Prior authorization is a quick and simple process (typically a few hours or days), where the physician submits some basic information regarding the patient and intended use of the treatment, and the insurance company confirms if the treatment meets certain criteria set by the insurance plan. It is generally recommended that patients ask their insurance company for a pre-determination, versus prior authorization, although this does not guarantee coverage. In many cases, while payers are developing policies, patients are considered on a case-by-case basis. This process is uncertain and requires a lot of work from the physicians and their staff.įor patients with private insurance, it could take several months for private (commercial) insurance companies to develop written policies regarding coverage of the PRRT procedure. If a doctor prescribes the medicine for off-label use, meaning for patients or conditions not included in the FDA approved indication, Medicare requires that the treatment is listed in compendia or supported by at least 2 peer-reviewed publications. ![]() This code is C9031.įor Medicare patients, there should be coverage for on-label use of Lutathera, based on historical precedent with other newly approved medicines. These codes help facilitate the reimbursement process for institutions.Īs of July 1, 2018, there is a pass through code for Lutathera (this code is only for the medication, not for anything else involved in the treatment) for Medicare patients treated in hospital outpatient facilities, when used as per the FDA approval of the medication, also described as on-label. A permanent billing code is expected to be issued by January 2019. Many NET patients have asked “What is the insurance/billing code for PRRT?” At the current time, because Lutathera is a newly approved therapy, and until the Centers for Medicare and Medicaid Services (CMS) issues a product-specific billing code, institutions must use a temporary code. Infographic, Key Facts about PRRT: Click here for the complete infographic which describes how PRRT works, who might benefit from it, how it is administered, etc: We will be adding details as they are received as well as additional locations as more institutions offer the treatment. ![]() Scroll down for a state-by-state list of where PRRT with Lutathera is being offered as well as details from each institution where available. Since we shared the news of the FDA’s Januapproval of peptide receptor radionuclide therapy, PRRT, with Lutathera (lutetium Lu 177 dotatate), more information has become available for the neuroendocrine tumor community, including updates about coverage and reimbursement information about patient assistance programs being offered by Advanced Accelerator Applications (AAA), the manufacturer of Lutathera new patient materials from Advanced Accelerator Applications and locations where the treatment is currently being offered. ![]() Medical Opinion: When to Start and How to Treat Metastatic Carcinoid.Medical Opinion: Diagnosis and Treatment. ![]() Resources for Carcinoid and NET Cancer Insurance Appeals.Nutrition and Diet for Carcinoid Patients.Nutritional Concerns For The Carcinoid Patient.
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