Does J1951 require prior authorization?

Yes, J1951 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J1951?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

Backwork Sign up free

`J1951`, Injection, leuprolide acetate for depot suspension (fensolvi), 0.25 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

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.

Central Precocious Puberty (continuation): Documentation patient is currently receiving therapy for CPP; documentation of positive clinical response to therapy; documentation patient is currently younger than the appropriate time point for onset of puberty (females <11 yrs; males <12 yrs).

Endometriosis (initial): Documentation of diagnosis or suspected endometriosis; documentation of contraindication/intolerance/failure of BOTH oral contraceptives or depot medroxyprogesterone AND NSAIDs, OR documentation patient had surgical ablation to prevent recurrence; plan stating intended course (initial course limited to 6 months).

Endometriosis (retreatment Lupron Depot): Documentation of recurrence of symptoms following initial course; documentation of concurrent add-back therapy; documentation addressing bone mineral density considerations.

Endometrial Thinning: Documentation ruling out other causes of bleeding; plan for endometrial ablation; confirmation patient will receive Zoladex 3.6 mg implant and that treatment will not exceed two depots.

Fertility Preservation: Documentation that patient is pre-menopausal and receiving a cytotoxic agent associated with causing primary ovarian insufficiency (examples listed in policy); documentation of start and expected duration of cytotoxic therapy; documentation that GnRH therapy will be discontinued upon completion of cytotoxic treatment.

Key Coverage Criteria

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.
Fertility Preservation: use of GnRH analogs for fertility preservation in pre-menopausal women receiving a cytotoxic agent associated with causing primary ovarian insufficiency.
Uterine Leiomyomata (Fibroids) (Lupron Depot): preoperative hematologic improvement for leiomyomata-related anemia unresponsive to iron therapy and/or preoperative size reduction to facilitate surgical procedure.
Gender Dysphoria in Adolescents: GnRH analogs may be covered for treatment of gender dysphoria in adolescents when comprehensive diagnostic, prescriber, laboratory, psychosocial support, and documentation criteria are met.

14 Active Policies

ARKBLUE-LEUPROLIDE-ACETATE-E-G-LUPRON-DEPOT-FENSOLVI-FOR-F7F51D8453, Leuprolide Acetate (e.g., Lupron Depot; Fensolvi) for Non-Oncologic Indications

HEALTHNET_OR-HNOR-LEUPROLIDE-ACETATE-ELIGARD-FENSOLVI-LUPRON-DEPOT-LUPRON-AC35C644FA, Leuprolide Acetate (Eligard, Fensolvi, Lupron Depot, Lupron Depot-Ped), Leuprolide mesylate (Camcevi); CP.PCH.53.

IBX-COMMERCIAL-08-01-33M-EFAC8FE1D4, Leuprolide (Camcevi, Camcevi ETM, Eligard, Fensolvi, Lupron Depot)

IBX-MEDICARE-ADVANTAGE-MA08-083M-246AFCEE23, Leuprolide (Camcevi, Camcevi ETM, Eligard, Fensolvi, Lupron Depot)

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

UMR-POL-UMR-gonadotropin-releasing-hormone-analogs, Gonadotropin Releasing Hormone Analogs

SUREST-POL-SUREST-gonadotropin-releasing-hormone-analogs, Gonadotropin Releasing Hormone Analogs

UHC-POL-gonadotropin-releasing-hormone-analogs, Gonadotropin Releasing Hormone Analogs

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-083M-84E4826A67, Leuprolide (Camcevi, Camcevi ETM, Eligard, Fensolvi, Lupron Depot)

EVICORE-MEDICAL_DRUG-1CE6A4748827, Leuprolide acetate (Fensolvi, Lupron Depot-PED, Lupron Depot) Non-oncology

AMERIHEALTH-COMMERCIAL-08-01-33M-EE1539D1CD, Leuprolide (Camcevi, Camcevi ETM, Eligard, Fensolvi, Lupron Depot)

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

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

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

Have a follow-up question?

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

Ask Backwork about J1951 Sign up free

J1951, Injection, leuprolide acetate for depot suspension (fensolvi), 0.25 mg