Leuprolide (Depot) prior authorization and medical necessity criteria
Defines prior authorization length, renewal rules, indication-specific initial and renewal medical necessity criteria, maximum billable HCPCS units per indication, dosing/administration guidance, billing HCPCS/NDC mappings, and ICD-10 code mappings for leuprolide depot products.
No material changes
Coverage Summary
This policy (Policy #: IC-0080) defines prior authorization and medical necessity criteria for leuprolide acetate depot formulations (multiple brand and generic depot products) used across pediatric and adult indications. The policy stance is covered with criteria, providing indication-specific initial and renewal rules, maximum billable HCPCS unit limits, dosing/administration guidance, and ICD-10 code mappings. Key authorized indications include central precocious puberty (CPP), endometriosis, uterine leiomyomata (fibroids), various hormone-sensitive cancers (breast, prostate, ovarian/fallopian/primary peritoneal, uterine sarcoma), gender dysphoria, prevention/management of menstrual bleeding with HCT, and fertility preservation during chemotherapy.
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