Zoladex (Goserelin) is considered medically necessary when the following
criteria are met:
Prostate Cancer
(3.6mg and 10.8mg)
·
Patient has a diagnosis
of locally confined carcinoma of the prostate OR
·
Patient has a diagnosis
of advanced or metastatic carcinoma of the prostate
Endometriosis
(3.6mg only)
·
In patients with
childbearing potential, pregnancy has been excluded and patient will be using
non-hormonal contraception during and for 12 weeks after therapy AND
·
Patient has a diagnosis
of endometriosis AND
·
Patient has had an
inadequate pain control response or patient has an intolerance or
contraindication to one of the following:
o
Danazol (six month trial)
OR
Combination (estrogen/progesterone) oral contraceptives (six month trial) OR
o
Progestin (six month
trial)
Endometrial
Thinning/Dysfunctional Uterine Bleeding
(3.6mg only)
·
In patients with
childbearing potential, pregnancy has been excluded and patient will be using
non-hormonal contraception during and for 12 weeks after therapy AND
·
Patient has a diagnosis
of dysfunctional uterine bleeding AND
·
Patient will use Zoladex
as an endometrial thinning agent prior to endometrial ablation AND
·
Patient is scheduled for
endometrial ablation
Breast Cancer
(3.6mg only)
·
Patient is female and
pre- or peri-menopausal AND
·
Patient has a diagnosis
of hormone-receptor positive (estrogen receptor and/or progesterone receptor +)
advanced breast cancer
Codes
Used In This BI:
J9202 Goserelin acetate implant, per 3.6mg