J9219, Leuprolide acetate implant, 65 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without 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.
- Claims must be submitted in compliance with the Local Coverage Determination L39387 and applicable billing/coding guidelines.
- When submitting claims with discarded Part B drugs/biologicals from single-use vials or packages, document the discarded amount and reason in the patient’s medical record.
- Use the JW modifier on claims reporting discarded drugs and ensure supporting documentation in the medical record justifies the modifier.
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).
- Administration of LHRH analogs is covered when prescribed, dosed, and administered consistent with FDA-approved labeling.
- Administration code 96402 may be billed with HCPCS codes J1950, J9217, J9202, J3315, J1952, and J1954.
- Administration codes 11981, 11982, and 11983 may be billed with HCPCS codes J9219 and J9225.
16 Active Policies
A52453, Billing and Coding: Luteinizing Hormone-Releasing Hormone (LHRH) Analogs
J6
PALMETTO-JJ-L39387, Luteinizing Hormone-Releasing Hormone (LHRH) Analogs
JJ
NGS-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses
JK
PALMETTO-JM-L39387, Luteinizing Hormone-Releasing Hormone (LHRH) Analogs
JM
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
AETNA-CPB-0788, Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments
A59160, Billing and Coding: Luteinizing Hormone-Releasing Hormone (LHRH) Analogs
AETNA-CPB-0079, Benign Prostatic Hyperplasia
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.