J2354, Injection, octreotide, non-depot form for subcutaneous or intravenous
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Documentation Required
- For acromegaly: documentation of 'inadequate response to or cannot be treated with surgical resection, pituitary irradiation, or dopamine agonist (e.g., bromocriptine, cabergoline) therapy' (record prior therapies and evidence of inadequate response or contraindication/unavailability of those therapies)
- For Sandostatin LAR: documentation that 'initial treatment with Sandostatin subcutaneous injection has been shown to be effective and tolerated' prior to starting LAR (record of prior IR octreotide treatment response and tolerability)
- For Signifor / Signifor LAR in Cushing's disease: documentation that pituitary surgery 'is not an option or has not been curative' (clinical notes indicating surgical candidacy or prior surgery with persistent disease)
- Documentation of indication-specific clinical findings as appropriate (e.g., diagnosis of metastatic carcinoid tumor or VIPoma, evidence of severe diarrhea and flushing episodes, diagnosis of bleeding gastroesophageal varices, chemotherapy- or radiation-induced diarrhea, malignant bowel obstruction)
- Administration documentation: Sandostatin LAR must be administered intramuscularly under physician supervision (record of administration date, dose, route, and supervising clinician)
- Use of the policy's listed HCPCS/CPT/diagnosis codes when billing: HCPCS J1930, J1932, J2353, J2354, J2502 and the corresponding ICD-10 diagnosis codes listed in the policy's 'Applicable Codes' section (documentation should support linkage between diagnosis code and drug use)
Key Coverage Criteria
- Acromegaly patients who have had inadequate response to or cannot be treated with surgical resection, pituitary irradiation, or dopamine agonist (e.g., bromocriptine, cabergoline) therapy
- Severe diarrhea and flushing episodes associated with metastatic carcinoid tumors
- Profuse watery diarrhea associated with vasoactive intestinal peptide tumors (VIPomas)-secreting tumors
- Bleeding gastroesophageal varices associated with liver disease
- Chemotherapy and/or radiation-induced diarrhea
- Malignant bowel disease
20 Active Policies
UHC-POL-somatostatin-analogs, Somatostatin Analogs
AETNA-CPB-0693, Somatostatin Analogs
RX501.156, Octreotide
BCBSIL-RX501.156, Octreotide
BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care
BCBSMT-RX501.156, Octreotide
BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care
BCBSNM-RX501.156, Octreotide
BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care
BCBSOK-RX501.156, Octreotide
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
EVICORE-HPLAN-CIGNA_MEDICARE-6408D93491D1, Q1 - 2026 1199 SEIU Benefit Funds MedOnc Master Drug List
EVICORE-HPLAN-CIGNA_MEDICARE-65E4ECCF1ADE, Q2 - 2025 1199 SEIU Benefit Funds MedOnc Master Drug List
EVICORE-HPLAN-CIGNA_MEDICARE-A5899B49CF60, Q2 - 2026 1199 SEIU Benefit Funds MedOnc Master Drug List
EVICORE-HPLAN-CIGNA_MEDICARE-C882D62DFEB4, Q3 - 2025 1199 SEIU Benefit Funds MedOnc Master Drug List
EVICORE-HPLAN-CIGNA_MEDICARE-44F27329FED1, Q4 - 2025 1199 SEIU Benefit Funds MedOnc Master Drug List
Related Codes
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