HIGHMARK COMMERCIAL MEDICAL POLICY - WEST VIRGINIA

 
 

Medical Policy:
I-16-024
Topic:
Gonadotropin Releasing Hormones (GnRHs) Analogs
Section:
Injections
Effective Date:
October 1, 2022
Issued Date:
October 1, 2022
Last Revision Date:
October 2022
Annual Review:
July 2022
 
 

Leuprolide acetate (Lupron®, Lupron Depot ®, Lupron Depot-Ped ®, Eligard®, Fensolvi™) and leuprolide mesylate (CamceviTM) are synthetic analogs of gonadotropin releasing hormone (GnRH). Although leuprolide has potent GnRH agonist properties during short-term or intermittent therapy, the principal effect of the drug during long-term administration is inhibition of gonadotropin secretion and suppression of ovarian and testicular steroidogenesis.

Leuprolide and norethindrone (Lupaneta®) is a combination medicine used to treat symptoms of endometriosis.

Triptorelin extended-release (Triptodur®) and triptorelin pamoate (Trelstar®) are synthetic decapeptide agonist analogs of GnRH that reversibly inhibits gonadotropin secretion when administered in continuous doses.

Histrelin (Vantas®, Supprelin LA®) is a synthetic nonapeptide analog of GnRH. Contained in an implant, histrelin (Vantas, Supprelin LA) is released via a diffusion-controlled hydrogel polymer reservoir. Histrelin (Vantas, Supprelin LA) functions as a GnRH agonist, and is a potent inhibitor of gonadotropin secretion when administered in continuous doses.

Policy Position

The use of leuprolide acetate (Lupron) may be considered medically necessary for the following conditions: 

Anemia due to Uterine Fibroids

  • For the preoperative treatment of anemia due to uterine fibroids in combination with iron supplementation when iron therapy alone fails to correct the anemia:
    • Duration of therapy not to exceed three (3) months; or

Central Precocious Puberty

  • For treatment of children with central precocious puberty when ALL the following criteria are met:
    • Confirmed clinical diagnosis of CPP defined by the following:
      • Measurement of LH and FSH following stimulation with a GnRH analog; and
      • Bone age versus chronological age assessment supports diagnosis of CPP; and
    • Individual has onset of secondary sexual characteristics;
      • Less than 11 years of age for females; or
      • Less than 12 years of age for males; and
    • Initial authorization will be for a period of 12 months.

Reauthorization criteria

  • Reauthorization of leuprolide acetate (Lupron) may be considered medically necessary when ALL of the following criteria are met:
    • Individual is currently receiving therapy; and
    • Documentation of positive clinical response (e.g. pre-pubertal slowing or decline, normalization of FSH or LH, or normalization of bone age); and
    • Reauthorization will be for a period of 12 months.

Endometriosis

  • For the management of endometriosis, including pain relief and reduction of endometriotic lesions; or
  • Duration of initial treatment or retreatment not to exceed six (6) months; or

Prostate Cancer

  • As palliative treatment of advanced prostate cancer; or

Compendia Sources

  • Leuprolide acetate (Lupron) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations.

The use of leuprolide/leuprolide acetate (Lupron) not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

J9218

 

 

 

 

 

 




The use of leuprolide acetate for depot suspension (Lupron Depot) may be considered medically necessary for ANY of the following conditions:

Anemia due to Uterine Fibroids

  • The preoperative treatment of anemia due to uterine fibroids in combination with iron supplementation when iron therapy alone fails to correct the anemia:
    • Duration of therapy not to exceed three (3) months and limited to one injection; or

Endometriosis

  • The management of endometriosis, including pain relief and reduction of endometriotic lesions:
    • Duration of initial treatment or retreatment not to exceed six (6) months; or
  • As initial management of painful symptoms of endometriosis and for management of recurrence of symptoms in combination with norethindrone acetate 5 mg tablet taken once daily as add-back therapy:
    • Duration of initial treatment or retreatment not to exceed six (6) monthsor

Prostate Cancer

  • The palliative treatment of advanced prostatic cancer; or

Compendia Sources

  • Leuprolide acetate for depot suspension (Lupron Depot) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations.

The use of leuprolide acetate for depot suspension (Lupron Depot) not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

J1950

J9217

 

 

 

 

 




          The use of leuprolide acetate for depot suspension (Lupron Depot Ped) may be considered medically necessary for the treatment of children with central precocious puberty: when ALL the following criteria are met:

  • Confirmed clinical diagnosis of CPP defined by the following:
    • Measurement of LH and FSH elevated following stimulation with a GnRH analog; and
    • Assessment confirms bone age advancement beyond chronological age; and
  • Individual has onset of secondary sexual characteristics;
    • Less than 11 years of age for females; or
    • Less than 12 years of age for males; and
  • Initial authorization will be for a period of 12 months.

Reauthorization criteria

  • Reauthorization of leuprolide acetate (Lupron Depot Ped) may be considered medically necessary when ALL of the following criteria are met:
    • Individual is currently receiving therapy; and
    • Documentation of positive clinical response (e.g. pre-pubertal slowing or decline, normalization of FSH or LH, or normalization of bone age); and
    • Reauthorization will be for a period of 12 months.

The use of leuprolide acetate for depot suspension (Lupron Depot Ped) not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

J1950

J9217

 

 

 

 

 




Leuprolide and norethindrone (Lupaneta Pack) may be considered medically necessary for women 18 years of age and older for:

  • The initial management of the painful symptoms of endometriosis; or
  • The management of recurrence of symptoms.

Initial treatment course is limited to six (6) months and use is not recommended longer than a total of 12 months due to concerns about adverse impact on bone mineral density.

The use of leuprolide and norethindrone (Lupaneta Pack) not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

J3490

 

 

 

 

 

 




The use of leuprolide acetate (Eligard) may be considered medically necessary for the following conditions:

Prostate Cancer

  • As palliative treatment of advanced prostate cancer; or     

Compendia Sources

  • Leuprolide acetate (Eligard) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations.

The use of leuprolide acetate (Eligard) not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

J9217

 

 

 

 

 

 




Leuprolide acetate (Fensolvi) may be considered medically necessary for the following condition:

Central Precocious Puberty

  • For the treatment of pediatric individuals two (2) years of age and older with central precocious puberty when ALL the following criteria are met:
    • Confirmed clinical diagnosis of CPP defined by the following:
      • Measurement of LH and FSH elevated following stimulation with a GnRH analog; and
      • Assessment confirms bone age advancement beyond chronological age; and
    • Individual has onset of secondary sexual characteristics
      • Less than 11 years of age for females; or
      • Less than 12 years of age for males; and
  • Initial authorization will be for a period of 12 months.

Reauthorization criteria

  • Reauthorization of leuprolide acetate (Fensolvi) may be considered medically necessary when ALL of the following criteria are met:
    • Individual is currently receiving therapy; and
    • Documentation of positive clinical response (e.g. pre-pubertal slowing or decline, normalization of FSH or LH, or normalization of bone age); and
    • Reauthorization will be for a period of 12 months.

The use of leuprolide acetate (Fensolvi) not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

J1951

 

 

 

 

 

 




Leuprolide mesylate (Camcevi) may be considered medically necessary for the following condition: 

Prostate Cancer

  • For the treatment of adult individuals with advanced prostate cancer; or

Compendia Sources

  • Leuprolide mesylate (Camcevi) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations.

The use of leuprolide mesylate (Camcevi) not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

J1952

 

 

 

 

 

 




The use of triptorelin extended-release (Triptodur) may be considered medically necessary for the treatment of pediatric individuals two (2) years or older with central precocious puberty (CPP) when ALL the following criteria are met:

Central Precocious Puberty

  • Confirmed clinical diagnosis of CPP by the following:
    • Measurement of LH and FSH elevated following stimulation with a GnRH analog; and
    • Assessment confirms bone age advancement beyond chronological age; and
  • Individual has onset of secondary sexual characteristics
    • Less than 11 years of age for females; or
    • Less than 12 years of age for males; and
  • Initial authorization will be for a period of 12 months.

Reauthorization criteria

 

  • Reauthorization of triptorelin extended-release (Triptodur) may be considered medically necessary when ALL of the following criteria are met:
    • Individual is currently receiving therapy; and
    • Documentation of positive clinical response (e.g. pre-pubertal slowing or decline, normalization of FSH or LH, or normalization of bone age); and
    • Reauthorization will be for a period of 12 months.

The use of triptorelin extended-release (Triptodur) not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

J3316

 

 

 

 

 

 




The use of triptorelin pamoate (Trelstar) may be considered medically necessary for the following conditions:

Prostate Cancer

  • The palliative treatment of advanced prostate cancer; or

Compendia Sources

Triptorelin pamoate (Trelstar) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations.

The use of triptorelin pamoate (Trelstar) not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

J3315

 

 

 

 

 

 




The use of histrelin acetate subcutaneous implant (Vantas) may be considered medically necessary for the following conditions:

Prostate Cancer

  • For the palliative treatment of advanced prostate cancer; or

Compendia Sources

  • Histrelin acetate subcutaneous implant (Vantas) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations.

The use of histrelin acetate subcutaneous implant (Vantas) for any other indication is considered not medically necessary, and therefore, non-covered.

The use of histrelin acetate subcutaneous implant (Vantas) not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

J9225

 

 

 

 

 

 




The use of histrelin acetate subcutaneous implant (Supprelin LA) may be considered medically necessary for the following condition:

Central Precocious Puberty (CPP)

  • For treatment of children with central precocious puberty when ALL the following criteria are met:

o   Confirmed clinical diagnosis of CPP defined by any of the following:

§  Measurement of LH and FSH elevated following stimulation with a GnRH analog; and

§  Assessment confirms bone age advancement beyond chronological age; and

o   Individual has onset of secondary sexual characteristics;

§  Less than 11 years of age for females; or

§  Less than 12 years of age for males; and

o   Initial authorization will be for a period of 12 months.

Reauthorization criteria

  • Reauthorization of histrelin acetate subcutaneous implant (Supprelin LA) may be considered medically necessary when ALL of the following criteria are met:
    • Individual is currently receiving therapy; and
    • Documentation of positive clinical response (e.g. pre-pubertal slowing or decline, normalization of FSH or LH, or normalization of bone age); and
    • Reauthorization will be for a period of 12 months.

The use of histrelin acetate subcutaneous implant (Supprelin LA) not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

J9226

 

 

 

 

 

 




Other Medically Accepted Non-FDA Approved Indications, Class IIb or Higher Grade Recommendations

The use of histrelin acetate (Supprelin LA, Vantas), leuprolide acetate (Lupron Depot, Lupron Depot-Ped Fensolvi), or triptorelin (Triptodur, Trelstar) may be considered medically necessary for puberty suppression in individuals with gender dysphoria when ALL of the following criteria are met:

  • The adolescent has demonstrated a long-lasting and intense pattern of gender non-conformity or gender dysphoria (whether suppressed or expressed); and
  • Gender dysphoria emerged or worsened with the onset of puberty; and
  • Any co-existing psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment; and
  • The adolescent has given informed consent and, particularly when the adolescent has not reached the age of medical consent, the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process.

The use of histrelin acetate (Supprelin LA, Vantas), leuprolide acetate (Lupron Depot, Lupron Depot-Ped), or triptorelin (Triptodur, Trelstar) not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

J1950

J1951

J9217

J9225

J9226

J3315

J3316

J3490

 

 

 

 

 

 




NOTE*: First generation antiandrogen must be given for seven (7) or more days to prevent testosterone flare if metastases are present in weight-bearing bone.

**

NOTEMen with breast cancer should be treated similarly to postmenopausal women, except that use of an aromatase inhibitor is ineffective without concomitant suppression of testicular steroidogenesis.

**

NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines. Highmark may deny, in full or in part, reimbursement for utilization that does not fall within the applicable dosage and/or frequency limits.


Related Policies

See Medical Policy Bulletin G-16 for information on chemotherapy for malignant disease.


Covered Diagnosis Codes for Procedure Code J1950, J9217:

C06.9

C07

C08.0

C08.1

C08.9

C48.1

C48.2

C48.8

C50.011

C50.012

C50.019

C50.021

C50.022

C50.029

C50.111

C50.112

C50.119

C50.121

C50.122

C50.129

C50.211

C50.212

C50.219

C50.221

C50.222

C50.229

C50.311

C50.312

C50.319

C50.321

C50.322

C50.329

C50.411

C50.412

C50.419

C50.421

C50.422

C50.429

C50.511

C50.512

C50.519

C50.521

C50.522

C50.529

C50.611

C50.612

C50.619

C50.621

C50.622

C50.629

C50.811

C50.812

C50.819

C50.821

C50.822

C50.829

C50.911

C50.912

C50.919

C50.921

C50.922

C50.929

C56.1

C56.2

C56.3

C56.9

C57.00

C57.01

C57.02

C57.10

C57.11

C57.12

C57.20

C57.21

C57.22

C57.3

C57.4

C57.7

C57.8

C57.9

C61

C79.63

D25.0

D25.1

D25.2

D25.9

D50.0

D50.9

E22.8

F64.0

F64.1

F64.2

F64.8

F64.9

N80.00

N80.01

N80.02

N80.03

N80.101

N80.102

N80.103

N80.109

N80.111

N80.112

N80.113

N80.119

N80.121

N80.122

N80.123

N80.129

N80.201

N80.202

N80.203

N80.209

N80.211

N80.212

N80.213

N80.219

N80.221

N80.222

N80.223

N80.229

N80.30

N80.311

N80.312

N80.319

N80.321

N80.322

N80.329

N80.331

N80.332

N80.333

N80.339

N80.341

N80.342

N80.343

N80.349

N80.351

N80.352

N80.353

N80.359

N80.361

N80.362

N80.363

N80.369

N80.371

N80.372

N80.373

N80.379

N80.381

N80.382

N80.383

N80.389

N80.391

N80.392

N80.399

N80.3A1

N80.3A2

N80.3A3

N80.3A9

N80.3B1

N80.3B2

N80.3B3

N80.3B9

N80.3C1

N80.3C2

N80.3C3

N80.3C9

N80.40

N80.41

N80.42

N80.50

N80.511

N80.512

N80.519

N80.521

N80.522

N80.529

N80.531

N80.532

N80.539

N80.541

N80.542

N80.549

N80.551

N80.552

N80.559

N80.561

N80.562

N80.569

N80.A0

N80.A1

N80.A2

N80.A41

N80.A42

N80.A43

N80.A49

N80.A51

N80.A52

N80.A53

N80.A59

N80.A61

N80.A62

N80.A63

N80.A69

N80.B1

N80.B2

N80.B31

N80.B32

N80.B39

N80.B4

N80.B5

N80.B6

N80.C0

N80.C10

N80.C11

N80.C19

N80.C2

N80.C3

N80.C4

N80.C9

N80.D0

N80.D1

N80.D2

N80.D3

N80.D4

N80.D5

N80.D6

N80.D9

Z87.890

 

Covered Diagnosis Codes for Procedure Code J9218:

C06.9

C07

C08.0

C08.1

C08.9

C61

D25.0

D25.1

D25.2

D25.9

D50.0

D50.9

E22.8

N80.00

N80.01

N80.02

N80.03

N80.101

N80.102

N80.103

N80.109

N80.111

N80.112

N80.113

N80.119

N80.121

N80.122

N80.123

N80.129

N80.201

N80.202

N80.203

N80.209

N80.211

N80.212

N80.213

N80.219

N80.221

N80.222

N80.223

N80.229

N80.30

N80.311

N80.312

N80.319

N80.321

N80.322

N80.329

N80.331

N80.332

N80.333

N80.339

N80.341

N80.342

N80.343

N80.349

N80.351

N80.352

N80.353

N80.359

N80.361

N80.362

N80.363

N80.369

N80.371

N80.372

N80.373

N80.379

N80.381

N80.382

N80.383

N80.389

N80.391

N80.392

N80.399

N80.3A1

N80.3A2

N80.3A3

N80.3A9

N80.3B1

N80.3B2

N80.3B3

N80.3B9

N80.3C1

N80.3C2

N80.3C3

N80.3C9

N80.40

N80.41

N80.42

N80.50

N80.511

N80.512

N80.519

N80.521

N80.522

N80.529

N80.531

N80.532

N80.539

N80.541

N80.542

N80.549

N80.551

N80.552

N80.559

N80.561

N80.562

N80.569

N80.A0

N80.A1

N80.A2

N80.A41

N80.A42

N80.A43

N80.A49

N80.A51

N80.A52

N80.A53

N80.A59

N80.A61

N80.A62

N80.A63

N80.A69

N80.B1

N80.B2

N80.B31

N80.B32

N80.B39

N80.B4

N80.B5

N80.B6

N80.C0

N80.C10

N80.C11

N80.C19

N80.C2

N80.C3

N80.C4

N80.C9

N80.D0

N80.D1

N80.D2

N80.D3

N80.D4

N80.D5

N80.D6

N80.D9

 

 

 

 

 

 

Covered Diagnosis Codes for Procedure Code J3316: 

E22.8

F64.0

F64.1

F64.2

F64.8

F64.9

Z87.890

 

Covered Diagnosis Codes for Procedure Code J3315:

C61

C50.011

C50.012

C50.019

C50.021

C50.022

C50.029

C50.111

C50.112

C50.119

C50.121

C50.122

C50.129

C50.211

C50.212

C50.219

C50.221

C50.222

C50.229

C50.311

C50.312

C50.319

C50.321

C50.322

C50.329

C50.411

C50.412

C50.419

C50.421

C50.422

C50.429

C50.511

C50.512

C50.519

C50.521

C50.522

C50.529

C50.611

C50.612

C50.619

C50.621

C50.622

C50.629

C50.811

C50.812

C50.819

C50.821

C50.822

C50.829

C50.911

C50.912

C50.919

C50.921

C50.922

C50.929

F64.0

F64.1

F64.2

F64.8

F64.9

N80.00

N80.01

N80.02

N80.03

N80.101

N80.102

N80.103

N80.109

N80.111

N80.112

N80.113

N80.119

N80.121

N80.122

N80.123

N80.129

N80.201

N80.202

N80.203

N80.209

N80.211

N80.212

N80.213

N80.219

N80.221

N80.222

N80.223

N80.229

N80.30

N80.311

N80.312

N80.319

N80.321

N80.322

N80.329

N80.331

N80.332

N80.333

N80.339

N80.341

N80.342

N80.343

N80.349

N80.351

N80.352

N80.353

N80.359

N80.361

N80.362

N80.363

N80.369

N80.371

N80.372

N80.373

N80.379

N80.381

N80.382

N80.383

N80.389

N80.391

N80.392

N80.399

N80.3A1

N80.3A2

N80.3A3

N80.3A9

N80.3B1

N80.3B2

N80.3B3

N80.3B9

N80.3C1

N80.3C2

N80.3C3

N80.3C9

N80.40

N80.41

N80.42

N80.50

N80.511

N80.512

N80.519

N80.521

N80.522

N80.529

N80.531

N80.532

N80.539

N80.541

N80.542

N80.549

N80.551

N80.552

N80.559

N80.561

N80.562

N80.569

N80.A0

N80.A1

N80.A2

N80.A41

N80.A42

N80.A43

N80.A49

N80.A51

N80.A52

N80.A53

N80.A59

N80.A61

N80.A62

N80.A63

N80.A69

N80.B1

N80.B2

N80.B31

N80.B32

N80.B39

N80.B4

N80.B5

N80.B6

N80.C0

N80.C10

N80.C11

N80.C19

N80.C2

N80.C3

N80.C4

N80.C9

N80.D0

N80.D1

N80.D2

N80.D3

N80.D4

N80.D5

N80.D6

N80.D9

Z87.890

Covered Diagnosis Codes for Procedure Code J9225:

C61

F64.0

F64.1

F64.2

F64.8

F64.9

 

Z87.890

 

 

 

 

 

 

Covered Diagnosis Codes for Procedure Code J9226 and J1951:

E22.8

F64.0

F64.1

F64.2

F64.8

F64.9

Z87.890

Covered Diagnosis Codes for Procedure Code J1952:

C61

Covered Diagnosis Codes for Procedure Code J3490:

N80.00

N80.01

N80.02

N80.03

N80.101

N80.102

N80.103

N80.109

N80.111

N80.112

N80.113

N80.119

N80.121

N80.122

N80.123

N80.129

N80.201

N80.202

N80.203

N80.209

N80.211

N80.212

N80.213

N80.219

N80.221

N80.222

N80.223

N80.229

N80.30

N80.311

N80.312

N80.319

N80.321

N80.322

N80.329

N80.331

N80.332

N80.333

N80.339

N80.341

N80.342

N80.343

N80.349

N80.351

N80.352

N80.353

N80.359

N80.361

N80.362

N80.363

N80.369

N80.371

N80.372

N80.373

N80.379

N80.381

N80.382

N80.383

N80.389

N80.391

N80.392

N80.399

N80.3A1

N80.3A2

N80.3A3

N80.3A9

N80.3B1

N80.3B2

N80.3B3

N80.3B9

N80.3C1

N80.3C2

N80.3C3

N80.3C9

N80.40

N80.41

N80.42

N80.50

N80.511

N80.512

N80.519

N80.521

N80.522

N80.529

N80.531

N80.532

N80.539

N80.541

N80.542

N80.549

N80.551

N80.552

N80.559

N80.561

N80.562

N80.569

N80.A0

N80.A1

N80.A2

N80.A41

N80.A42

N80.A43

N80.A49

N80.A51

N80.A52

N80.A53

N80.A59

N80.A61

N80.A62

N80.A63

N80.A69

N80.B1

N80.B2

N80.B31

N80.B32

N80.B39

N80.B4

N80.B5

N80.B6

N80.C0

N80.C10

N80.C11

N80.C19

N80.C2

N80.C3

N80.C4

N80.C9

N80.D0

N80.D1

N80.D2

N80.D3

N80.D4

N80.D5

N80.D6

N80.D9

 

 

 

 

 



Place of Service: Outpatient

The administration of gonadatropin releasing hormone (GnRH) analogs is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.


Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as: 
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as: 
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator. 

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. 

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: 

U.S. Department of Health and Human Services 
200 Independence Avenue, SW 
Room 509F, HHH Building 
Washington, D.C. 20201 
1-800-368-1019, 800-537-7697 (TDD) 

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. 





Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.