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ph-90131

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Trelstar® (triptorelin) (Precertification not required)

Policy Number: PH-90131

Intramuscular

Last Review Date: 07/01/2025

Date of Origin: 11/28/2011

Dates Reviewed: 12/2011, 03/2012, 06/19/2012, 09/2012, 12/2012, 03/2013, 06/2013, 09/2013, 12/2013, 03/2014, 06/2014, 09/2014, 12/2014, 3/2015, 05/2015, 8/2015, 11/2015, 2/2016, 5/2016, 8/2016, 11/2016, 02/2017, 5/2017, 8/2017, 11/2017, 02/2018, 05/2018, 04/2019, 04/2020, 04/2021, 03/2022, 10/2022, 04/2023, 04/2024, 07/2025

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.

  1. Length of Authorization
  • Initial: Prior authorization validity will be provided initially for 12 months, unless otherwise specified.
    • Endometriosis/Uterine Leiomyomata (fibroids): Prior authorization validity will be provided initially for 6 months.
  • Renewal: Prior authorization validity may be renewed every 12 months thereafter, unless otherwise specified.
    • Endometriosis/Uterine Leiomyomata (fibroids): Prior authorization validity may NOT be renewed.
    • Fertility Preservation: Prior authorization validity may be renewed every 12 months thereafter, while patient is receiving concomitant cytotoxic chemotherapy.
  1. Dosing Limits

    Max Units (per dose and over time) [HCPCS Unit]:

  • Prostate Cancer: 6 units every 168 days
  • Gender Dysphoria: 1 unit at weeks 0, 2, and 4 and every 28 days thereafter
  • Head and Neck Cancer: 3 units every 84 days
  • All Other Indications: 1 unit every 28 days
  1. Initial Approval Criteria

Coverage is provided in the following conditions:

  • Patient is at least 18 years of age (unless otherwise specified); AND

Prostate Cancer † 1,2

Central Precocious Puberty (CPP) ‡ 9-12,16

  • 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 gonadotropin-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

Gender Dysphoria (formerly Gender Identity Disorder) ‡ 13,17,18

  • Patient has experienced puberty development to at least Tanner stage 2 (Note: this applies only to patients <18 yrs of age); 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, Text Revision (DSM-5-TR) 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 patient’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
  • For adolescent patients, 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 18
  • Are licensed by their statutory body and hold, at a minimum, a master’s degree or equivalent training in a clinical field relevant to this role and granted by a nationally accredited statutory institution; AND
  • For countries requiring a diagnosis for access to care, the health care professional should be competent using the latest edition of the World Health Organization's International Classification of Diseases (ICD) for diagnosis. In countries that have not implemented the latest ICD, other taxonomies may be used; efforts should be undertaken to utilize the latest ICD as soon as practicable; AND
  • Are able to identify co-existing mental health or other psychosocial concerns and distinguish these from gender dysphoria, incongruence, and diversity; AND
  • Are able to assess capacity to consent for treatment; AND
  • Have experience or be qualified to assess clinical aspects of gender dysphoria, incongruence, and diversity; AND
  • Undergo continuing education in health care relating to gender dysphoria, incongruence, and diversity

§ DSM-5-TR Criteria for Gender Dysphoria in Adolescents and Adults 17
  • A marked incongruence between one’s experienced/expressed gender and natal gender of at least 6mo in duration, as manifested by at least TWO of the following:
    • A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics)
    • A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
    • A strong desire for the primary and/or secondary sex characteristics of the other gender
    • A strong desire to be of the other gender (or some alternative gender different from one’s designated gender)
    • A strong desire to be treated as the other gender (or some alternative gender different from one’s designated gender)
    • A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s designated gender); AND
  • The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning

Endometriosis ‡ 3,4

  • Patient’s diagnosis has been confirmed by a workup/evaluation (versus presumptive treatment)

Uterine Leiomyomata (fibroids) ‡ 8,19

  • Patient’s diagnosis has been confirmed by a workup/evaluation (versus presumptive treatment); AND
  • Patient is receiving iron therapy

Breast Cancer ‡ 2

  • 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 (local or regional) or stage IV (M1) disease; OR
  • Patient is a male (sex assigned at birth); AND
    • Used in combination with aromatase inhibitor therapy

Fertility Preservation While Receiving Chemotherapy ‡ 2,20

  • 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.)

Head and Neck Cancer ‡ 2

  • Patient has salivary gland tumors; AND
  • Used in combination with abiraterone and prednisone; AND
  • Patient has androgen-receptor positive recurrent disease with one of the following:
    • Distant metastases
    • Unresectable locoregional recurrence with prior radiation therapy (RT)
    • Unresectable second primary with prior RT

Uterine Neoplasms – Uterine Sarcoma ‡ 2

  • Patient has a diagnosis of low-grade endometrial stromal sarcoma (ESS) or adenosarcoma without sarcomatous overgrowth; AND
  • Patient is premenopausal and not suitable for surgery (i.e. bilateral salpingo-oophorectomy); AND
  • Used for patients with small tumor volume or an indolent growth pace; AND
  • Used in combination with anastrozole, letrozole or exemestane

† FDA Approved Indication(s); ‡ Compendia Recommended Indication(s); Ф Orphan Drug

  1. Renewal Criteria 1

Coverage may be renewed based upon the following criteria:

  • Patient continues to meet the indication-specific relevant criteria identified in section III; AND
  • Duration of authorization has not been exceeded (refer to Section I); AND
  • Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include: hypersensitivity reactions, tumor flare, severe QT/QTc interval prolongation, metabolic syndrome (hyperglycemia, diabetes mellitus, hyperlipidemia), cardiovascular diseases (e.g., myocardial infarction, stroke, etc.) etc.; AND

Prostate Cancer; Head and Neck Cancer; Breast Cancer; Uterine Neoplasms – Uterine Sarcoma 1,2

  • Disease response with treatment as defined by stabilization of disease or decrease in size of tumor or tumor spread

Central Precocious Puberty (CPP) 9-12,16

  • Disease response as indicated by lack of progression or stabilization of secondary sexual characteristics, decrease in height velocity, and a decrease in the ratio of bone age to chronological age (BA:CA), and improvement in final height prediction

Gender Dysphoria 13,17

  • Patient has shown a beneficial response to treatment as evidenced by routine monitoring of clinical pubertal development (if applicable) and applicable laboratory parameters

Fertility Preservation While Receiving Chemotherapy 2,20

  • Patient is still receiving treatment with cytotoxic chemotherapy
  1. Dosage/Administration

Indication

Dose

Prostate Cancer

3.75 mg intramuscularly (IM) once every 4 weeks, 11.25 mg IM once every 12 weeks, or 22.5 mg IM once every 24 weeks

Head and Neck Cancer

3.75 mg intramuscularly (IM) every 4 weeks or 11.25 mg IM every 12 weeks

Gender Dysphoria

3.75 mg intramuscularly (IM) at weeks 0, 2, 4 and every 4 weeks thereafter

All other indications

3.75 mg intramuscularly (IM) every 4 weeks
  1. Billing Code/Availability Information

HCPCS Code:

  • J3315 – Injection, triptorelin pamoate, 3.75 mg; 1 billable unit = 3.75 mg

NDC(s):

  • Trelstar 3.75mg single-dose injection kit:74676-5902-xx
  • Trelstar 11.25mg single-dose injection kit: 74676-5904-xx
  • Trelstar 22.5mg single-dose injection kit: 74676-5906-xx
  1. References
  1. Trelstar [package insert]. Ewing, NJ; Verity Pharmaceuticals, Inc; March 2025. Accessed June 2025.
  2. Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) for triptorelin pamoate. National Comprehensive Cancer Network, 2025. 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 June 2025.
  3. Bergqvist A, Bergh T, Hogström L, et al. Effects of triptorelin versus placebo on the symptoms of endometriosis. Fertil Steril. 1998 Apr;69(4):702-8.
  4. Donnez J, Dewart PJ, Hedon B, et al. Equivalence of the 3-month and 28-day formulations of triptorelin with regard to achievement and maintenance of medical castration in women with endometriosis. Fertil Steril. 2004 Feb;81(2):297-304.
  5. Swaenepoel C, Chaussain JL, & Roger M: Long-term results of long-acting luteinizing-hormone-releasing hormone agonist in central precocious puberty. Horm Res 1991; 36:126-130.
  6. Oostdijk W, Hummelink R, Odink RJH, et al: Treatment of children with central precocious puberty by a slow-release gonadotropin-releasing hormone agonist. Eur J Pediatr 1990; 149:308-313.
  7. Fuqua JS. Treatment and Outcomes of Precocious Puberty: An Update. The Journal of Clinical Endocrinology & Metabolism 2013 98:6, 2198-2207
  8. van Leusden HAIM: Symptom-free interval after triptorelin treatment of uterine fibroids: long-term results. Gynecol Endocrinol 1992; 6:189-198.
  9. 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/.
  10. 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.
  11. Carel JC, Eugster EA, 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.
  12. Kaplowitz P, Bloch C; Section on Endocrinology, American Academy of Pediatrics. Evaluation and Referral of Children With Signs of Early Puberty. Pediatrics. 2016 Jan;137(1). Doi: 10.1542/peds.2015-3732. Epub 2015 Dec 14.
  13. 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.
  14. The World Professional Association for Transgender Health (WPATH), Standards of Care for the Health of Transsexual, and Gender Nonconforming People. Seventh Version. July 2012.
  15. Schagen SE, Cohen-Kettenis PT, Delemarre-van de Waal HA, et al; Efficacy and safety of gonadotropin-releasing hormone agonist treatment to suppress puberty in gender dysphoric adolescents. J Sex Med 2016; 13(7):1125-1132.
  16. Krishna KB, Fuqua JS, Rogol AD, et al. Use of Gonadotropin-Releasing Hormone Analogs in Children: Update by an International Consortium Horm Res Paediatr 2019;91:357–372.
  17. American Psychiatric Association. (2022) Diagnostic and Statistical Manual of Mental Disorders. 5th ed, text revision. Arlington, VA: American Psychiatric Association Publishing.
  18. 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.
  19. Stewart EA, Laughlin-Tommaso SK. (2025) Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history. In: Barbieri R, Chakrabarti A (Eds). UpToDate. Last update: July 15, 2024. Accessed June 5, 2025. Available from: https://www.uptodate.com/contents/uterine-fibroids-leiomyomas-epidemiology-clinical-features-diagnosis-and-natural-history.
  20. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Adolescent and Young Adult (AYA) Oncology Version 2.2025. National Comprehensive Cancer Network, 2025. 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 June 2025.
  21. 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 11/20/2023 with effective date 01/01/2023. Accessed June 2025.
  22. 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 June 2025.

Appendix 1 – Covered Diagnosis Codes

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

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

C54.0

Malignant neoplasm of isthmus uteri

C54.1

Malignant neoplasm of endometrium

C54.2

Malignant neoplasm of myometrium

C54.3

Malignant neoplasm of fundus uteri

C54.8

Malignant neoplasm of overlapping sites of corpus uteri

C54.9

Malignant neoplasm of corpus uteri, unspecified

C55

Malignant neoplasm of uterus, part unspecified

C61

Malignant neoplasm of prostate

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

N80.6

Endometriosis in cutaneous scar

N80.9

Endometriosis, unspecified

N80.A0

Endometriosis of bladder, unspecified depth

N80.A1

Superficial endometriosis of bladder

N80.A2

Deep endometriosis of bladder

N80.A41

Superficial endometriosis of right ureter

N80.A42

Superficial endometriosis of left ureter

N80.A43

Superficial endometriosis of bilateral ureters

N80.A49

Superficial endometriosis of unspecified ureter

N80.A51

Deep endometriosis of right ureter

N80.A52

Deep endometriosis of left ureter

N80.A53

Deep endometriosis of bilateral ureters

N80.A59

Deep endometriosis of unspecified ureter

N80.A61

Endometriosis of right ureter, unspecified depth

N80.A62

Endometriosis of left ureter, unspecified depth

N80.A63

Endometriosis of bilateral ureters, unspecified depth

N80.A69

Endometriosis of unspecified ureter, unspecified depth

N80.B1

Endometriosis of pleura

N80.B2

Endometriosis of lung

N80.B31

Superficial endometriosis of diaphragm

N80.B32

Deep endometriosis of diaphragm

N80.B39

Endometriosis of diaphragm, unspecified depth

N80.B4

Endometriosis of the pericardial space

N80.B5

Endometriosis of the mediastinal space

N80.B6

Endometriosis of cardiothoracic space

N80.C0

Endometriosis of the abdomen, unspecified

N80.C10

Endometriosis of the anterior abdominal wall, subcutaneous tissue

N80.C11

Endometriosis of the anterior abdominal wall, fascia and muscular layers

N80.C19

Endometriosis of the anterior abdominal wall, unspecified depth

N80.C2

Endometriosis of the umbilicus

N80.C3

Endometriosis of the inguinal canal

N80.C4

Endometriosis of extra-pelvic abdominal peritoneum

N80.C9

Endometriosis of other site of abdomen

N80.D0

Endometriosis of the pelvic nerves, unspecified

N80.D1

Endometriosis of the sacral splanchnic nerves

N80.D2

Endometriosis of the sacral nerve roots

N80.D3

Endometriosis of the obturator nerve

N80.D4

Endometriosis of the sciatic nerve

N80.D5

Endometriosis of the pudendal nerve

N80.D6

Endometriosis of the femoral nerve

N80.D9

Endometriosis of other pelvic nerve

Z31.84

Encounter for fertility preservation procedure

Z85.3

Personal history of malignant neoplasm of breast

Z85.42

Personal history of malignant neoplasm of other parts of uterus

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.

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