Does J9217 require prior authorization?

Yes, J9217 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J9217?

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

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`J9217`, Leuprolide acetate (for depot suspension), 7.5 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

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.
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).

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).
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.

20 Active Policies

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

A52453, Billing and Coding: Luteinizing Hormone-Releasing Hormone (LHRH) Analogs

NGS-J6-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

PALMETTO-JJ-L39387, Luteinizing Hormone-Releasing Hormone (LHRH) Analogs

NGS-JK-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

PALMETTO-JM-L39387, Luteinizing Hormone-Releasing Hormone (LHRH) Analogs

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)

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

UHC-POL-oncology-medication-clinical-coverage-policy, Oncology Medication Clinical Coverage

AETNA-CPB-0788, Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments

AETNA-CPB-0079, Benign Prostatic Hyperplasia

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

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J9217, Leuprolide acetate (for depot suspension), 7.5 mg