Octreotide (Sandostatin LAR)

Moda Health Plan, Inc.
Medical Necessity Criteria
Subject: Octreotide (Sandostatin LAR)
Page 1 of 2
Origination Date: 09/14
Developed By: Medical Criteria Committee
Approved:
Mary Engrav, MD
Revision Date(s):
Date: 09/30/2014
Description:
Octreotide exerts pharmacologic actions similar to the natural hormone somatostatin. It is an even more potent
inhibitor of GH, glucagon, and insulin than somatostatin. Like somatostatin, it also suppresses luteinizing
hormone (LH) response to gonadotropin-releasing hormone (GnRH), decreases splanchnic blood flow, and
inhibits release of serotonin, gastrin, vasoactive intestinal peptide (VIP), secretin, motilin, and pancreatic
polypeptide. By virtue of these pharmacological actions, octreotide has been used to treat the symptoms
associated with metastatic carcinoid tumors (flushing and diarrhea), and VIP-secreting adenomas (watery
diarrhea)
Criteria:
1. Octreotide is medically necessary for one or more of the following conditions:
a. Diarrhea associated with Carcinoid tumors
b. Diarrhea associated with Vasoactive intestinal peptide tumors (VIPomas)
c. Acromegaly
d. Meningiomas (CNS Cancers)
e. Neuroendocrine Tumor
f. Thymic Cancer and Thymomas
2. Renewal of Octreotide is medically necessary for All of the following:
a. (Oncology)
i. Tumor response with stabilization of disease or decrease in size of tumor or tumor
spread; AND
ii. Absence of unacceptable toxicity from the drug
b. (Non-Oncology)
i. Patient continues to meet criteria identified in section 1; AND
ii. Disease response; AND
iii. Absence of unacceptable toxicity from the drug
3. Octreotide is considered NOT medically necessary for one or more of the following:
a. Treatment requested for diagnoses not FDA approved
b. Indications described in section 1 criteria are not met and may be considered experimental or
investigational
Information to be Submitted with Pre-Authorization Request:
1. Chart notes with documentation of diagnosis
2. Laboratory and pathology reports
3. Imaging study reports
Applicable CPT Codes:
CPT/HCPC Codes
J2353
Description
Injection; Sandostatin, 1mg
References:
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Sandostatin LAR [package insert]. Schaftenau, Austria; Sandoz GmbH; May 2014.
Accessed June 2014.
Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN
Compendium®) for Octreotide. National Comprehensive Cancer Network, 2014. The
NCCN Compendium® is a derivative work of the NCCN Guidelines®. NATIONAL
COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks
owned by the National Comprehensive Cancer Network, Inc.” To view the most recent
and complete version of the Compendium, go online to NCCN.org. Accessed June 2014.
Cahaba Government Benefit Administrators, LLC. Local Coverage Determination (LCD):
Drugs and Biologicals: Octreotide Acetate for Injectable Suspension (Sandostatin LAR ®
Depot) (L30032). Centers for Medicare & Medicaid Services, Inc. Updated on
03/21/2013 with effective date 04/15/2013. Accessed June 2014.
Palmetto GBA. Local Coverage Determination (LCD): Octreotide Acetate for Injectable
Suspension (Sandostatin LAR depot) (L31713). Centers for Medicare & Medicaid
Services, Inc. Updated on 10/25/2013 with effective date 10/31/2013. Accessed June
2014.
Wisconsin Physicians Service Insurance Corporation. Local Coverage Determination
(LCD) for Chemotherapy Drugs and their Adjuncts (L28576). Centers for Medicare &
Medicaid Services, Inc. Updated on 05/21/2014 with effective date 06/01/2014.
Accessed June 2014.

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