J2353, Injection, octreotide, depot form for intramuscular injection, 1 mg
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Documentation Required
- For selection/anticipated benefit in NETs or other tumor uses: when discussed, documentation of somatostatin receptor (SSTR) imaging/assay (e.g., octreotide scan / SSTR expression) may be used to identify patients most likely to benefit (Feun 2018; Shoushtari 2016).
- For perioperative pasireotide for pancreatic surgery: documentation of type of pancreatic resection (pancreaticoduodenectomy or distal pancreatectomy), peri-operative dosing schedule (pasireotide 900 μg subcut twice daily in Allen trial), and outcome tracking for postoperative pancreatic fistula/leak/abscess grades (use RECIST/CTCAE as applicable).
- For pancreatic fistula/high-output fistula management: documentation of fistula output, amylase level in drain fluid (Adachi 2015 referenced drain amylase thresholds), and prior/concurrent surgical management strategies.
- For VIPoma treatment: documentation of WDHA syndrome (watery diarrhea, hypokalemia, achlorhydria) or clinical syndrome consistent with VIP-secreting tumor when using octreotide.
- Adverse event monitoring documentation where relevant: blood glucose monitoring (due to hyperglycemia risk especially with pasireotide), ECG monitoring in infants (risk of QT prolongation reported), liver function tests for transaminase elevations, and documentation of infections (e.g., hepatic cyst infection with lanreotide noted in DIPAK-1 interim analysis).
- No documentation requirements or required clinical records are specified in this document chunk.
Key Coverage Criteria
- Signifor LAR (pasireotide pamoate): "Treatment of patients with acromegaly who have had an inadequate response to surgery and/or for whom surgery is not an option" (FDA‑approved indication, text)
- Signifor LAR (pasireotide pamoate): "Treatment of patients with Cushing’s disease for whom pituitary surgery is not an option or has not been curative" (FDA‑approved indication, text)
- Somatuline Depot / lanreotide (lanreotide injection / prolonged‑release lanreotide): treatment of carcinoid syndrome ("Somatuline Depot (lanreotide) injection 120 mg for the treatment of carcinoid syndrome") (FDA approval cited in text)
- Acromegaly — treatment when member has a high pretreatment insulin-like growth factor-1 (IGF-1) level for age and/or gender based on the laboratory reference range and member had an inadequate or partial response to surgery or radiotherapy or there is a clinical reason why the member has not had surgery or radiotherapy (applies to octreotide, lanreotide, pasireotide pamoate (Signifor LAR)).
- Carcinoid syndrome — symptomatic treatment (octreotide and lanreotide).
- Acquired immune deficiency syndrome (AIDS)-associated severe secretory diarrhea — treatment when anti-microbial (e.g., ciprofloxacin or metronidazole) or anti-motility agents (e.g., loperamide or diphenoxylate and atropine) have become ineffective (octreotide).
20 Active Policies
PALMETTO-JJ-L33438, Octreotide Acetate for Injectable Suspension (Sandostatin LAR depot)
JJ
PALMETTO-JM-L33438, Octreotide Acetate for Injectable Suspension (Sandostatin LAR depot)
JM
AETNA-CPB-0693, Somatostatin Analogs
RX501.156, Octreotide
BCBSIL-RX501.156, Octreotide
BCBSIL-RX502.061, Oncology Medications
BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care
BCBSMT-RX501.156, Octreotide
BCBSMT-RX502.061, Oncology Medications
BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care
BCBSNM-RX501.156, Octreotide
BCBSNM-RX502.061, Oncology Medications
BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care
BCBSOK-RX501.156, Octreotide
BCBSOK-RX502.061, Oncology Medications
BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care
UMR-POL-UMR-somatostatin-analogs, Somatostatin Analogs
SUREST-POL-SUREST-somatostatin-analogs, Somatostatin Analogs
EVICORE-HPLAN-CIGNA-91DEEEDD92F8, Cigna MedOnc Master Drug List
EVICORE-HPLAN-CIGNA_MEDICARE-F57DF6FC9C3C, Q1 - 2025 1199 SEIU Benefit Funds MedOnc Master Drug List
Related Codes
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