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Contractor Information

Contractor Name: Palmetto GBA - Full list of policies of this Medicare Contractor Contractor Number: 11202 Contractor Type: MAC B

LCD Information

LCD ID Number: L33438 Status: A-Approved LCD Title: Octreotide Acetate for Injectable Suspension (Sandostatin® LAR Depot) Geographic Jurisdiction: South Carolina Other Jurisdictions Original Determination Effective Date: 10/01/2015 Original Determination Ending Date: Revision Effective Date: 07/18/2024 Revision End Date: CMS National Coverage Policy: Title XVIII of the Social Security Act, §1861(s) and (t) defines the terms "drugs" and "biological" and outlines coverage for the drugs, biologicals, services and supplies. Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §50 Drugs and Biologicals, §50.1 Definition of Drug or Biological, §50.2 Determining Self-Administration of Drug or Biological, §50.4 Reasonableness and Necessity, §50.4.1 Approved Use of Drug, §50.4.2 Unlabeled Use of Drug, §50.4.3 Examples of Not Reasonable and Necessary, §50.4.4.1 Antigens, §50.4.4.2 Immunizations, §50.4.5 Off Label Use of Anti-Cancer Drugs and Biologicals and §50.4.5.1 Process for Amending the List of Compendia for Determination of Medically-Accepted Indications for Off-Label Uses of Drugs and Biologicals in an Anti-Cancer Chemotherapeutic Regimen Sorry, you need to login or register to view additional sections of this Medicare policy. *