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Medical Policy Revision: Gonadotropin-Releasing Hormone (GnRH) Receptor Antagonist [Degarelix (Firmagon™)]

Effective August 6, 2019, Horizon BCBSNJ will change the way we consider certain professional claims based on revisions to our medical policy, Gonadotropin-Releasing Hormone (GnRH) Receptor Antagonist [Degarelix (Firmagon™)].

Access our Medical Policy Manual to review this medical policy content.¹

Claims submitted for services provided on and after August 6, 2019 to patients enrolled in Horizon BCBSNJ commercial, Administrative Services Only (ASO) or Medicare Advantage (MA) plans will be processed as follows.

For services provided to patients 18 years of age or older:

  • Based on the submitted diagnosis code(s), information may be requested to help us determine the medical appropriateness of the services represented by HCPCS code J9155. Following our review of medical record information, the code above may be denied as an experimental/investigational, non-covered service.

For services provided to patients under 18 years of age:

  • Regardless of the submitted diagnosis code(s), the administration of drugs represented by HCPCS code J9155 will be denied as an experimental/investigational, non-covered service.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been canceled or postponed, the changes will be applied to claims for dates of service on and after August 6, 2019.

¹The content of Horizon BCBSNJ medical policies that apply to Horizon BCBSNJ MA plans may include reference to pertinent National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs). We follow Centers for Medicare & Medicaid Services (CMS) guidelines, NCDs and/or LCDs in our processing of claims for services provided to our MA members. For those services where no LCD or NCD exists, claims for MA members will be processed based on our policy guidelines.

Published on: May 7, 2019, 10:46 a.m. ET
Last updated on: April 27, 2021, 10:44 a.m. ET