate cancer (clinical benefit e.g., serum testosterone <50 ng/dL, no unacceptable toxicity); gender dysphoria continued pubertal suppression or gender transition (all baseline criteria maintained including prior Tanner stage ≥2, informed decision, comorbid control, education, fertility preservation counseling); or for specified indications (endometriosis, endometrial‑thinning, ovarian preservation, porphyria prevention, uterine leiomyomata) when all initial authorization criteria are met.

Serum testosterone <50 ng/dL for prostate cancer; prior attainment of Tanner stage thresholds for GD continuation; duration limits per indication (e.g., endometriosis lifetime max rules elsewhere)

Histrelin (Supprelin LA) - Continuation: Continuation medically necessary for CPP in female members currently <12 years and males currently <13 years who are receiving previously authorized medication and are not experiencing treatment failure; for gender dysphoria continued pubertal suppression or gender transition when all baseline criteria met; and for all other indications when members meet initial selection criteria.Continuation age cutoffs: female <12 yrs; male <13 yrs; no clinical pubertal progression or excessive bone age advancement

Leuprolide formulations - Continuation: Continuation medically necessary for CPP (female currently <12; male currently <13 and not experiencing treatment failure) and for specified indications (salivary gland tumors, prostate cancer with clinical benefit e.g., serum testosterone <50 ng/dL and no unacceptable toxicity); members with other specified indications must meet initial selection criteria for continuation.Serum testosterone <50 ng/dL for prostate cancer; CPP continuation age thresholds

Lupron Depot - Continuation (3.75 mg, 11.25 mg): Continuation medically necessary when criteria met: endometriosis retreatment for lifetime maximum 12 months if recurrence and bone mineral density within normal limits; uterine leiomyomata continuation for lifetime maximum 6 months when anemia or preoperative use criteria met; breast, ovarian, and salivary gland tumors when no unacceptable toxicity or disease progression; gender dysphoria continuation for pubertal suppression or gender transition when baseline criteria maintained; preservation of ovarian function and porphyria prevention when initial criteria met.Lifetime limits: endometriosis total max 12 months; uterine leiomyomata max 6 months

All members requesting continuation for specified indications must meet initial criteria

Lupron Depot (1‑ & multi‑month) - Continuation: Continuation for prostate cancer when experiencing clinical benefit (e.g., serum testosterone <50 ng/dL) and no unacceptable toxicity; for gender dysphoria continued pubertal suppression or gender transition when baseline criteria maintained; ovarian cancer indications when no evidence of unacceptable toxicity or disease progression.Serum testosterone <50 ng/dL for prostate cancer

Lupron Depot‑PED - Continuation: Continuation for CPP when female members currently <12 or male members currently <13, receiving previously authorized medication and not experiencing treatment failure; continuation for gender dysphoria pubertal suppression or gender transition when baseline criteria maintained.Continuation age thresholds female <12, male <13; no clinical pubertal progression

Camcevi continuation: Continuation medically necessary for members with prostate cancer who are experiencing clinical benefit to therapy (e.g., serum testosterone less than 50 ng/dL) and who have not experienced an unacceptable toxicity.Serum testosterone <50 ng/dL

All other indications experimental/investigational

Triptorelin / Triptodur - Continuation: Continuation considered medically necessary when initial criteria are met and: prostate cancer members experience clinical benefit (e.g., serum testosterone <50 ng/dL) and no unacceptable toxicity; breast cancer ovarian suppression up to 5 years total for those premenopausal at diagnosis and still on endocrine therapy; gender dysphoria continued pubertal suppression or gender transition when baseline criteria maintained; CPP continuation for females <12 and males <13 receiving previously authorized medication and not experiencing treatment failure; all other indications require meeting initial selection criteria.Serum testosterone <50 ng/dL for prostate cancer; breast cancer ovarian suppression up to 5 years total; CPP continuation age thresholds

Histrelin (Supprelin LA): Prescribing Specialties - For prevention of recurrent menstrual related attacks in acute porphyria, must be prescribed by or in consultation with a provider experienced in management of porphyrias.

Leuprolide, Triptorelin, and other listed GnRH agents: When used for gender dysphoria in adolescents, prescribing clinician should be specialized in transgender youth care or in documented consultation with such a specialist and have evidence of mental health collaboration for members < 18 years.

Provider consultation requirement: For gender dysphoria indications, documentation must show diagnosis of gender dysphoria and that the prescriber either is the specialized provider or has consulted/collaborated with one and with a mental health provider for minors.

Provider consultation requirement: For porphyria indications, documentation must show that the prescriber either is experienced in porphyria management or has consulted with a porphyria-experienced provider prior to initiation.

Prior Authorization

Precertification Required

Precertification is required for listed products. See contact details for precertification and Statement of Medical Necessity (SMN) forms.

Precertification required for: cetrorelix acetate (Cetrotide); degarelix (Firmagon); ganirelix acetate (Ganirelix AC); goserelin acetate implant (Zoladex); leuprolide acetate (Eligard); leuprolide acetate, 7.5 mg (Lupron Depot); leuprolide mesylate (Camcevi); triptorelin (Trelstar).
Call precertification: (866) 752-7021.
Fax precertification: (888) 267-3277.
For Statement of Medical Necessity (SMN) forms and specialty pharmacy precertification forms, see Aetna Specialty Pharmacy Precertification forms.

Documentation Required

Documentation Requirements

Documentation that must be provided with requests for initiation and continuation of therapy.

Documentation of diagnostic testing for central precocious puberty (CPP): imaging (CT or MRI) to evaluate intracranial tumor when indicated; confirmation of CPP by pubertal response to a GnRH agonist test or pubertal level on a third-generation LH assay; assessment of bone age versus chronological age; record of age at onset of secondary sexual characteristics (females < 8 years, males < 9 years as applicable).
Imaging and laboratory confirmation for CPP: include appropriate lab results, GnRH stimulation test results, third-generation LH assay values, and bone age radiograph report.
Gender dysphoria prescribing specialty and counseling documentation: diagnosis of gender dysphoria; evidence prescriber is specialized in transgender youth care or is consulting with such a specialist; documentation of collaboration with a mental health provider for members < 18 years.
Documentation of informed decision and fertility counseling: member (or guardian when applicable) is able to make an informed decision; documentation that member has been educated on contraindications and side effects; explicit documentation that member was informed of fertility preservation options and that informed consent discussion occurred.
Continuation requirements and monitoring clinical benefit: For continuation, evidence of clinical benefit must be provided (e.g., for prostate cancer, serum testosterone < 50 ng/dL) and absence of unacceptable toxicity; for other indications, documentation that initial criteria continue to be met.
Baseline evaluation prior to Supprelin LA (histrelin implant): document baseline pubertal status (Tanner stage), confirmation of CPP diagnosis with imaging/labs as above, review of comorbid conditions, and informed consent including fertility discussion.
Monitoring during Supprelin LA therapy: document periodic assessment of pubertal suppression, adverse effects, bone age progression, and monitoring of bone mineral density as clinically indicated.
Monitoring during Fensolvi therapy: document appropriate monitoring of clinical response and adverse effects per product labeling (safety monitoring and counseling).
Safety counseling and monitoring (all GnRH agents): document counseling on potential adverse effects including effects on bone mineral density; plan for monitoring and management of adverse risk factors; avoid concomitant use of multiple LHRH agents—do not prescribe overlapping GnRH agonist/antagonist therapies.
Hypersensitivity and contraindication documentation: document any history of hypersensitivity reactions or contraindications to specific agents and rationale for selected product if alternative agents are contraindicated/intolerant/ineffective.
Agent-specific administration and indication documentation: include product-specific information (e.g., implant vs depot formulation), indication being treated, dosing and duration limits (e.g., endometriosis 6 months total for goserelin; uterine leiomyomata 3 months prior to surgery; Lupaneta Pack duration limits where applicable), and alignment with product-specific coverage statements.
Infertility use documentation and counseling: when used in context of fertility treatment (e.g., cetrorelix/ganirelix for ART), document indication, ART plan, and discussion of risks/benefits including infertility considerations.
Monitor bone mineral density during GnRH therapy: document baseline and follow-up BMD assessments when clinically indicated, and plans to mitigate bone loss.
Monitor and document adverse risk factors: record and follow-up on risk factors (e.g., osteoporosis risk, cardiovascular risk) and any adverse events during therapy.
Use of specified HCPCS/CPT codes: include and document appropriate HCPCS/CPT codes for drug administration and implants per billing guidance; ensure coding aligns with product (e.g., implant removal/placement codes when applicable).
Claims denial for non-covered ICD-10 indications: note that claims may be denied if ICD-10 diagnosis codes submitted do not match covered indications; ensure submitted diagnosis codes correspond to covered uses per policy.
Product-specific coverage alignment and duration limits: document that requested product aligns with policy coverage (e.g., brand selection rules for prostate cancer) and observe duration limits (e.g., Lupaneta Pack limits).

Agent-specific administration and billing rules: many depot/implant products must be administered by a healthcare professional and billed with the exact HCPCS/CPT codes listed in the policy; surgical codes apply for implant insertion where relevant.

Examples of HCPCS/CPT codes: J9226, J9155, J3315, J3316, J1951, J1952, S0132, 11980, 96372
Depot/implant administrations (e.g., histrelin, goserelin, triptorelin, leuprolide formulations) generally must be provided by a healthcare professional
Use surgical CPT (e.g., 11980) for subcutaneous implant/pellet procedures when applicable and report injection administration codes (e.g., 96372) as appropriate

Denial Risk

Denial risk for experimental / non‑covered indications

Indications not listed in the policy are considered experimental/investigational and may be denied. Claims may be denied if billed with ICD-10 codes listed as not covered for CPB indications (examples shown in the policy).

All other/unlisted indications are experimental/investigational and will not be approved
Claims may be denied when billed with ICD-10 codes listed as not covered for the CPB (see policy lists)

Documentation Required

Monitoring, safety and documentation during therapy

Monitoring and safety documentation requirements include bone mineral density monitoring as clinically indicated, scheduled monitoring of LH/FSH and sex steroids after treatment initiation, implant removal timing, and counseling for psychiatric and seizure risks.

Supprelin LA monitoring: measure LH, FSH and estradiol or testosterone at 1 month post-implant then every 6 months; assess height and bone age every 6–12 months; remove implant after 12 months
Fensolvi monitoring: confirm suppression with GnRH stimulation test, basal LH or sex steroids at 1–2 months and as needed; measure height every 3–6 months and assess bone age periodically
Safety counseling: advise about initial transient hormone surge, psychiatric events, seizure risk, pseudotumor cerebri (monitor for headache/vision changes), and decreased bone density; document follow-up plans and BMD testing when indicated

Implication for coverage decisions: approve agents for indications and patient groups specifically enumerated in the policy where randomized or regulatory evidence supports use (e.g., prostate cancer, CPP, ART indications, specified oncologic uses), but treat many fertility-preservation and other off-label uses as conditional or investigational given inconsistent evidence and guideline caution.

Some infertility uses may be excluded by benefit plans or ART riders

Preservation of ovarian function during chemotherapy: Use of GnRHa (e.g., goserelin, triptorelin, leuprolide) during chemotherapy for ovarian preservation is described in compendia and trials; evidence mixed—some RCTs/meta‑analyses show reduced premature ovarian failure or increased resumption of menses, but fertility preservation remains controversial and ASCO considers it investigational; counseling required.

Documented informed consent and discussion of standard fertility preservation options recommended

Prevention of recurrent menstrual‑related attacks in acute porphyria: GnRH analogues (goserelin, triptorelin, leuprolide, histrelin) noted as potential prevention of recurrent luteal‑phase porphyria attacks per guideline and UpToDate; caution for initial hormone surge which may trigger attack; prescribe in consultation with porphyria‑experienced provider.

Gynecologic review and bone density monitoring advised; review after 1 year

Gender dysphoria (pubertal suppression and transition) - Compendial use: GnRH analogs (histrelin, leuprolide, goserelin, triptorelin) used to suppress puberty in transgender adolescents at Tanner stage 2 and for gender transition when criteria met; authors cite Endocrine Society/WPATH guidance with low/very low quality evidence; monitoring for bone density and counseling required.Tanner stage ≥2 for initiation; mental health involvement for minors; fertility preservation counseling prior to therapy

Long‑term bone outcomes uncertain; monitoring recommended

Leiomyoma and uterine bleeding uses (compendial/off‑label): Leuprolide and goserelin used as short‑term preoperative therapy for uterine fibroids (1–3 months) or for endometrial thinning prior to ablation; benefits in tumor volume reduction documented; retreatment and duration limits apply due to bone density concerns.Lupron Depot limits: endometriosis total therapy ≤12 months; leiomyomata preoperative up to 3 months or specific continuation limits

Lupaneta Pack duration limits: initial 6 months, single retreatment up to 6 months, total not recommended >12 months (pack discontinued)

Salivary gland and ovarian cancer compendial uses: Triptorelin and leuprolide listed for androgen receptor positive salivary gland tumors and certain ovarian cancers or sex cord‑stromal tumors as single‑agent compendial uses; evidence limited and often single‑arm or case series.

Clinical benefit and absence of unacceptable toxicity required for continuation

Other investigational/off‑label uses discussed: Multiple investigational or limited‑evidence uses are discussed (paraphilias, angiomyxoma, benign metastasizing leiomyoma, periodontal/neurologic conditions, etc.); policy states indications not listed as initial approvals are considered experimental/investigational.

Requests for experimental indications will be denied absent robust evidence