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Asset Publisher
Kymriah (tisagenlecleucel) (Intravenous)
Policy Number: VP-0319
Intravenous
Last Review Date: 10/30/2023
Date of Origin: 09/19/2017
Dates Reviewed: 09/2017, 06/2018, 11/2018, 10/2019, 12/2019, 11/2020, 11/2021, 07/2022, 11/2022, 11/2023
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
Coverage will be provided for one treatment course (1 dose of Kymriah) and may not be renewed.
- Dosing Limits
A. Quantity Limit (max daily dose) [NDC Unit]:
- 1 dose of up to 600 million CAR-positive viable T-cells (supplied as 1-3 infusion bags)
B. Max Units (per dose and over time) [HCPCS Unit]:
- 1 billable unit (1 infusion of up to 600 million CAR-positive viable T-cells)
- Initial Approval Criteria 1,4-7
Submission of medical records (chart notes) related to the medical necessity criteria is REQUIRED on all requests for authorizations. Records will be reviewed at the time of submission. Please provide documentation related to diagnosis, step therapy, and clinical markers (i.e. genetic and mutational testing) supporting initiation when applicable. Please provide documentation via direct upload through the PA web portal or by fax. |
Coverage is provided in the following conditions:
- Patient does not have an active infection or inflammatory disorder; AND
- Patient has not received live vaccines within 6 weeks prior to the start of lymphodepleting chemotherapy, and will not receive live vaccines during tisagenlecleucel treatment and until immune recovery following treatment; AND
- Patient has been screened for hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) in accordance with clinical guidelines prior to collection of cells (leukapheresis); AND
- Prophylaxis for infection will be followed according to local guidelines; AND
- Healthcare facility has enrolled in the Kymriah REMS Program and training has been given to providers on the management of cytokine release syndrome (CRS) and neurological toxicities; AND
- Patient has not received prior CAR-T therapy; AND
- Patient has not received other anti-CD19 therapy (e.g., blinatumomab, tafasitamab, loncastuximab tesirine, etc.) OR patient previously received other anti-CD19 therapy and re-biopsy indicates CD-19 positive disease; AND
- Used as single agent therapy (not applicable to lymphodepleting or bridging chemotherapy while awaiting manufacture); AND
Adult B-Cell Precursor Acute Lymphoblastic Leukemia (ALL) † Ф 1,8,10-13
- Patient is 18 to 25 years of age; AND
- Patient has Philadelphia chromosome (Ph)-positive disease; AND
- Patient has refractory disease; OR
- Disease is in second or greater relapse and previous therapy has included two (2) tyrosine kinase inhibitors (e.g., dasatinib, imatinib, ponatinib, nilotinib, or bosutinib.); OR
- Patient has Philadelphia chromosome (Ph)-negative disease; AND
- Disease is refractory or in second or later relapse
Pediatric B-Cell Precursor Acute Lymphoblastic Leukemia (ALL) † Ф 1,8,10-13
- Patient is 2 to 17 years of age; AND
- Patient has Philadelphia chromosome (Ph)-positive disease; AND
- Disease is tyrosine kinase inhibitor (TKI) intolerant or refractory; OR
- Patient has relapsed disease post-hematopoietic stem cell transplant (HSCT); OR
- Patient has Philadelphia chromosome (Ph)-negative disease; AND
- Disease is refractory or in second or later relapse
B-Cell Lymphomas † ‡ Ф 1,3,8,9,14-16
- Patient is at least 18 years of age; AND
- Patient has an ECOG performance status of 0-1; AND
- Patient does not have primary central nervous system lymphoma; AND
- Patient has follicular lymphoma (grade 1, 2 or 3A); AND
- Patient has received at least two (2) prior lines of systemic therapy; AND
- Patient has had partial or no response OR has relapsed, refractory, or progressive disease; OR
- Patient has histologic transformation of follicular lymphoma or nodal marginal zone lymphoma to diffuse large B-cell lymphoma (DLBCL) OR Richter’s transformation of CLL to DLBCL; AND
- Patient has follicular lymphoma (grade 1, 2 or 3A); AND
- Patient has received at least two (2) prior lines of chemoimmunotherapy for indolent or transformed disease which must have included an anthracycline or anthracenedione-based regimen, unless contraindicated; OR
- Patient has DLBCL or monomorphic post-transplant lymphoproliferative disorder (B-cell type); AND
- Patient has received at least two (2) prior lines of therapy; AND
- Used as additional therapy for relapsed or refractory disease >12 months after completion of first-line therapy if partial response following second-line therapy; OR
- Used for treatment of disease that is in second or greater relapse in patients with partial response, no response, or progressive disease following therapy for relapsed or refractory disease; OR
- Patient has HIV-related B-cell lymphoma (i.e., HIV-related DLBCL, primary effusion lymphoma, or HHV8-positive DLBCL, not otherwise specified) or high-grade B-cell lymphoma; AND
- Patient has received at least two (2) prior lines of therapy; AND
- Used as additional therapy for relapsed or refractory disease >12 months after completion of first-line therapy in patients with intention to proceed to transplant who have a partial response following second-line therapy; OR
- Used for treatment of disease that is in second or greater relapse in patients with partial response, no response, or progressive disease following therapy for relapsed or refractory disease
- Patient has received at least two (2) prior lines of therapy; AND
- Patient has received at least two (2) prior lines of therapy; AND
- Patient has DLBCL or monomorphic post-transplant lymphoproliferative disorder (B-cell type); AND
† FDA Approved Indication(s); ‡ Compendia Recommended Indication(s); Ф Orphan Drug
- Renewal Criteria
Coverage cannot be renewed.
- Dosage/Administration 1
Indication |
Dose |
|
B-Cell Precursor ALL
|
Lymphodepleting chemotherapy:
Kymriah Infusion:
|
|
B-Cell Lymphomas |
Lymphodepleting chemotherapy (lymphodepleting chemotherapy may be omitted if a patient’s white blood cell [WBC] count is less than 1 x 109/L within 1 week prior to Kymriah infusion):
Kymriah infusion:
|
|
For autologous use only. For intravenous use only.
|
||
Premedication:
Monitoring after infusion:
|
||
|
- Billing Code/Availability Information
HCPCS Code:
- Q2042 - Tisagenlecleucel, up to 600 million car-positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose
NDC(s):
- Kymriah suspension for intravenous infusion (Ped ALL); 1 infusion bag (10 to 50 mL): 00078-0846-xx
- Kymriah suspension for intravenous infusion (DLBCL and FL); 1 infusion bag (10 to 50 mL): 00078-0958-xx
- References
- Kymriah [package insert]. East Hanover, NJ; Novartis Pharmaceuticals Corp., May 2022. Accessed October 2023.
- Porter DL, Hwang WT, Frey NV, et al. Chimeric antigen receptor T cells persist and induce sustained remissions in relapsed refractory chronic lymphocytic leukemia. Sci Transl Med. 2015 Sep 2;7(303):303ra139. doi: 10.1126/scitranslmed.aac5415.
- Schuster S, Bishop MR, Constantine T, et al. Global Pivotal Phase 2 Trial of the CD19-Targeted Therapy CTL019 In Adult Patients with Relapsed or Refractory (R/R) Diffuse Large B-Cell Lymphoma (DLBCL)—An Interim Analysis. Clinical Lymphoma, Myeloma and Leukemia, Volume 17, S373 - S374.
- Mejstrikova E, Hrusak O, Borowitz MJ, et al. CD19-negative relapse of pediatric B-cell precursor acute lymphoblastic leukemia following blinatumomab treatment. Blood Cancer J. 20177; 659. DOI 10.1038/s41408-017-0023-x
- Ruella M, Maus MV. Catch me if you can: Leukemia Escape after CD19-Directed T Cell Immunotherapies. Computational and Structural Biotechnology Journal 14 (2016) 357–362.
- Braig F, Brandt A, Goebeler M, et al. Resistance to anti-CD19/CD3 BiTE in acute lymphoblastic leukemia may be mediated by disrupted CD19 membrane trafficking. Blood; 129:1, 2017 Jan.
- Majzner RG, Mackall CL. Tumor Antigen Escape from CAR T-cell Therapy. Cancer Discov 2018;8:1219-1226.
- Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) tisagenlecleucel. 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 October 2023.
- Schuster SJ, Bishop MR, Tam CS, et al; JULIET Investigators. Tisagenlecleucel in adult relapsed or refractory diffuse large B-cell lymphoma. N Engl J Med. 2019;380(1):45-56. doi:10.1056/NEJMoa1804980.
- Lee DW, Kochenderfer JN, Stetler-Stevenson M, et al. T cells expressing CD19 chimeric antigen receptors for acute lymphoblastic leukaemia in children and young adults: a phase 1 dose-escalation trial. Lancet. 2015;385(9967):517-528.
- Maude SL, Frey N, Shaw PA, et al. Chimeric antigen receptor T cells for sustained remissions in leukemia. N Engl J Med. 2014;371(16):1507-1517.
- Maude SL, Laetsch TW, Buechner J, et al. Tisagenlecleucel in Children and Young Adults with B-Cell Lymphoblastic Leukemia. N Engl J Med. 2018;378(5):439-448.
- Fitzgerald JC, Weiss SL, Maude SL, et al. Cytokine release syndrome after chimeric antigen receptor T cell therapy for acute lymphoblastic leukemia. Crit Care Med. 2017;45(2):e124-e131.
- Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma Version 3.2023. National Comprehensive Cancer Network, 2023. 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 October 2023.
- Fowler NH, Dickinson M, Dreyling M, et al. Tisagenlecleucel in adult relapsed or refractory follicular lymphoma: the phase 2 ELARA trial. Nat Med. 2022 Feb;28(2):325-332. doi: 10.1038/s41591-021-01622-0.
- Thudium Mueller K, Grupp SA, Maude SL, et al. Tisagenlecleucel immunogenicity in relapsed/refractory acute lymphoblastic leukemia and diffuse large B-cell lymphoma. Blood Adv. 2021 Dec 14;5(23):4980-4991. doi: 10.1182/bloodadvances.2020003844.
Appendix 1 – Covered Diagnosis Codes
ICD-10 |
ICD-10 Description |
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 |
C83.30 |
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 |
C83.36 |
Diffuse large B-cell lymphoma intrapelvic lymph nodes |
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 |
C83.50 |
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 |
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 |
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 |
C91.00 |
Acute lymphoblastic leukemia not having achieved remission |
C91.01 |
Acute lymphoblastic leukemia, in remission |
C91.02 |
Acute lymphoblastic leukemia, 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 |
D47.Z1 |
Post-transplant lymphoproliferative disorder (PTLD) |
Appendix 2 – Centers for Medicare and Medicaid Services (CMS)
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 Determination (NCD), Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs) may exist and compliance with these policies is required where applicable. They can be found at https://www.cms.gov/medicare-coverage-database/search.aspx. Additional indications may be covered 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 |