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Asset Publisher
Tocilizumab: Actemra®; Tofidence™; Tyenne®
Policy Number: PH-0002
Intravenous
Last Review Date: 08/01/2024
Date of Origin: 09/21/2010
Dates Reviewed: 12/2010, 03/2011, 05/2011, 06/2011, 09/2011, 12/2011, 03/2012, 06/2012, 09/2012, 09/2012, 11/2012, 12/2012, 03/2013, 06/2013, 09/2013, 11/2013, 12/2013, 03/2014, 06/2014, 09/2014, 12/2014, 03/2015, 05/2015, 09/2015, 12/0215, 03/2016, 06/2016, 09/2016, 12/2016, 03/2017, 05/2017, 09/2017, 12/2017, 03/2018, 06/2018, 10/2018, 10/2019, 10/2020, 11/2020, 10/2021, 04/2022, 10/2022, 10/2023, 11/2023, 04/2024, 08/2024
FOR PEEHIP Members Only -Coverage excludes the provider-administered medication(s) outlined in this drug policy from being accessed through a specialty pharmacy. It must be obtained through buy and bill. |
- Length of Authorization 1-3,19,31
Coverage will be provided as follows:
- Castleman Disease: 4 months and may be renewed
- Cytokine Release Syndrome: 4 doses only and may NOT be renewed
- Immune Checkpoint Inhibitor Related Toxicities: 1 dose only* and may NOT be renewed
- Giant Cell Arteritis: 1 year of therapy
- All other indications: 6 months and may be renewed
- Dosing Limits
- Quantity Limit (max daily dose) [NDC Unit]:
- Actemra 80 mg/4 mL single-dose vial: 1 vial per 14 days
- Actemra 200 mg/10 mL single-dose vial: 3 vials per 28 days
- Actemra 400 mg/20 mL single-dose vial: 2 vials per 14 days
- Tofidence 80 mg/4 mL single-dose vial: 1 vial per 14 days
- Tofidence 200 mg/10 mL single-dose vial: 3 vials per 28 days
- Tofidence 400 mg/20 mL single-dose vial: 2 vials per 14 days
- Tyenne 80 mg/4 mL single-dose vial: 1 vial per 14 days
- Tyenne 200 mg/10 mL single-dose vial: 3 vials per 28 days
- Tyenne 400 mg/20 mL single-dose vial: 2 vials per 14 days
- Max Units (per dose and over time) [HCPCS Unit]:
Diagnosis |
Billable Units |
Interval (days) |
Giant Cell Arteritis |
600 |
28 |
Rheumatoid Arthritis & Polyarticular Juvenile Idiopathic Arthritis, NMOSD |
800 |
28 |
Systemic Juvenile Idiopathic Arthritis, Castleman’s Disease (B-Cell Lymphomas) & Acute Graft Versus Host Disease (aGVHD) |
800 |
14 |
Cytokine Release Syndrome (CRS) |
3200 |
1 course of therapy only |
Immune Checkpoint Inhibitor Related Toxicities |
800 |
1 course of therapy only |
- Initial Approval Criteria 1-3
Depending on member benefits, additional criteria may apply for coverage of this drug in an outpatient facility setting. Verify any Site of Service requirements with the member’s plan and refer to the Voluntary Site of Service Policy or the Mandatory Site of Service Policy for additional information. |
Coverage is provided in the following conditions:
- Patient is at least 18 years of age (unless otherwise specified); AND
Universal Criteria 1-3
- Patient has been evaluated and screened for the presence of latent tuberculosis (TB) infection prior to initiating treatment and will receive ongoing monitoring for presence of TB during treatment; AND
- Patient does not have an active infection, including clinically important localized infections; AND
- Patient will not receive live vaccines during therapy; AND
- Patient is not on concurrent treatment with another IL-inhibitor, TNF-inhibitor, biologic response modifier or other non-biologic agent (i.e., abrocitinib, apremilast, tofacitinib, baricitinib, upadacitinib, deucravacitinib, etc.), unless otherwise specified; AND
Rheumatoid Arthritis † 1-3,21,29
- Physician has assessed baseline disease severity utilizing an objective measure/tool; AND
- Documented moderate to severe active disease; AND
- Patient has had at least a 3 month trial and failed previous therapy with ONE oral disease modifying anti-rheumatic agent (DMARD) such as methotrexate, azathioprine, auranofin, hydroxychloroquine, penicillamine, sulfasalazine, leflunomide, etc.; AND
- May be used as a single agent or in combination with methotrexate or other non-biologic DMARDs (e.g., methotrexate, hydroxychloroquine, leflunomide, sulfasalazine, etc.)
Giant Cell Arteritis (GCA) † 1-3,31-34
- Patient has large vessel arteritis that has at some point been verified with biopsy or with imaging of the large vessels (color Doppler ultrasound [CDUS], MRI, PET-CT, or CT angiography); AND
- Patient has active disease and an elevated c-reactive protein (CRP) and erythrocyte sedimentation rate (ESR); AND
- Patient has had an inadequate response, contraindication, or intolerance to glucocorticoid therapy alone; AND
- Used in combination with a tapering course of glucocorticoids (NOTE: tocilizumab can be used alone following discontinuation of glucocorticoids.)
Juvenile Idiopathic Arthritis (JIA) † Ф 1-3,7,20
- Patient is at least 2 years of age; AND
- Physician has assessed baseline disease severity utilizing an objective measure/tool; AND
- Patient has active systemic juvenile idiopathic arthritis (sJIA) OR polyarticular juvenile idiopathic arthritis (pJIA); AND
- Patient has had at least a 1-month trial and failure (unless contraindicated or intolerant) of previous therapy with either oral non-steroidal anti-inflammatory drugs (NSAIDs) OR an oral disease-modifying anti-rheumatic agent (DMARD) (e.g., methotrexate, leflunomide, sulfasalazine, etc.); AND
- May be used as a single agent or in combination with methotrexate
Castleman Disease (B-Cell Lymphomas) ‡ 4
- Used as a single agent; AND
- Patient has unicentric disease; AND
- Patient is human immunodeficiency virus (HIV)-negative and human herpesvirus-8 (HHV-8)-negative; AND
- Used as second-line therapy for relapsed or refractory disease; OR
- Patient has multicentric disease; AND
- Used as subsequent therapy for relapsed, refractory, or progressive disease
Cytokine Release Syndrome (CRS) † ‡ Ф 1,4
- Patient is at least 2 years of age; AND
- Patient has received or will be receiving chimeric antigen receptor (CAR) T cell therapy (e.g., axicabtagene ciloleucel, brexucabtagene autoleucel, idecabtagene vicleucel, lisocabtagene maraleucel, tisagenlecleucel, ciltacabtagene autoleucel, etc.); AND
- Tocilizumab is being ordered to have on-hand, prior to the administration of CAR-T therapy, if needed for the treatment of CRS; OR
- Used for management of one of the following:
- Prolonged (>3 days) G1 CRS in patients with significant symptoms, comorbidities, and/or in elderly patients; OR
- G1 CRS symptoms that persist >24 hours in patients who have been treated with axicabtagene ciloleucel or brexucabtagene autoleucel; OR
- G1 CRS that develops <72 hours after infusion in patients who have been treated with lisocabtagene maraleucel; OR
- G2-4 CRS; OR
- G1-4 neurotoxicity as additional single-dose therapy if the patient has concurrent CRS; OR
- Used as supportive care in patients with acute lymphoblastic leukemia (ALL) who have severe CRS related to blinatumomab therapy
- Patient has received or will be receiving chimeric antigen receptor (CAR) T cell therapy (e.g., axicabtagene ciloleucel, brexucabtagene autoleucel, idecabtagene vicleucel, lisocabtagene maraleucel, tisagenlecleucel, ciltacabtagene autoleucel, etc.); AND
Management of Immune Checkpoint Inhibitor Related Toxicities ‡ 4,19,28
- Patient has been receiving therapy with an immune checkpoint inhibitor (e.g., nivolumab, pembrolizumab, atezolizumab, avelumab, durvalumab, cemiplimab, ipilimumab, dostarlimab nivolumab/relatlimab-rmbw, retifanlimab, etc.); AND
- Used as additional therapy for management of immunotherapy-related giant cell arteritis; OR
- Used as additional disease modifying antirheumatic therapy (DMARD) for moderate or severe immunotherapy-related inflammatory arthritis; AND
- Patient’s symptoms have not improved after holding immunotherapy; AND
- Patient has not responded to oral corticosteroids; OR
- Patient is unable to taper corticosteroids; OR
- Patient’s symptoms have not improved after holding immunotherapy; AND
- Patient has polymyalgia rheumatica and is unable to taper prednisone OR has no improvement in symptoms
Acute Graft Versus Host Disease (aGVHD) ‡ 4,22-24,30
- Patient has received an allogeneic hematopoietic stem cell transplant; AND
- Used for steroid-refractory acute GVHD; AND
- Used in combination with systemic corticosteroids as additional therapy following no response to first-line therapies
Neuromyelitis Optica Spectrum Disorder (NMOSD) ‡ 25-27,35
- Patient has a confirmed diagnosis based on the following:
- Patient is seropositive for aquaporin-4 (AQP4) IgG antibodies; AND
- Patient has at least one core clinical characteristic § (*Note: some core clinical characteristics require both clinical and typical MRI findings); AND
- Alternative diagnoses have been excluded (e.g., myelin oligodendrocyte glycoprotein (MOG) antibody disease (MOGAD), multiple sclerosis, sarcoidosis, cancer, chronic infection, etc.); OR
- Patient is seronegative for AQP-4 IgG antibodies OR has unknown AQP-4-IgG status; AND
- Patient has at least two core clinical characteristics§ occurring as a result of one or more clinical attacks; AND
- Patient experienced ALL of the following:
- At least 1 core clinical characteristic must be acute optic neuritis, acute myelitis with LETM*, or area postrema syndrome; AND
- Fulfillment of typical MRI finding requirements for each area affected ψ; AND
- Alternative diagnoses have been excluded (e.g., myelin oligodendrocyte glycoprotein (MOG) antibody disease (MOGAD), multiple sclerosis, sarcoidosis, cancer, chronic infection, etc.); AND
- Patient is seropositive for aquaporin-4 (AQP4) IgG antibodies; AND
- Used as a single agent or in combination with immunosuppressive therapy (e.g., azathioprine, methotrexate, mycophenolate, etc.)
§ Core Clinical Characteristics of NMOSD 25,35 |
|
ψ Typical MRI findings in NMOSD related to clinical presentation (T2 unless noted otherwise) 35 |
|
*LETM = longitudinally extensive transverse myelitis lesions |
† FDA Approved Indication(s); ‡ Compendia Recommended Indication(s); Ф Orphan Drug
- Renewal Criteria 1-3
Coverage can be renewed based upon the following criteria:
- Patient continues to meet the universal and other indication-specific relevant criteria identified in section III; AND
- Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include: serious infections, severe neutropenia, severe thrombocytopenia, severe hepatotoxicity, gastrointestinal perforation, immunosuppression, severe hypersensitivity reactions, demyelinating disorders, etc.; AND
Oncology Indications
Castleman Disease (B-Cell Lymphomas) 4
- Disease response with treatment as defined by stabilization of disease or decrease in size of tumor or tumor spread
Acute Graft Versus Host Disease (aGVHD) 22-24,30
- Response to therapy with an improvement in one or more of the following:
- Clinician assessments (e.g., NIH Skin Score, Upper GI Response Score, NIH Lung Symptom Score, etc.)
- Patient-reported symptoms (e.g., Lee Symptom Scale, etc.)
Non-Oncology Indications
Rheumatoid arthritis (RA) 14-16
- Disease response as indicated by improvement in signs and symptoms compared to baseline such as the number of tender and swollen joint counts, reduction of C-reactive protein, improvement of patient global assessment, and/or an improvement on a disease activity scoring tool [e.g., an improvement on a composite scoring index such as Disease Activity Score-28 (DAS28) of 1.2 points or more or a ≥20% improvement on the American College of Rheumatology-20 (ACR20) criteria]
Giant Cell Arteritis 1-3,31-33
- Disease response as indicated by improvement in signs and compared to baseline such as headache, temporal artery tenderness, visual symptoms, inflammatory parameters (e.g., erythrocyte sedimentation rate [ESR], C-reactive protein), etc.
Juvenile Idiopathic Arthritis (sJIA/pJIA) 17,18
- Disease response as indicated by improvement in signs and symptoms compared to baseline such as the number of tender and swollen joint counts, reduction of C-reactive protein, improvement of patient global assessment, and/or an improvement on a disease activity scoring tool [e.g., an improvement on a composite scoring index such as Juvenile Arthritis Disease Activity Score (JADAS) or the American College of Rheumatology (ACR) Pediatric (ACR-Pedi 30) of at least 30% improvement from baseline in three of six variables].
Cytokine Release Syndrome 1,4
- May not be renewed
Management of Immune Checkpoint Inhibitor Related Toxicities 19
- May not be renewed
NMOSD 25,26
- Disease response as indicated by stabilization/improvement in any of the following:
- Neurologic symptoms as evidenced by a decrease in acute relapses or improvement of stability
- Reduced hospitalizations
- Reduction/discontinuation in plasma exchange treatments
- Reduction/discontinuation of corticosteroids without relapse
- Dosage/Administration 1-3,10,19,22-24,27,30
Doses exceeding 800 mg per infusion are not recommended (unless otherwise specified).
Indication |
Dose |
Adult Rheumatoid Arthritis |
Administer 4 mg/kg intravenously every 4 weeks
|
Polyarticular Juvenile Idiopathic Arthritis |
Weight ≥ 30 kg
Weight < 30 kg
|
Systemic Juvenile Idiopathic Arthritis |
Weight ≥ 30 kg
Weight < 30 kg
|
Castleman Disease (B-Cell Lymphomas) |
Administer 8 mg/kg intravenously every 2 weeks for 16 weeks (8 doses total) |
Cytokine Release Syndrome (CRS) |
Weight ≥ 30 kg
Weight < 30 kg
*If no clinical improvement in the signs and symptoms of CRS occurs after the first dose, up to 3 additional doses may be administered. The interval between consecutive doses should be at least 8 hours. May be used with or without corticosteroids. Doses exceeding 800 mg per infusion are not recommended in CRS patients. |
Immune-Checkpoint Inhibitor Related Toxicities |
Administer 4 mg/kg intravenously one time only*
*Additional doses may be approved on a case by case basis |
Acute GVHD |
Administer 8 mg/kg intravenously, every 2-4 weeks until disease progression or unacceptable toxicity |
NMOSD |
Administer 8 mg/kg intravenously, every 4 weeks |
Giant Cell Arteritis |
Administer 6 mg/kg intravenously every 4 weeks in combination with a tapering course of glucocorticoids
|
- Billing Code/Availability Information
HCPCS Code:
- J3262 – Injection, tocilizumab, 1 mg; 1 billable unit = 1 mg (Actemra IV Only)
- J3590 – Unclassified biologics (Tyenne Only) (Discontinue use on 10/01/2024)
- Q5133 – Injection, tocilizumab-bavi (tofidence), biosimilar, 1 mg; 1 billable unit = 1 mg
- Q5135 – Injection, tocilizumab-aazg (tyenne), biosimilar, 1 mg; 1 billable unit = 1 mg (Effective 10/01/2024)
NDC(s):
- Actemra 80 mg/4 mL single-dose vial: 50242-0135-xx
- Actemra 200 mg/10 mL single-dose vial: 50242-0136-xx
- Actemra 400 mg/20 mL single-dose vial: 50242-0137-xx
- Tofidence 80 mg/4 mL single-dose vial: 64406-0024-xx
- Tofidence 200 mg/10 mL single-dose vial: 64406-0022-xx
- Tofidence 400 mg/20 mL single-dose vial: 64406-0023-xx
- Tyenne 80 mg/4 mL single-dose vial: 65219-0590-xx
- Tyenne 200 mg/10 mL single-dose vial: 65219-0592-xx
- Tyenne 400 mg/20 mL single-dose vial 65219-0594-xx
- References
- Actemra [package insert]. South San Francisco, CA; Genentech, Inc.; December 2022. Accessed September 2023.
- Tofidence [package insert]. Cambridge, MA; Biogen MA Inc.; July 2024. Accessed July 2024.
- Tyenne [package insert]. Lake Zurich, IL; Fresenius Kabi USA, LLC. March 2024. Accessed March 2024.
- Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) tocilizumab. National Comprehensive Cancer Network, 2023. 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 September 2023.
- Singh JA, Saag KG, Bridges SL Jr, et al. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care Res (Hoboken). 2015 Nov 6. doi: 10.1002/acr.22783.
- Beukelman T, Patkar NM, Saag KG, et al. 2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis: initiation and safety monitoring of therapeutic agents for the treatment of arthritis and systemic features. Arthritis Care Res (Hoboken). 2011 Apr;63(4):465-82.
- Ringold S, Weiss PF, Beukelman T, et al. 2013 update of the 2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis: recommendations for the medical therapy of children with systemic juvenile idiopathic arthritis and tuberculosis screening among children receiving biologic medications. Arthritis Rheum. 2013 Oct;65(10):2499-512.
- Ringold, S, Angeles-Han, S, Beukelman, T, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Treatment of Juvenile Idiopathic Arthritis: Therapeutic Approaches for Non‐Systemic Polyarthritis, Sacroiliitis, and Enthesitis. Arthritis Care Res, 71: 717-734.
- DeWitt EM, Kimura Y, Beukelman T, et al. Consensus treatment plans for new-onset systemic juvenile idiopathic arthritis. Arthritis Care Res (Hoboken). 2012 Jul;64(7):1001-10.
- Nishimoto N, Kanakura Y, Aozasa K, et al. Humanized anti-interleukin-6 receptor antibody treatment of multicentric Castleman disease. Blood 2005;106:2627-2632
- Smolen JS, Landewé R, Bijlsma J, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update. Ann Rheum Dis. 2017 Mar 6. pii: annrheumdis-2016-210715.
- Fraser JA, Weyand CM, Newman NJ, Biousse V. The treatment of giant cell arteritis. Rev Neurol Dis. 2008 Summer;5(3):140-52.
- Dasgupta B, Borg FA, Hassan N, et al. BSR and BHPR guidelines for the management of giant cell arteritis. Rheumatology (Oxford). 2010 Aug;49(8):1594-7.
- National Institute for Health and Care Excellence. NICE 2018. Rheumatoid Arthritis in Adults: Management. Published 11 July 2018. Last updated 12 October 2020. NICE Guideline [NG100]. https://www.nice.org.uk/guidance/ng100. Accessed September 2023.
- National Institute for Health and Care Excellence. NICE 2010. Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after failure of a TNF inhibitor. Published 25 August 2010. Technology appraisal guidance [TA195]. https://www.nice.org.uk/guidance/ta195. Accessed September 2023.
- Ward MM, Guthri LC, Alba MI. Rheumatoid Arthritis Response Criteria And Patient-Reported Improvement in Arthritis Activity: Is an ACR20 Response Meaningful to Patients”. Arthritis Rheumatol. 2014 Sep; 66(9): 2339–2343. doi: 10.1002/art.38705
- Ringold S, Bittner R, Neggi T, et al. Performance of rheumatoid arthritis disease activity measures and juvenile arthritis disease activity scores in polyarticular-course juvenile idiopathic arthritis: Analysis of their ability to classify the American College of Rheumatology pediatric measures of response and the preliminary criteria for flare and inactive disease. Arthritis Care Res (Hoboken). 2010 Aug;62(8):1095-102.
- Consolaro A, Giancane G, Schiappapietra B, et al. Clinical outcome measures in juvenile idiopathic arthritis. Pediatric Rheumatology 18 April 2016 14:23.
- Stroud C, Hedge A, Cherry C, et al. Tocilizumab for the management of immune mediated adverse events secondary to PD-1 blockage. Journal of Oncology Pharmacy Practice. 2017 December. https://doi.org/10.1177/1078155217745144.
- Ringold S, Angeles‐Han ST, Beukelman T, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Treatment of Juvenile Idiopathic Arthritis: Therapeutic Approaches for Non-Systemic Polyarthritis, Sacroiliitis, and Enthesitis. Arthritis Care & Research, Vol. 71, No. 6, June 2019, pp 717–734 DOI 10.1002/acr.23870.
- Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Annals of the Rheumatic Diseases 2020;79:685-699.
- Yucebay F, Matthews C, Puto M, et al. Tocilizumab as first-line therapy for steroid-refractory acute graft-versus-host-disease: analysis of a single-center experience, Leukemia & Lymphoma. 2019 60:9, 2223-2229, DOI: 10.1080/10428194.2019.1573996
- Ganetsky A, Frey NV, Hexner EO, et al. Tocilizumab for the treatment of severe steroid-refractory acute graft-versus-host disease of the lower gastrointestinal tract. Bone Marrow Transplant. 54, 212–217 (2019). https://doi.org/10.1038/s41409-018-0236-z
- Dobryski WR, Pasquini M, Kovatovic K, et al. Tocilizumab for the Treatment of Steroid Refractory Graft-versus-Host Disease. 17:12, 1862-1868 (2011). DOI:https://doi.org/10.1016/j.bbmt.2011.07.001
- Wingerchuk DM, Banwell B, Bennett JL, et al. International consensus diagnostic criteria for neuromyelitis optica spectrum disorders. Neurology. 2015 Jul;85(2):177-89. Epub 2015 Jun 19.
- Trebst C, Jarius S, Berthele A, et al. Update on the diagnosis and treatment of neuromyelitis optica: recommendations of the Neuromyelitis Optica Study Group (NEMOS). J Neurol 2014; 261:1.
- Zhang C, Zhang M, Qiu W, et al, TANGO Study Investigators. Safety and efficacy of tocilizumab versus azathioprine in highly relapsing neuromyelitis optica spectrum disorder (TANGO): an open-label, multicentre, randomised, phase 2 trial. Lancet Neurol. 2020;19(5):391
- Stone J, Tuckwell K, Dimonaco S, et al. Trial of Tocilizumab in Giant-Cell Arteritis. N Engl J Med 2017; 377:317-328 doi: 10.1056/NEJMoa1613849
- Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Rheumatol. 2021 Jul;73(7):1108-1123. doi: 10.1002/art.41752.
- Roddy JV, Haverkos BM, McBride A, et al. Tocilizumab for steroid refractory acute graft-versus-host disease. Leuk Lymphoma. 2016;57(1):81-5. doi: 10.3109/10428194.2015.1045896.
- Turesson C, Börjesson O, Larsson K, et al. (2019) Swedish Society of Rheumatology 2018 guidelines for investigation, treatment, and follow-up of giant cell arteritis, Scandinavian Journal of Rheumatology, 48:4, 259-265, doi: 10.1080/03009742.2019.1571223.
- Mackie SL, Dejaco C, Appenzeller S, et al. British Society for Rheumatology guideline on diagnosis and treatment of giant cell arteritis. Rheumatology (Oxford). 2020 Mar 1;59(3):e1-e23. doi: 10.1093/rheumatology/kez672.
- Ehlers L, Askling J, Bijlsma HW, et al. 2018 EULAR recommendations for a core data set to support observational research and clinical care in giant cell arteritis. Annals of the Rheumatic Diseases 2019;78:1160-1166.
- Maz M, Chung SA, Abril A, et. al. 2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Giant Cell Arteritis and Takayasu Arteritis. Arthritis Rheumatol. 2021 Aug;73(8):1349-1365. doi: 10.1002/art.41774. Epub 2021 Jul 8. PMID: 34235884.
- Jarius, S., Aktas, O., Ayzenberg, I. et al. Update on the diagnosis and treatment of neuromyelitis optica spectrum disorders (NMOSD) – revised recommendations of the Neuromyelitis Optica Study Group (NEMOS). Part I: Diagnosis and differential diagnosis. J Neurol 270, 3341–3368 (2023). https://doi.org/10.1007/s00415-023-11634-0
Appendix 1 – Covered Diagnosis Codes
ICD-10 |
ICD-10 Description |
C83.50 |
Lymphoblastic (diffuse) lymphoma unspecified site |
C83.51 |
Lymphoblastic (diffuse) lymphoma lymph nodes of head, face, and neck |
C83.52 |
Lymphoblastic (diffuse) lymphoma intrathoracic lymph nodes |
C83.53 |
Lymphoblastic (diffuse) lymphoma intra-abdominal lymph nodes |
C83.54 |
Lymphoblastic (diffuse) lymphoma lymph nodes of axilla and upper limb |
C83.55 |
Lymphoblastic (diffuse) lymphoma lymph nodes of inguinal region and lower limb |
C83.56 |
Lymphoblastic (diffuse) lymphoma intrapelvic lymph nodes |
C83.57 |
Lymphoblastic (diffuse) lymphoma spleen |
C83.58 |
Lymphoblastic (diffuse) lymphoma lymph nodes of multiple sites |
C83.59 |
Lymphoblastic (diffuse) lymphoma extranodal and solid organ sites |
C91.00 |
Acute lymphoblastic leukemia not having achieved remission |
C91.01 |
Acute lymphoblastic leukemia, in remission |
C91.02 |
Acute lymphoblastic leukemia, in relapse |
D47.Z2 |
Castleman disease |
D89.810 |
Acute graft-versus-host disease |
D89.812 |
Acute on chronic graft-versus-host disease |
D89.813 |
Graft-versus-host disease, unspecified |
D89.831 |
Cytokine release syndrome, grade 1 |
D89.832 |
Cytokine release syndrome, grade 2 |
D89.833 |
Cytokine release syndrome, grade 3 |
D89.834 |
Cytokine release syndrome, grade 4 |
D89.839 |
Cytokine release syndrome, grade unspecified |
G36.0 |
Neuromyelitis optica [Devic] |
G92.00 |
Immune effector cell-associated neurotoxicity syndrome, grade unspecified |
G92.01 |
Immune effector cell-associated neurotoxicity syndrome, grade 1 |
G92.02 |
Immune effector cell-associated neurotoxicity syndrome, grade 2 |
G92.03 |
Immune effector cell-associated neurotoxicity syndrome, grade 3 |
G92.04 |
Immune effector cell-associated neurotoxicity syndrome, grade 4 |
M05.10 |
Rheumatoid lung disease with rheumatoid arthritis of unspecified site |
M05.111 |
Rheumatoid lung disease with rheumatoid arthritis of right shoulder |
M05.112 |
Rheumatoid lung disease with rheumatoid arthritis of left shoulder |
M05.119 |
Rheumatoid lung disease with rheumatoid arthritis of unspecified shoulder |
M05.121 |
Rheumatoid lung disease with rheumatoid arthritis of right elbow |
M05.122 |
Rheumatoid lung disease with rheumatoid arthritis of left elbow |
M05.129 |
Rheumatoid lung disease with rheumatoid arthritis of unspecified elbow |
M05.131 |
Rheumatoid lung disease with rheumatoid arthritis of right wrist |
M05.132 |
Rheumatoid lung disease with rheumatoid arthritis of left wrist |
M05.139 |
Rheumatoid lung disease with rheumatoid arthritis of unspecified wrist |
M05.141 |
Rheumatoid lung disease with rheumatoid arthritis of right hand |
M05.142 |
Rheumatoid lung disease with rheumatoid arthritis of left hand |
M05.149 |
Rheumatoid lung disease with rheumatoid arthritis of unspecified hand |
M05.151 |
Rheumatoid lung disease with rheumatoid arthritis of right hip |
M05.152 |
Rheumatoid lung disease with rheumatoid arthritis of left hip |
M05.159 |
Rheumatoid lung disease with rheumatoid arthritis of unspecified hip |
M05.161 |
Rheumatoid lung disease with rheumatoid arthritis of right knee |
M05.162 |
Rheumatoid lung disease with rheumatoid arthritis of left knee |
M05.169 |
Rheumatoid lung disease with rheumatoid arthritis of unspecified knee |
M05.171 |
Rheumatoid lung disease with rheumatoid arthritis of right ankle and foot |
M05.172 |
Rheumatoid lung disease with rheumatoid arthritis of left ankle and foot |
M05.179 |
Rheumatoid lung disease with rheumatoid arthritis of unspecified ankle and foot |
M05.19 |
Rheumatoid lung disease with rheumatoid arthritis of multiple sites |
M05.20 |
Rheumatoid vasculitis with rheumatoid arthritis of unspecified site |
M05.211 |
Rheumatoid vasculitis with rheumatoid arthritis of right shoulder |
M05.212 |
Rheumatoid vasculitis with rheumatoid arthritis of left shoulder |
M05.219 |
Rheumatoid vasculitis with rheumatoid arthritis of unspecified shoulder |
M05.221 |
Rheumatoid vasculitis with rheumatoid arthritis of right elbow |
M05.222 |
Rheumatoid vasculitis with rheumatoid arthritis of left elbow |
M05.229 |
Rheumatoid vasculitis with rheumatoid arthritis of unspecified elbow |
M05.231 |
Rheumatoid vasculitis with rheumatoid arthritis of right wrist |
M05.232 |
Rheumatoid vasculitis with rheumatoid arthritis of left wrist |
M05.239 |
Rheumatoid vasculitis with rheumatoid arthritis of unspecified wrist |
M05.241 |
Rheumatoid vasculitis with rheumatoid arthritis of right hand |
M05.242 |
Rheumatoid vasculitis with rheumatoid arthritis of left hand |
M05.249 |
Rheumatoid vasculitis with rheumatoid arthritis of unspecified hand |
M05.251 |
Rheumatoid vasculitis with rheumatoid arthritis of right hip |
M05.252 |
Rheumatoid vasculitis with rheumatoid arthritis of left hip |
M05.259 |
Rheumatoid vasculitis with rheumatoid arthritis of unspecified hip |
M05.261 |
Rheumatoid vasculitis with rheumatoid arthritis of right knee |
M05.262 |
Rheumatoid vasculitis with rheumatoid arthritis of left knee |
M05.269 |
Rheumatoid vasculitis with rheumatoid arthritis of unspecified knee |
M05.271 |
Rheumatoid vasculitis with rheumatoid arthritis of right ankle and foot |
M05.272 |
Rheumatoid vasculitis with rheumatoid arthritis of left ankle and foot |
M05.279 |
Rheumatoid vasculitis with rheumatoid arthritis of unspecified ankle and foot |
M05.29 |
Rheumatoid vasculitis with rheumatoid arthritis of multiple sites |
M05.30 |
Rheumatoid heart disease with rheumatoid arthritis of unspecified site |
M05.311 |
Rheumatoid heart disease with rheumatoid arthritis of right shoulder |
M05.312 |
Rheumatoid heart disease with rheumatoid arthritis of left shoulder |
M05.319 |
Rheumatoid heart disease with rheumatoid arthritis of unspecified shoulder |
M05.321 |
Rheumatoid heart disease with rheumatoid arthritis of right elbow |
M05.322 |
Rheumatoid heart disease with rheumatoid arthritis of left elbow |
M05.329 |
Rheumatoid heart disease with rheumatoid arthritis of unspecified elbow |
M05.331 |
Rheumatoid heart disease with rheumatoid arthritis of right wrist |
M05.332 |
Rheumatoid heart disease with rheumatoid arthritis of left wrist |
M05.339 |
Rheumatoid heart disease with rheumatoid arthritis of unspecified wrist |
M05.341 |
Rheumatoid heart disease with rheumatoid arthritis of right hand |
M05.342 |
Rheumatoid heart disease with rheumatoid arthritis of left hand |
M05.349 |
Rheumatoid heart disease with rheumatoid arthritis of unspecified hand |
M05.351 |
Rheumatoid heart disease with rheumatoid arthritis of right hip |
M05.352 |
Rheumatoid heart disease with rheumatoid arthritis of left hip |
M05.359 |
Rheumatoid heart disease with rheumatoid arthritis of unspecified hip |
M05.361 |
Rheumatoid heart disease with rheumatoid arthritis of right knee |
M05.362 |
Rheumatoid heart disease with rheumatoid arthritis of left knee |
M05.369 |
Rheumatoid heart disease with rheumatoid arthritis of unspecified knee |
M05.371 |
Rheumatoid heart disease with rheumatoid arthritis of right ankle and foot |
M05.372 |
Rheumatoid heart disease with rheumatoid arthritis of left ankle and foot |
M05.379 |
Rheumatoid heart disease with rheumatoid arthritis of unspecified ankle and foot |
M05.39 |
Rheumatoid heart disease with rheumatoid arthritis of multiple sites |
M05.40 |
Rheumatoid myopathy with rheumatoid arthritis of unspecified site |
M05.411 |
Rheumatoid myopathy with rheumatoid arthritis of right shoulder |
M05.412 |
Rheumatoid myopathy with rheumatoid arthritis of left shoulder |
M05.419 |
Rheumatoid myopathy with rheumatoid arthritis of unspecified shoulder |
M05.421 |
Rheumatoid myopathy with rheumatoid arthritis of right elbow |
M05.422 |
Rheumatoid myopathy with rheumatoid arthritis of left elbow |
M05.429 |
Rheumatoid myopathy with rheumatoid arthritis of unspecified elbow |
M05.431 |
Rheumatoid myopathy with rheumatoid arthritis of right wrist |
M05.432 |
Rheumatoid myopathy with rheumatoid arthritis of left wrist |
M05.439 |
Rheumatoid myopathy with rheumatoid arthritis of unspecified wrist |
M05.441 |
Rheumatoid myopathy with rheumatoid arthritis of right hand |
M05.442 |
Rheumatoid myopathy with rheumatoid arthritis of left hand |
M05.449 |
Rheumatoid myopathy with rheumatoid arthritis of unspecified hand |
M05.451 |
Rheumatoid myopathy with rheumatoid arthritis of right hip |
M05.452 |
Rheumatoid myopathy with rheumatoid arthritis of left hip |
M05.459 |
Rheumatoid myopathy with rheumatoid arthritis of unspecified hip |
M05.461 |
Rheumatoid myopathy with rheumatoid arthritis of right knee |
M05.462 |
Rheumatoid myopathy with rheumatoid arthritis of left knee |
M05.469 |
Rheumatoid myopathy with rheumatoid arthritis of unspecified knee |
M05.471 |
Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot |
M05.472 |
Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot |
M05.479 |
Rheumatoid myopathy with rheumatoid arthritis of unspecified ankle and foot |
M05.49 |
Rheumatoid myopathy with rheumatoid arthritis of multiple sites |
M05.50 |
Rheumatoid myopathy with rheumatoid arthritis of unspecified sites |
M05.511 |
Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulder |
M05.512 |
Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulder |
M05.519 |
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified shoulder |
M05.521 |
Rheumatoid polyneuropathy with rheumatoid arthritis of right elbow |
M05.522 |
Rheumatoid polyneuropathy with rheumatoid arthritis of left elbow |
M05.529 |
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified elbow |
M05.531 |
Rheumatoid polyneuropathy with rheumatoid arthritis of right wrist |
M05.532 |
Rheumatoid polyneuropathy with rheumatoid arthritis of left wrist |
M05.539 |
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified wrist |
M05.541 |
Rheumatoid polyneuropathy with rheumatoid arthritis of right hand |
M05.542 |
Rheumatoid polyneuropathy with rheumatoid arthritis of left hand |
M05.549 |
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hand |
M05.551 |
Rheumatoid polyneuropathy with rheumatoid arthritis of right hip |
M05.552 |
Rheumatoid polyneuropathy with rheumatoid arthritis of left hip |
M05.559 |
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hip |
M05.561 |
Rheumatoid polyneuropathy with rheumatoid arthritis of right knee |
M05.562 |
Rheumatoid polyneuropathy with rheumatoid arthritis of left knee |
M05.569 |
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified knee |
M05.571 |
Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot |
M05.572 |
Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot |
M05.579 |
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified ankle and foot |
M05.59 |
Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites |
M05.60 |
Rheumatoid arthritis of unspecified site with involvement of other organs and systems |
M05.611 |
Rheumatoid arthritis of right shoulder with involvement of other organs and systems |
M05.612 |
Rheumatoid arthritis of left shoulder with involvement of other organs and systems |
M05.619 |
Rheumatoid arthritis of unspecified shoulder with involvement of other organs and systems |
M05.621 |
Rheumatoid arthritis of right elbow with involvement of other organs and systems |
M05.622 |
Rheumatoid arthritis of left elbow with involvement of other organs and systems |
M05.629 |
Rheumatoid arthritis of unspecified elbow with involvement of other organs and systems |
M05.631 |
Rheumatoid arthritis of right wrist with involvement of other organs and systems |
M05.632 |
Rheumatoid arthritis of left wrist with involvement of other organs and systems |
M05.639 |
Rheumatoid arthritis of unspecified wrist with involvement of other organs and systems |
M05.641 |
Rheumatoid arthritis of right hand with involvement of other organs and systems |
M05.642 |
Rheumatoid arthritis of left hand with involvement of other organs and systems |
M05.649 |
Rheumatoid arthritis of unspecified hand with involvement of other organs and systems |
M05.651 |
Rheumatoid arthritis of right hip with involvement of other organs and systems |
M05.652 |
Rheumatoid arthritis of left hip with involvement of other organs and systems |
M05.659 |
Rheumatoid arthritis of unspecified hip with involvement of other organs and systems |
M05.661 |
Rheumatoid arthritis of right knee with involvement of other organs and systems |
M05.662 |
Rheumatoid arthritis of left knee with involvement of other organs and systems |
M05.669 |
Rheumatoid arthritis of unspecified knee with involvement of other organs and systems |
M05.671 |
Rheumatoid arthritis of right ankle and foot with involvement of other organs and systems |
M05.672 |
Rheumatoid arthritis of left ankle and foot with involvement of other organs and systems |
M05.679 |
Rheumatoid arthritis of unspecified ankle and foot with involvement of other organs and systems |
M05.69 |
Rheumatoid arthritis of multiple sites with involvement of other organs and systems |
M05.7A |
Rheumatoid arthritis with rheumatoid factor of other specified site without organ or systems involvement |
M05.711 |
Rheumatoid arthritis with rheumatoid factor of right shoulder without organ or systems involvement |
M05.712 |
Rheumatoid arthritis with rheumatoid factor of left shoulder without organ or systems involvement |
M05.719 |
Rheumatoid arthritis with rheumatoid factor of unspecified shoulder without organ or systems involvement |
M05.721 |
Rheumatoid arthritis with rheumatoid factor of right elbow without organ or systems involvement |
M05.722 |
Rheumatoid arthritis with rheumatoid factor of left elbow without organ or systems involvement |
M05.729 |
Rheumatoid arthritis with rheumatoid factor of unspecified elbow without organ or systems involvement |
M05.731 |
Rheumatoid arthritis with rheumatoid factor of right wrist without organ or systems involvement |
M05.732 |
Rheumatoid arthritis with rheumatoid factor of left wrist without organ or systems involvement |
M05.739 |
Rheumatoid arthritis with rheumatoid factor of unspecified wrist without organ or systems involvement |
M05.741 |
Rheumatoid arthritis with rheumatoid factor of right hand without organ or systems involvement |
M05.742 |
Rheumatoid arthritis with rheumatoid factor of left hand without organ or systems involvement |
M05.749 |
Rheumatoid arthritis with rheumatoid factor of unspecified hand without organ or systems involvement |
M05.751 |
Rheumatoid arthritis with rheumatoid factor of right hip without organ or systems involvement |
M05.752 |
Rheumatoid arthritis with rheumatoid factor of left hip without organ or systems involvement |
M05.759 |
Rheumatoid arthritis with rheumatoid factor of unspecified hip without organ or systems involvement |
M05.761 |
Rheumatoid arthritis with rheumatoid factor of right knee without organ or systems involvement |
M05.762 |
Rheumatoid arthritis with rheumatoid factor of left knee without organ or systems involvement |
M05.769 |
Rheumatoid arthritis with rheumatoid factor of unspecified knee without organ or systems involvement |
M05.771 |
Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systems involvement |
M05.772 |
Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or systems involvement |
M05.779 |
Rheumatoid arthritis with rheumatoid factor of unspecified ankle and wrist without organ or systems involvement |
M05.79 |
Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement |
M05.8A |
Other rheumatoid arthritis with rheumatoid factor of other specified site |
M05.811 |
Other rheumatoid arthritis with rheumatoid factor of right shoulder |
M05.812 |
Other rheumatoid arthritis with rheumatoid factor of left shoulder |
M05.819 |
Other rheumatoid arthritis with rheumatoid factor of unspecified shoulder |
M05.821 |
Other rheumatoid arthritis with rheumatoid factor of right elbow |
M05.822 |
Other rheumatoid arthritis with rheumatoid factor of left elbow |
M05.829 |
Other rheumatoid arthritis with rheumatoid factor of unspecified elbow |
M05.831 |
Other rheumatoid arthritis with rheumatoid factor of right wrist |
M05.832 |
Other rheumatoid arthritis with rheumatoid factor of left wrist |
M05.839 |
Other rheumatoid arthritis with rheumatoid factor of unspecified wrist |
M05.841 |
Other rheumatoid arthritis with rheumatoid factor of right hand |
M05.842 |
Other rheumatoid arthritis with rheumatoid factor of left hand |
M05.849 |
Other rheumatoid arthritis with rheumatoid factor of unspecified hand |
M05.851 |
Other rheumatoid arthritis with rheumatoid factor of right hip |
M05.852 |
Other rheumatoid arthritis with rheumatoid factor of left hip |
M05.859 |
Other rheumatoid arthritis with rheumatoid factor of unspecified hip |
M05.861 |
Other rheumatoid arthritis with rheumatoid factor of right knee |
M05.862 |
Other rheumatoid arthritis with rheumatoid factor of left knee |
M05.869 |
Other rheumatoid arthritis with rheumatoid factor of unspecified knee |
M05.871 |
Other rheumatoid arthritis with rheumatoid factor of right ankle and foot |
M05.872 |
Other rheumatoid arthritis with rheumatoid factor of left ankle and foot |
M05.879 |
Other rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot |
M05.89 |
Other rheumatoid arthritis with rheumatoid factor of multiple sites |
M05.9 |
Rheumatoid arthritis with rheumatoid factor, unspecified |
M06.0A |
Rheumatoid arthritis without rheumatoid factor, other specified site |
M06.019 |
Rheumatoid arthritis without rheumatoid factor, unspecified shoulder |
M06.021 |
Rheumatoid arthritis without rheumatoid factor, right elbow |
M06.022 |
Rheumatoid arthritis without rheumatoid factor, left elbow |
M06.029 |
Rheumatoid arthritis without rheumatoid factor, unspecified elbow |
M06.031 |
Rheumatoid arthritis without rheumatoid factor, right wrist |
M06.032 |
Rheumatoid arthritis without rheumatoid factor, left wrist |
M06.039 |
Rheumatoid arthritis without rheumatoid factor, unspecified wrist |
M06.041 |
Rheumatoid arthritis without rheumatoid factor, right hand |
M06.042 |
Rheumatoid arthritis without rheumatoid factor, left hand |
M06.049 |
Rheumatoid arthritis without rheumatoid factor, unspecified hand |
M06.051 |
Rheumatoid arthritis without rheumatoid factor, right hip |
M06.052 |
Rheumatoid arthritis without rheumatoid factor, left hip |
M06.059 |
Rheumatoid arthritis without rheumatoid factor, unspecified hip |
M06.061 |
Rheumatoid arthritis without rheumatoid factor, right knee |
M06.062 |
Rheumatoid arthritis without rheumatoid factor, left knee |
M06.069 |
Rheumatoid arthritis without rheumatoid factor, unspecified knee |
M06.071 |
Rheumatoid arthritis without rheumatoid factor, right ankle and foot |
M06.072 |
Rheumatoid arthritis without rheumatoid factor, left ankle and foot |
M06.079 |
Rheumatoid arthritis without rheumatoid factor, unspecified ankle and foot |
M06.08 |
Rheumatoid arthritis without rheumatoid factor, vertebrae |
M06.09 |
Rheumatoid arthritis without rheumatoid factor, multiple sites |
M06.4 |
Inflammatory polyarthropathy |
M06.8A |
Other specified rheumatoid arthritis, other specified site |
M06.811 |
Other specified rheumatoid arthritis, right shoulder |
M06.812 |
Other specified rheumatoid arthritis, left shoulder |
M06.819 |
Other specified rheumatoid arthritis, unspecified shoulder |
M06.821 |
Other specified rheumatoid arthritis, right elbow |
M06.822 |
Other specified rheumatoid arthritis, left elbow |
M06.829 |
Other specified rheumatoid arthritis, unspecified elbow |
M06.831 |
Other specified rheumatoid arthritis, right wrist |
M06.832 |
Other specified rheumatoid arthritis, left wrist |
M06.839 |
Other specified rheumatoid arthritis, unspecified wrist |
M06.841 |
Other specified rheumatoid arthritis, right hand |
M06.842 |
Other specified rheumatoid arthritis, left hand |
M06.849 |
Other specified rheumatoid arthritis, unspecified hand |
M06.851 |
Other specified rheumatoid arthritis, right hip |
M06.852 |
Other specified rheumatoid arthritis, left hip |
M06.859 |
Other specified rheumatoid arthritis, unspecified hip |
M06.861 |
Other specified rheumatoid arthritis, right knee |
M06.862 |
Other specified rheumatoid arthritis, left knee |
M06.869 |
Other specified rheumatoid arthritis, unspecified knee |
M06.871 |
Other specified rheumatoid arthritis, right ankle and foot |
M06.872 |
Other specified rheumatoid arthritis, left ankle and foot |
M06.879 |
Other specified rheumatoid arthritis, unspecified ankle and foot |
M06.88 |
Other specified rheumatoid arthritis, vertebrae |
M06.89 |
Other specified rheumatoid arthritis, multiple sites |
M06.9 |
Rheumatoid arthritis, unspecified |
M08.0A |
Unspecified juvenile rheumatoid arthritis, other specified site |
M08.011 |
Unspecified juvenile rheumatoid arthritis, right shoulder |
M08.012 |
Unspecified juvenile rheumatoid arthritis, left shoulder |
M08.019 |
Unspecified juvenile rheumatoid arthritis, unspecified shoulder |
M08.021 |
Unspecified juvenile rheumatoid arthritis, right elbow |
M08.022 |
Unspecified juvenile rheumatoid arthritis, left elbow |
M08.029 |
Unspecified juvenile rheumatoid arthritis, unspecified elbow |
M08.031 |
Unspecified juvenile rheumatoid arthritis, right wrist |
M08.032 |
Unspecified juvenile rheumatoid arthritis, left wrist |
M08.039 |
Unspecified juvenile rheumatoid arthritis, unspecified wrist |
M08.041 |
Unspecified juvenile rheumatoid arthritis, right hand |
M08.042 |
Unspecified juvenile rheumatoid arthritis, left hand |
M08.049 |
Unspecified juvenile rheumatoid arthritis, unspecified hand |
M08.051 |
Unspecified juvenile rheumatoid arthritis, right hip |
M08.052 |
Unspecified juvenile rheumatoid arthritis, left hip |
M08.059 |
Unspecified juvenile rheumatoid arthritis, unspecified hip |
M08.061 |
Unspecified juvenile rheumatoid arthritis, right knee |
M08.062 |
Unspecified juvenile rheumatoid arthritis, left knee |
M08.069 |
Unspecified juvenile rheumatoid arthritis, unspecified knee |
M08.071 |
Unspecified juvenile rheumatoid arthritis, right ankle and foot |
M08.072 |
Unspecified juvenile rheumatoid arthritis, left ankle and foot |
M08.079 |
Unspecified juvenile rheumatoid arthritis, unspecified ankle and foot |
M08.08 |
Unspecified juvenile rheumatoid arthritis, vertebrae |
M08.09 |
Unspecified juvenile rheumatoid arthritis, multiple sites |
M08.2A |
Juvenile rheumatoid arthritis with systemic onset, other specified site |
M08.211 |
Juvenile rheumatoid arthritis with systemic onset, right shoulder |
M08.212 |
Juvenile rheumatoid arthritis with systemic onset, left shoulder |
M08.219 |
Juvenile rheumatoid arthritis with systemic onset, unspecified shoulder |
M08.221 |
Juvenile rheumatoid arthritis with systemic onset, right elbow |
M08.222 |
Juvenile rheumatoid arthritis with systemic onset, left elbow |
M08.229 |
Juvenile rheumatoid arthritis with systemic onset, unspecified elbow |
M08.231 |
Juvenile rheumatoid arthritis with systemic onset, right wrist |
M08.232 |
Juvenile rheumatoid arthritis with systemic onset, left wrist |
M08.239 |
Juvenile rheumatoid arthritis with systemic onset, unspecified wrist |
M08.241 |
Juvenile rheumatoid arthritis with systemic onset, right hand |
M08.242 |
Juvenile rheumatoid arthritis with systemic onset, left hand |
M08.249 |
Juvenile rheumatoid arthritis with systemic onset, unspecified hand |
M08.251 |
Juvenile rheumatoid arthritis with systemic onset, right hip |
M08.252 |
Juvenile rheumatoid arthritis with systemic onset, left hip |
M08.259 |
Juvenile rheumatoid arthritis with systemic onset, unspecified hip |
M08.261 |
Juvenile rheumatoid arthritis with systemic onset, right knee |
M08.262 |
Juvenile rheumatoid arthritis with systemic onset, left knee |
M08.269 |
Juvenile rheumatoid arthritis with systemic onset, unspecified knee |
M08.271 |
Juvenile rheumatoid arthritis with systemic onset, right ankle and foot |
M08.272 |
Juvenile rheumatoid arthritis with systemic onset, left ankle and foot |
M08.279 |
Juvenile rheumatoid arthritis with systemic onset, unspecified ankle and foot |
M08.28 |
Juvenile rheumatoid arthritis with systemic onset, vertebrae |
M08.29 |
Juvenile rheumatoid arthritis with systemic onset, multiple sites |
M08.3 |
Juvenile rheumatoid polyarthritis (seronegative) |
M08.4A |
Pauciarticular juvenile rheumatoid arthritis, other specified site |
M08.411 |
Pauciarticular juvenile rheumatoid arthritis, right shoulder |
M08.412 |
Pauciarticular juvenile rheumatoid arthritis, left shoulder |
M08.419 |
Pauciarticular juvenile rheumatoid arthritis, unspecified shoulder |
M08.421 |
Pauciarticular juvenile rheumatoid arthritis, right elbow |
M08.422 |
Pauciarticular juvenile rheumatoid arthritis, left elbow |
M08.429 |
Pauciarticular juvenile rheumatoid arthritis, unspecified elbow |
M08.431 |
Pauciarticular juvenile rheumatoid arthritis, right wrist |
M08.432 |
Pauciarticular juvenile rheumatoid arthritis, left wrist |
M08.439 |
Pauciarticular juvenile rheumatoid arthritis, unspecified wrist |
M08.441 |
Pauciarticular juvenile rheumatoid arthritis, right hand |
M08.442 |
Pauciarticular juvenile rheumatoid arthritis, left hand |
M08.449 |
Pauciarticular juvenile rheumatoid arthritis, unspecified hand |
M08.451 |
Pauciarticular juvenile rheumatoid arthritis, right hip |
M08.452 |
Pauciarticular juvenile rheumatoid arthritis, left hip |
M08.459 |
Pauciarticular juvenile rheumatoid arthritis, unspecified hip |
M08.461 |
Pauciarticular juvenile rheumatoid arthritis, right knee |
M08.462 |
Pauciarticular juvenile rheumatoid arthritis, left knee |
M08.469 |
Pauciarticular juvenile rheumatoid arthritis, unspecified knee |
M08.471 |
Pauciarticular juvenile rheumatoid arthritis, right ankle and foot |
M08.472 |
Pauciarticular juvenile rheumatoid arthritis, left ankle and foot |
M08.479 |
Pauciarticular juvenile rheumatoid arthritis, unspecified ankle and foot |
M08.48 |
Pauciarticular juvenile rheumatoid arthritis, vertebrae |
M08.80 |
Other juvenile arthritis, unspecified site |
M08.811 |
Other juvenile arthritis, right shoulder |
M08.812 |
Other juvenile arthritis, left shoulder |
M08.819 |
Other juvenile arthritis, unspecified shoulder |
M08.821 |
Other juvenile arthritis, right elbow |
M08.822 |
Other juvenile arthritis, left elbow |
M08.829 |
Other juvenile arthritis, unspecified elbow |
M08.831 |
Other juvenile arthritis, right wrist |
M08.832 |
Other juvenile arthritis, left wrist |
M08.839 |
Other juvenile arthritis, unspecified wrist |
M08.841 |
Other juvenile arthritis, right hand |
M08.842 |
Other juvenile arthritis, left hand |
M08.849 |
Other juvenile arthritis, unspecified hand |
M08.851 |
Other juvenile arthritis, right hip |
M08.852 |
Other juvenile arthritis, left hip |
M08.859 |
Other juvenile arthritis, unspecified hip |
M08.861 |
Other juvenile arthritis, right knee |
M08.862 |
Other juvenile arthritis, left knee |
M08.869 |
Other juvenile arthritis, unspecified knee |
M08.871 |
Other juvenile arthritis, right ankle and foot |
M08.872 |
Other juvenile arthritis, left ankle and foot |
M08.879 |
Other juvenile arthritis, unspecified ankle and foot |
M08.88 |
Other juvenile arthritis, other specified site |
M08.89 |
Other juvenile arthritis, multiple sites |
M08.9A |
Juvenile arthritis, unspecified, other specified site |
M08.911 |
Juvenile arthritis, unspecified, right shoulder |
M08.912 |
Juvenile arthritis, unspecified, left shoulder |
M08.919 |
Juvenile arthritis, unspecified, unspecified shoulder |
M08.921 |
Juvenile arthritis, unspecified, right elbow |
M08.922 |
Juvenile arthritis, unspecified, left elbow |
M08.929 |
Juvenile arthritis, unspecified, unspecified elbow |
M08.931 |
Juvenile arthritis, unspecified, right wrist |
M08.932 |
Juvenile arthritis, unspecified, left wrist |
M08.939 |
Juvenile arthritis, unspecified, unspecified wrist |
M08.941 |
Juvenile arthritis, unspecified, right hand |
M08.942 |
Juvenile arthritis, unspecified, left hand |
M08.949 |
Juvenile arthritis, unspecified, unspecified hand |
M08.951 |
Juvenile arthritis, unspecified, right hip |
M08.952 |
Juvenile arthritis, unspecified, left hip |
M08.959 |
Juvenile arthritis, unspecified, unspecified hip |
M08.961 |
Juvenile arthritis, unspecified, right knee |
M08.962 |
Juvenile arthritis, unspecified, left knee |
M08.969 |
Juvenile arthritis, unspecified, unspecified knee |
M08.971 |
Juvenile arthritis, unspecified, right ankle and foot |
M08.972 |
Juvenile arthritis, unspecified, left ankle and foot |
M08.979 |
Juvenile arthritis, unspecified, unspecified ankle and foot |
M08.98 |
Juvenile arthritis, unspecified, vertebrae |
M08.99 |
Juvenile arthritis, unspecified, multiple sites |
M31.5 |
Giant cell arteritis with polymyalgia rheumatica |
M31.6 |
Other giant cell arteritis |
M35.3 |
Polymyalgia rheumatica |
T80.82XA |
Complication of immune effector cellular therapy, initial encounter |
T80.82XS |
Complication of immune effector cellular therapy, sequela |
T80.89XA |
Other complications following infusion, transfusion and therapeutic injection, initial encounter |
T80.89XS |
Other complications following infusion, transfusion and therapeutic injection, sequela |
T86.09 |
Other complications of bone marrow transplant |
Appendix 2 – Centers for Medicare and Medicaid Services (CMS)
The preceding information is intended for non-Medicare coverage determinations. Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs) may exist and compliance with these policies is required where applicable. Local Coverage Articles (LCAs) may also exist for claims payment purposes or to clarify benefit eligibility under Part B for drugs which may be self-administered. The following link may be used to search for NCD, LCD, or LCA documents: https://www.cms.gov/medicare-coverage-database/search.aspx. Additional indications, including any preceding information, may be applied at the discretion of the health plan..
Medicare Part B Covered Diagnosis Codes (applicable to existing NCD/LCD/LCA): N/A
Medicare Part B Administrative Contractor (MAC) Jurisdictions |
||
Jurisdiction |
Applicable State/US Territory |
Contractor |
E (1) |
CA, HI, NV, AS, GU, CNMI |
Noridian Healthcare Solutions, LLC |
F (2 & 3) |
AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ |
Noridian Healthcare Solutions, LLC |
5 |
KS, NE, IA, MO |
Wisconsin Physicians Service Insurance Corp (WPS) |
6 |
MN, WI, IL |
National Government Services, Inc. (NGS) |
H (4 & 7) |
LA, AR, MS, TX, OK, CO, NM |
Novitas Solutions, Inc. |
8 |
MI, IN |
Wisconsin Physicians Service Insurance Corp (WPS) |
N (9) |
FL, PR, VI |
First Coast Service Options, Inc. |
J (10) |
TN, GA, AL |
Palmetto GBA |
M (11) |
NC, SC, WV, VA (excluding below) |
Palmetto GBA |
L (12) |
DE, MD, PA, NJ, DC (includes Arlington & Fairfax counties and the city of Alexandria in VA) |
Novitas Solutions, Inc. |
K (13 & 14) |
NY, CT, MA, RI, VT, ME, NH |
National Government Services, Inc. (NGS) |
15 |
KY, OH |
CGS Administrators, LLC |