J9218, Leuprolide acetate, per 1 mg
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Documentation Required
- 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.
- Laboratory values as applicable (e.g., PSA measurements reported in many trials and used as a secondary outcome).
- Imaging/angiographic documentation for PAE (prostatic arterial anatomy identification) and documentation of technical feasibility or reasons for technical failure.
- Erectile and ejaculatory function assessment (IIEF-5 or IIEF-15, MSHQ, MSHQ-EjD, SHIM) where preservation of sexual function is a treatment goal.
Key Coverage Criteria
- 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).
- ICD-10 codes covered if selection criteria are met: N35.010 - N35.92 Urethral stricture
- PAE can be considered in patients with hematuria of prostatic origin as a method of achieving cessation of bleeding. (Level of Evidence: D; strength of recommendation: strong)
- Alpha adrenergic blockers (alfuzosin, doxazosin, silodosin, tamsulosin, and terazosin)
20 Active Policies
A52453, Billing and Coding: Luteinizing Hormone-Releasing Hormone (LHRH) Analogs
J6
NGS-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses
JK
AETNA-CPB-0079, Benign Prostatic Hyperplasia
AETNA-CPB-0501, Gonadotropin-Releasing Hormone Analogs and Antagonists
BCBSIL-RX501.041, Gonadotropin-Releasing Hormone (GnRH) Agonists and Antagonists
BCBSIL-RX502.061, Oncology Medications
BCBSMT-RX501.041, Gonadotropin-Releasing Hormone (GnRH) Agonists and Antagonists
BCBSMT-RX502.061, Oncology Medications
BCBSNM-RX501.041, Gonadotropin-Releasing Hormone (GnRH) Agonists and Antagonists
BCBSNM-RX502.061, Oncology Medications
BCBSOK-RX501.041, Gonadotropin-Releasing Hormone (GnRH) Agonists and Antagonists
BCBSOK-RX502.061, Oncology Medications
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
EVICORE-HPLAN-HEALTH_PARTNERS_PLANS-1D3B8C21C093, Q2 - 2026 Health Partners Plans MedOnc Master Drug List
Related Codes
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