Category Filter
- Advanced Imaging
- Autism Spectrum Mandate
- Behavioral Health
- Blue Advantage Policies
- Chronic Condition Management
- Genetic Testing
- HelpScript Program
- Hemophilia Drugs
- Medical Policies
- Pre-Service Review (Predetermination/Precertification)
- Provider-Administered Drug Policies
- Radiation Therapy
- Self-Administered Drug Policies
- Transgender Services
Asset Publisher
Bendamustine: Treanda®; Bendeka®; Belrapzo®; Vivimusta™; Bendamustine Ψ (Intravenous)
Policy Number: VP-0130
(Intravenous)
Last Review Date: 03/05/2024
Date of Origin: 01/01/12
Dates Reviewed: 12/2011, 02/2013, 09/2013, 12/2013, 03/2014, 06/2014, 09/2014, 12/2014, 03/2015, 05/2015, 11/2015, 02/2016, 05/2016, 08/2016, 11/2016, 02/2017, 05/2017, 08/2017, 11/2017, 02/2018, 05/2018, 09/2018, 12/2018, 03/2019, 06/2019, 09/2019, 12/2019, 03/2020, 06/2020, 09/2020, 03/2021, 03/2022, 06/2022, 01/2023, 02/2023, 03/2024
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 1-6,9,14,18
Coverage will be provided for 6 months and may be renewed (unless otherwise specified).
- Waldenström Macroglobulinemia (WM)/Lymphoplasmacytic Lymphoma (LPL):
- Coverage will be provided for six months and may NOT be renewed, unless otherwise specified.
- May be renewed for an additional six months for relapsed disease if previously used as primary therapy.
- Coverage will be provided for six months and may NOT be renewed, unless otherwise specified.
- Non-Hodgkin Lymphoma (NHL), Chronic Lymphocytic Leukemia (CLL)/Small Lymphocytic Lymphoma (SLL), Hodgkin Lymphoma, Systemic Light Chain Amyloidosis:
- Coverage will be provided for six months and may NOT be renewed.
- Multiple Myeloma:
- Coverage will be provided for eight months and may NOT be renewed.
- HSCT Conditioning:
- Coverage will be provided for one time only and may NOT be renewed.
- Dosing Limits
- Quantity Limit (max daily dose) [NDC Unit]:
- Treanda 100 mg single-dose vial: 6 vials every 21 days
- Treanda 25 mg single-dose vial: 3 vials every 21 days
- Bendeka 100 mg/4 mL multi-dose vial: 6 vials every 21 days
- Belrapzo 100 mg/4 mL RTD multi-dose vial: 6 vials every 21 days
- Vivimusta 100 mg/4 mL multi-dose vial: 6 vials every 21 days
- Max Units (per dose and over time) [HCPCS Unit]:
NHL:
- 600 billable units every 21 days
WM/LPL:
- 450 billable units every 28 days
Hodgkin Lymphoma:
- 600 billable units every 28 days
CLL/SLL, Systemic Light Chain Amyloidosis & Multiple Myeloma:
- 500 billable units every 28 days
HSCT Conditioning:
- 500 billable units for 2 doses
Primary Cutaneous Lymphomas
- 450 billable units every 21 days
- Initial Approval Criteria 1-4
Coverage is provided in the following conditions:
- Patient is at least 18 years of age, unless otherwise specified; AND
- Patient must not have received bendamustine in a previous line of therapy, unless otherwise specified; AND
Non-Hodgkin Lymphoma (NHL) † ‡ Ф 1-5,16
- Coverage is provided for B-Cell Lymphomas when:
- Used as subsequent therapy; AND
- Used as a single agent for indolent lymphoma †; OR
- Used in combination with rituximab for:
- Classic Follicular Lymphoma (cFL)
-
-
-
- Extranodal Marginal Zone Lymphoma (EMZL) of the Stomach & Nongastric Sites (Noncutaneous)
-
-
-
-
-
- Mantle Cell Lymphoma (may also be used as a component of RBAC500 [rituximab, bendamustine, and cytarabine])
-
-
-
-
- Nodal Marginal Zone Lymphoma
- Splenic Marginal Zone Lymphoma; OR
- Used in combination with obinutuzumab for:
- Classic Follicular Lymphoma (cFL)
- Extranodal Marginal Zone Lymphoma (EMZL) of the Stomach & Nongastric Sites (Noncutaneous)
-
-
-
-
- Nodal Marginal Zone Lymphoma
-
-
-
-
- Splenic Marginal Zone Lymphoma; OR
- Used in combination with polatuzumab (with or without rituximab) for:
- HIV-Related Diffuse Large B-Cell Lymphoma (DLBCL), Primary Effusion Lymphoma, or HHV8-positive DLBCL, not otherwise specified (NOS)
- HIV-Related plasmablastic lymphoma in non-candidates for transplant (excluding use with rituximab)
- DLBCL
- Histologic Transformation of Indolent Lymphomas to DLBCL
- High-Grade B-Cell Lymphomas
- Monomorphic Post-Transplant Lymphoproliferative Disorder (B-cell type); OR
-
- Used as first-line therapy ‡; AND
- Used in combination with rituximab for:
- Classic Follicular Lymphoma (cFL)
- Used in combination with rituximab for:
-
-
- Extranodal Marginal Zone Lymphoma (EMZL) of the Stomach & Nongastric Sites (Noncutaneous)
- Mantle Cell Lymphoma (may also be used as a component of RBAC500 [rituximab, bendamustine, and cytarabine])
- Nodal Marginal Zone Lymphoma
- Splenic Marginal Zone Lymphoma; OR
- Used in combination with obinutuzumab for:
- Classic Follicular Lymphoma (cFL)
- Nodal Marginal Zone Lymphoma
-
- Used as CAR T-cell bridging therapy after leukapheresis ‡; AND
- Used in combination with polatuzumab (with or without rituximab) for:
- HIV-Related DLBCL, primary effusion lymphoma, or HHV8-positive DLBCL, NOS
- HIV-Related plasmablastic lymphoma in non-candidates for transplant (excluding use with rituximab)
- High-Grade B-Cell Lymphomas
- DLBCL
- Monomorphic Post-Transplant Lymphoproliferative Disorder (B-cell type)
- Used in combination with polatuzumab (with or without rituximab) for:
- Coverage is provided for the following T-Cell Lymphomas ‡
- Adult T-Cell Leukemia/Lymphoma
- Used as a single agent; AND
- Used as subsequent therapy for non-responders to first-line therapy for chronic high risk, acute, or lymphoma subtypes
- Breast Implant-Associated Anaplastic Large Cell Lymphoma (ALCL)
- Used as subsequent therapy as a single agent for relapsed or refractory disease
- Hepatosplenic T-Cell Lymphoma
- Used as subsequent therapy as a single agent for refractory disease after two (2) first-line therapy regimens
- Peripheral T-Cell Lymphomas (includes peripheral T-cell not otherwise specified, enteropathy-associated T-cell, monomorphic epitheliotropic intestinal T-cell, angioimmunoblastic T-cell, nodal peripheral T-cell with TFH phenotype, follicular T-cell, or anaplastic large cell lymphomas)
- Used as a single agent; AND
- Used as initial palliative intent therapy; OR
- Used as subsequent therapy for relapsed or refractory disease
- Used as a single agent; AND
- Adult T-Cell Leukemia/Lymphoma
Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL) † ‡ Ф 1-5,17
- Used as first-line therapy; AND
- Used as a single agent †; OR
- Used in combination with rituximab or obinutuzumab for disease without del(17p)/TP53 mutations (excluding use in frail patients); OR
- Used as subsequent therapy; AND
- Patient has relapsed or refractory disease after prior Bruton Tyrosine Kinase inhibitor- and venetoclax-based regimens; AND
- Used in combination with rituximab for disease without del(17p)/TP53 mutations in patients <65 years of age without significant comorbidities
Waldenström Macroglobulinemia/Lymphoplasmacytic Lymphoma (WM/LPL) ‡ 5,23,24
- Used as a single agent or in combination with rituximab; AND
- Used as primary therapy; OR
- Used for relapse, if previously used as primary therapy that was well tolerated and elicited a prolonged response; OR
- Used as alternative therapy for previously treated disease that does not respond to primary therapy; OR
- Used for progressive or relapsed disease; OR
- Used for the management of symptomatic Bing-Neel syndrome
Adult Hodgkin Lymphoma ‡ 5,6
- Patient has classic Hodgkin Lymphoma (cHL); AND
- Used as second-line or subsequent therapy (if not used second-line) for relapsed or refractory disease; AND
- Used in combination with gemcitabine and vinorelbine; OR
- Used in combination with brentuximab vedotin; OR
- Used as subsequent therapy for disease refractory to at least 3 prior lines of therapy; AND
- Used as a single agent; OR
- Used in combination with carboplatin and etoposide; OR
- Used as palliative therapy for relapsed or refractory disease; AND
- Used as a single agent; AND
- Patient is >60 years of age OR has poor performance status or substantial comorbidities; OR
- Used as second-line or subsequent therapy (if not used second-line) for relapsed or refractory disease; AND
- Patient has Nodular Lymphocyte-Predominant Hodgkin Lymphoma (NLPHL); AND
- Used as subsequent therapy for progressive, relapsed, or refractory disease; AND
- Used in combination with rituximab
Pediatric Hodgkin Lymphoma ‡ 5,6
- Patient is 18 years of age and under*; AND
- Used in combination with brentuximab vedotin; AND
- Used as re-induction therapy or subsequent therapy (if not previously used) for relapsed or refractory disease; AND
- Used in patients heavily pretreated with platinum or anthracycline-based chemotherapy; OR
- Used if a decrease in cardiac function is observed
* Pediatric Hodgkin Lymphoma may be applicable to adolescent and young adult (AYA) patients up to the age of 39 years.
Multiple Myeloma ‡ Ф 5,14,22
- Used for relapsed or refractory disease after 3 prior therapies; AND
- Used as a single agent; OR
- Used in combination with dexamethasone AND either bortezomib, carfilzomib, or lenalidomide
Systemic Light Chain Amyloidosis ‡ 5,18
- Patient has relapsed or refractory disease; AND
- Used in combination with dexamethasone
Hematopoietic Cell Transplantation ‡ 5,19
- Used as conditioning for autologous transplant; AND
- Used in combination with etoposide, cytarabine and melphalan (BEAM); AND
- Patient has Non-Hodgkin Lymphoma without CNS disease or Hodgkin Lymphoma
Primary Cutaneous Lymphomas ‡ 5
- Patient has Mycosis Fungoides/Sezary Syndrome; AND
- Used in combination with brentuximab vedotin; AND
- Used as primary therapy for CD30+ disease; AND
- Patient has stage IVA2 non-Sezary or stage IVB visceral disease (solid organ); OR
- Patient has generalized cutaneous or extracutaneous lesions with large cell transformation (LCT); AND
- Used in combination with skin-directed therapy; OR
- Used as subsequent therapy; AND
- Used for disease refractory to multiple previous therapies; AND
- Used in combination with skin-directed therapy; AND
- Patient has stage IIB Mycosis Fungoides with generalized tumor lesions; OR
- Patient has stage III Mycosis Fungoides; OR
- Patient has limited cutaneous lesions with large cell transformation (LCT); OR
- Used for relapsed or persistent disease; AND
- Patient has stage IVA2 non-Sezary or stage IVB visceral disease (solid organ); OR
- Patient has LCT with generalized cutaneous or extracutaneous lesions; AND
- Used in combination with skin-directed therapy
- Used for disease refractory to multiple previous therapies; AND
† FDA Approved Indication(s); ‡ Compendia Recommended Indication(s); Ф Orphan Drug
- Renewal Criteria 1-5
Coverage may be renewed based upon the following criteria:
- Patient continues to meet the indication-specific relevant criteria such as concomitant therapy requirements (not including prerequisite therapy), performance status, etc. identified in section III; AND
- Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include: severe myelosuppression, infections, progressive multifocal leukoencephalopathy (PML), anaphylaxis, severe infusion reactions, tumor lysis syndrome (TLS), fatal and serious skin reactions, fatal and serious hepatotoxicity, secondary malignancies, extravasation injury, etc.; AND
Primary Cutaneous Lymphomas
- Refer to Section III for criteria (see Primary Cutaneous Lymphomas)
Waldenström Macroglobulinemia/Lymphoplasmacytic Lymphoma (if bendamustine was previously used as primary therapy)
- Refer to Section III for criteria (see WM/LPL)
All Other Indications
- Coverage may NOT be renewed.
- Dosage/Administration 1-6,9,14,18,26
Indication |
Dose |
Non-Hodgkin Lymphoma |
Up to 120 mg/m² intravenously on days 1 and 2 of a 21-day cycle, up to 8 cycles |
CLL/SLL & Systemic Light Chain Amyloidosis |
Up to 100 mg/m² intravenously on days 1 and 2 of a 28-day cycle, up to 6 cycles |
Waldenström Macroglobulinemia/ Lymphoplasmacytic Lymphoma |
Up to 90 mg/m2 intravenously on days 1 and 2 of a 28-day cycle, up to 6 cycles *May be repeated for relapsed disease if primary therapy was well tolerated and elicited a prolonged response. |
Hodgkin Lymphoma |
Up to 120 mg/m² intravenously on days 1 and 2 of a 28-day cycle, up to 6 cycles |
Multiple Myeloma |
Up to 100 mg/m² intravenously on days 1 and 2 of a 28-day cycle, up to 8 cycles |
HSCT Conditioning |
Up to 200 mg/m² intravenously on days –7 and –6 leading up to transplant. |
Primary Cutaneous Lymphomas |
90 mg/m2 intravenously on days 1 and 2 of a 21-day cycle until disease progression or unacceptable toxicity |
- Billing Code/Availability Information
HCPCS Code(s):
- J9033 – Injection, bendamustine hcl (treanda), 1 mg; 1 billable unit = 1 mg
- J9034 – Injection, bendamustine hcl (bendeka), 1 mg; 1 billable unit = 1 mg
- J9036 – Injection, bendamustine hydrochloride, (belrapzo/bendamustine), 1 mg; 1 billable unit = 1 mg
- J9056 – Injection, bendamustine hydrochloride (vivimusta), 1 mg; 1 billable unit = 1 mg
- J9058 – Injection, bendamustine hydrochloride (apotex), 1 mg; 1 billable unit = 1 mg
- J9059 – Injection, bendamustine hydrochloride (baxter), 1 mg; 1 billable unit = 1 mg
NDC(s):
- Treanda 100 mg lyophilized powder in a single-dose vial for reconstitution: 63459-0391-xx
- Treanda 25 mg lyophilized powder in a single-dose vial for reconstitution: 63459-0390-xx
- Treanda 45 mg/0.5 mL solution in a single-dose vial: 63459-0395-xx * §
- Treanda 180 mg/2 mL solution in a single-dose vial: 63459-0396-xx * §
- Bendeka 100 mg/4 mL ready-to-dilute solution in a multi-dose vial: 63459-0348-xx § Ψ
- Belrapzo 100 mg/4 mL ready-to-dilute solution in a multi-dose vial: 42367-0521-xx Ψ
- Vivimusta 100 mg/4 mL solution in a multi-dose vial: 71225-0120-xx Ψ
Ψ Designated products approved by the FDA as a 505(b)(2) NDA of the innovator product. These products are not rated as therapeutically equivalent to their reference listed drug in the Food and Drug Administration’s (FDA) Orange Book and are therefore considered single source products based on the statutory definition of “single source drug” in section 1847A(c)(6) of the Act. For a complete list of all approved 505(b)(2) NDA products please reference the latest edition of the Orange Book: Approved Drug Products with Therapeutic Equivalence Evaluations | Orange Book | FDA |
- References
- Treanda [package insert]. Parsippany, NJ; Teva Pharmaceuticals; October 2022. Accessed January 2024.
- Bendeka [package insert]. Parsippany, NJ; Teva Pharmaceuticals; January 2024. Accessed January 2024.
- Belrapzo [package insert]. Woodcliff Lake, NJ; Eagle Pharmaceuticals, Inc.; January 2024. Accessed January 2024.
- Vivimusta [package insert]. Princeton, NJ; Slayback Pharma LLC; December 2022. Accessed January 2024.
- Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) for bendamustine. National Comprehensive Cancer Network, 2024. 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 January 2024.
- Moskowitz AJ, Hamlin PA Jr, Perales MA, et al. Phase II study of bendamustine in relapsed and refractory Hodgkin lymphoma. J Clin Oncol. 2013;31(4):456-460.
- Kahl BS, Bartlett NL, Leonard JP, et al. Bendamustine is effective therapy in patients with rituximab-refractory, indolent B-cell non-Hodgkin lymphoma: results from a Multicenter Study. Cancer. 2010;116(1):106-114. doi:10.1002/cncr.24714.
- Knauf WU, Lissitchkov T, Aldaoud A, et al. Bendamustine compared with chlorambucil in previously untreated patients with chronic lymphocytic leukaemia: updated results of a randomized phase III trial. Br J Haematol. 2012;159(1):67-77. doi:10.1111/bjh.12000.
- Rummel MJ, Niederle N, Maschmeyer G, et al. Bendamustine plus rituximab versus CHOP plus rituximab as first-line treatment for patients with indolent and mantle-cell lymphomas: an open-label, multicentre, randomised, phase 3 non-inferiority trial [published correction appears in Lancet. 2013 Apr 6;381(9873):1184]. Lancet. 2013;381(9873):1203-1210. doi:10.1016/S0140-6736(12)61763-2.
- O'Connor OA, Lue JK, Sawas A, et al. Brentuximab vedotin plus bendamustine in relapsed or refractory Hodgkin's lymphoma: an international, multicentre, single-arm, phase 1-2 trial. Lancet Oncol 2018; 19:257-266.
- Santoro A, Mazza R, Pulsoni A, et al. Bendamustine in Combination With Gemcitabine and Vinorelbine Is an Effective Regimen As Induction Chemotherapy Before Autologous Stem-Cell Transplantation for Relapsed or Refractory Hodgkin Lymphoma: Final Results of a Multicenter Phase II Study. J Clin Oncol 2016; 34:3293.
- Budde LE, Wu D, Martin DB, et al. Bendamustine with rituximab, etoposide and carboplatin (T(R)EC) in relapsed or refractory aggressive lymphoma: a prospective multicentre phase 1/2 clinical trial. Br J Haematol. 2018;183(4):601-607. doi:10.1111/bjh.15585.
- Ludwig H, Kasparu H, Leitgeb C, et al. Bendamustine-bortezomib-dexamethasone is an active and well-tolerated regimen in patients with relapsed or refractory multiple myeloma. Blood. 2014;123(7):985-991. doi:10.1182/blood-2013-08-521468.
- Lentzsch S, O'Sullivan A, Kennedy RC, et al. Combination of bendamustine, lenalidomide, and dexamethasone (BLD) in patients with relapsed or refractory multiple myeloma is feasible and highly effective: results of phase 1/2 open-label, dose escalation study. Blood. 2012;119(20):4608-4613. doi:10.1182/blood-2011-12-395715.
- Knop S, Straka C, Haen M, Schwedes R, Hebart H, Einsele H. The efficacy and toxicity of bendamustine in recurrent multiple myeloma after high-dose chemotherapy. Haematologica. 2005;90(9):1287-1288.
- Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for B-Cell Lymphomas 1.2024. National Comprehensive Cancer Network, 2024. 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 Guidelines, go online to NCCN.org. Accessed January 2024.
- Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma 1.2024. National Comprehensive Cancer Network, 2024. 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 Guidelines, go online to NCCN.org. Accessed January 2024.
- Lentzsch S, Lagos G, Comenzo R, et.al. Bendamustine With Dexamethasone in Relapsed/Refractory Systemic Light-Chain Amyloidosis: Results of a Phase II Study. J Clin Oncol. 2020 May 1;38(13):1455-1462. doi: 10.1200/JCO.19.01721. Epub 2020 Feb 21.
- Frankiewicz A, Saduś-Wojciechowska M, Najda J, et al. Comparable safety profile of BeEAM (bendamustine, etoposide, cytarabine, melphalan) and BEAM (carmustine, etoposide, cytarabine, melphalan) as conditioning before autologous haematopoietic cell transplantation. Contemp Oncol (Pozn) 2018;22:113-117
- Sehn LH, Chua N, Mayer J, et al. Obinutuzumab plus bendamustine versus bendamustine monotherapy in patients with rituximab-refractory indolent non-Hodgkin lymphoma (GADOLIN): a randomised, controlled, open-label, multicentre, phase 3 trial. Lancet Oncol 2016;17:1081-1093.
- Rummel M, Kaiser U, Balser C, et al. Bendamustine plus rituximab versus fludarabine plus rituximab for patients with relapsed indolent and mantle-cell lymphomas: a multicentre, randomised, open-label, non-inferiority phase 3 trial. Lancet Oncol. 2016 Jan;17(1):57-66.
- Gay F, Gunther A, Offidani M, et al. Carfilzomib, bendamustine, and dexamethasone in patients with advanced multiple myeloma: The EMN09 phase 1/2 study of the European Myeloma Network. Cancer 2021;127:3413-3421.
- Minnema MC, Kimby E, D'Sa S, et al. Guideline for the diagnosis, treatment and response criteria for Bing-Neel syndrome. Haematologica 2017;102:43-51.
- Varettoni M, Marchioni E, Bonfichi M, et al. Successful treatment with Rituximab and Bendamustine in a patient with newly diagnosed Waldenstrom’s Macroglobulinemia complicated by Bing-Neel syndrome. Am J Hematol. 2015; 90(8):E152–E153.
- Damaj G, Gressin R, Bouabdallah K, et al. Results from a prospective, open-label, phase II trial of bendamustine in refractory or relapsed T-cell lymphomas: the BENTLY trial. J Clin Oncol 2013;31:104- 110.
- Aubrais R, Bouabdallah K, Chartier L, et al. Salvage therapy with brentuximab-vedotin and bendamustine for patients with R/R PTCL: a retrospective study from the LYSA group. Blood Adv. 2023 Oct 10; 7(19): 5733–5742. Published online 2022 Dec 10. doi: 10.1182/bloodadvances.2022008524.
Appendix 1 – Covered Diagnosis Codes
ICD-10 |
ICD-10 Description |
C81.00 |
Nodular lymphocyte predominant Hodgkin lymphoma, unspecified site |
C81.01 |
Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of head, face, and neck |
C81.02 |
Nodular lymphocyte predominant Hodgkin lymphoma, intrathoracic lymph nodes |
C81.03 |
Nodular lymphocyte predominant Hodgkin lymphoma, intra-abdominal lymph nodes |
C81.04 |
Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of axilla and upper limb |
C81.05 |
Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
C81.06 |
Nodular lymphocyte predominant Hodgkin lymphoma, intrapelvic lymph nodes |
C81.07 |
Nodular lymphocyte predominant Hodgkin lymphoma, spleen |
C81.08 |
Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of multiple sites |
C81.09 |
Nodular lymphocyte predominant Hodgkin lymphoma, extranodal and solid organ sites |
C81.10 |
Nodular sclerosis Hodgkin lymphoma, unspecified site |
C81.11 |
Nodular sclerosis Hodgkin lymphoma, lymph nodes of head, face, and neck |
C81.12 |
Nodular sclerosis Hodgkin lymphoma, intrathoracic lymph nodes |
C81.13 |
Nodular sclerosis Hodgkin lymphoma, intra-abdominal lymph nodes |
C81.14 |
Nodular sclerosis Hodgkin lymphoma, lymph nodes of axilla and upper limb |
C81.15 |
Nodular sclerosis Hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
C81.16 |
Nodular sclerosis Hodgkin lymphoma, intrapelvic lymph nodes |
C81.17 |
Nodular sclerosis Hodgkin lymphoma, spleen |
C81.18 |
Nodular sclerosis Hodgkin lymphoma, lymph nodes of multiple sites |
C81.19 |
Nodular sclerosis Hodgkin lymphoma, extranodal and solid organ sites |
C81.20 |
Mixed cellularity Hodgkin lymphoma, unspecified site |
C81.21 |
Mixed cellularity Hodgkin lymphoma, lymph nodes of head, face, and neck |
C81.22 |
Mixed cellularity Hodgkin lymphoma, intrathoracic lymph nodes |
C81.23 |
Mixed cellularity Hodgkin lymphoma, intra-abdominal lymph nodes |
C81.24 |
Mixed cellularity Hodgkin lymphoma, lymph nodes of axilla and upper limb |
C81.25 |
Mixed cellularity Hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
C81.26 |
Mixed cellularity Hodgkin lymphoma, intrapelvic lymph nodes |
C81.27 |
Mixed cellularity Hodgkin lymphoma, spleen |
C81.28 |
Mixed cellularity Hodgkin lymphoma, lymph nodes of multiple sites |
C81.29 |
Mixed cellularity Hodgkin lymphoma, extranodal and solid organ sites |
C81.30 |
Lymphocyte depleted Hodgkin lymphoma, unspecified site |
C81.31 |
Lymphocyte depleted Hodgkin lymphoma, lymph nodes of head, face, and neck |
C81.32 |
Lymphocyte depleted Hodgkin lymphoma, intrathoracic lymph nodes |
C81.33 |
Lymphocyte depleted Hodgkin lymphoma, intra-abdominal lymph nodes |
C81.34 |
Lymphocyte depleted Hodgkin lymphoma, lymph nodes of axilla and upper limb |
C81.35 |
Lymphocyte depleted Hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
C81.36 |
Lymphocyte depleted Hodgkin lymphoma, intrapelvic lymph nodes |
C81.37 |
Lymphocyte depleted Hodgkin lymphoma, spleen |
C81.38 |
Lymphocyte depleted Hodgkin lymphoma, lymph nodes of multiple sites |
C81.39 |
Lymphocyte depleted Hodgkin lymphoma, extranodal and solid organ sites |
C81.40 |
Lymphocyte-rich Hodgkin lymphoma, unspecified site |
C81.41 |
Lymphocyte-rich Hodgkin lymphoma, lymph nodes of head, face, and neck |
C81.42 |
Lymphocyte-rich Hodgkin lymphoma, intrathoracic lymph nodes |
C81.43 |
Lymphocyte-rich Hodgkin lymphoma, intra-abdominal lymph nodes |
C81.44 |
Lymphocyte-rich Hodgkin lymphoma, lymph nodes of axilla and upper limb |
C81.45 |
Lymphocyte-rich Hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
C81.46 |
Lymphocyte-rich Hodgkin lymphoma, intrapelvic lymph nodes |
C81.47 |
Lymphocyte-rich Hodgkin lymphoma, spleen |
C81.48 |
Lymphocyte-rich Hodgkin lymphoma, lymph nodes of multiple sites |
C81.49 |
Lymphocyte-rich Hodgkin lymphoma, extranodal and solid organ sites |
C81.70 |
Other Hodgkin lymphoma unspecified site |
C81.71 |
Other Hodgkin lymphoma lymph nodes of head, face, and neck |
C81.72 |
Other Hodgkin lymphoma intrathoracic lymph nodes |
C81.73 |
Other Hodgkin lymphoma intra-abdominal lymph nodes |
C81.74 |
Other Hodgkin lymphoma lymph nodes of axilla and upper limb |
C81.75 |
Other Hodgkin lymphoma lymph nodes of inguinal region and lower limb |
C81.76 |
Other Hodgkin lymphoma intrapelvic lymph nodes |
C81.77 |
Other Hodgkin lymphoma spleen |
C81.78 |
Other Hodgkin lymphoma lymph nodes of multiple sites |
C81.79 |
Other Hodgkin lymphoma extranodal and solid organ sites |
C81.90 |
Hodgkin lymphoma, unspecified, unspecified site |
C81.91 |
Hodgkin lymphoma, unspecified, lymph nodes of head, face, and neck |
C81.92 |
Hodgkin lymphoma, unspecified, intrathoracic lymph nodes |
C81.93 |
Hodgkin lymphoma, unspecified, intra-abdominal lymph nodes |
C81.94 |
Hodgkin lymphoma, unspecified, lymph nodes of axilla and upper limb |
C81.95 |
Hodgkin lymphoma, unspecified, lymph nodes of inguinal region and lower limb |
C81.96 |
Hodgkin lymphoma, unspecified, intrapelvic lymph nodes |
C81.97 |
Hodgkin lymphoma, unspecified, spleen |
C81.98 |
Hodgkin lymphoma, unspecified, lymph nodes of multiple sites |
C81.99 |
Hodgkin lymphoma, unspecified, extranodal and solid organ sites |
C82.00 |
Follicular lymphoma grade I, unspecified site |
C82.01 |
Follicular lymphoma grade I, lymph nodes of head, face and neck |
C82.02 |
Follicular lymphoma, grade I, intrathoracic lymph nodes |
C82.03 |
Follicular lymphoma grade I, intra-abdominal lymph nodes |
C82.04 |
Follicular lymphoma grade I, lymph nodes of axilla and upper limb |
C82.05 |
Follicular lymphoma grade I, lymph nodes of inguinal regional and lower limb |
C82.06 |
Follicular lymphoma grade I, intrapelvic lymph nodes |
C82.07 |
Follicular lymphoma grade I, spleen |
C82.08 |
Follicular lymphoma grade I, lymph nodes of multiple sites |
C82.09 |
Follicular lymphoma grade I, extranodal and solid organ sites |
C82.10 |
Follicular lymphoma grade II, unspecified site |
C82.11 |
Follicular lymphoma grade II, lymph nodes of head, face and neck |
C82.12 |
Follicular lymphoma, grade II, intrathoracic lymph nodes |
C82.13 |
Follicular lymphoma grade II, intra-abdominal lymph nodes |
C82.14 |
Follicular lymphoma grade II, lymph nodes of axilla and upper limb |
C82.15 |
Follicular lymphoma grade II, lymph nodes of inguinal region and lower limb |
C82.16 |
Follicular lymphoma grade II, intrapelvic lymph nodes |
C82.17 |
Follicular lymphoma grade II, spleen |
C82.18 |
Follicular lymphoma grade II, lymph nodes of multiple sites |
C82.19 |
Follicular lymphoma grade II, extranodal and solid organ sites |
C82.20 |
Follicular lymphoma grade III, unspecified, unspecified site |
C82.21 |
Follicular lymphoma grade III, unspecified, lymph nodes of head, face and neck |
C82.22 |
Follicular lymphoma, grade III, unspecified, intrathoracic lymph nodes |
C82.23 |
Follicular lymphoma grade III, unspecified, intra-abdominal lymph nodes |
C82.24 |
Follicular lymphoma grade III, unspecified, lymph nodes of axilla and upper limb |
C82.25 |
Follicular lymphoma grade III, unspecified, lymph nodes of inguinal region and lower limb |
C82.26 |
Follicular lymphoma grade III, unspecified, intrapelvic lymph nodes |
C82.27 |
Follicular lymphoma grade III, unspecified, spleen |
C82.28 |
Follicular lymphoma grade III, unspecified, lymph nodes of multiple sites |
C82.29 |
Follicular lymphoma grade III, unspecified, extranodal and solid organ sites |
C82.30 |
Follicular lymphoma grade IIIa, unspecified site |
C82.31 |
Follicular lymphoma grade IIIa, lymph nodes of head, face and neck |
C82.32 |
Follicular lymphoma, grade IIIa, intrathoracic lymph nodes |
C82.33 |
Follicular lymphoma grade IIIa, intra-abdominal lymph nodes |
C82.34 |
Follicular lymphoma grade IIIa, lymph nodes of axilla and upper limb |
C82.35 |
Follicular lymphoma grade IIIa, lymph nodes of inguinal region and lower limb |
C82.36 |
Follicular lymphoma grade IIIa, intrapelvic lymph nodes |
C82.37 |
Follicular lymphoma grade IIIa, spleen |
C82.38 |
Follicular lymphoma grade IIIa, lymph nodes of multiple sites |
C82.39 |
Follicular lymphoma grade IIIa, extranodal and solid organ sites |
C82.40 |
Follicular lymphoma grade IIIb, unspecified site |
C82.41 |
Follicular lymphoma grade IIIb, lymph nodes of head, face and neck |
C82.42 |
Follicular lymphoma, grade IIIb, intrathoracic lymph nodes |
C82.43 |
Follicular lymphoma grade IIIb, intra-abdominal lymph nodes |
C82.44 |
Follicular lymphoma grade IIIb, lymph nodes of axilla and upper limb |
C82.45 |
Follicular lymphoma grade IIIb, lymph nodes of inguinal region and lower limb |
C82.46 |
Follicular lymphoma grade IIIb, intrapelvic lymph nodes |
C82.47 |
Follicular lymphoma grade IIIb, spleen |
C82.48 |
Follicular lymphoma grade IIIb, lymph nodes of multiple sites |
C82.49 |
Follicular lymphoma grade IIIb, extranodal and solid organ sites |
C82.50 |
Diffuse follicle center lymphoma unspecified site |
C82.51 |
Diffuse follicle center lymphoma lymph nodes of head, face, and neck |
C82.52 |
Diffuse follicle center lymphoma intrathoracic lymph nodes |
C82.53 |
Diffuse follicle center lymphoma intra-abdominal lymph nodes |
C82.54 |
Diffuse follicle center lymphoma lymph nodes of axilla and upper limb |
C82.55 |
Diffuse follicle center lymphoma lymph nodes of inguinal region and lower limb |
C82.56 |
Diffuse follicle center lymphoma intrapelvic lymph nodes |
C82.57 |
Diffuse follicle center lymphoma spleen |
C82.58 |
Diffuse follicle center lymphoma lymph nodes of multiple sites |
C82.59 |
Diffuse follicle center lymphoma extranodal and solid organ sites |
C82.60 |
Cutaneous follicle center lymphoma, unspecified site |
C82.61 |
Cutaneous follicle center lymphoma, lymph nodes of head, face and neck |
C82.62 |
Cutaneous follicle center lymphoma, intrathoracic lymph nodes |
C82.63 |
Cutaneous follicle center lymphoma, intra-abdominal lymph nodes |
C82.64 |
Cutaneous follicle center lymphoma, lymph nodes of axilla and upper limb |
C82.65 |
Cutaneous follicle center lymphoma, lymph nodes of inguinal region and lower limb |
C82.66 |
Cutaneous follicle center lymphoma, intrapelvic lymph nodes |
C82.67 |
Cutaneous follicle center lymphoma, spleen |
C82.68 |
Cutaneous follicle center lymphoma, lymph nodes of multiple sites |
C82.69 |
Cutaneous follicle center lymphoma, extranodal and solid organ sites |
C82.80 |
Other types of follicular lymphoma unspecified site |
C82.81 |
Other types of follicular lymphoma lymph nodes of head, face, and neck |
C82.82 |
Other types of follicular lymphoma intrathoracic lymph nodes |
C82.83 |
Other types of follicular lymphoma intra-abdominal lymph nodes |
C82.84 |
Other types of follicular lymphoma lymph nodes of axilla and upper limb |
C82.85 |
Other types of follicular lymphoma lymph nodes of inguinal region and lower limb |
C82.86 |
Other types of follicular lymphoma intrapelvic lymph nodes |
C82.87 |
Other types of follicular lymphoma spleen |
C82.88 |
Other types of follicular lymphoma lymph nodes of multiple sites |
C82.89 |
Other types of follicular lymphoma extranodal and solid organ sites |
C82.90 |
Follicular lymphoma, unspecified, unspecified site |
C82.91 |
Follicular lymphoma, unspecified, lymph nodes of head, face and neck |
C82.92 |
Follicular lymphoma, unspecified, intrathoracic lymph nodes |
C82.93 |
Follicular lymphoma, unspecified, intra-abdominal lymph nodes |
C82.94 |
Follicular lymphoma, unspecified, lymph nodes of axilla and upper limb |
C82.95 |
Follicular lymphoma, unspecified lymph nodes of inguinal region and lower limb |
C82.96 |
Follicular lymphoma, unspecified, intrapelvic lymph nodes |
C82.97 |
Follicular lymphoma, unspecified, spleen |
C82.98 |
Follicular lymphoma, unspecified, lymph nodes of multiple sites |
C82.99 |
Follicular lymphoma, unspecified, extranodal and solid organ sites |
C83.00 |
Small cell B-cell lymphoma, unspecified site |
C83.01 |
Small cell B-cell lymphoma, lymph nodes of head, face and neck |
C83.02 |
Small cell B-cell lymphoma, intrathoracic lymph nodes |
C83.03 |
small cell B-cell lymphoma, intra-abdominal lymph nodes |
C83.04 |
Small cell B-cell lymphoma, lymph nodes of axilla and upper limb |
C83.05 |
Small cell B-cell lymphoma, lymph nodes of inguinal region and lower limb |
C83.06 |
Small cell B-cell lymphoma, intrapelvic lymph nodes |
C83.07 |
Small cell B-cell lymphoma, spleen |
C83.08 |
Small cell B-cell lymphoma, lymph nodes of multiple sites |
C83.09 |
Small cell B-cell lymphoma, extranodal and solid organ sites |
C83.10 |
Mantle cell lymphoma, unspecified site |
C83.11 |
Mantle cell lymphoma, lymph nodes of head, face and neck |
C83.12 |
Mantle cell lymphoma, intrathoracic lymph nodes |
C83.13 |
Mantle cell lymphoma, intra-abdominal lymph nodes |
C83.14 |
Mantle cell lymphoma, lymph nodes of axilla and upper limb |
C83.15 |
Mantle cell lymphoma, lymph nodes of inguinal region and lower limb |
C83.16 |
Mantle cell lymphoma, intrapelvic lymph nodes |
C83.17 |
Mantle cell lymphoma, spleen |
C83.18 |
Mantle cell lymphoma, lymph nodes of multiple sites |
C83.19 |
Mantle cell lymphoma, extranodal and solid organ sites |
C83.30 |
Diffuse large B-cell lymphoma, unspecified site |
C83.31 |
Diffuse large B-cell lymphoma, lymph nodes of head, face and neck |
C83.32 |
Diffuse large B-cell lymphoma intrathoracic lymph nodes |
C83.33 |
Diffuse large B-cell lymphoma, intra-abdominal lymph nodes |
C83.34 |
Diffuse large B-cell lymphoma, lymph nodes of axilla and upper limb |
C83.35 |
Diffuse large B-cell lymphoma, lymph nodes of inguinal region and lower limb |
C83.37 |
Diffuse large B-cell lymphoma, spleen |
C83.38 |
Diffuse large B-cell lymphoma, lymph nodes of multiple sites |
C83.39 |
Diffuse large B-cell lymphoma, extranodal and solid organ sites |
C83.80 |
Other non-follicular lymphoma, unspecified site |
C83.81 |
Other non-follicular lymphoma, lymph nodes of head, face and neck |
C83.82 |
Other non-follicular lymphoma, intrathoracic lymph nodes |
C83.83 |
Other non-follicular lymphoma, intra-abdominal lymph nodes |
C83.84 |
Other non-follicular lymphoma, lymph nodes of axilla and upper limb |
C83.85 |
Other non-follicular lymphoma, lymph nodes of inguinal region and lower limb |
C83.86 |
Other non-follicular lymphoma, intrapelvic lymph nodes |
C83.87 |
Other non-follicular lymphoma, spleen |
C83.88 |
Other non-follicular lymphoma, lymph nodes of multiple sites |
C83.89 |
Other non-follicular lymphoma, extranodal and solid organ sites |
C83.90 |
Non-follicular (diffuse) lymphoma, unspecified site |
C83.91 |
Non-follicular (diffuse) lymphoma, unspecified lymph nodes of head, face, and neck |
C83.92 |
Non-follicular (diffuse) lymphoma, unspecified intrathoracic lymph nodes |
C83.93 |
Non-follicular (diffuse) lymphoma, unspecified intra-abdominal lymph nodes |
C83.94 |
Non-follicular (diffuse) lymphoma, unspecified lymph nodes of axilla and upper limb |
C83.95 |
Non-follicular (diffuse) lymphoma, unspecified lymph nodes of inguinal region and lower limb |
C83.96 |
Non-follicular (diffuse) lymphoma, unspecified intrapelvic lymph nodes |
C83.97 |
Non-follicular (diffuse) lymphoma, unspecified spleen |
C83.98 |
Non-follicular (diffuse) lymphoma, unspecified lymph nodes of multiple sites |
C83.99 |
Non-follicular (diffuse) lymphoma, unspecified extranodal and solid organ sites |
C84.00 |
Mycosis fungoides, unspecified site |
C84.01 |
Mycosis fungoides, lymph nodes of head, face, and neck |
C84.02 |
Mycosis fungoides, intrathoracic lymph nodes |
C84.03 |
Mycosis fungoides, intra-abdominal lymph nodes |
C84.04 |
Mycosis fungoides, lymph nodes of axilla and upper limb |
C84.05 |
Mycosis fungoides, lymph nodes of inguinal region and lower limb |
C84.06 |
Mycosis fungoides, intrapelvic lymph nodes |
C84.07 |
Mycosis fungoides, spleen |
C84.08 |
Mycosis fungoides, lymph nodes of multiple sites |
C84.09 |
Mycosis fungoides, extranodal and solid organ sites |
C84.10 |
Sézary disease, unspecified site |
C84.11 |
Sézary disease, lymph nodes of head, face, and neck |
C84.12 |
Sézary disease, intrathoracic lymph nodes |
C84.13 |
Sézary disease, intra-abdominal lymph nodes |
C84.14 |
Sézary disease, lymph nodes of axilla and upper limb |
C84.15 |
Sézary disease, lymph nodes of inguinal region and lower limb |
C84.16 |
Sézary disease, intrapelvic lymph nodes |
C84.17 |
Sézary disease, spleen |
C84.18 |
Sézary disease, lymph nodes of multiple sites |
C84.19 |
Sézary disease, extranodal and solid organ sites |
C84.40 |
Peripheral T-cell lymphoma, not classified, unspecified site |
C84.41 |
Peripheral T-cell lymphoma, not classified, lymph nodes of head, face, and neck |
C84.42 |
Peripheral T-cell lymphoma, not classified, intrathoracic lymph nodes |
C84.43 |
Peripheral T-cell lymphoma, not classified, intra-abdominal lymph nodes |
C84.44 |
Peripheral T-cell lymphoma, not classified, lymph nodes of axilla and upper limb |
C84.45 |
Peripheral T-cell lymphoma, not classified, lymph nodes of inguinal region and lower limb |
C84.46 |
Peripheral T-cell lymphoma, not classified, intrapelvic lymph nodes |
C84.47 |
Peripheral T-cell lymphoma, not classified, spleen |
C84.48 |
Peripheral T-cell lymphoma, not classified, lymph nodes of multiple sites |
C84.49 |
Peripheral T-cell lymphoma, not classified, extranodal and solid organ sites |
C84.60 |
Anaplastic large cell lymphoma, ALK-positive, unspecified site |
C84.61 |
Anaplastic large cell lymphoma, ALK-positive, lymph nodes of head, face, and neck |
C84.62 |
Anaplastic large cell lymphoma, ALK-positive, intrathoracic lymph nodes |
C84.63 |
Anaplastic large cell lymphoma, ALK-positive, intra-abdominal lymph nodes |
C84.64 |
Anaplastic large cell lymphoma, ALK-positive, lymph nodes of axilla and upper limb |
C84.65 |
Anaplastic large cell lymphoma, ALK-positive, lymph nodes of inguinal region and lower limb |
C84.66 |
Anaplastic large cell lymphoma, ALK-positive, intrapelvic lymph nodes |
C84.67 |
Anaplastic large cell lymphoma, ALK-positive, spleen |
C84.68 |
Anaplastic large cell lymphoma, ALK-positive, lymph nodes of multiple sites |
C84.69 |
Anaplastic large cell lymphoma, ALK-positive, extranodal and solid organ sites |
C84.7A |
Anaplastic large cell lymphoma, ALK-negative, breast |
C84.70 |
Anaplastic large cell lymphoma, ALK-negative, unspecified site |
C84.71 |
Anaplastic large cell lymphoma, ALK-negative, lymph nodes of head, face, and neck |
C84.72 |
Anaplastic large cell lymphoma, ALK-negative, intrathoracic lymph nodes |
C84.73 |
Anaplastic large cell lymphoma, ALK-negative, intra-abdominal lymph nodes |
C84.74 |
Anaplastic large cell lymphoma, ALK-negative, lymph nodes of axilla and upper limb |
C84.75 |
Anaplastic large cell lymphoma, ALK-negative, lymph nodes of inguinal region and lower limb |
C84.76 |
Anaplastic large cell lymphoma, ALK-negative, intrapelvic lymph nodes |
C84.77 |
Anaplastic large cell lymphoma, ALK-negative, spleen |
C84.78 |
Anaplastic large cell lymphoma, ALK-negative, lymph nodes of multiple sites |
C84.79 |
Anaplastic large cell lymphoma, ALK-negative, extranodal and solid organ sites |
C84.90 |
Mature T/NK-cell lymphomas, unspecified, unspecified site |
C84.91 |
Mature T/NK-cell lymphomas, unspecified, lymph nodes of head, face and neck |
C84.92 |
Mature T/NK-cell lymphomas, unspecified, intrathoracic lymph nodes |
C84.93 |
Mature T/NK-cell lymphomas, unspecified, intra-abdominal lymph nodes |
C84.94 |
Mature T/NK-cell lymphomas, unspecified, lymph nodes of axilla and upper limb |
C84.95 |
Mature T/NK-cell lymphomas, unspecified, lymph nodes of inguinal region and lower limb |
C84.96 |
Mature, T/NK-cell lymphomas, unspecified, intrapelvic lymph nodes |
C84.97 |
Mature T/NK-cell lymphomas, unspecified, spleen |
C84.98 |
Mature T/NK-cell lymphomas, unspecified, lymph nodes of multiple sites |
C84.99 |
Mature T/NK-cell lymphomas, unspecified, extranodal and solid organ sites |
C84.Z0 |
Other mature T/NK-cell lymphomas, unspecified site |
C84.Z1 |
Other mature T/NK-cell lymphomas, lymph nodes of head, face and neck |
C84.Z2 |
Other mature T/NK-cell lymphomas, intrathoracic lymph nodes |
C84.Z3 |
Other mature T/NK-cell lymphomas, intra-abdominal lymph nodes |
C84.Z4 |
Other mature T/NK-cell lymphomas, lymph nodes of axilla and upper limb |
C84.Z5 |
Other mature T/NK-cell lymphomas, lymph nodes of inguinal region and lower limb |
C84.Z6 |
Other mature T/NK-cell lymphomas, intrapelvic lymph nodes |
C84.Z7 |
Other mature T/NK-cell lymphomas, spleen |
C84.Z8 |
Other mature T/NK-cell lymphomas, lymph nodes of multiple sites |
C84.Z9 |
Other mature T/NK-cell lymphomas, extranodal and solid organ sites |
C85.10 |
Unspecified B-cell lymphoma, unspecified site |
C85.11 |
Unspecified B-cell lymphoma, lymph nodes of head, face, and neck |
C85.12 |
Unspecified B-cell lymphoma, intrathoracic lymph nodes |
C85.13 |
Unspecified B-cell lymphoma, intra-abdominal lymph nodes |
C85.14 |
Unspecified B-cell lymphoma, lymph nodes of axilla and upper limb |
C85.15 |
Unspecified B-cell lymphoma, lymph nodes of inguinal region and lower limb |
C85.16 |
Unspecified B-cell lymphoma, intrapelvic lymph nodes |
C85.17 |
Unspecified B-cell lymphoma, spleen |
C85.18 |
Unspecified B-cell lymphoma, lymph nodes of multiple sites |
C85.19 |
Unspecified B-cell lymphoma, extranodal and solid organ sites |
C85.20 |
Mediastinal (thymic) large B-cell lymphoma unspecified site |
C85.21 |
Mediastinal (thymic) large B-cell lymphoma lymph nodes of head, face, and neck |
C85.22 |
Mediastinal (thymic) large B-cell lymphoma intrathoracic lymph nodes |
C85.23 |
Mediastinal (thymic) large B-cell lymphoma intra-abdominal lymph nodes |
C85.24 |
Mediastinal (thymic) large B-cell lymphoma lymph nodes of axilla and upper limb |
C85.25 |
Mediastinal (thymic) large B-cell lymphoma lymph nodes of inguinal region and lower limb |
C85.26 |
Mediastinal (thymic) large B-cell lymphoma intrapelvic lymph nodes |
C85.27 |
Mediastinal (thymic) large B-cell lymphoma spleen |
C85.28 |
Mediastinal (thymic) large B-cell lymphoma lymph nodes of multiple sites |
C85.29 |
Mediastinal (thymic) large B-cell lymphoma extranodal and solid organ sites |
C85.80 |
Other specified types of non-Hodgkin lymphoma, unspecified site |
C85.81 |
Other specified types of non-Hodgkin lymphoma, lymph nodes of head, face and neck |
C85.82 |
Other specified types of non-Hodgkin lymphoma, intrathoracic lymph nodes |
C85.83 |
Other specified types of non-Hodgkin lymphoma, intra-abdominal lymph nodes |
C85.84 |
Other specified types of non-Hodgkin lymphoma, lymph nodes of axilla and upper limb |
C85.85 |
Other specified types of non-Hodgkin lymphoma, lymph nodes of inguinal region of lower limb |
C85.86 |
Other specified types of non-Hodgkin lymphoma, intrapelvic lymph nodes |
C85.87 |
Other specified types of non-Hodgkin lymphoma, spleen |
C85.88 |
Other specified types of non-Hodgkin lymphoma, lymph nodes of multiple sites |
C85.89 |
Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites |
C86.1 |
Hepatosplenic T-cell lymphoma |
C86.2 |
Enteropathy-type (intestinal) T-cell lymphoma |
C86.5 |
Angioimmunoblastic T-cell lymphoma |
C88.0 |
Waldenström macroglobulinemia |
C88.4 |
Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT-lymphoma) |
C90.00 |
Multiple myeloma not having achieved remission |
C90.02 |
Multiple myeloma in relapse |
C90.10 |
Plasma cell leukemia not having achieved remission |
C90.12 |
Plasma cell leukemia in relapse |
C90.20 |
Extramedullary plasmacytoma not having achieved remission |
C90.22 |
Extramedullary plasmacytoma in relapse |
C90.30 |
Solitary plasmacytoma not having achieved remission |
C90.32 |
Solitary plasmacytoma in relapse |
C91.10 |
Chronic lymphocytic leukemia of B-cell type not having achieved remission |
C91.12 |
Chronic lymphocytic leukemia of B-cell type in relapse |
C91.50 |
Adult T-cell lymphoma/leukemia (HTLV-1-associated) not having achieved remission |
C91.52 |
Adult T-cell lymphoma/leukemia (HTLV-1-associated) in relapse |
D47.Z1 |
Post-transplant lymphoproliferative disorder (PTLD) |
E85.3 |
Secondary systemic amyloidosis |
E85.4 |
Organ-limited amyloidosis |
E85.81 |
Light chain (AL) amyloidosis |
E85.89 |
Other amyloidosis |
E85.9 |
Amyloidosis, unspecified |
Z85.71 |
Personal history of Hodgkin lymphoma |
Z85.72 |
Personal history of non-Hodgkin lymphomas |
Z85.79 |
Personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues |
Z94.81 |
Bone marrow transplant status |
Z94.89 |
Other transplanted organ and tissue status |
Z94.9 |
Transplanted organ and tissue status, unspecified |
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, LLC |
M (11) |
NC, SC, WV, VA (excluding below) |
Palmetto GBA, LLC |
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 |