ganirelix acetate — United Healthcare

Initial criteria

• Diagnosis of infertility AND one of the following: unexplained infertility OR endometriosis OR male factor infertility OR tubal factor infertility OR diminished ovarian reserve OR uterine factor infertility OR ovulatory dysfunction OR recurrent pregnancy loss OR failure to achieve conception with other treatment modalities AND for the development of one or more follicles (ovarian stimulation) AND will be used in conjunction only with assisted reproductive technology (ART)
• Used for fertility preservation AND the individual will undergo gonadotoxic therapy (e.g., exposure to cytotoxic agents, invasive surgery, prolonged hormonal ovarian suppression, radiation therapy) AND will be used as part of an assisted reproductive technology (e.g., in vitro fertilization) procedure

Approval duration

2 months