Asset Publisher
Orencia® (abatacept)
Policy Number: PH-0091
Intravenous/Subcutaneous
Last Review Date: 12/07/2023
Date of Origin: 07/02/2010
Dates Reviewed: 07/2010, 09/2010, 12/2010, 02/2011, 03/2011, 06/2011, 09/2011, 12/2011, 03/2012, 06/2012, 09/2012, 12/2012, 03/2013, 06/2013, 09/2013, 12/2013, 03/2014, 06/2014, 09/2014, 12/2014, 03/2015, 06/2015, 09/2015, 12/2015, 03/2016, 06/2016, 09/2016, 12/2016, 03/2017, 04/2017, 06/2017, 08/2017, 09/2017, 12/2017, 03/2018, 06/2018, 08/2018, 08/2019, 01/2020, 08/2020, 08/2021, 01/2022, 08/2022, 08/2023, 12/2023
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 1,23
Coverage will be provided for 6 months and may be renewed, unless otherwise specified.
- Therapy for the Management of Immunotherapy-Related Toxicity and Prophylaxis for Acute Graft Versus Host Disease (aGVHD) may not be renewed.
- Dosing Limits
A. Quantity Limit (max daily dose) [NDC Unit]:
- Orencia ClickJect 125 mg single-dose autoinjector: 4 syringes per 28 days
- Orencia single-dose prefilled syringes (50 mg, 87.5 mg, or 125 mg): 4 syringes per 28 days
- Orencia 250 mg single-dose vials:
- Management of Immune-Checkpoint Inhibitor Related Toxicity
- 2 vials every 14 days for a total of 5 dose
- Prophylaxis for aGVHD
- 4 vials for a total of 4 doses
- All other indications
- Loading: 4 vials (1000 mg) at weeks 0, 2 & 4
- Maintenance: 4 vials (1000 mg) per 28 days
- Management of Immune-Checkpoint Inhibitor Related Toxicity
B. Max Units (per dose and over time) [HCPCS Unit]:
- Management of Immune-Checkpoint Inhibitor Related Toxicity
- 50 billable units per 2 weeks for a total of 5 doses
- Prophylaxis for aGVHD
- 100 billable units for a total of 4 doses
- All other indications
- Loading: 100 billable units at weeks 0, 2, & 4
- Maintenance: 100 billable units per 4 weeks
- Initial Approval Criteria 1
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
- Patient is up to date with all age-appropriate vaccinations, in accordance with current vaccination guidelines, prior to initiating therapy; AND
- Patient has been evaluated and screened for the presence of hepatitis B virus (HBV) prior to initiating treatment; 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 the presence of TB during treatment; AND
- Patient does not have an active infection, including clinically important localized infections; AND
- Patient will not receive live vaccines during therapy; AND
- Patient is not on concurrent treatment with another TNF-inhibitor, IL-inhibitor, biologic response modifier or other non-biologic immunomodulating agent (e.g., apremilast, tofacitinib, baricitinib, upadacitinib, abrocitinib, deucravacitinib, etc.); AND
Rheumatoid Arthritis (RA) † 1,27,30
- Physician has assessed baseline disease severity utilizing an objective measure/tool; AND
- Documented moderate to severe active disease; AND
- Patient has had at least a 3-month trial and failed previous therapy with ONE oral disease modifying anti-rheumatic agent (DMARD) such as methotrexate, azathioprine, auranofin, hydroxychloroquine, penicillamine, sulfasalazine, leflunomide, etc.; AND
- May be used as a single agent or in combination with other non-biologic DMARDs (e.g., methotrexate, hydroxychloroquine, leflunomide, sulfasalazine, etc.)
Polyarticular Juvenile Idiopathic Arthritis (pJIA) † 1,16
- Patient is at least 2 years of age (6 years of age for the IV formulation); AND
- Physician has assessed baseline disease severity utilizing an objective measure/tool; AND
- Documented moderate to severe active polyarticular disease; AND
- Patient has had at least a 1-month trial and failure (unless contraindicated or intolerant) of previous therapy with either oral non-steroidal anti-inflammatory drugs (NSAIDs) OR an oral disease-modifying anti-rheumatic agent (DMARD) (e.g., methotrexate, leflunomide, sulfasalazine, etc.); AND
- May be used as single agent or in combination with methotrexate
Adult Psoriatic Arthritis (PsA) † 1,18,28,33,37
- Physician has assessed baseline disease severity utilizing an objective measure/tool; AND
- Documented moderate to severe active disease; AND
- For patients with predominantly axial disease, a trial and failure of at least a 4-week trial of ONE non-steroidal anti-inflammatory agents (NSAIDs), unless use is contraindicated; OR
- For patients with peripheral arthritis, dactylitis, OR active enthesitis, a trial and failure of at least a 3-month trial of ONE oral disease-modifying anti-rheumatic drug (DMARD) such as methotrexate, azathioprine, sulfasalazine, hydroxychloroquine, etc.; AND
- May be used as a single agent or in combination with other non-biologic DMARDs (e.g. methotrexate, hydroxychloroquine, leflunomide, sulfasalazine, etc.)
Juvenile Psoriatic Arthritis (JPsA) † 1,4,16
- Patient is at least 2 years of age; AND
- Physician has assessed baseline disease severity utilizing an objective measure/tool; AND
- Documented moderate to severe active polyarticular disease; AND
- May be used as a single agent or in combination with methotrexate; 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.)
Treatment of Chronic Graft Versus Host Disease (cGVHD) ‡ 1,19,20,22
- Patient is post-allogeneic hematopoietic cell transplant (generally 3 or more months); AND
- Used as additional therapy in combination with systemic corticosteroids; AND
- Patient has no response (e.g., steroid-refractory disease) to first-line therapy options
Prophylaxis of Acute Graft Versus Host Disease (aGVHD) (IV formulation only) † Ф 1,35.36
- Patient is undergoing a hematopoietic stem cell transplant (HSCT) from a matched or 1 allele-mismatched unrelated-donor; AND
- Patient is at least 2 years of age; AND
- Used in combination with a calcineurin inhibitor and methotrexate; AND
- Patient will receive antiviral prophylactic treatment for Epstein-Barr Virus (EBV) reactivation and prophylaxis will continue for 6 months post-transplantation; AND
- Patient will be monitored for both EBV reactivation and cytomegalovirus (CMV) infection/reactivation
Management of Immunotherapy-Related Toxicity (IV formulation only) ‡ 19,21,23
- Patient has been receiving therapy with an immune checkpoint inhibitor (e.g., nivolumab, pembrolizumab, atezolizumab, avelumab, durvalumab, cemiplimab, ipilimumab, dostarlimab, etc.); AND
- Patient has had no improvement within 24-48 hours of starting high-dose methylprednisolone; AND
- Used as additional therapy for the management of myocarditis
† FDA Approved Indication(s); ‡ Compendia Recommended Indication(s); Ф Orphan Drug
- 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: serious infections, severe hypersensitivity reactions, respiratory adverse events in those with predisposing conditions, reactivation of CMV or EBV, etc.; AND
Rheumatoid Arthritis 9-11
- 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].
Polyarticular Juvenile Idiopathic Arthritis 12,13
- 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 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].
Adult Psoriatic Arthritis 14,34
- Disease response as indicated by improvement in signs and symptoms compared to baseline such as the number of tender and swollen joint counts and/or an improvement on a disease activity scoring tool [e.g. defined as an improvement in at least 2 of the 4 Psoriatic Arthritis Response Criteria (PsARC), 1 of which must be joint tenderness or swelling score, with no worsening in any of the 4 criteria].
Juvenile Psoriatic Arthritis (JPsA) 1,12,13
- 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 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].
Treatment of Chronic Graft Versus Host Disease (cGVHD) 20,22
- Response to therapy with an improvement in one or more of the following:
- Clinician assessments (e.g., NIH Skin Score, Upper GI Response Score, NIH Lung Symptom Score, etc.)
- Patient-reported symptoms (e.g., Lee Symptom Scale, etc.)
Prophylaxis of Acute Graft Versus Host Disease (aGVHD) 1
- May not be renewed
Management of Immunotherapy-Related Toxicity 23
- May not be renewed
- Dosage/Administration 1,22,23
Indication |
Dose |
Rheumatoid Arthritis |
Intravenous Dosing
Subcutaneous Dosing (Orencia ClickJect or Orencia prefilled syringes)
Patients transitioning from Orencia intravenous therapy to subcutaneous administration should administer the first subcutaneous dose instead of the next scheduled intravenous dose. |
Adult Psoriatic Arthritis |
Intravenous Dosing
Subcutaneous Dosing (Orencia ClickJect or Orencia prefilled syringes)
Patients transitioning from Orencia intravenous therapy to subcutaneous administration should administer the first subcutaneous dose instead of the next scheduled intravenous dose |
Juvenile Psoriatic Arthritis |
Subcutaneous Dosing (Orencia ClickJect or Orencia prefilled syringes)
|
Polyarticular Juvenile Idiopathic Arthritis |
Intravenous Dosing (patients aged 6 years or older ONLY)
Subcutaneous Dosing (Orencia ClickJect or Orencia prefilled syringes and ONLY in patients aged 2 years or older)
|
Treatment of Chronic GVHD
|
Intravenous/Subcutaneous Dosing
|
Prophylaxis for Acute GVHD
|
Intravenous Dosing
|
Management of Immunotherapy- Related Toxicity |
Intravenous Dosing 500 mg every 2 weeks for a total of 5 doses |
- Billing Code/Availability Information
HCPCS Code:
- J0129 – Injection, Abatacept, 10 mg; 1 billable unit = 10 mg
(Code may be used for Medicare when drug is administered under the direct supervision of a physician; NOT for use when drug is self-administered)
NDC(s):
- Orencia 250 mg single-dose vial: 00003-2187-xx
- Orencia 125 mg/mL single-dose ClickJectTM Autoinjector: 00003-2188-xx
- Orencia 50 mg/0.4 mL single-dose prefilled syringe: 00003-2814-xx
- Orencia 87.5 mg/0.7 mL single-dose prefilled syringe: 00003-2818-xx
- Orencia 125 mg/mL single-dose prefilled syringe: 00003-2188-xx
- References
- Orencia [package insert]. Princeton, NJ; Bristol-Myers Squibb; October 2023. Accessed November 2023.
- Singh JA, Saag KG, Bridges SL Jr, et al. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care Res (Hoboken). 2015 Nov 6. doi: 10.1002/acr.22783.
- Beukelman T, Patkar NM, Saag KG, et al. 2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis: initiation and safety monitoring of therapeutic agents for the treatment of arthritis and systemic features. Arthritis Care Res (Hoboken). 2011 Apr;63(4):465-82.
- Ringold S, Weiss PF, Beukelman T, et al. 2013 update of the 2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis: recommendations for the medical therapy of children with systemic juvenile idiopathic arthritis and tuberculosis screening among children receiving biologic medications. Arthritis Rheum. 2013 Oct;65(10):2499-512.
- 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.
- Gottlieb A, Korman NJ, Gordon KB, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 2. Psoriatic arthritis: overview and guidelines of care for treatment with an emphasis on the biologics. J Am Acad Dermatol 2008 May;58(5):851-64.
- Gossec L, Smolen JS, Ramiro S, et al. European League Against Rheumatism (EULAR) recommendations for the management of psoriatic arthritis with pharmacological therapies: 2015 update. Ann Rheum Dis. 2015 Dec 7. pii: annrheumdis-2015-208337. doi: 10.1136/annrheumdis-2015-208337.
- Smolen JS, Landewe R, Bijilsma 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; 76: 935-938.
- National Institute for Health and Care Excellence. NICE 2018. Rheumatoid Arthritis in Adults: Management. Published 11th July 2018. NICE Guideline [NG100]. https://www.nice.org.uk/guidance/ng100/chapter/Recommendations.
- 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.
- Ward MM, Guthri LC, Alba MI. Rheumatoid Arthritis Response Criteria And Patient-Reported Improvement in Arthritis Activity: Is an ACR20 Response Meaningful to Patients”. Arthritis Rheumatol. 2014 Sep; 66(9): 2339–2343. doi: 10.1002/art.38705
- Ringold S, Bittner R, Neggi T, et al. Performance of rheumatoid arthritis disease activity measures and juvenile arthritis disease activity scores in polyarticular-course juvenile idiopathic arthritis: Analysis of their ability to classify the American College of Rheumatology pediatric measures of response and the preliminary criteria for flare and inactive disease. Arthritis Care Res (Hoboken). 2010 Aug;62(8):1095-102.
- Consolaro A, Giancane G, Schiappapietra B, et al. Clinical outcome measures in juvenile idiopathic arthritis. Pediatric Rheumatology 18 April 2016 14:23.
- National Institute for Health and Care Excellence. NICE 2017. Certolizumab pegol and secukinumab for treating active psoriatic arthritis after inadequate response to DMARDs. Published 24 May 2017. Technology Appraisal Guidance [TA445]. https://www.nice.org.uk/guidance/ta445. Accessed July 2022.
- Ogdie A, Singh JA, Siegel E, Gladman DD, Husni ME. Treatment of psoriatic arthritis: a new ACR/NPF clinical guideline. Presented at: 2017 ACR/ARHP Annual Meeting; November 3-8, 2017; San Diego, CA. Scientific Session 5T064.
- Ringold S, Angeles‐Han ST, Beukelman T, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Treatment of Juvenile Idiopathic Arthritis: Therapeutic Approaches for Non-Systemic Polyarthritis, Sacroiliitis, and Enthesitis. Arthritis Care & Research, Vol. 71, No. 6, June 2019, pp 717–734 DOI 10.1002/acr.23870.
- Menter A, Strober BE, Kaplan DH, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics. J Am Acad Dermatol https://doi.org/10.1016/j.jaad.2018.11.057
- Singh JA, Guyatt G, Ogdie A, et al. 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis. Arthritis Rheumatol. 2019 Jan;71(1):5-32. Doi: 10.1002/art.40726.
- Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) abatacept. 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 July 2023.
- Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) Hematopoietic Cell Transplantation (HCT). Version 1.2023. 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 July 2023.
- Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) Management of Immunotherapy-Related Toxicities. Version 2.2023. 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 July 2023.
- Nahas MR, Soiffer RJ, Kim HT, et al. Phase 1 clinical trial evaluating abatacept in patients with steroid-refractory chronic graft-versus-host disease. Blood. 2018;131(25):2836-2845. doi:10.1182/blood-2017-05-780239.
- Salem JE, Allenbach Y, Vozy A, et al. Abatacept for Severe Immune Checkpoint Inhibitor-Associated Myocarditis. N Engl J Med. 2019;380(24):2377-2379. doi:10.1056/NEJMc1901677.
- Vital EM, Emery P. Abatacept in the treatment of rheumatoid arthritis. Ther Clin Risk Manag. 2006;2(4):365-375. doi:10.2147/tcrm.2006.2.4.365.
- Ruperto N, Lovell DJ, Quartier P, et al. Long-term safety and efficacy of abatacept in children with juvenile idiopathic arthritis. Arthritis Rheum. 2010;62(6):1792-1802. doi:10.1002/art.27431.
- Mease P, Genovese MC, Gladstein G, et al. Abatacept in the treatment of patients with psoriatic arthritis: results of a six-month, multicenter, randomized, double-blind, placebo-controlled, phase II trial. Arthritis Rheum. 2011;63(4):939-948. doi:10.1002/art.30176.
- 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.
- American Academy of Dermatology Work Group. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 6. Guidelines of care for the treatment of psoriasis and psoriatic arthritis: case-based presentations and evidence-based conclusions. J Am Acad Dermatol. 2011 Jul;65(1):137-74.
- Ramiro S, Smolen JS, Landewé R, et al. Pharmacological treatment of psoriatic arthritis: a systematic literature review for the 2015 update of the EULAR recommendations for the management of psoriatic arthritis. Ann Rheum Dis 2016;75:490-498 doi:10.1136/annrheumdis-2015-208466.
- Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care Res (Hoboken). 2021 Jun 8. doi: 10.1002/acr.24596.
- Genovese MC, Covarrubias A, Leon G, et al. Subcutaneous abatacept versus intravenous abatacept: a phase IIIb noninferiority study in patients with an inadequate response to methotrexate. Arthritis Rheum. 2011;63(10):2854-2864. doi:10.1002/art.30463.
- Brunner HI, Tzaribachev N, Vega-Cornejo G, et al. Subcutaneous Abatacept in Patients With Polyarticular-Course Juvenile Idiopathic Arthritis: Results From a Phase III Open-Label Study. Arthritis Rheumatol. 2018;70(7):1144-1154. doi:10.1002/art.40466.
- Gossec L, Baraliakos X, Kerschbaumer A, et al. EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2019 update. Ann Rheum Dis. 2020 Jun;79(6):700-712. doi: 10.1136/annrheumdis-2020-217159.
- Mease PJ. Measures of psoriatic arthritis: Tender and Swollen Joint Assessment, Psoriasis Area and Severity Index (PASI), Nail Psoriasis Severity Index (NAPSI), Modified Nail Psoriasis Severity Index (mNAPSI), Mander/Newcastle Enthesitis Index (MEI), Leeds Enthesitis Index (LEI), Spondyloarthritis Research Consortium of Canada (SPARCC), Maastricht Ankylosing Spondylitis Enthesis Score (MASES), Leeds Dactylitis Index (LDI), Patient Global for Psoriatic Arthritis, Dermatology Life Quality Index (DLQI), Psoriatic Arthritis Quality of Life (PsAQOL), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Psoriatic Arthritis Response Criteria (PsARC), Psoriatic Arthritis Joint Activity Index (PsAJAI), Disease Activity in Psoriatic Arthritis (DAPSA), and Composite Psoriatic Disease Activity Index (CPDAI). Arthritis Care Res (Hoboken). 2011 Nov;63 Suppl 11:S64-85. doi: 10.1002/acr.20577.
- Watkins B, Qayed M, McCracken C, et al. Phase II Trial of Costimulation Blockade With Abatacept for Prevention of Acute GVHD. Journal of Clinical Oncology. Volume 39, Issue 17
- Kean L, Burns L, Kou T, et al. Improved Overall Survival of Patients Treated with Abatacept in Combination with a Calcineurin Inhibitor and Methotrexate Following 7/8 HLA-Matched Unrelated Allogeneic Hematopoietic Stem Cell Transplantation: Analysis of the Center for International Blood and Marrow Transplant Research Database. Blood (2021) 138 (Supplement 1): 3912.https://doi.org/10.1182/blood-2021-150742
- Tucker L, Allen A, Chandler D, et al. The 2022 British Society for Rheumatology guideline for the treatment of psoriatic arthritis with biologic and targeted synthetic DMARDs. Rheumatology (Oxford). 2022 Aug 30;61(9):e255-e266. doi: 10.1093/rheumatology/keac295.
- Mease PJ, Gottlieb AB, van der Heijde D, et al. Efficacy and safety of abatacept, a T-cell modulator, in a randomised, double-blind, placebo-controlled, phase III study in psoriatic arthritis. Ann Rheum Dis. 2017 Sep;76(9):1550-1558. doi: 10.1136/annrheumdis-2016-210724
Appendix 1 – Covered Diagnosis Codes
ICD-10 |
ICD-10 Description |
D89.810 |
Acute graft-versus-host disease |
D89.811 |
Chronic graft-versus-host disease |
D89.812 |
Acute on chronic graft-versus-host disease |
D89.813 |
Graft-versus-host disease, unspecified |
I30.8 |
Other forms of acute pericarditis |
I30.9 |
Acute pericarditis, unspecified |
I40.8 |
Other acute myocarditis |
I40.9 |
Acute myocarditis, unspecified |
I44.0 |
Atrioventricular block, first degree |
I44.1 |
Atrioventricular block, second degree |
I44.2 |
Atrioventricular block, complete |
I44.3 |
Other and unspecified atrioventricular block |
I44.30 |
Unspecified atrioventricular block |
I44.39 |
Other atrioventricular block |
I45.0 |
Right fascicular block |
I45.10 |
Unspecified right bundle-branch block |
I45.19 |
Other right bundle-branch block |
I45.2 |
Bifascicular block |
I45.3 |
Trifascicular block |
I45.4 |
Nonspecific intraventricular block |
I45.5 |
Other specified heart block |
I45.6 |
Pre-excitation syndrome |
I45.81 |
Long QT syndrome |
I45.89 |
Other specified conduction disorders |
I45.9 |
Conduction disorder, unspecified |
I47.0 |
Re-entry ventricular arrhythmia |
I47.2 |
Ventricular tachycardia |
I49.9 |
Cardiac arrhythmia, unspecified |
I50.9 |
Heart failure, unspecified |
L40.50 |
Arthropathic psoriasis, unspecified |
L40.51 |
Distal interphalangeal psoriatic arthropathy |
L40.52 |
Psoriatic arthritis mutilans |
L40.53 |
Psoriatic spondylitis |
L40.59 |
Other psoriatic arthropathy |
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 polyneuropathy with rheumatoid arthritis of unspecified site |
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 foot 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 |
M06.011 |
Rheumatoid arthritis without rheumatoid factor, right shoulder |
M06.012 |
Rheumatoid arthritis without rheumatoid factor, left shoulder |
M06.019 |
Rheumatoid arthritis without rheumatoid factor, unspecified shoulder |
M06.021 |
Rheumatoid arthritis without rheumatoid factor, right elbow |
M06.022 |
Rheumatoid arthritis without rheumatoid factor, left elbow |
M06.029 |
Rheumatoid arthritis without rheumatoid factor, unspecified elbow |
M06.031 |
Rheumatoid arthritis without rheumatoid factor, right wrist |
M06.032 |
Rheumatoid arthritis without rheumatoid factor, left wrist |
M06.039 |
Rheumatoid arthritis without rheumatoid factor, unspecified wrist |
M06.041 |
Rheumatoid arthritis without rheumatoid factor, right hand |
M06.042 |
Rheumatoid arthritis without rheumatoid factor, left hand |
M06.049 |
Rheumatoid arthritis without rheumatoid factor, unspecified hand |
M06.051 |
Rheumatoid arthritis without rheumatoid factor, right hip |
M06.052 |
Rheumatoid arthritis without rheumatoid factor, left hip |
M06.059 |
Rheumatoid arthritis without rheumatoid factor, unspecified hip |
M06.061 |
Rheumatoid arthritis without rheumatoid factor, right knee |
M06.062 |
Rheumatoid arthritis without rheumatoid factor, left knee |
M06.069 |
Rheumatoid arthritis without rheumatoid factor, unspecified knee |
M06.071 |
Rheumatoid arthritis without rheumatoid factor, right ankle and foot |
M06.072 |
Rheumatoid arthritis without rheumatoid factor, left ankle and foot |
M06.079 |
Rheumatoid arthritis without rheumatoid factor, unspecified ankle and foot |
M06.08 |
Rheumatoid arthritis without rheumatoid factor, vertebrae |
M06.09 |
Rheumatoid arthritis without rheumatoid factor, multiple sites |
M06.8A |
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) |
M08.3 |
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 |
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: 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 |