Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
| Contract | Contractor | Type | States |
|---|---|---|---|
| 11202 | Palmetto GBA | A and B and HHH MAC | SC |
| 11302 | Palmetto GBA | A and B and HHH MAC | VA |
| 11402 | Palmetto GBA | A and B and HHH MAC | WV |
| 11502 | Palmetto GBA | A and B and HHH MAC | NC |
| 10112 | Palmetto GBA | A and B MAC | AL |
| 10212 | Palmetto GBA | A and B MAC | GA |
| 10312 | Palmetto GBA | A and B MAC | TN |
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A56531 (Billing and Coding: Octreotide Acetate for Injectable Suspension (Sandostatin® LAR Depot)) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A56531: Billing and Coding: Octreotide Acetate for Injectable Suspension (Sandostatin® LAR Depot) (Billing and Coding, effective 2024-10-01)
- Covered ICD-10-CM codes
- 72
- 7 groups
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 1
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| C25.4 | — |
| C26.0 | — |
| C37 | Malignant neoplasm of thymus |
| C7A.010 | — |
| C7A.011 | — |
| C7A.012 | — |
| C7A.019 | — |
| C7A.020 | — |
| C7A.021 | — |
| C7A.022 | — |
| C7A.023 | — |
| C7A.024 | — |
| C7A.025 | — |
| C7A.026 | — |
| C7A.029 | — |
| C7A.090 | — |
| C7A.091 | — |
| C7A.092 | — |
| C7A.093 | — |
| C7A.094 | — |
| C7A.095 | — |
| C7A.096 | — |
| C7A.098 | — |
| C7A.1 | — |
Procedure codes: J2353 (Injection, Octreotide, Depot Form For Intramuscular Injection, 1 Mg).
Coverage indications, limitations and medical necessity
Octreotide acetate is the acetate salt of a cyclic octapeptide. It is a long-acting octapeptide with pharmacologic properties mimicking those of the natural hormone, somatostatin. Octreotide acetate for injectable suspension is a long-acting dosage form containing octreotide. It maintains all of the clinical and pharmacological characteristics of the immediate-release dosage form, octreotide acetate, with the added feature of slow release of octreotide from the site of injection, reducing the need for frequent administration.
Octreotide exerts pharmacologic actions similar to the natural hormone, somatostatin. It is an even more potent inhibitor of growth hormone, glucagon, and insulin than somatostatin. By virtue of these pharmacological actions, octreotide has been used to treat the symptoms associated with metastatic carcinoid tumors (severe diarrhea and flushing) and vasoactive intestinal peptide (VIP) secreting adenomas (profuse watery diarrhea).
Octreotide substantially reduces, and in many cases, can normalize growth hormone and/or IGF-1 (somatomedin C) levels in patients with acromegaly.
• Octreotide acetate for injectable suspension is Food and Drug Administration (FDA) approved for the reduction of growth hormone and IGF-1 in patients with acromegaly, for whom medical treatment is appropriate, and who have been shown to respond to and can tolerate short-acting subcutaneous octreotide acetate. The goal of treatment is to reduce growth hormone and IGF-1 levels to normal. It is also used in patients who have had an inadequate response to surgery or in those for whom surgical resection is not an option. It is also used in patients who have received radiation and have had an inadequate therapeutic response.
• It is FDA approved for the suppression of severe diarrhea and flushing associated with malignant carcinoid syndrome in patients in whom initial treatment with short-acting, subcutaneous octreotide acetate has been effective and tolerated.
• It is FDA approved for long-term treatment of the profuse watery diarrhea associated with VIP-secreting tumors in patients in whom initial treatment with short-acting, subcutaneous octreotide acetate has been shown to be effective.
• The approved route of administration of octreotide acetate for injectable suspension is intragluteally, and it must be administered under the direct supervision of a physician.
• Octreotide acetate for injectable suspension is covered only when it is used according to FDA guidelines.
• A trial of therapy using the short-acting, subcutaneous form of octreotide acetate is a prerequisite prior to administering the long-acting octreotide acetate suspension. However, the short-acting, subcutaneous form of octreotide is noncovered by this A/B MAC, because it is self-administrable.
• Octreotide is covered for chemotherapy-induced diarrhea (CID) when oral antidiarrheal medications, such as loperamide, have become ineffective.
Summary of evidence (opening)
N/A
the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2015-10-01
- Current revision effective
- 2024-07-18
- Last reviewed by the contractor
- 2024-06-11
- MCD version
- 47
- Derived from
- L31713
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Palmetto GBA hub lists every other active policy from the same contractor.
Frequently asked questions
What does LCD L33438 cover?
Octreotide acetate is the acetate salt of a cyclic octapeptide. It is a long-acting octapeptide with pharmacologic properties mimicking those of the natural hormone, somatostatin. Octreotide acetate for injectable suspension is a long-acting dosage form containing octreotide. It maintains all of the clinical and pharmacological characteristics of the immediate-release dosage form, octreotide acetate, with the added… The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L33438 apply to?
Palmetto GBA applies it to Medicare claims in AL, GA, NC, SC, TN, VA, WV. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L33438?
The companion billing and coding article A56531 lists 72 ICD-10-CM codes in 7 groups that support medical necessity; the first 24 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L33438?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.