Medical Policy
Effective Date:03/01/2009 Title:Supprelin LA (Histrelin)
Revision Date:08/01/2023 Document:BI240:00
CPT Code(s):J9226
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Supprelin LA is a histrelin implant that is covered for the treatment of central precocious puberty.

2)    Supprelin LA is not covered for other diagnoses.

3)    Supprelin LA is covered under the medical benefit.
Medical Statement

1)    Supprelin LA (Histrelin implant) is only covered for the treatment of central precocious puberty (CPP) defined as (must meet all 3) :

a)    Elevated basal luteinizing hormone (LH) level > 0.2 – 0.3 mIU/L (dependent on type of assay used) and/or elevated leuprolide-stimulated LH level > 3.3 – 5 IU/L (dependent on type of assay used)

b)    Difference between bone age and chronological age was > 1 year (bone age-chronological age);

c)    Age at onset of secondary sex characteristics (i or ii):

i)     Female: < 8 years;

ii)    Male: < 9 years;

2)    Supprelin LA is Prescribed by or in consultation with a pediatric endocrinologist.

3)    Member meets one of the following age requirements (a or b):

a)    Female: 2-11 years;

b)    Male: 2-12 years
Limits

Supprelin LA (Histrelin) is not covered for other diagnoses.
Reference
  1. http://www.fda.gov/cder/foi/label/2008/022058s003lbl.pdf

 

Addendum:

Effective 12/01/2017: Language and code clarification.

Effective 08/01/2023: Update diagnosis confirmation criteria for CPP.

 
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.