Does J2354 require prior authorization?

No, J2354 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for J2354?

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 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)

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

AETNA-CPB-0693 — Somatostatin Analogs

UHC-POL-somatostatin-analogs — Somatostatin Analogs

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

SUREST-POL-SUREST-somatostatin-analogs — Somatostatin Analogs

BCBSIL-RX501.156 — Octreotide

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