Mountain State Medical Policy Bulletin |
Section: | Injections |
Number: | I-16 |
Topic: | Leuprolide/Leuprolide Acetate (Lupron, Lupron Depot, Lutrepulse, Viadur™) |
Effective Date: | June 19, 2006 |
Issued Date: | August 25, 2008 |
Date Last Reviewed: | 06/2006 |
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:
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 every twelve months. The implantation and removal of this device is eligible for payment and should be reported with codes 11981, 11982, and 11983. 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. NOTE: See Medical Policy Bulletin G-16 for information on chemotherapy for malignant disease. |
|
11981 | 11982 | 11983 | J1950 | J9217 | J9218 |
J9219 |
Under the Federal Employee Program, all services that utilize FDA-approved drugs, devices, or biological products are eligible when intended for the treatment of a serious or life-threatening condition and when medically necessary and appropriate for the patient’s condition. The use of the FDA approved drug Lupron for conditions other than those listed as eligible on this policy is considered eligible when determined medically necessary based on the patient’s condition. |
Leuprolide, USPDI-Vol. I, Edition 21, 2001, Micromedex, Inc. |
[Version 004 of I-16] |
[Version 003 of I-16] |
[Version 002 of I-16] |
[Version 001 of I-16] |