ND Committee Review
Internal Medical Policy Committee 5-15-2019 Adopted policy
Internal Medical Policy Committee 1-22-2020
- Added gender dysphoria criteria; and
- Added diagnosis codes
Internal Medical Policy Committee 7-22-2020
- Added new product, Fensolvi,
- Revised criteria,
- Added additional diagnosis code, C06.9
Internal Medical Policy Committee 7-22-2021 Effective July 01, 2021
- Added new code J1951 for leuprolide acetate (Fensolvi) to policy
Internal Medical Policy Committee 9-21-2021
- Added additional diagnosis codes C56.3 and C79.63 to J1950 and J9217
Internal Medical Policy Committee 9-28-2022 - Effective October 03, 2022
- Added leuprolide mesylate (Camcevi) to the policy,
- Added CPP criteria and CPP reauthorization criteria,
- Update Diagnosis codes as follows:
- Procedure codes J1950 and J9217
- Removed Z85.43 and Z85.46,
- Procedure code J9218
- Removed Z85.46; and
- Added D50.0 and D50.9,
- Procedure code J3315
- Procedure code J9225
- Procedure code J1952
- Added C61
- Removed NCCN recommendations; and
- Added this statement "[Drug] may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations." and
- Updated experimental/investigational statement
Internal Medical Policy Committee 1-26-2023 - Effective January 1, 2023
- Added new code J1954 for leuprolide acetate (Lutrate Depot) to the policy
- Updated experimental/investigational statements
Internal Medical Policy Committee 1-16-2024 Effective March 01, 2024
- Added CPP criteria for Triptodur
Internal Medical Policy Committee 11-19-2024 Effective December 08, 2024