Policy: Gonadotropin-Releasing Hormone Agonist (Eligard®, Lupron Depot®)
Policy Number: 08.01.33b
Last Update: 2019-12-02
Issued in: New Jersey, Pennsylvania

Youth Services:

Leuprolide acetate for injection is considered medically necessary and, therefore, covered for puberty suppression when all of the following criteria are met:

• The adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed), in accordance with criteria established in the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition, [DSM-5].
• Gender dysphoria emerged or worsened with the onset of puberty.
• The individual has reached at least Tanner stage 2 of development.