Lupron Depot (J1950): Medicare covered diagnoses & ICD-10 codes

What Medicare pays for Lupron Depot (2026 Q3)

Once a claim carries a covered diagnosis, Medicare Part B reimburses the drug at the ASP + 6% payment limit. Current allowed amounts per billing unit:

Source: CMS ASP Drug Pricing File, 2026 Q3. Payment = ASP + 6% per unit; multiply by units billed (watch JZ/JW wastage). Your patient's share is typically 20% after the deductible. Estimate the full cost & patient out-of-pocket →

Lupron Depot is a physician-administered biologic billed under Medicare Part B (not the Part D pharmacy benefit). Under Part B, Medicare pays the practice for the drug (HCPCS J1950) plus its administration — but only when the claim's diagnosis (ICD-10) code supports medical necessity. Each MAC publishes the specific covered diagnoses in a Billing & Coding Article; a claim with a diagnosis outside that list is typically denied as not medically necessary (CO-50).

Covered ICD-10 diagnoses for Lupron Depot

The 176 codes below are the diagnoses Wellpoint Federal accepts for J1950 under Article A52453, grouped exactly as CMS groups them and organized by condition category for scanning. Use the filter in each group to find a specific code or condition.

What commercial payers require for Lupron Depot

Medicare Part B is only half the answer — most Lupron Depot claims are adjudicated by a commercial plan with its own medical policy. Below is what 20 commercial payers publish for Lupron Depot, read from each payer's own policy document. 17 of 20 that state a position require prior authorization, and 2 run a site-of-care program that can push the infusion out of the hospital outpatient setting.

What Lupron Depot payers put in writing

Quoted from the medical policies linked above — 26 distinct requirements across 20 payers. These are the sentences an appeal has to answer.

Clinical prerequisites — what must be true before they pay

• Member has anemia due to uterine leiomyomata; or Lupron Depot will be used prior to surgery for uterine leiomyomata— Aetna policy ↗
• Individual is using prior to surgical treatment (myomectomy or hysterectomy) in those with a diagnosis of confirmed anemia— Anthem / Elevance policy ↗
• Patient has been adherent to requested medications as evidenced by pharmacy claims, medical claims, or clinical notes— BCBS Nebraska policy ↗
• History of inadequate pain control response following a trial of at least 6 months, or history of intolerance or contraindication to one of the following: Danazol Combination (estrogen/progestin) oral contraceptive Progestins— BCBS South Carolina policy ↗
• Patient has tried and had an inadequate response to at least 1 month of monotherapy with iron— BCBS South Carolina policy ↗
• Patient is at least 18 years of age (unless otherwise specified)— Capital BlueCross policy ↗

Prior authorization

• Endometriosis: Prior authorization validity will be provided initially for 6 months.— BCBS Minnesota, Capital BlueCross policy ↗
• Uterine Leiomyomata (fibroids): Prior authorization validity will be provided for 3 months.— BCBS Minnesota, Capital BlueCross policy ↗
• For the prostate cancer indication only, precertification of gonadotropin-releasing hormone products (also called luteinizing hormone-releasing hormone agents) is required of all Aetna participating providers and members in applicable plan designs.— Aetna policy ↗
• When a drug is being reviewed for coverage under a member’s medical benefit plan or is otherwise subject to clinical review (including prior authorization)— Anthem / Elevance policy ↗
• Prior approval is required to ensure the safe, clinically appropriate, and cost-effective use of leuprolide while maintaining optimal therapeutic outcomes.— BCBS Federal Employee Program policy ↗
• The patient has been previously approved for the requested agent through the plan’s Prior Authorization process— BCBS Nebraska policy ↗

Quantity and frequency limits

• Uterine leiomyomata (fibroids) - (for a lifetime maximum of 6 months total) when either of the following criteria is met— Aetna policy ↗
• Lupron Depot (leuprolide acetate) 3.75 mg, 7.5 mg 1 kit per 4 weeks— Anthem / Elevance policy ↗
• Diagnosis Duration ART - IVF procedures 4 months ART - AI procedures 12 months All other indications 12 months— BCBS Federal Employee Program policy ↗
• Lupron (leuprolide) for longer than 3 months for uterine leiomyomata and longer than 6 months for endometriosis is not recommended and will not be approved for continuation.— BCBS Mississippi policy ↗
• Authorization of up to 6 months (one treatment course) may be granted to members for initial treatment of endometriosis.— BCBS Tennessee policy ↗
• Authorization of up to 3 months may be granted for initial treatment of uterine leiomyomata (fibroids) when either of the following criteria is met: Member has anemia due to uterine leiomyomata Lupron Depot will be used prior to surgery for uterine leiomyomata.— BCBS Tennessee policy ↗

Dosing rules

• Acetate for Depot Suspension (Lupron Depot 1-Month 3.75 mg, 3-Month 11.25 mg) Prescribing— Aetna policy ↗
• Lupron Depot - 3.75 mg per month; 11.25 mg per 3 months— Centene / Ambetter policy ↗
• Lupron Depot (IM) - 3.75 mg/month, 11.25 mg per 3 months— Centene / Ambetter policy ↗
• Approve ONE of the following dosing regimens (A or B): A) 3.75 mg IM once every month; OR B) 11.25 mg IM once every 3 months.— Cigna policy ↗

Reauthorization / continuation

• Endometriosis: Prior authorization validity may be renewed up to one time only for 6 months.— BCBS Minnesota, Capital BlueCross policy ↗
• Uterine Leiomyomata (fibroids): Prior authorization validity may NOT be renewed.— BCBS Minnesota, Capital BlueCross policy ↗
• Retreatment: A single course may be approved for 6 months. Total duration of therapy should not exceed 12 months— Anthem / Elevance policy ↗
• Recurrence of symptoms following a trial of at least 6 months with leuprolide acetate Used in combination with one of the following: Norethindrone 5 mg daily Other “add-back” sex-hormones (e.g., estrogen, medroxyprogesterone) Other bone-sparing agents (e.g., bisphosphonates)— BCBS South Carolina policy ↗

Read from each payer's published medical policy between 2026-08-03 and 2026-08-13. Every requirement above is quoted from the policy it links to. Commercial policy changes without notice — confirm before you bill.

How to bill Lupron Depot

Put the patient's covered ICD-10 diagnosis on the claim line with J1950. Matching codes, units and JZ/JW wastage →

Which policy governs Lupron Depot

The covered code lists live in Article A52453 (tied to LCD L33394) — CMS moved code lists out of LCDs and into Articles, which is why the diagnoses live in the Article. What an LCD, an Article and an NCD each govern →

If a claim for Lupron Depot is denied

The usual cause is a diagnosis outside Article A52453's covered list, or a product code and unit count that do not match what was given. The five denial patterns and how to fix each →