HCPCS J9202 is officially defined as "Goserelin acetate implant, per 3.6 mg." HCPCS J9202 is referenced in 13 tracked payer policy changes from Highmark, WellCare, and 4 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS J9202 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Effective May 1, 2026, Highmark is adding 115 oncology-related codes to their prior authorization requirement list, including common chemotherapy medications and radiation therapy procedures. All authorization requests for these codes must be submitted electronically through Availity Essentials and will be reviewed by Evolent as part of Highmark's oncology value-based care strategy.
Beginning January 1, 2026, the procedure codes in this Centene bulletin require prior authorization through Evolent, which manages prior authorizations for Centene in medical oncology, radiation oncology, pediatric and dose optimization, and cardiology. The change applies to all Ambetter (Marketplace), Medicaid and Medicare products offered by Centene. The code table includes anti-emetics, bone metastasis drugs, cancer treatment drugs, and supportive medications such as iron products, ESAs, myeloid growth factors and immune globulins.
Humana Medicaid Indiana has issued a NEW prior authorization policy (effective October 1, 2025) for Zoladex (goserelin) covering four indications: prostate cancer, breast cancer, endometriosis, and endometrial thinning. This is a NEW policy requiring prior authorization for all Zoladex claims with specific approval criteria and exclusions for each indication. Billing teams must implement prior auth requirements immediately to prevent claim denials.
Humana Medicaid (Louisiana) implemented a new Prior Authorization policy for Zoladex (goserelin) effective October 1, 2025, covering four indications: prostate cancer, breast cancer, endometriosis, and endometrial thinning. The policy establishes specific approval criteria, exclusions (including pediatric restrictions and contraindications with other LHRH agents), and varying approval durations by indication. All Zoladex claims in Louisiana Medicaid must now obtain prior authorization before dispensing.
The Zoladex (goserelin) policy added ICD-10 diagnosis codes C50.A0, C50.A1 and C50.A2 for malignant inflammatory neoplasm of breast, effective 10/01/2025. Prior authorization is required, and the use of samples is not considered current or stable therapy. Medically necessary criteria include individuals aged 18 or older with advanced breast cancer in pre- or perimenopausal women with hormone-receptor positive breast cancer, prostate cancer, endometriosis, or endometrial thinning before endometrial ablation, with approval lengths of 12 months for breast and prostate cancer, 6 months for endometriosis and 2 months for endometrial thinning.
Zoladex (goserelin) may be considered medically necessary for adults 18 years of age or older with advanced breast cancer in pre- or perimenopausal women with hormone-receptor positive disease, for prostate cancer that is T2b-T4 (stage B2-C) used with flutamide or advanced prostate cancer, for endometriosis, and for endometrial thinning before endometrial ablation. Approval lengths are 12 months for breast cancer and prostate cancer, 6 months for endometriosis and 2 months for endometrial thinning, and use for endometriosis beyond 6 months is considered investigational and will not be approved. The code reference section was updated on 10/01/2025 to add ICD-10 diagnosis codes C50.A0, C50.A1 and C50.A2 for malignant inflammatory neoplasm of breast.
Humana revised its Zoladex (goserelin) prior authorization policy effective August 27, 2025, affecting pharmacy coverage for prostate cancer, breast cancer, endometriosis, and endometrial thinning across Medicare and four Medicaid state programs (Florida, Kentucky, South Carolina, Virginia). The policy maintains prior authorization requirements with specific clinical criteria, dosage restrictions (3.6 mg only for endometriosis and endometrial thinning), and exclusions for concomitant LHRH agents and pediatric patients. Billing teams must verify member eligibility against these updated criteria before claim submission to avoid denials.
Aetna's Clinical Policy Bulletin 0079 on benign prostatic hyperplasia (BPH), reviewed 2026-10-15, states that Aetna considers several treatments medically necessary for members with BPH as alternatives to transurethral resection of the prostate (TURP), including alpha adrenergic blockers, hormonal manipulation, laser-based procedures, Aquablation, prostatic urethral lift, prostatic arterial embolization and temporary implanted prostatic devices such as the iTind. It lists other approaches, such as absolute ethanol injection, botulinum toxin, high-intensity focused ultrasound, histotripsy and mirabegron, as experimental, investigational, or unproven, and it sets selection criteria and code-level coverage limits for several services.
Aetna considers gonadotropin-releasing hormone (GnRH) analogs and antagonists medically necessary for commercial plan members only for the specific indications listed for each drug, including leuprolide, goserelin, histrelin, triptorelin, degarelix, cetrorelix and ganirelix, and treats all other indications as experimental, investigational or unproven. Each drug has separate criteria for initial approval and for continuation of therapy, and continuation for prostate cancer requires clinical benefit such as serum testosterone less than 50 ng/dL and no unacceptable toxicity. Precertification is required for the prostate cancer indication, and gender dysphoria treatment for members under 18 must be prescribed by or in consultation with a provider specialized in the care of transgender youth who has collaborated care with a mental health provider.
Aetna covers gonadotropin-releasing hormone (GnRH) analogs and antagonists under its commercial medical plans for the indications the policy lists, including prostate cancer, breast cancer, ovarian cancer, central precocious puberty, endometriosis, uterine leiomyomata (fibroids), and ovulation induction or assisted reproductive technology. The policy also sets criteria for gender dysphoria treatment, including pubertal suppression in adolescents and gender transition, and for continuation of therapy. Aetna considers all other indications experimental, investigational, or unproven.
Aetna considers embolization of gonadal or ovarian veins, with or without the internal iliac veins, medically necessary for pelvic congestion syndrome when the member has had a definitive diagnostic venography, CT or MRI and has failed a trial of appropriate pharmacotherapy such as analgesics or hormonal therapy. Gonadal or ovarian vein embolization for pelvic congestion syndrome is experimental, investigational, or unproven when those criteria are not met. Median sacral vein embolization for pelvic congestion syndrome, ovarian vein transposition, sacral nerve root neuromodulation for chronic pelvic pain, and micronized purified flavonoid fraction for pelvic congestion syndrome are listed as experimental, investigational, or unproven.
For benign prostatic hyperplasia (BPH), alpha blockers, finasteride, dutasteride, tadalafil (5 mg daily), prostatic urethral lift, prostatic arterial embolization, Aquablation, laser prostatectomy, TUVP, TUIP, TUMT and TUNA are medically necessary alternatives to transurethral resection of the prostate (TURP). Temporary implanted prostatic devices such as the iTind are medically necessary when prostate volume is between 25 and 75 g and there is no obstruction in the median lobe, and UroLume is medically necessary for men at least 60 years old, or under 60 and poor surgical candidates, whose prostates are at least 2.5 cm long. Absolute ethanol injection, botulinum toxin, cryosurgical ablation, high-intensity focused ultrasound, histotripsy, melatonin, mirabegron and phytotherapy are listed as experimental, investigational or unproven for BPH.
This Premera medical policy and coding update lists changes from September 2021. Effective September 1, 2021, Keytruda was added for high-risk, early-stage triple negative breast cancer, and varicose vein procedures such as ligation and stripping and phlebectomy were removed from the varicose vein policy. Coding changes effective September 1, 2021 removed medical necessity and prior authorization review for varicose vein codes 37500 through 37785, and coding changes effective September 3, 2021 added medical necessity and prior authorization review for alpha1-proteinase inhibitor codes J0256 and J0257 and gonadotropin releasing hormone analog codes J1950 through J9226.
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