Does J2353 require prior authorization?

No, J2353 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for J2353?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

For CID codes (T38.895*/T43.215*/T43.225*/T50.995*), the medical record must document the specific chemotherapy agent(s) causing the diarrhea and prior antidiarrheal treatments that have been ineffective.
For VIPoma diagnosis codes (C25.4, C26.0, D13.7, D13.91, D13.99), the medical record must document that the patient’s diagnosis is VIPoma.
When code R79.89 is used, the medical record must document the abnormal clinical or laboratory findings that prompted suspicion of VIPoma.
When code R94.7 is used, the medical record must document an abnormal octreotide scan that prompted suspicion of VIPoma.

Octreotide is covered for chemotherapy-induced diarrhea (CID) when claim includes ICD-10-CM codes T38.895A/T38.895D/T38.895S, T43.215A/T43.215D/T43.215S, T43.225A/T43.225D/T43.225S, or T50.995A/T50.995D/T50.995S and the medical record documents the chemotherapy agent(s) causing the CID and prior antidiarrheal treatments that became ineffective.
Octreotide is covered for treatment of VIPoma when claim includes ICD-10-CM codes C25.4, C26.0, D13.7, D13.91, or D13.99 and the medical record documents that the patient’s diagnosis is VIPoma.
Octreotide may be considered when ICD-10-CM code R79.89 is submitted if the medical record documents abnormal clinical or laboratory findings that led to suspicion of VIPoma.
Octreotide may be considered when ICD-10-CM code R94.7 is submitted if the medical record documents an abnormal octreotide scan that led to suspicion of VIPoma.
Long-acting octreotide acetate (Sandostatin LAR) is covered for reduction of growth hormone (GH) and IGF-1 in patients with acromegaly who are appropriate for medical treatment and who have demonstrated response to and tolerability of short-acting subcutaneous octreotide.
Long-acting octreotide acetate is covered for suppression of severe diarrhea and flushing associated with malignant carcinoid syndrome when initial treatment with short-acting subcutaneous octreotide has been effective and tolerated.

AETNA-CPB-0693 — Somatostatin Analogs

UHC-POL-somatostatin-analogs — Somatostatin Analogs

A56531 — Billing and Coding: Octreotide Acetate for Injectable Suspension (Sandostatin LAR Depot)

L33438 — Octreotide Acetate for Injectable Suspension (Sandostatin LAR Depot)

UMR-POL-UMR-somatostatin-analogs — Somatostatin Analogs

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