Question MUE for Lanreotide-J1930

[Codinggma]

Our provider ordered 180mg's of Lanreotide for a Medicare patient which has a MUE of 120. Has anyone had experience with billing over the MUE limit for this drug, are you submitting the claim and then appealing the denial?

 

[Pam Warren]

When providers report medications administered beyond CMS' MUE, they will have to submit documentation to support the necessity of the mega-dose. CMS sets this standard based on what is recommended and approved by the FDA, so if a provider believes it's medically necessary and appropriate to provide the higher dose and get paid for it, he/she will have to appeal. Generally, citing any US studies or relevant clinical trials that support the higher dosage are arguments that can be made to secure the additional payment. Otherwise, CMS won't exceed the MUE.