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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.39 Clinician-Administered Drugs : 9.2.39.27 Leuprolide Acetate (Lupron Depot)

9.2.39.27
Procedure codes J9217, J1950, J9218, or J9219 may be reimbursed for leuprolide acetate injections with the following limitations:
 
Procedure code J9217 may be reimbursed in monthly, three-month, four-month, and six-month doses as follows:
 
Billed with a quantity of 1
Reimbursed once per month
Billed with a quantity of 3
Reimbursed once every three months
Billed with a quantity of 4
Reimbursed once every 4 months
Billed with a quantity of 6
Reimbursed once every 6 months

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.