Does 11981 require prior authorization?

No, 11981 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 11981?

Medicare facility rate: $54.78. Non-facility rate: $107.55. Work RVU: 1.11.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

1.11

Facility

$54.78

Non-Facility

$107.55

Medical records for patients receiving a once‑yearly implant must document ongoing follow‑up visits at least every 3 to 4 months and must be provided upon request; lack of requested documentation will result in denial as not medically necessary.
Physician documentation supporting reasonable expectation of survival >12 months is required for coverage of once‑yearly implants for prostate cancer.
Billing frequency should match the drug formulation administered (e.g., bill Vantas 50 mg implant once per 12 months, Eligard 22.5 mg billed per its 3‑month formulation); medical record must support billed frequency when requested.
Claims must be submitted in compliance with the Local Coverage Determination L39387 and applicable billing/coding guidelines.

GnRH/LHRH analogs (leuprolide, goserelin, triptorelin, histrelin, leuprolide mesylate/Camcevi) are covered for FDA‑approved indications and for recognized off‑label uses that meet the criteria of LCD L33394.
Leuprolide acetate and histrelin implants administered every 12 months are covered for treatment of prostate cancer when the treating physician reasonably expects the patient to survive at least 12 months.
GnRH analogs are covered when administered at frequencies consistent with the specific product's labeled duration of action (e.g., monthly, every 3, 4, 6, or 12 months).
Administration of LHRH analogs is covered when prescribed, dosed, and administered consistent with FDA-approved labeling.
Administration code 96402 may be billed with HCPCS codes J1950, J9217, J9202, J3315, J1952, and J1954.
Administration codes 11981, 11982, and 11983 may be billed with HCPCS codes J9219 and J9225.

L33394 — Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

J06

A52453 — Billing and Coding: Luteinizing Hormone-Releasing Hormone (LHRH) Analogs

J06

A59160 — Billing and Coding: Luteinizing Hormone-Releasing Hormone (LHRH) Analogs

L39387 — Luteinizing Hormone-Releasing Hormone (LHRH) Analogs

UHC-POL-subcutaneous-implant-naltrexone-pellets

Ask Verity about documentation requirements, denial risks, or coverage in your state.