J2502 — Injection, pasireotide long acting, 1 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
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)
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
4 Active Policies
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
Related Codes
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