Quick answer
J2353
What Medicare pays for Sandostatin LAR (2026 Q4)
2026 Q4 payment limit per billing unit for Sandostatin LAR’s HCPCS code (how ASP + 6% works):
| HCPCS | Description | Per unit | Allowed (ASP + 6%) |
|---|---|---|---|
| J2353 | Octreotide injection, depot | 1 mg | $211.321 |
CMS ASP Drug Pricing File, 2026 Q4. Sandostatin LAR patient out-of-pocket estimate →
Worked billing example for Sandostatin LAR
A concrete, paste-checkable example using J2353’s own billing-unit basis and vial sizes — not a hypothetical.
| Scenario | 20 mg LAR depot IM every 4 weeks (standard starting dose, acromegaly / carcinoid syndrome) |
| Dose administered | 20 mg |
| Billing unit basis | 1 unit = 1 mg |
| Billing units (dose ÷ unit basis, rounded up) | 20 units of J2353 |
| Vial combination drawn (min-waste plan) | 1 × 20 mg vial |
| Discarded (waste) | None |
| Wastage modifier (JW / JZ) | Bill all 20 units on a single line with JZ (attests zero drug discarded). What JZ/JW mean → |
| Medicare allowable (ASP + 6%, 2026 Q4) | 20 units × $211.321/unit = $4226.42 |
Allowable, not paid: sequestration and the covered diagnosis still apply.
Dose source: drugs/sandostatin.html — "LAR comes in 10/20/30 mg single-use kits, so the standard q4w dose" is one 20 mg kit = 20 units of J2353 (1 mg per unit); Sandostatin LAR label: 20 mg IM at 4-week intervals for acromegaly and carcinoid tumors. Different dose or drug? Compute your own dose → or estimate the full cost & patient out-of-pocket →.
Sandostatin LAR (HCPCS J2353) is paid under Part B only when the claim’s ICD-10 code is one Palmetto GBA lists in Article A56531; otherwise expect a CO-50 denial. How Part B drug coverage is decided →
Covered ICD-10 diagnoses for Sandostatin LAR
The 72 codes below are the diagnoses Palmetto GBA accepts for J2353 under Article A56531, 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.
Group 1 — 26 covered diagnoses
Use of these codes does not guarantee reimbursement. The patient s medical record must document that the coverage criteria in this policy have been met.
Neoplasms (22)
| ICD-10 | Covered diagnosis |
|---|---|
| C7A.010 | Malignant carcinoid tumor of the duodenum |
| C7A.011 | Malignant carcinoid tumor of the jejunum |
| C7A.012 | Malignant carcinoid tumor of the ileum |
| C7A.019 | Malignant carcinoid tumor of the small intestine, unspecified portion |
| C7A.020 | Malignant carcinoid tumor of the appendix |
| C7A.021 | Malignant carcinoid tumor of the cecum |
| C7A.022 | Malignant carcinoid tumor of the ascending colon |
| C7A.023 | Malignant carcinoid tumor of the transverse colon |
| C7A.024 | Malignant carcinoid tumor of the descending colon |
| C7A.025 | Malignant carcinoid tumor of the sigmoid colon |
| C7A.026 | Malignant carcinoid tumor of the rectum |
| C7A.029 | Malignant carcinoid tumor of the large intestine, unspecified portion |
| C7A.090 | Malignant carcinoid tumor of the bronchus and lung |
| C7A.091 | Malignant carcinoid tumor of the thymus |
| C7A.092 | Malignant carcinoid tumor of the stomach |
| C7A.093 | Malignant carcinoid tumor of the kidney |
| C7A.094 | Malignant carcinoid tumor of the foregut, unspecified |
| C7A.095 | Malignant carcinoid tumor of the midgut, unspecified |
| C7A.096 | Malignant carcinoid tumor of the hindgut, unspecified |
| C7A.098 | Malignant carcinoid tumors of other sites |
| C7A.1 | Malignant poorly differentiated neuroendocrine tumors |
| C7A.8 | Other malignant neuroendocrine tumors |
Endocrine, nutritional & metabolic diseases (4)
| ICD-10 | Covered diagnosis |
|---|---|
| E22.0 | Acromegaly and pituitary gigantism |
| E34.00 | Carcinoid syndrome, unspecified |
| E34.01 | Carcinoid heart syndrome |
| E34.09 | Other carcinoid syndrome |
Group 2 — 25 covered diagnoses
NOTE: For K52.1, per ICD-10-CM coding conventions, use an additional code for adverse effect, if applicable, to identify the drug (toxic substance). For chemotherapy induced diarrhea (CID) use:
Injury, poisoning & external causes (24)
| ICD-10 | Covered diagnosis |
|---|---|
| T38.895A | Adverse effect of other hormones and synthetic substitutes, initial encounter |
| T38.895D | Adverse effect of other hormones and synthetic substitutes, subsequent encounter |
| T38.895S | Adverse effect of other hormones and synthetic substitutes, sequela |
| T43.215A | Adverse effect of selective serotonin and norepinephrine reuptake inhibitors, initial encounter |
| T43.215D | Adverse effect of selective serotonin and norepinephrine reuptake inhibitors, subsequent encounter |
| T43.215S | Adverse effect of selective serotonin and norepinephrine reuptake inhibitors, sequela |
| T43.225A | Adverse effect of selective serotonin reuptake inhibitors, initial encounter |
| T43.225D | Adverse effect of selective serotonin reuptake inhibitors, subsequent encounter |
| T43.225S | Adverse effect of selective serotonin reuptake inhibitors, sequela |
| T43.641A | Poisoning by ecstasy, accidental (unintentional), initial encounter |
| T43.641D | Poisoning by ecstasy, accidental (unintentional), subsequent encounter |
| T43.641S | Poisoning by ecstasy, accidental (unintentional), sequela |
| T43.642A | Poisoning by ecstasy, intentional self-harm, initial encounter |
| T43.642D | Poisoning by ecstasy, intentional self-harm, subsequent encounter |
| T43.642S | Poisoning by ecstasy, intentional self-harm, sequela |
| T43.643A | Poisoning by ecstasy, assault, initial encounter |
| T43.643D | Poisoning by ecstasy, assault, subsequent encounter |
| T43.643S | Poisoning by ecstasy, assault, sequela |
| T43.644A | Poisoning by ecstasy, undetermined, initial encounter |
| T43.644D | Poisoning by ecstasy, undetermined, subsequent encounter |
| T43.644S | Poisoning by ecstasy, undetermined, sequela |
| T50.995A | Adverse effect of other drugs, medicaments and biological substances, initial encounter |
| T50.995D | Adverse effect of other drugs, medicaments and biological substances, subsequent encounter |
| T50.995S | Adverse effect of other drugs, medicaments and biological substances, sequela |
Diseases of the digestive system (1)
| ICD-10 | Covered diagnosis |
|---|---|
| K52.1 | Toxic gastroenteritis and colitis |
Group 3 — 7 covered diagnoses
The following ICD-10-CM diagnoses codes must be used to designate VIPoma or suspected VIPoma:
Neoplasms (5)
| ICD-10 | Covered diagnosis |
|---|---|
| C25.4 | Malignant neoplasm of endocrine pancreas |
| C26.0 | Malignant neoplasm of intestinal tract, part unspecified |
| D13.7 | Benign neoplasm of endocrine pancreas |
| D13.91 | Familial adenomatous polyposis |
| D13.99 | Benign neoplasm of ill-defined sites within the digestive system |
Symptoms, signs & abnormal findings (2)
| ICD-10 | Covered diagnosis |
|---|---|
| R79.89 | Other specified abnormal findings of blood chemistry |
| R94.7 | Abnormal results of other endocrine function studies |
Group 4 — 2 covered diagnoses
The diagnosis for VIPoma or suspected VIPoma must also be accompanied by:
Diseases of the digestive system (1)
| ICD-10 | Covered diagnosis |
|---|---|
| K52.89 | Other specified noninfective gastroenteritis and colitis |
Symptoms, signs & abnormal findings (1)
| ICD-10 | Covered diagnosis |
|---|---|
| R19.7 | Diarrhea, unspecified |
Group 5 — 9 covered diagnoses
Severe Liver Disease
Diseases of the circulatory system (4)
| ICD-10 | Covered diagnosis |
|---|---|
| I85.00 | Esophageal varices without bleeding |
| I85.01 | Esophageal varices with bleeding |
| I85.10 | Secondary esophageal varices without bleeding |
| I85.11 | Secondary esophageal varices with bleeding |
Diseases of the digestive system (3)
| ICD-10 | Covered diagnosis |
|---|---|
| K76.7 | Hepatorenal syndrome |
| K91.82 | Postprocedural hepatic failure |
| K91.83 | Postprocedural hepatorenal syndrome |
Pregnancy, childbirth & the puerperium (2)
| ICD-10 | Covered diagnosis |
|---|---|
| O90.41 | Hepatorenal syndrome following labor and delivery |
| O90.49 | Other postpartum acute kidney failure |
Group 6 — 2 covered diagnoses
Sulfa urea induced hypoglycemia
Endocrine, nutritional & metabolic diseases (2)
| ICD-10 | Covered diagnosis |
|---|---|
| E13.641 | Other specified diabetes mellitus with hypoglycemia with coma |
| E13.649 | Other specified diabetes mellitus with hypoglycemia without coma |
Group 7 — 1 covered diagnoses
Thymoma advanced NOTE: Approved for use as a second line therapy when disease progression occurs despite treatment with first line therapies.
Neoplasms (1)
| ICD-10 | Covered diagnosis |
|---|---|
| C37 | Malignant neoplasm of thymus |
How to bill Sandostatin LAR
Put the patient's covered ICD-10 diagnosis on the claim line with J2353. Matching codes, units and JZ/JW wastage →
Which policy governs Sandostatin LAR
The covered code lists live in Article A56531 (tied to LCD L33438) — 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 Sandostatin LAR is denied
The usual cause is a diagnosis outside Article A56531'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 →
Frequently asked questions
- Is Sandostatin LAR covered by Medicare?
- Yes. Sandostatin LAR (J2353) is covered under Medicare Part B as a physician-administered drug when billed for a medically necessary, covered diagnosis. Local coverage is defined by Palmetto GBA in Billing & Coding Article A56531, tied to LCD L33438.
- What diagnoses are covered for Sandostatin LAR (J2353)?
- Medicare lists 72 covered ICD-10 diagnosis codes for J2353 under Article A56531. The full list is on this page, grouped by condition category. Coverage can vary by Medicare Administrative Contractor (MAC); confirm against the article that applies in your state.
- Which Medicare policy covers Sandostatin LAR?
- Billing & Coding Article A56531 (v19), tied to LCD L33438 (“Octreotide Acetate for Injectable Suspension (Sandostatin® LAR Depot)”), published by Palmetto GBA and last updated 08/12/2024.
- Why was my Sandostatin LAR claim denied as not medically necessary?
- The most common cause is an ICD-10 diagnosis on the claim that is not in the covered list for J2353. Confirm the patient's diagnosis is in the groups below, that documentation supports medical necessity, and that you are using the article for your MAC.
Related references
Covered is only half the answer.
You know the diagnosis is payable. Now quote the patient before the visit and catch underpayments: get Sandostatin LAR's exact Medicare allowed amount, your payer's rate vs. ASP+6%, and the patient's out-of-pocket — in about 30 seconds, free.
Estimate Sandostatin LAR cost & patient owe →Source & verification
- Source
- CMS Medicare Coverage Database — Billing & Coding Article A56531 (v19), LCD L33438 “Octreotide Acetate for Injectable Suspension (Sandostatin® LAR Depot)” — Palmetto GBA.
- Primary sources
- DailyMed — Sandostatin LAR prescribing information · CMS Part B Drug ASP Pricing File — the quarterly payment limit quoted above · CMS Medicare Coverage Database — Article A56531
- CMS article last revised
- 08/12/2024
- Page last reviewed by CareCost
- Sep 21, 2026 (coverage data retrieved 2026-09-21; we re-verify against CMS quarterly).
- Notes
- ICD-10-CM is public domain; CPT® (AMA) is intentionally not listed. Reference, not billing advice — built from the CMS Coverage API per our methodology; corrections to editorial@carecostestimate.com.