Effective March 14, 2017, changes will apply to providers
who bill for leuprolide acetate (Lupron Depot and Eligard).
Coding updates
The following coding guidelines will apply when billing for leuprolide
acetate:
- J1950 (Injection, leuprolide acetate [for depot
suspension], per 3.75 mg) should only be reported with non-oncologic diagnoses.
Please also note the following:
- – Reporting breast, ovarian, or prostate cancer with J1950 will be
considered not medically necessary and, therefore, not covered.
- – Reporting any other diagnosis with J1950 will be considered
experimental/investigational and, therefore, not covered.
- J9217 (Leuprolide acetate [for depot suspension], 7.5 mg)
will be covered when reported for all indications (oncologic and non-oncologic)
based on the medical necessity criteria outlined in our medical policies.
Medical necessity criteria
According to the AmeriHealth definition of medical necessity, a service
cannot be more costly than an alternative service that is at least as likely to
produce equivalent therapeutic or diagnostic results for the treatment of an
individual's illness.
Although Lupron Depot has been approved by the U.S. Food and Drug
Administration (FDA) for prostate cancer and Compendia supports the use of
Lupron Depot for breast and ovarian cancers, AmeriHealth considers Eligard to
be a lower-cost alternative for treatment of oncologic and non-oncologic
diagnoses with leuprolide acetate.
For more information
AmeriHealth has created Medical Policy: #08.01.33: Gonadotropin-Releasing
Hormone Agonist (Eligard?, Lupron Depot?), which is
currently posted as a Notification and will become effective on March 14, 2017.
To view the Notification for this policy, visit our Medical
Policy Portal and select Accept and Go to Medical Policy Online.
Then select Commercial under Active Notifications.