Lanreotide Injection, for Subcutaneous Use HCPCS Code J3490: Billing Guidelines
Effective April 18, 2022, Medicaid and NC Health Choice cover lanreotide injection

Effective April 18, 2022, Medicaid and NC Health Choice cover lanreotide injection

Effective with date of service April 18, 2022, the Medicaid and NC Health Choice programs cover lanreotide injection, for subcutaneous use for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3490 - Unclassified drugs.

Strength/Package Size: Injection: 120 mg/0.5 mL of lanreotide in single-dose prefilled syringes

Indicated for:

  • The long-term treatment of acromegalic patients who have had an inadequate response to or cannot be treated with surgery and/or radiotherapy.
  • The treatment of adult patients with unresectable, well- or moderately differentiated, locally advanced or metastatic gastroenteropancreatic neuroendocrine tumors (GEP-NETs) to improve progression-free survival. 

Recommended Dose (See full prescribing information for further detail): 

  • Acromegaly: 90 mg every four weeks for three months. Adjust thereafter based on GH and/or IGF-1 levels. See full prescribing information for titration regimen. 
  • GEP-NETs: 120 mg every four weeks.

For Medicaid and NC Health Choice Billing

  • The ICD-10-CM diagnosis codes required for billing are:  
    • C18.8 - Malignant neoplasm of overlapping sites of colon;
    • C25.4 - Malignant neoplasm of endocrine pancreas;
    • C7A.010 - Malignant carcinoid tumor of the duodenum;
    • C7A.011 - Malignant carcinoid tumor of the jejunum;
    • C7A.012 - Malignant carcinoid tumor of the ileum;
    • C7A.021 - Malignant carcinoid tumor of the cecum;
    • C7A.022 - Malignant carcinoid tumor of the ascending colon;
    • C7A.023 - Malignant carcinoid tumor of the transverse colon;
    • C7A.024 - Malignant carcinoid tumor of the descending colon;
    • C7A.025 - Malignant carcinoid tumor of the sigmoid colon;
    • C7A.026 - Malignant carcinoid tumor of the rectum;
    • C7A.092 - Malignant carcinoid tumor of the stomach;
    • C7A.098 - Malignant carcinoid tumors of other sites;
    • C7A.8 - Other malignant neuroendocrine tumors;
    • C7B.02 - Secondary carcinoid tumors of liver;
    • C7B.09 - Secondary carcinoid tumors of other sites; 
    • C7B.8 - Other secondary neuroendocrine tumors; 
    • D37.4 - Neoplasm of uncertain behavior of colon;
    • E22.0 - Acromegaly and pituitary gigantism
  • Providers must bill with HCPCS code: J3490 - Unclassified drugs
  • One Medicaid and NC Health Choice unit of coverage is: 1 mg 
  • The maximum reimbursement rate per unit is: $80.03 
  • The NDC units should be reported as “UN1”
  • For additional information, refer to the January 2012, Special Bulletin, National Drug Code Implementation Update and PADP Clinical Coverage Policy 1B, Attachment A, H.7 on Medicaid's website.
  • Providers shall bill their usual and customary charge for non-340B drugs
  • PADP reimburses for drugs billed for Medicaid and NC Health Choice beneficiaries by 340B participating providers who have registered with the Office of Pharmacy Affairs (OPA).  Providers billing for 340B drugs shall bill the cost that is reflective of their acquisition cost. Providers shall indicate that a drug was purchased under a 340B purchasing agreement by appending the “UD” modifier on the drug detail.
  • The fee schedule for the PADP is available on Medicaid's PADP web page.

Contact

NCTracks Call Center: 800-688-6696

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