Does J2502 require prior authorization?

Yes, J2502 requires prior authorization (high confidence). Code explicitly requires prior authorization.

What is the Medicare reimbursement rate for J2502?

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

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`J2502`, Injection, pasireotide long acting, 1 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

Code explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

For acromegaly: documentation of 'inadequate response to or cannot be treated with surgical resection, pituitary irradiation, or dopamine agonist (e.g., bromocriptine, cabergoline) therapy' (record prior therapies and evidence of inadequate response or contraindication/unavailability of those therapies)

For Sandostatin LAR: documentation that 'initial treatment with Sandostatin subcutaneous injection has been shown to be effective and tolerated' prior to starting LAR (record of prior IR octreotide treatment response and tolerability)

For Signifor / Signifor LAR in Cushing's disease: documentation that pituitary surgery 'is not an option or has not been curative' (clinical notes indicating surgical candidacy or prior surgery with persistent disease)

Documentation of indication-specific clinical findings as appropriate (e.g., diagnosis of metastatic carcinoid tumor or VIPoma, evidence of severe diarrhea and flushing episodes, diagnosis of bleeding gastroesophageal varices, chemotherapy- or radiation-induced diarrhea, malignant bowel obstruction)

Administration documentation: Sandostatin LAR must be administered intramuscularly under physician supervision (record of administration date, dose, route, and supervising clinician)

Use of the policy's listed HCPCS/CPT/diagnosis codes when billing: HCPCS J1930, J1932, J2353, J2354, J2502 and the corresponding ICD-10 diagnosis codes listed in the policy's 'Applicable Codes' section (documentation should support linkage between diagnosis code and drug use)

Key Coverage Criteria

Acromegaly patients who have had inadequate response to or cannot be treated with surgical resection, pituitary irradiation, or dopamine agonist (e.g., bromocriptine, cabergoline) therapy
Severe diarrhea and flushing episodes associated with metastatic carcinoid tumors
Profuse watery diarrhea associated with vasoactive intestinal peptide tumors (VIPomas)-secreting tumors
Bleeding gastroesophageal varices associated with liver disease
Chemotherapy and/or radiation-induced diarrhea
Malignant bowel disease

12 Active Policies

ARKBLUE-PASIREOTIDE-E-G-SIGNIFOR-OR-SIGNIFOR-LAR-EBA028BE4D, Pasireotide (e.g., Signifor or Signifor LAR)

BCBSLA-00384-CA2EA12EE4, 00384 pasireotide Injection (Signifor/Signifor LAR)

HEALTHPARTNERS-CC-AENTRY-046147, Somatostatin analogues for acromegaly (Sandostatin LAR, Somatuline Depot, Signifor LAR, Somavert, Lanreotide)

MULTI

BCBSNJ-DRUGS-118-6096E061EB, Sandostatin, Sandostatin LAR depot (Octreotide), Somatuline Depo (lanreotide), Signifor LAR (pasireotide)

MODA-SIGNIFOR-LAR-D3B1D603EC, Signifor LAR (pasireotide)

HEALTHNET_OR-HNOR-PASIREOTIDE-SIGNIFOR-LAR-SINGIFOR-CP-PHAR-332-D04DD4D61E, Pasireotide (Signifor LAR, Singifor); CP.PHAR.332

UMR-POL-UMR-somatostatin-analogs, Somatostatin Analogs

BCBSTN-b6fc911f6b, Pasireotide (Signifor LAR)

EVICORE-MEDICAL_DRUG-995A772FC07B, Signifor LAR (pasireotide) Injectable Suspension

UHC-POL-somatostatin-analogs, Somatostatin Analogs

AETNA-CPB-0693, Somatostatin Analogs

SUREST-POL-SUREST-somatostatin-analogs, Somatostatin Analogs

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J2502, Injection, pasireotide long acting, 1 mg