Policy: Gonadotropin Releasing Hormone Analogs (GnRH) for the Treatment of Non-Oncologic Indications
Policy Number: ING-CC-0061
Last Update: 2020-07-20

Youth Services:

Requests for all GnRH Analogs—Zoladex (goserelin acetate), Vantas or Supprelin LA (histrelin acetate), Fensolvi, Lupron Depot or Lupron Depot-Ped, (leuprolide acetate), Lupaneta Pack (leuprolide acetate for depot suspension and norethindrone acetate tablets), Synarel Nasal Spray (nafarelin acetate), or Triptodur (triptorelin pamoate intramuscular extended release) may be approved if the following criteria are met:

I. Individual has a diagnosis of gender dysphoria in adolescents (Hembree 2009, 2017); AND

II. Individual fulfills the DSM V criteria for gender dysphoria (American Psychiatric Association 2013); AND

III. Individual has experienced puberty to at least Tanner stage 2 (Hembree 2009, 2017); AND

IV. Individual has (early) pubertal changes that have resulted in an increase of their gender dysphoria (Hembree 2009, 2017); AND

V. Individual does not suffer from a psychiatric comorbidity that interferes with the diagnostic work-up or treatment (Hembree 2009, 2017); AND

VI. Individual has psychological and social support during treatment confirmed (Hembree 2009, 2017); AND

VII. Individual has confirmed to demonstrate knowledge and understanding of the expected outcomes of GnRH analog treatment (Hembree 2009, 2017).