Does J3316 require prior authorization?

No, J3316 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for J3316?

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

Medical records for patients receiving a once‑yearly implant must document ongoing follow‑up visits at least every 3 to 4 months and must be provided upon request; lack of requested documentation will result in denial as not medically necessary.
Physician documentation supporting reasonable expectation of survival >12 months is required for coverage of once‑yearly implants for prostate cancer.
Billing frequency should match the drug formulation administered (e.g., bill Vantas 50 mg implant once per 12 months, Eligard 22.5 mg billed per its 3‑month formulation); medical record must support billed frequency when requested.
Central Precocious Puberty (initial): Documentation of diagnosis of central precocious puberty (idiopathic or neurogenic); documentation of onset of secondary sexual characteristics by age (females 64; 8 yrs; males 64; 9 yrs); confirmation of diagnosis by one of the following: pubertal basal LH (based on lab reference ranges), a pubertal LH response to a GnRH stimulation test, or bone age advanced one year beyond chronological age.

GnRH/LHRH analogs (leuprolide, goserelin, triptorelin, histrelin, leuprolide mesylate/Camcevi) are covered for FDA‑approved indications and for recognized off‑label uses that meet the criteria of LCD L33394.
Leuprolide acetate and histrelin implants administered every 12 months are covered for treatment of prostate cancer when the treating physician reasonably expects the patient to survive at least 12 months.
GnRH analogs are covered when administered at frequencies consistent with the specific product's labeled duration of action (e.g., monthly, every 3, 4, 6, or 12 months).
Central Precocious Puberty (Fensolvi, Lupron Depot-Ped, Supprelin LA, Triptodur): treatment of central precocious puberty (idiopathic or neurogenic) when criteria are met (see diagnosis/age/confirmation requirements).
Endometriosis (Lupron Depot, Zoladex): treatment of endometriosis or suspected endometriosis when criteria are met (see prior therapy or surgical ablation requirements).
Endometrial Thinning/Dysfunctional Uterine Bleeding (Zoladex): endometrial thinning prior to endometrial ablation when criteria are met.

A52453, Billing and Coding: Luteinizing Hormone-Releasing Hormone (LHRH) Analogs

NGS-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

BCBSIL-RX501.041, Gonadotropin-Releasing Hormone (GnRH) Agonists and Antagonists

BCBSMT-RX501.041, Gonadotropin-Releasing Hormone (GnRH) Agonists and Antagonists

BCBSNM-RX501.041

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