ph-0002
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Actemra® (tocilizumab)

Policy Number: PH-0002

Intravenous

 

Last Review Date: 10/26/2020

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

 

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.

 

  1. Length of Authorization

Coverage will be provided as follows:

  • Castleman’s Disease: 4 months and may be renewed
  • Cytokine Release Syndrome: 4 doses only and may not be renewed
  • Immune Checkpoint Inhibitor related arthritis: 1 dose and may not be renewed
  • All other indications: 6 months and may be renewed.
  1. Dosing Limits

A.  Quantity Limit (max daily dose) [NDC Unit]:

  • Actemra 80 mg/4 mL vial: 1 vial per 14 days
  • Actemra 200 mg/10 mL vial: 1 vial per 14 days
  • Actemra 400 mg/20 mL vial: 2 vials per 14 days

B.  Max Units (per dose and over time) [HCPCS Unit]:

Diagnosis

Billable Units

Interval (days)

Rheumatoid Arthritis & Polyarticular Juvenile Idiopathic Arthritis, NMOSD

800

28

Systemic Juvenile Idiopathic Arthritis, Castleman’s Disease (NHL) & Acute Graft Versus Host Disease (aGVHD)

800

14

Cytokine Release Syndrome (CRS)

3200

1 course of therapy only

Immune Checkpoint Inhibitor related arthritis

800

1 course of therapy only

  1. Initial Approval Criteria

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

  • 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
  • Must not be administered concurrently with live vaccines; AND
  • Patient is not on concurrent treatment with another TNF-inhibitor, biologic response modifier or other non-biologic agent (i.e., apremilast, tofacitinib, baricitinib, upadacitinib, etc.), unless otherwise specified; AND

Rheumatoid Arthritis † 1,3,19

  • 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 ; AND
  • May be used alone or in combination with methotrexate or other non-biologic DMARDs

Juvenile Idiopathic Arthritis (JIA) † Ф  1,18

  • Patient is at least 2 years of age; AND
  • Patient has active systemic (SJIA) or polyarticular (PJIA) Ф disease; AND
  • Physician has assessed baseline disease severity utilizing an objective measure/tool; 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 alone or in combination with methotrexate

Castleman’s Disease (NHL) ‡ 2

  • 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 1,2

  • Patient is at least 2 years of age; AND
    • Patient has received or will be receiving chimeric antigen receptor (CAR) T cell therapy; 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
      • Patient has a confirmed diagnosis of CAR-T therapy induced Grades 2-4 CRS; OR
      • Patient has Grade 1-4 neurotoxicity with concurrent CRS; OR
    • Used as supportive care in patients with refractory CRS secondary to anti-CD19 therapy (i.e., blinatumomab)

Management of Immune Checkpoint Inhibitor related Inflammatory Arthritis 2,17

  • Patient has been receiving therapy with an immune checkpoint inhibitor (e.g. nivolumab, pembrolizumab, atezolizumab, avelumab, durvalumab, cemiplimab, etc.); AND
  • Patient has inflammatory arthritis related to their immunotherapy; AND
  • Documented severe disease; AND
  • Patient’s condition is refractory to high-dose corticosteroids (i.e., no improvement within 2 weeks of starting therapy)

Acute Graft Versus Host Disease (aGVHD) 2,20-22

  • Patient has received a hematopoietic stem cell transplant; AND
  • Used for steroid-refractory acute GVHD; AND
  • Used in combination with systemic corticosteroids as additional therapy following no response (steroid-refractory disease) to first-line therapies

Neuromyelitis Optica Spectrum Disorder (NMOSD) 23-25

  • Patient has a confirmed diagnosis based on the following:
    • Patient was found to be seropositive for aquaporin-4 (AQP4) IgG antibodies; AND
      • Patient has at least one core clinical characteristic §; AND
      • Alternative diagnoses have been excluded (e.g., multiple sclerosis, sarcoidosis, cancer, chronic infection, etc.); OR
    • Patient was found to be 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 optic neuritis, acute myelitis with LETM*, or area postrema syndrome; AND
        • Dissemination in space (≥2 different core clinical characteristics); AND
        • Fulfillment of additional MRI requirements, as applicable ψ; AND
      • Alternative diagnoses have been excluded (e.g., multiple sclerosis, sarcoidosis, cancer, chronic infection, etc.); AND
  • Used as a single agent or in combination with immunosuppressive therapy (e.g. azathioprine, methotrexate, mycophenolate, etc.)

§ Core Clinical Characteristics of NMOSD 23

  • Optic neuritis
  • Acute myelitis
  • Area postrema syndrome: episode of otherwise unexplained hiccups or nausea and vomiting
  • Acute brainstem syndrome
  • Symptomatic narcolepsy or acute diencephalic clinical syndrome with NMOSD-typical diencephalic MRI lesions
  • Symptomatic cerebral syndrome with NMOSD-typical brain lesions

ψ Core Clinical Characteristics of NMOSD 23

  • Acute optic neuritis: requires brain MRI showing (a) normal findings or only nonspecific white matter lesions, OR (b) optic nerve MRI with T2-hyperintense lesion or T1-weighted gadolinium-enhancing lesion extending over >1/2 optic nerve length or involving optic chiasm
  • Acute myelitis: requires associated intramedullary MRI lesion extending over ≥3 contiguous segments (LETM) OR ≥3 contiguous segments of focal spinal cord atrophy in patients with history compatible with acute myelitis
  • Area postrema syndrome: requires associated dorsal medulla/area postrema lesions
  • Acute brainstem syndrome: requires associated peri-ependymal brainstem lesions

*LETM = longitudinally extensive transverse myelitis lesions

FDA Approved Indication(s); Compendia Recommended Indication(s); Ф Orphan Drug

  1. Renewal Criteria 1

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 the following: serious infection, severe neutropenia, severe thrombocytopenia, severe hepatotoxicity, gastrointestinal perforation, immunosuppression, severe hypersensitivity reactions, demyelinating disorders, etc.; AND

Oncology Indications

Castleman’s Disease (NHL)

  • 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) 20-22

  • The patient displayed a beneficial response to therapy (i.e., a complete or partial response) as determined by clinical assessment (e.g., International Bone Marrow Transplant Registry (IBMTR) scoring system, modified Glucksberg criteria, etc.)

Non-Oncology Indications

Rheumatoid arthritis (RA) 11-13

  • 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]

Juvenile Idiopathic Arthritis (SJIA/PJIA) 14-15

  • 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

  • May not be renewed

Management of Immune Checkpoint Inhibitor related Inflammatory Arthritis

  • May not be renewed

NMOSD 23,24

  • Disease response as indicated by stabilization/improvement in any of the following: neurologic symptoms as evidenced by a decrease in acute relapses, stability reduced hospitalizations, reduction/discontinuation in plasma exchange treatments, and/or reduction/discontinuation of corticosteroids without relapse
  1. Dosage/Administration

Doses exceeding 800 mg per infusion are not recommended

Indication

Dose

Adult Rheumatoid Arthritis

Administer 4 mg/kg intravenously every 4 weeks

  • May increase to 8 mg/kg every 4 weeks based on clinical response, up to a maximum of 800 mg per dose.

Polyarticular Juvenile Idiopathic Arthritis

Weight ≥ 30 kg

  • Administer 8 mg/kg intravenously every 4 weeks

Weight < 30 kg

  • Administer 10 mg/kg intravenously every 4 weeks

Systemic Juvenile Idiopathic Arthritis

Weight ≥ 30 kg

  • Administer 8 mg/kg intravenously every 2 weeks

Weight < 30 kg

  • Administer 12 mg/kg intravenously every 2 weeks

Castleman’s Disease (NHL)

Administer 8 mg/kg intravenously every 2 weeks for 16 weeks (8 doses total)

Cytokine Release Syndrome (CRS)

Weight ≥ 30 kg

  • Administer 8 mg/kg intravenously every 8 hours, if needed, up to a maximum of 4 total doses*

Weight < 30 kg

  • Administer 12 mg/kg intravenously every 8 hours, if needed, up to a maximum of 4 total doses*

*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 inflammatory arthritis

Administer 4 mg/kg intravenously one time only

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

  1. Billing Code/Availability Information

HCPCS code:

  • J3262 – Injection, tocilizumab, 1 mg; 1 billable unit = 1 mg

NDC:

  • 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
  1. References
  1. Actemra [package insert]. South San Francisco, CA; Genentech, Inc; May 2020. Accessed August 2020.
  2. Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) tocilizumab. National Comprehensive Cancer Network, 2020. 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 August 2020.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. Nishimoto N, Kanakura Y, Aozasa K, et al. Humanized anti-interleukin-6 receptor antibody treatment of multicentric Castleman disease. Blood 2005;106:2627-2632
  9. 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.
  10. Fraser JA, Weyand CM, Newman NJ, Biousse V. The treatment of giant cell arteritis. Rev Neurol Dis. 2008 Summer;5(3):140-52.
  11. 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.
  12. National Institute for Health and Care Excellence. NICE 2009. Rheumatoid Arthritis in Adults: Management. Published 25 February 2009. Clinical Guideline [CG79]. https://www.nice.org.uk/guidance/cg79/resources/rheumatoid-arthritis-in-adults-management-pdf-975636823525.
  13. 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 10 October 2012. Clinical Guideline [TA195]. https://www.nice.org.uk/guidance/ta195/resources/adalimumab-etanercept-infliximab-rituximab-and-abatacept-for-the-treatment-of-rheumatoid-arthritis-after-the-failure-of-a-tnf-inhibitor-pdf-82598558287813.
  14. 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
  15. 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.
  16. Consolaro A, Giancane G, Schiappapietra B, et al. Clinical outcome measures in juvenile idiopathic arthritis. Pediatric Rheumatology 18 April 2016 14:23.
  17. Stroud C, Hedge A, Cherry C, et al. Tociluzumab 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.
  18. Ringold S, AngelesHan 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.
  19. 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.
  20. 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
  21. 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
  22. 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
  23. 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.
  24. 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.
  25. 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

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

D36.0

Benign neoplasm of lymph nodes

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

G36.0

Neuromyelitis optica [Devic]

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

M06.4

Inflammatory polyarthropathy

M06.08

Rheumatoid arthritis without rheumatoid factor, vertebrae

M06.09

Rheumatoid arthritis without rheumatoid factor, multiple sites

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

R59.0

Localized enlarged lymph nodes

R59.1

Generalized enlarged lymph nodes

R59.9

Enlarged lymph nodes, unspecified

T80.90XA

Unspecified complication following infusion and therapeutic injection, initial encounter

T80.90XS

Unspecified complication following infusion and therapeutic injection, sequela

T86.09

Other complications of bone marrow transplant

Z94.81

Bone marrow transplant status

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: http://www.cms.gov/medicare-coverage-database/search/advanced-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