By Counterforce Health Team in Somatuline Depot (lanreotide) —

Getting Somatuline Depot (Lanreotide) Covered by UnitedHealthcare in California: Complete Prior Authorization and Billing Guide

Answer Box: Your Path to Coverage

Getting Somatuline Depot (lanreotide) covered by UnitedHealthcare in California requires prior authorization through OptumRx. Start with proper medical coding: ICD-10 E22.0 for acromegaly or appropriate NET codes, HCPCS J1930 (1 mg per unit), and correct NDCs. UnitedHealthcare often requires step therapy with octreotide first. If denied, California's Independent Medical Review (IMR) through the DMHC offers strong appeal rights with no patient fees. Begin by gathering diagnosis documentation, prior therapy records, and submitting PA via the UnitedHealthcare provider portal.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 Mapping for Somatuline Depot
  3. Product Coding: HCPCS, NDCs, and Units
  4. Clean Prior Authorization Anatomy
  5. Frequent Coding and Billing Pitfalls
  6. UnitedHealthcare Verification Resources
  7. Pre-Submission Audit Checklist
  8. California Appeals Process
  9. Cost-Saving Resources

Coding Basics: Medical vs. Pharmacy Benefit

Somatuline Depot (lanreotide) typically falls under the medical benefit since it's a provider-administered injection. This means billing through UnitedHealthcare's medical claims processing rather than OptumRx pharmacy benefits.

Coverage Pathway

  • Medical Benefit: HCPCS J1930 billing with prior authorization
  • Administration: Usually in specialty clinics, oncology centers, or endocrinology offices
  • Prior Authorization: Required through UnitedHealthcare OptumRx portal
  • Step Therapy: Often requires octreotide trial first per UnitedHealthcare's 2025 Part B step therapy program

ICD-10 Mapping for Somatuline Depot

Proper diagnosis coding is critical for medical necessity. Here are the primary ICD-10 codes that support Somatuline Depot coverage:

Condition ICD-10 Code Documentation Requirements
Acromegaly E22.0 GH >1 ng/mL post-OGTT OR elevated age/gender-adjusted IGF-1
GEP-NETs C25.4 (pancreatic), C7A.010-011 (small intestine) Histologic confirmation, imaging studies
Carcinoid Syndrome E16.4 Elevated 5-HIAA, chromogranin A, clinical symptoms
Pancreatic NETs C25.4, D13.7 Biopsy results, staging information
Tip: Include specific lab values and dates in your documentation. UnitedHealthcare often requires objective evidence of hormone elevation or tumor markers.

Product Coding: HCPCS, NDCs, and Units

HCPCS Coding

Primary Code: J1930 - Injection, lanreotide, 1 mg

  • Bill units equal to total milligrams administered
  • Example: 120 mg syringe = 120 units of J1930

NDC Numbers by Strength

Strength NDC Package Size
60 mg/0.2 mL 15054-1060-04 Single-dose syringe
90 mg/0.3 mL 15054-1090-04 Single-dose syringe
120 mg/0.5 mL 15054-1061-04 Single-dose syringe

Units Calculation

  • 60 mg syringe: Bill 60 units of J1930
  • 90 mg syringe: Bill 90 units of J1930
  • 120 mg syringe: Bill 120 units of J1930
Note: Each syringe is single-dose. Never bill multiple syringes for a single administration unless clinically documented.

Clean Prior Authorization Anatomy

A successful PA request includes these essential elements:

Required Documentation

  1. Diagnosis Confirmation
    • ICD-10 code with supporting lab values
    • Endocrinologist or oncologist consultation notes
    • Imaging studies (MRI, octreotide scan, CT)
  2. Step Therapy Documentation
    • Prior octreotide trial details (dose, duration, response)
    • Intolerance or contraindication evidence
    • Treatment failure documentation with specific metrics
  3. Clinical Justification
    • Current symptoms and functional impact
    • Treatment goals and monitoring plan
    • FDA-approved indication confirmation

Sample PA Request Structure

Patient: [Name], DOB [Date], Member ID [Number]
Diagnosis: Acromegaly (E22.0)
Medication: Somatuline Depot 120 mg every 4 weeks
Prior Therapy: Octreotide LAR 30 mg monthly x 6 months
Failure Criteria: IGF-1 remained >300 ng/mL (normal <220)
Clinical Rationale: [Endocrinologist statement]

Frequent Coding and Billing Pitfalls

Common Mistakes That Cause Denials

Error Consequence Fix
Wrong unit calculation Claim rejection Bill exact mg as units (120 mg = 120 units)
Missing diagnosis code Medical necessity denial Include primary ICD-10 in Box 21
Incorrect NDC Processing delay Use current, active NDCs from FDA database
No step therapy documentation Prior authorization denial Submit octreotide trial records
Off-label indication Coverage denial Stick to FDA-approved uses only

Billing Best Practices

  • Always include the 24G modifier when applicable
  • Submit claims within 90 days of service
  • Attach clinical notes supporting medical necessity
  • Use exact NDC numbers, not abbreviated versions

UnitedHealthcare Verification Resources

Before submitting claims or PA requests, verify current requirements:

Provider Resources

  • UnitedHealthcare Provider Portal: Check PA status, formulary tier
  • OptumRx Portal: Specialty drug prior authorization submissions
  • Provider Services: 1-888-842-4571 for billing questions

Policy Verification

  1. Log into the UHC Provider Portal
  2. Navigate to "Prior Authorization" section
  3. Search for "lanreotide" or "Somatuline Depot"
  4. Download current medical policy documents
Important: UnitedHealthcare policies update regularly. Always verify current requirements before submission.

Pre-Submission Audit Checklist

Use this checklist before submitting any Somatuline Depot request:

Documentation Review

  • ICD-10 code matches primary diagnosis
  • HCPCS J1930 units equal total mg administered
  • Current, valid NDC number included
  • Provider NPI and facility information complete
  • Prior authorization number (if applicable)

Clinical Requirements

  • FDA-approved indication documented
  • Step therapy requirements addressed
  • Baseline lab values included (GH, IGF-1, tumor markers)
  • Specialist consultation notes attached
  • Treatment duration and monitoring plan specified

Administrative Details

  • Patient insurance verification current
  • Benefit verification shows medical coverage
  • Prior authorization submitted if required
  • Appeal deadlines noted if applicable

California Appeals Process

If UnitedHealthcare denies your Somatuline Depot request, California offers robust appeal rights through the Department of Managed Health Care (DMHC).

Internal Appeals (First Step)

  1. Timeline: Submit within 180 days of denial
  2. Method: UnitedHealthcare member portal or written appeal
  3. Documentation: Include denial letter, supporting clinical evidence
  4. Decision: 30 days for standard, 72 hours for expedited

Independent Medical Review (Second Step)

California's IMR process provides external review by independent physicians:

  • Eligibility: Available after internal appeal or if UHC doesn't respond in 30 days
  • Cost: No fee to patients
  • Timeline: 45 days standard, 7 days expedited
  • Success Rate: High for medically necessary treatments
  • Authority: IMR decisions are binding on health plans

Filing an IMR

  1. Complete DMHC IMR application
  2. Attach denial letters and clinical documentation
  3. Submit within 6 months of final internal denial
  4. Track status through DMHC online portal
California Advantage: The state's consumer-friendly regulations and high IMR success rates make appeals particularly effective for specialty drugs like Somatuline Depot.

Cost-Saving Resources

Manufacturer Support

Ipsen Cares Patient Assistance Program

  • Copay assistance for eligible patients
  • Free drug program for uninsured/underinsured
  • Apply at Ipsen Cares website

Foundation Grants

  • Patient Access Network Foundation: NET-specific grants
  • HealthWell Foundation: Rare disease assistance
  • National Organization for Rare Disorders: Emergency financial aid

State Resources

  • California Prescription Drug Discount Program: Additional savings
  • Medi-Cal: California's Medicaid program with expanded eligibility

From Our Advocates

We've seen many Somatuline Depot denials overturned when patients included comprehensive step therapy documentation. One key strategy: if you've tried octreotide outside California, make sure those records clearly show the trial duration, doses, and specific failure criteria. UnitedHealthcare often accepts out-of-state step therapy completion, but the documentation needs to be thorough and objective.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters, identifies specific coverage criteria, and drafts evidence-backed appeals tailored to each payer's requirements. For complex cases like Somatuline Depot, we help ensure your appeal addresses UnitedHealthcare's specific step therapy and medical necessity requirements.

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take for Somatuline Depot? Standard PA decisions take up to 14 days. Expedited requests (for urgent medical needs) are typically decided within 72 hours.

What if Somatuline Depot isn't on UnitedHealthcare's formulary? You can request a formulary exception with strong clinical justification. Include evidence that preferred alternatives are inappropriate or ineffective.

Can I appeal if I haven't tried octreotide? Yes, but you'll need documented contraindications or medical reasons why octreotide isn't appropriate. This requires strong specialist support.

Does UnitedHealthcare cover off-label uses? Generally no. Stick to FDA-approved indications (acromegaly, GEP-NETs) for the best chance of approval.

What's the quantity limit for Somatuline Depot? Typically one syringe per 28-day period, aligned with the recommended every-4-weeks dosing schedule.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for specific coverage decisions. Appeal rights and timelines may vary by plan type. For personalized assistance with complex cases, consider consulting with Counterforce Health or other patient advocacy organizations.

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