Medical Policy
Effective Date:01/01/2017 Title:Zoladex (Goserelin)
Revision Date:01/13/2020 Document:BI530:00
CPT Code(s):J9202
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)    Zoladex (Goserelin) requires prior authorization.

2)    Zoladex is used to treat prostate cancer, breast cancer, endometriosis, and dysfunctional uterine bleeding.

3)    Zoladex is specialty drug covered under the medical benefit.
Medical Statement

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
Limits
Intentially left empty
Reference

1)    Zoladex Package Insert. Astra Zeneca Pharmaceuticals. February 2016.

2)    Clinical Pharmacology. Accessed online November 22, 2016.
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.