Lupron Medical Policy

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Gonadotropin Releasing Hormone …

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/gonadotropin-releasing-hormone-analogs.pdf

Gonadotropin-Releasing Hormone Analogs and …

https://www.aetna.com/cpb/medical/data/500_599/0501.html

CLINICAL MEDICATION POLICY - Highmark Health Options

https://www.highmarkhealthoptions.com/content/dam/digital-marketing/en/highmark/highmarkhealthoptions/providers/medical-payment-policies/Lupron.pdf

1. Lupron Depot and Lupron Depot-PED is considered medically necessary as an intramuscular injection when the member meets the following criteria: A. Palliative …

Clinical Policy: Leuprolide Acetate (Eligard, …

https://www.healthnet.com/content/dam/centene/healthnet/pdfs/provider/ca/policies/876.pdf

It is the policy of health plans affiliated with Centene Corporation® that leuprolide acetate, Eligard, Lupaneta Pack, Lupron Depot, and Lupron Depot-Ped are medically necessary …

Hormone Therapy for Gender Dysphoria - Washington

https://www.hca.wa.gov/assets/billers-and-providers/gender-dysphoria.pdf

Note: New-to-market drugs included in this class based on the Apple Health Preferred Drug List are non-preferred and subject to this prior authorization (PA) criteria. …

Leuprolide - Long Acting - Cigna

https://static.cigna.com/assets/chcp/pdf/coveragePolicies/pharmacy/ip_0109_coveragepositioncriteria_leuprolide_la.pdf

If retreatment is needed, Lupron Depot must be used in combination with norethindrone acetate (for 6 months). Total duration of treatment is limited to 12 months. o Uterine …

Article - Billing and Coding: Luteinizing Hormone …

https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52453&CptHcpcsCode=J9217

The medical record documentation for patients receiving a once-yearly implant should support ongoing follow-up visits at least every three (3) to four (4) …

Billing guidelines for leuprolide acetate (Lupron Depot® …

https://provcomm.ibx.com/ibc/Archive/Pages/F1CFB2A301C6D11A852580A00071E2F1.aspx

Although Lupron Depot has been approved by the U.S. Food and Drug Administration (FDA) for prostate cancer and Compendia supports the use of Lupron Depot for breast …

Clinical Criteria - Anthem

https://www.anthem.com/ca/ms/pharmacyinformation/clinicalcriteria.html

Clinical Criteria Welcome to the Clinical Criteria Page This page provides the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies …

Oncology Medications - Cigna

https://static.cigna.com/assets/chcp/pdf/coveragePolicies/pharmacy/ph_1403_coveragepositioncriteria_oncology.pdf

This coverage policy addresses medications used for the primary treatment of cancer. The use of oncology agents for non-oncology uses are addressed in separate coverage …

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