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Service Specific
Procedure Code J9217 Lupron
The Office of Inspector General (OIG) is charged with the responsibility for oversight to protect the integrity of the Medicare Trust Fund and in that capacity they undertook a study of Lupron, and the least costly alternative Zoladex. Currently Health
and Human Services is monitoring each Carrier’s Lupron policy and reimbursement.
Listed below are the specifics of the Arkansas Consortium’s reimbursement.
At the present time any patient who was on Lupron prior to Jan 1998 were grandfathered and reimbursement continues to be made at Lupron rates. Otherwise:
- Lupron decreases to Zoladex rate
- Procedure code is not changed on a claim to avoid problems for beneficiaries related to secondary coverage
- Extenuating circumstances for Lupron coverage should be referred to the Medical Director.
- Medical review looks at beneficiary history on each claim to determine the appropriate interval between current claim and prior claim for number of units billed. If the interval is not appropriate claims are denied on the basis of frequency.
References: OIG (OEI-03-03-00250) Medicare Reimbursement for Lupron 2004
LMRP AC-01-019 Luprolide Acetate / Goserelin (Gonadotropin Releasing Hormone Analogs) |
