Mountain State Medical Policy Bulletin |
Section: | Injections |
Number: | I-16 |
Topic: | Leuprolide/Leuprolide Acetate (Lupron, Lupron Depot, Lutrepulse, ViadurTM) |
Effective Date: | August 1, 2005 |
Issued Date: | August 1, 2005 |
Date Last Reviewed: | 06/2005 |
Indications and Limitations of Coverage
Leuprolide acetate (LUPRON) (J1950, J9217, J9218) is a synthetic analog of gonadotropin release hormone (GnRh). Although leuprolide has potent GnRh agonist properties during short-term or intermittent therapy, the principal effect of the drug during long-term administration is inhibition of gonadotropin (LH, FSH) secretion and suppression of ovarian and testicular steroidogenesis. Coverage for leuprolide/leuprolide acetate treatment is determined according to individual or group customer benefits. Treatment is eligible for the following conditions:
Leuprolide/leuprolide acetate used in the treatment of conditions other than those listed above, should be denied as not medically necessary and, therefore, not covered. A participating, preferred, or network provider cannot bill the member for the denied service. Viadur, (J9219), is an implantable form of leuprolide acetate which is used in the treatment of advanced prostate cancer (185, 189.3, 198.1, 198.82, 233.4, 233.9). It is implanted once yearly. The implantation and removal of this device is eligible for payment and should be reported with codes 11981, 11982, and 11983. NOTE: See Mountain State Medical Policy Bulletin G-16 for information on chemotherapy for malignant disease. |
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11981 | 11982 | 11983 | J1950 | J9217 | J9218 |
J9219 |
PRN Reference |
Leuprolide, USPDI-Vol. I, Edition 21, 2001, Micromedex, Inc. |