Does J9219 require prior authorization?

No, J9219 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for J9219?

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

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`J9219`, Leuprolide acetate implant, 65 mg

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without 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.

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).
Administration of LHRH analogs is covered when prescribed, dosed, and administered consistent with FDA-approved labeling.
Administration code 96402 may be billed with HCPCS codes J1950, J9217, J9202, J3315, J1952, and J1954.
Administration codes 11981, 11982, and 11983 may be billed with HCPCS codes J9219 and J9225.

17 Active Policies

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

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

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

BCBSOK-RX502.061, Oncology Medications

A59160, Billing and Coding: Luteinizing Hormone-Releasing Hormone (LHRH) Analogs

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

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J9219, Leuprolide acetate implant, 65 mg