ph-0109
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Rituximab: Rituxan®, Truxima®, Ruxience®

Policy Number: PH-0109

Intravenous

 

Last Review Date: 06/02/2020

Date of Origin: 7/20/2010

Dates Reviewed: 09/2010, 12/2010, 02/2011, 03/2011, 05/2011, 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, 05/2015, 08/2015, 11/2015, 02/2016, 05/2016, 08/2016, 10/2016, 02/2017, 05/2017, 08/2017, 10/2017, 02/2018, 05/2018, 07/2018, 09/2018, 12/2018, 03/2019, 06/2019, 09/2019, 10/2019, 12/2019, 03/2020, 06/2020

  1. Length of Authorization 1,2,3,4,43

Coverage will be provided for 6 months (12 months initially for pemphigus vulgaris) and may be renewed unless otherwise specified.

  • Maintenance therapy for oncology indications (excluding ALL and Mantle cell lymphoma) may be renewed for up to a maximum of 2 years.
    • Mantle cell lymphoma may be renewed until disease progression or intolerable toxicity.
    • Acute lymphoblastic leukemia (ALL) may not be renewed.
  • Relapse therapy for pemphigus vulgaris must be at least 16 weeks past a prior infusion.
  1. Dosing Limits

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

  • Rituxan 100 mg/10 mL injection: 12 vials per 28 day supply
  • Rituxan 500 mg/50 mL injection: 8 vials per 28 day supply
  • Truxima 100 mg/10 mL injection: 12 vials per 28 day supply
  • Truxima 500 mg/50 mL injection: 8 vials per 28 day supply
  • Ruxience 100 mg/10 mL injection: 12 vials per 28 day supply
  • Ruxience 500 mg/50 mL injection: 8 vials per 28 day supply

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

Oncology Indications

Chronic Lymphocytic Leukemia (CLL)/Small Lymphocytic Leukemia (SLL):

  • Initial therapy:
    • Loading dose: 100 units x 1 dose
    • Subsequent doses: 130 units every 28 days x 5 doses per 6 months
  • Renewal therapy: 100 units per dose every 8 weeks x 4 doses per 6 months

Immunotherapy Toxicity Treatment:

  • 100 units per dose weekly x 4 doses in a 6 month period

All other oncology indications:

  • Initial therapy: 100 units per dose weekly x 8 doses per 6 months
  • Renewal therapy: 100 units per dose every 8 weeks x 4 doses per 6 months

Non-Oncology Indications

Rheumatoid Arthritis (RA):

  • 100 units per dose every 14 days x 2 doses in a 16 week period

Pemphigus Vulgaris:

  • Initiation: 100 units every 14 days x 2 doses in a 12 month period
  • Maintenance: 50 units every 16 weeks

GPA(WG)/MPA:

  • Induction: 100 units per dose weekly x 4 doses in a 4 month period
  • Initial Maintenance: 100 units x 2 doses in a 6 month period
  • Subsequent Maintenance: 50 units every 6 months

cGVHD

  • 100 units per dose weekly x 4 doses, then 100 units monthly x 4 months

All other non-oncology indications:

  • 100 units per dose weekly x 4 doses in a 6 month period

  1. Initial Approval Criteria

Coverage is provided in the following conditions:

  • Ruxience (rituxumab-pvvr) is the preferred product. Patient must have tried and had an inadequate response or intolerance to, or a contraindication to Ruxience, attributable to the biosimilar formulation, prior to consideration of a non-preferred rituximab product including Rituxan (rituximab) and Truxima (rituximab-abbs) OR Patient is continuing treatment with a non-preferred rituximab product including Rituxan or Truxima; AND
  • Patient age is 18 years or older (unless otherwise specified); AND

Universal Criteria 1,2,3

  • Patient must be screened for HBV infection (i.e., HBsAg and anti-HBc) prior to initiating therapy and monitored for HBV during treatment; AND

Oncology Indications 1,2,3,4

  • Patient CD20 antigen expression is positive; AND

Acute Lymphoblastic Leukemia (ALL) ‡ 4

  • Induction/Consolidation Treatment
    • Patient’s disease is Philadelphia chromosome-negative (Ph-); AND
      • Patient is at least 15 years of age; AND
        • Used in combination with an anthracycline, cyclophosphamide, and vincristine-based regimen
  • Relapsed/Refractory Treatment
  • Used as a component of MOpAD regimen (methotrexate, vincristine, pegaspargase, dexamethasone); AND
    • Patient’s disease is Philadelphia chromosome-negative (Ph-); OR
    • Patient is Philadelphia chromosome (Ph)-positive and failed previous therapy (i.e., intolerant or refractory) with a tyrosine kinase inhibitor (e.g., imatinib, dasatinib, ponatinib, bosutinib, nilotinib, etc.)

Central Nervous System (CNS) Cancer ‡ 4, 43

  • Patient has leptomeningeal metastases from lymphomas; AND
    • Rituximab will be administered intrathecally; OR
  • Patient has primary CNS lymphoma; AND
    • Patient will receive as a component of induction therapy in combination with a methotrexate-containing regimen, temozolomide, lenalidomide, or as a single agent; OR
    • Patient will receive in combination with a methotrexate-containing regimen as a component of consolidation therapy with a complete response (CR) or a complete response unconfirmed (CRu) to induction therapy; OR
    • Patient has relapsed or refractory disease and will receive rituximab as a single agent, or in combination with temozolomide, lenalidomide, or high-dose methotrexate

Hodgkin Lymphoma ‡ 4

  • Patient has nodular lymphocyte-predominant disease

Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL) † ‡ Ф 1,2,3,4

  • Used in combination with fludarabine and cyclophosphamide (FC); OR
  • Patient has disease that is without del(17p)/TP53 mutation; AND
    • Used as first-line therapy in combination with:
      • Bendamustine (patients ≥ 65 years or younger patients with or without significant comorbidities)
      • Fludarabine (patient is without del(11q) and is <65 years without significant comorbidities); OR
    • Used for relapsed or refractory disease in combination with:
      • Alemtuzumab
      • Chlorambucil (patients ≥ 65 years or younger patients with significant comorbidities)
      • High-dose methylprednisolone
      • Idelalisib
      • Lenalidomide
      • Venetoclax
      • PCR (pentostatin, cyclophosphamide, and rituximab); OR
  • Patient has disease with del(17p)/TP53 mutation; AND
    • Used as first-line therapy in combination with:
      • Alemtuzumab
      • High-dose methylprednisolone; OR
    • Used for relapsed or refractory disease in combination with:
      • Alemtuzumab
      • High-dose methylprednisolone
      • Idelalisib
      • Lenalidomide
      • Venetoclax; OR
  • Used as first line therapy for histologic (Richter’s) transformation to diffuse large B-cell lymphoma in combination with cyclophosphamide, doxorubicin, and vincristine based regimens or as a component of OFAR (oxaliplatin, fludarabine, cytarabine, and rituximab)

Waldenström’s Macroglobulinemia/Lymphoplasmacytic Lymphoma ‡ 4

Non-Hodgkin’s lymphomas (NHL) † Ф 1,2,3,4,43 including, but not limited to, the following:

  • AIDS-Related B-Cell Lymphoma
    • Disease is related to Burkitt Lymphoma or diffuse large B-cell lymphoma (including HHV-8 DLBCL, not otherwise specified or primary effusion lymphoma)
  • Burkitt Lymphoma
    • Used in combination with other chemotherapy
  • Castleman’s Disease
    • Patient has multicentric disease; OR
    • Patient has unicentric disease; AND
      • Used as second-line therapy for relapsed or refractory disease; OR
      • Used for patients with symptoms after resection or unresectable disease
  • Diffuse Large B-Cell LymphomaФ
  • Low-grade or Follicular Lymphoma  Ф
  • Gastric & Non-Gastric MALT Lymphoma
  • Hairy Cell Leukemia
    • Used for relapsed or refractory disease or in patients with a less than complete response (CR) to initial therapy
  • High Grade B-Cell Lymphoma
  • Mantle Cell Lymphoma
  • Nodal & Splenic Marginal Zone Lymphoma
  • Histologic transformation of Follicular or Nodal Marginal Zone Lymphoma to Diffuse Large B-Cell Lymphoma
  • Post-transplant lymphoproliferative disorder (PTLD) (B-cell type)
    • Patient has had solid organ transplant or allogeneic hematopoietic stem cell transplantation
  • Pediatric Aggressive Mature B-Cell Lymphomas
      • Used in combination with other chemotherapy  
  • Primary Cutaneous B-Cell Lymphomas

Management of Immunotherapy-Related Toxicities ‡ 4

  • Patient has been receiving therapy with an immune checkpoint inhibitor (e.g., cemiplimab, nivolumab, pembrolizumab, atezolizumab, avelumab, durvalumab, ipilimumab, etc.); AND
    • Patient has non-viral encephalitis related to their immunotherapy; AND
      • Patient is autoimmune-encephalopathy-antibody positive; OR
      • Patient is refractory to methylprednisolone with or without IV immunoglobulin (IVIG); OR
    • Patient has bullous dermatitis related to their immunotherapy; AND
      • Used as additional therapy for moderate (G2), severe (G3) or life-threatening (G4) disease; OR
    • Patient has severe (G3-4) myasthenia gravis that is refractory to plasmapheresis or IV immunoglobulin (IVIG)

Non-Oncology Indications

  • Patient is not on concurrent treatment with another TNF-inhibitor, biologic response modifier or other non-biologic agent (i.e., apremilast tofacitinib, baricitinib); AND

Rheumatoid Arthritis (RA) † 1,2,11,12,45,46,47,48

  • Documented moderate to severe disease; AND
  • Must be used in combination with methotrexate unless the patient has a contraindication or intolerance; AND
  • Patient tried and failed at least a 3 month trial with ONE oral disease modifying anti-rheumatic drug (DMARD) (e.g., methotrexate, azathioprine, auranofin, hydroxychloroquine, penicillamine, sulfasalazine, leflunomide, etc.); AND
  • Previous failure with one or more preferred TNF antagonists at least one of which should be a self-injectable; AND
  • Physician has assessed baseline disease severity utilizing an objective measure/tool; AND
  • Patient has not had treatment with rituximab in the previous 4 months

Pemphigus Vulgaris † Ф 1, ,9,10,34,35,3711

  • Patient has a diagnosis of pemphigus vulgaris as determined by the following:
    • One or more of the following clinical features:
      • Appearance of lesions, erosions and/or blisters
      • Nikolsky sign (induction of blistering via mechanical pressure at the edge of a blister or on normal skin)
      • Characteristic scarring and lesion distribution; AND
    • Histopathologic confirmation by skin/mucous membrane biopsy; AND
    • Presence of autoantibodies as detected by indirect immunofluorescence or enzyme-linked immunosorbent assay (ELISA); AND
  • Patient has moderate to severe disease as assessed utilizing an objective measure/tool (i.e. PDAI, PSS, ABSIS); AND
  • Patient is on combination glucocorticoid therapy; AND
  • Other causes of blistering or erosive skin and mucous membrane diseases have been ruled out

Granulomatosis with Polyangiitis (GPA) (Wegener’s granulomatosis) and Microscopic Polyangiitis (MPA) † Ф 1,2,3

  • Patient is at least 2 years of age; AND
  • Used in combination with glucocorticoids (e.g., prednisone, methylprednisolone, etc.)

Thrombocytopenic Purpura ‡ 5,6,7,8,9,15,16,17,19,20

  • Patient has previously failed or has a contraindication or intolerance to therapy with corticosteroids; AND
  • The patient has a platelet count ≤30 x 109/L OR 30 x 109/L to < 50 x 109/L with symptomatic bleeding or with increased risk for bleeding; AND
  • Patient diagnosis includes one of the following:
  • Primary thrombocytopenia
  • Idiopathic (Immune) thrombocytopenia purpura (ITP)
  • Evan’s syndrome
  • Congenital and hereditary thrombocytopenic purpura
  • Thrombotic thrombocytopenic purpura in patients with ADAMTS13-deficiency

Chronic Graft-Versus-Host Disease (cGVHD) ‡ 4,21,22,23,24,44

  • Patient is post-allogeneic stem cell transplant (generally 3 or more months); AND
  • Used as additional therapy in combination with corticosteroids; AND
  • Patient has failed one or more previous lines of systemic therapy for the treatment of cGVHD (e.g., corticosteroids or immunosuppressants such as cyclosporine); AND
  • Patient must try and have an inadequate response, contraindication, or intolerance to at least a three (3) month trial of ibrutinib

Autoimmune Hemolytic Anemia (AIHA) 25,26,27,28,29,30,31

  • Patient has warm-reactive disease refractory to or dependent on glucocorticoids; OR
  • Patient has cold agglutinin disease with symptomatic anemia, transfusion-dependence, and/or disabling circulatory symptoms

Neuromyelitis optica

  • Patient has ONE of the following:
  • The patient has failed azathioprine or mycophenolate mofetil OR
  • The patient has a documented intolerance, FDA labeled contraindication, or hypersensitivity to azathioprine and mycophenolate mofetil OR
  • The patient is less than 18 years of age

Systemic lupus erythematosus

  • The patient’s disease is active; AND
  • The patient has a history of positive autoantibody test results [positive antinuclear antibody (ANA >1:80) and/or anti-dsDNA (>30 IU/mL)]; AND
  • The patient has a history of at least 4 SLE related disease manifestations (SLE related disease manifestations include, but are not limited to: serositis malar rash, discoid rash, photosensitivity, oral ulcers, nonerosive arthritis, pleuritis/pericarditis, renal disorder [persistent proteinuria >0.5 grams/day or cellular casts], hematologic disorder [hemolytic anemia (with reticulocytosis), leucopenia, lymphopenia, positive finding of antiphospholipid antibodies, or anti-Sm antibodies]); AND
    • The patient is currently on a standard of care SLE treatment regimen comprised of at least one of the following: corticosteroids, antimalarials (e.g. hydroxychloroquine, chloroquine), nonsteroidal anti-inflammatory drugs (e.g. NSAIDS), aspirin, and/or immunosuppressives (e.g. azathioprine, methotrexate, cyclosporine, oral cyclophosphamide, or mycophenolate); OR
    • The patient has a documented intolerance, FDA labeled contraindication, or hypersensitivity to ALL the standard of care drug classes listed above

FDA-labeled indication(s); Compendia recommended indication(s); Ф Orphan Drug

  1. Renewal Criteria 1,2,3

Coverage can be renewed based upon the following criteria:

  • Patient continues to meet universal and other indication-specific relevant criteria such as concomitant therapy requirements (not including prerequisite therapy), performance status, etc. identified in section III; AND
  • Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include the following: severe infusion-related reactions, tumor lysis syndrome (TLS), severe mucocutaneous reactions, progressive multifocal leukoencephalopathy (PML), hepatitis B virus reactivation, serious bacterial, fungal, or viral infections, cardiac arrhythmias, renal toxicity, bowel obstruction or perforation; AND

Oncology Indications 1,2,3,4,43

  • Disease response with treatment as defined by stabilization of disease or decrease in size of tumor or tumor spread; AND
  • Patient has not exceeded dosing or duration limits as defined in Sections I, II, and V

Non-Oncology Indications 1,2,3,6,7,8,9,10,11,33

Rheumatoid arthritis (RA)

  • 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]; AND
  • Dose escalation (up to the maximum dose and frequency specified below) may occur upon clinical review on a case by case basis provided that the patient has:
    • Shown an initial response to therapy; AND
    • Received a minimum of one maintenance dose at the dose and interval specified below; AND
    • Responded to therapy with subsequent loss of response

Thrombocytopenic purpura

  • Disease response as indicated by the achievement and maintenance of a platelet count of at least 50 × 109/L as necessary to reduce the risk for bleeding

Thrombotic thrombocytopenic purpura (TTP)

  • Disease response as indicated by an increase in ADAMTS13 activity with a reduction in thrombotic risk

Granulomatosis with Polyangiitis (GPA) (Wegener’s granulomatosis) and Microscopic polyangiitis (MPA)

  • Disease response as indicated by disease control and improvement in signs and symptoms of condition compared to baseline; AND
  • A decrease frequency in the occurrence of major relapses (defined by the reappearance of clinical and/or laboratory signs of vasculitis activity that could lead to organ failure or damage, or could be life threatening)

Pemphigus vulgaris 1,2,3,10,11,34

  • Patient is currently receiving tapering doses of corticosteroids or has discontinued use of corticosteroids; AND
    • Disease response as indicated by complete epithelialization of lesions and improvement in signs and symptoms of condition compared to baseline; OR
    • Patient has not experienced continued development of new lesions, continued extension of old lesions, or failure of established lesions to begin to heal despite therapy; OR
      • For Relapses ONLY: Patient has had active disease control; AND
      • Patient has the appearance of 3 or more new lesions a month that do not heal spontaneously within 1 week, or by the extension of established lesions

Chronic graft-versus-host disease (cGVHD)

  • Disease response as indicated by improvement in patient-reported symptoms or clinician assessments (e.g., manifestations of disease to the skin, oral cavity, musculoskeletal system, etc.)

Autoimmune hemolytic anemia (AIHA)

  • Disease response as indicated by improvement in anemia signs and symptoms (e.g., dyspnea, fatigue, etc.) as well as: improvement in laboratory values (Hb/Hct), reduced transfusion needs, and/or reduced glucocorticoid use
  1. Dosage/Administration 1,2,3,4,8,22,25,31,36,41,43

Indication

Dose

CLL/SLL

Initial Therapy

375 mg/m² weekly x 8 doses; OR

375 mg/m² cycle 1, then 500 mg/m² every 28 days cycles 2-6 (6 total doses)

Renewal Therapy

375 mg/m² once weekly for 4 doses per 6 month period; OR

375 mg/ m² every 8 weeks

NHL, PTLD, Waldenström’s, Castleman’s, or HL

Initial Therapy

375 mg/m2 once weekly for 4 - 8 doses in a 6 month period

Renewal Therapy

375 mg/m² once weekly for 4 doses per 6 month period; OR

375 mg/ m² every 8 weeks

Pediatric Aggressive B-cell Lymphoma

Induction*

375 mg/m2 once to twice during the first week of the induction cycle (typically 21-day cycle)

Consolidation*

375 mg/m2 once weekly on day-1 of the consolidation cycle (typically 21-day cycle)

Relapsed/Refractory

RCYVE – 375mg/m2 on day-1 of each 21-day cycle

RICE – 375 mg/m2 on days 2 and 3 of courses 1 and 2, and on day 1 only of course 3 if needed.

*Note: dosing and dosing schedules are highly variable and dependent on regimen used, please refer to NCCN for different protocols.

CNS Lymphoma

Intravenous

Initial: 375 mg/m2 once weekly for 4 - 8 doses in a 6 month period

Renewal Therapy:375 mg/m² once weekly for 4 doses per 6 month period; OR

375 mg/ m² every 8 weeks

Intrathecal/Intraventricular

10-40 mg weekly to every 3 weeks

ALL

375 mg/m2 once weekly for 4 - 8 doses in a 6 month period

RA

1,000 mg on days 1 and 15, repeated every 24 weeks. May repeat up to every 16 weeks in patients requiring more frequent dosing based on clinical evaluation.

Pemphigus Vulgaris

Initiation

        • Administer 1,000 mg on days 1 and 15 in combination with tapering doses of glucocorticoids

Maintenance

        • Administer 500 mg at month 12 and repeat every 6 months thereafter or based on clinical evaluation.

Relapse

        • Administer 1000 mg upon relapse, resumption of glucocorticoids may be considered.

*Subsequent infusions (maintenance and relapse) should be no sooner than 16 weeks after the previous infusion.

Thrombocytopenia, AIHA, or Immunotherapy Toxicity Treatment

375 mg/m² weekly x 4 doses in a 6 month period

GPA (WG), MPA

Induction (Pediatric and Adult)

        • 375 mg/m² weekly x 4 doses,  initially

Maintenance

        • Pediatric:
          • 250 mg/m² on days 1 and 15, then 250 mg/m² every 6 months thereafter based on clinical evaluation
        • Adult:
          • 500 mg on days 1 and 15, then 500mg every 6 months thereafter based on clinical evaluation.

*Initial MAINTENANCE infusions should be no sooner than 16 weeks and no later than 24 weeks after the previous infusion if Rituxan was used for initial induction therapy.

*Initial MAINTENANCE infusions should be initiated within 4 weeks following disease control when initial induction occurred with other standard of care immunosuppressants.

cGVHD

375 mg/m² weekly x 4 doses, then 375 mg/m² monthly x 4 months

Neuromyelitis optica

375 mg/m2 once weekly for 4 weeks OR

1000 mg infusion separated by 2 weeks x 2 doses

Systemic Lupus Erythematosus

375 mg/ m2 once weekly for 4 weeks

  1. Billing Code/Availability Information

HCPCS Code:

  • J9312 – Injection, rituximab, 10 mg; 1 billable unit = 10 mg (Rituxan IV only)
  • Q5115 − Injection, rituximab-abbs, biosimilar, 10 mg (Truxima only)
  • J9999 – Not otherwise classified, antineoplastic drugs (Ruxience only)
  • C9399 – Unclassified drugs or biologicals (Ruxience only)
  • Q5119 – Injection, rituximab-pvvr, biosimilar (Ruxience), 10 mg; 1 billable unit = 10 mg (Ruxience only – effective 7/1/2020)

NDC(s):

  • Rituxan 100 mg/10 mL single-use vial for injection: 50242-0051-xx
  • Rituxan 500 mg/50 mL single-use vial for injection: 50242-0053-xx
  • Truxima 100 mg/10 mL single-use vial for injection: 63459-0103-xx
  • Truxima 500 mg/50 mL single-use vial for injection: 63459-0104-xx
  • Ruxience 100 mg/10 mL single-use vial for injection: 00069-0238-xx
  • Ruxience 500 mg/50 mL single-use vial for injection: 00069-0249-xx
  1. References
  1. Rituxan [package insert]. South San Francisco, CA; Genentech, Inc; March 2020. Accessed May 2020.
  2. Truxima [package insert]. Incheon, Korea; Celltrion, Inc; December 2019. Accessed May 2020.
  3. Ruxience [package insert]. New York, NY; Pfizer, Inc; July 2019. Accessed May 2020.
  4. Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) rituximab. 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 May 2020.
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Appendix 1 – Covered Diagnosis Codes

ICD-10

Description

C79.32

Secondary malignant neoplasm of cerebral meninges

C81.00

Nodular lymphocyte predominant Hodgkin lymphoma, unspecified site

C81.01

Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of head, face, and neck

C81.02

Nodular lymphocyte predominant Hodgkin lymphoma, intrathoracic lymph nodes

C81.03

Nodular lymphocyte predominant Hodgkin lymphoma, intra-abdominal lymph nodes

C81.04

Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of axilla and upper limb

C81.05

Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of inguinal region and lower limb

C81.06

Nodular lymphocyte predominant Hodgkin lymphoma, intrapelvic lymph nodes

C81.07

Nodular lymphocyte predominant Hodgkin lymphoma, spleen

C81.08

Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of multiple sites

C81.09

Nodular lymphocyte predominant Hodgkin lymphoma, extranodal and solid organ sites

C82.00

Follicular lymphoma grade I, unspecified site

C82.01

Follicular lymphoma grade I, lymph nodes of head, face and neck

C82.02

Follicular lymphoma, grade I, intrathoracic lymph nodes

C82.03

Follicular lymphoma grade I, intra-abdominal lymph nodes

C82.04

Follicular lymphoma grade I, lymph nodes of axilla and upper limb

C82.05

Follicular lymphoma grade I, lymph nodes of inguinal regional and lower limb

C82.06

Follicular lymphoma grade I, intrapelvic lymph nodes

C82.07

Follicular lymphoma grade I, spleen

C82.08

Follicular lymphoma grade I, lymph nodes of multiple sites

C82.09

Follicular lymphoma grade I, extranodal and solid organ sites

C82.10

Follicular lymphoma grade II, unspecified site

C82.11

Follicular lymphoma grade II, lymph nodes of head, face and neck

C82.12

Follicular lymphoma, grade II, intrathoracic lymph nodes

C82.13

Follicular lymphoma grade II, intra-abdominal lymph nodes

C82.14

Follicular lymphoma grade II, lymph nodes of axilla and upper limb

C82.15

Follicular lymphoma grade II, lymph nodes of inguinal region and lower limb

C82.16

Follicular lymphoma grade II, intrapelvic lymph nodes

C82.17

Follicular lymphoma grade II, spleen

C82.18

Follicular lymphoma grade II, lymph nodes of multiple sites

C82.19

Follicular lymphoma grade II, extranodal and solid organ sites

C82.20

Follicular lymphoma grade III, unspecified, unspecified site

C82.21

Follicular lymphoma grade III, unspecified, lymph nodes of head, face and neck

C82.22

Follicular lymphoma, grade III, unspecified, intrathoracic lymph nodes

C82.23

Follicular lymphoma grade III, unspecified, intra-abdominal lymph nodes

C82.24

Follicular lymphoma grade III, unspecified, lymph nodes of axilla and upper limb

C82.25

Follicular lymphoma grade III, unspecified, lymph nodes of inguinal region and lower limb

C82.26

Follicular lymphoma grade III, unspecified, intrapelvic lymph nodes

C82.27

Follicular lymphoma grade III, unspecified, spleen

C82.28

Follicular lymphoma grade III, unspecified, lymph nodes of multiple sites

C82.29

Follicular lymphoma grade III, unspecified, extranodal and solid organ sites

C82.30

Follicular lymphoma grade IIIa, unspecified site

C82.31

Follicular lymphoma grade IIIa, lymph nodes of head, face and neck

C82.32

Follicular lymphoma, grade IIIa, intrathoracic lymph nodes

C82.33

Follicular lymphoma grade IIIa, intra-abdominal lymph nodes

C82.34

Follicular lymphoma grade IIIa, lymph nodes of axilla and upper limb

C82.35

Follicular lymphoma grade IIIa, lymph nodes of inguinal region and lower limb

C82.36

Follicular lymphoma grade IIIa, intrapelvic lymph nodes

C82.37

Follicular lymphoma grade IIIa, spleen

C82.38

Follicular lymphoma grade IIIa, lymph nodes of multiple sites

C82.39

Follicular lymphoma grade IIIa, extranodal and solid organ sites

C82.40

Follicular lymphoma grade IIIb, unspecified site

C82.41

Follicular lymphoma grade IIIb, lymph nodes of head, face and neck

C82.42

Follicular lymphoma, grade IIIb, intrathoracic lymph nodes

C82.43

Follicular lymphoma grade IIIb, intra-abdominal lymph nodes

C82.44

Follicular lymphoma grade IIIb, lymph nodes of axilla and upper limb

C82.45

Follicular lymphoma grade IIIb, lymph nodes of inguinal region and lower limb

C82.46

Follicular lymphoma grade IIIb, intrapelvic lymph nodes

C82.47

Follicular lymphoma grade IIIb, spleen

C82.48

Follicular lymphoma grade IIIb, lymph nodes of multiple sites

C82.49

Follicular lymphoma grade IIIb, extranodal and solid organ sites

C82.50

Diffuse follicle center lymphoma, unspecified site

C82.51

Diffuse follicle center lymphoma, lymph nodes of head, face and neck

C82.52

Diffuse follicle center lymphoma, intrathoracic lymph nodes

C82.53

Diffuse follicle center lymphoma, intra-abdominal lymph nodes

C82.54

Diffuse follicle center lymphoma, lymph nodes of axilla and upper limb

C82.55

Diffuse follicle center lymphoma, lymph nodes of inguinal region and lower limb

C82.56

Diffuse follicle center lymphoma, intrapelvic lymph nodes

C82.57

Diffuse follicle center lymphoma, spleen

C82.58

Diffuse follicle center lymphoma, lymph nodes of multiple sites

C82.59

Diffuse follicle center lymphoma, extranodal and solid organ sites

C82.60

Cutaneous follicle center lymphoma, unspecified site

C82.61

Cutaneous follicle center lymphoma, lymph nodes of head, face and neck

C82.62

Cutaneous follicle center lymphoma, intrathoracic lymph nodes

C82.63

Cutaneous follicle center lymphoma, intra-abdominal lymph nodes

C82.64

Cutaneous follicle center lymphoma, lymph nodes of axilla and upper limb

C82.65

Cutaneous follicle center lymphoma, lymph nodes of inguinal region and lower limb

C82.66

Cutaneous follicle center lymphoma, intrapelvic lymph nodes

C82.67

Cutaneous follicle center lymphoma, spleen

C82.68

Cutaneous follicle center lymphoma, lymph nodes of multiple sites

C82.69

Cutaneous follicle center lymphoma, extranodal and solid organ sites

C82.80

Other types of follicular lymphoma, unspecified site

C82.81

Other types of follicular lymphoma, lymph nodes of head, face and neck

C82.82

Other types of follicular lymphoma, intrathoracic lymph nodes

C82.83

Other types of follicular lymphoma, intra-abdominal lymph nodes

C82.84

Other types of follicular lymphoma, lymph nodes of axilla and upper limb

C82.85

Other types of follicular lymphoma, lymph nodes of inguinal region and lower limb

C82.86

Other types of follicular lymphoma, intrapelvic lymph nodes

C82.87

Other types of follicular lymphoma, spleen

C82.88

Other types of follicular lymphoma, lymph nodes of multiple sites

C82.89

Other types of follicular lymphoma, extranodal and solid organ sites

C82.90

Follicular lymphoma, unspecified, unspecified site

C82.91

Follicular lymphoma, unspecified, lymph nodes of head, face and neck

C82.92

Follicular lymphoma, unspecified, intrathoracic lymph nodes

C82.93

Follicular lymphoma, unspecified, intra-abdominal lymph nodes

C82.94

Follicular lymphoma, unspecified, lymph nodes of axilla and upper limb

C82.95

Follicular lymphoma, unspecified lymph nodes of inguinal region and lower limb

C82.96

Follicular lymphoma, unspecified, intrapelvic lymph nodes

C82.97

Follicular lymphoma, unspecified, spleen

C82.98

Follicular lymphoma, unspecified, lymph nodes of multiple sites

C82.99

Follicular lymphoma, unspecified, extranodal and solid organ sites

C83.00

Small cell B-cell lymphoma, unspecified site

C83.01

Small cell B-cell lymphoma, lymph nodes of head, face and neck

C83.02

Small cell B-cell lymphoma, intrathoracic lymph nodes

C83.03

Small cell B-cell lymphoma, intra-abdominal lymph nodes

C83.04

Small cell B-cell lymphoma, lymph nodes of axilla and upper limb

C83.05

Small cell B-cell lymphoma, lymph nodes of inguinal region and lower limb

C83.06

Small cell B-cell lymphoma, intrapelvic lymph nodes

C83.07

Small cell B-cell lymphoma, spleen

C83.08

Small cell B-cell lymphoma, lymph nodes of multiple sites

C83.09

Small cell B-cell lymphoma, extranodal and solid organ sites

C83.10

Mantle cell lymphoma, unspecified site

C83.11

Mantle cell lymphoma, lymph nodes of head, face and neck

C83.12

Mantle cell lymphoma, intrathoracic lymph nodes

C83.13

Mantle cell lymphoma, intra-abdominal lymph nodes

C83.14

Mantle cell lymphoma, lymph nodes of axilla and upper limb

C83.15

Mantle cell lymphoma, lymph nodes of inguinal region and lower limb

C83.16

Mantle cell lymphoma, intrapelvic lymph nodes

C83.17

Mantle cell lymphoma, spleen

C83.18

Mantle cell lymphoma, lymph nodes of multiple sites

C83.19

Mantle cell lymphoma, extranodal and solid organ sites

C83.30

Diffuse large B-cell lymphoma unspecified site

C83.31

Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck

C83.32

Diffuse large B-cell lymphoma intrathoracic lymph nodes

C83.33

Diffuse large B-cell lymphoma intra-abdominal lymph nodes

C83.34

Diffuse large B-cell lymphoma lymph nodes of axilla and upper limb

C83.35

Diffuse large B-cell lymphoma, lymph nodes of inguinal region and lower limb

C83.36

Diffuse large B-cell lymphoma intrapelvic lymph nodes

C83.37

Diffuse large B-cell lymphoma, spleen

C83.38

Diffuse large B-cell lymphoma lymph nodes of multiple sites

C83.39

Diffuse large B-cell lymphoma extranodal and solid organ sites

C83.50

Lymphoblastic (diffuse) lymphoma, unspecified site

C83.51

Lymphoblastic (diffuse) lymphoma, lymph nodes of head, face, and neck

C83.52

Lymphoblastic (diffuse) lymphoma, intrathoracic lymph nodes

C83.53

Lymphoblastic (diffuse) lymphoma, intra-abdominal lymph nodes

C83.54

Lymphoblastic (diffuse) lymphoma, lymph nodes of axilla and upper limb

C83.55

Lymphoblastic (diffuse) lymphoma, lymph nodes of inguinal region and lower limb

C83.56

Lymphoblastic (diffuse) lymphoma, intrapelvic lymph nodes

C83.57

Lymphoblastic (diffuse) lymphoma, spleen

C83.58

Lymphoblastic (diffuse) lymphoma, lymph nodes of multiple sites

C83.59

Lymphoblastic (diffuse) lymphoma, extranodal and solid organ sites

C83.70

Burkitt lymphoma, unspecified site

C83.71

Burkitt lymphoma, lymph nodes of head, face, and neck

C83.72

Burkitt lymphoma, intrathoracic lymph nodes

C83.73

Burkitt lymphoma, intra-abdominal lymph nodes

C83.74

Burkitt lymphoma, lymph nodes of axilla and upper limb

C83.75

Burkitt lymphoma, lymph nodes of inguinal region and lower limb

C83.76

Burkitt lymphoma, intrapelvic lymph nodes

C83.77

Burkitt lymphoma, spleen

C83.78

Burkitt lymphoma, lymph nodes of multiple sites

C83.79

Burkitt lymphoma, extranodal and solid organ sites

C83.80

Other non-follicular lymphoma, unspecified site

C83.81

Other non-follicular lymphoma, lymph nodes of head, face and neck

C83.82

Other non-follicular lymphoma, intrathoracic lymph nodes

C83.83

Other non-follicular lymphoma, intra-abdominal lymph nodes

C83.84

Other non-follicular lymphoma, lymph nodes of axilla and upper limb

C83.85

Other non-follicular lymphoma, lymph nodes of inguinal region and lower limb

C83.86

Other non-follicular lymphoma, intrapelvic lymph nodes

C83.87

Other non-follicular lymphoma, spleen

C83.88

Other non-follicular lymphoma, lymph nodes of multiple sites

C83.89

Other non-follicular lymphoma, extranodal and solid organ sites

C83.90

Non-follicular (diffuse) lymphoma, unspecified site

C83.91

Non-follicular (diffuse) lymphoma, unspecified lymph nodes of head, face, and neck

C83.92

Non-follicular (diffuse) lymphoma, unspecified intrathoracic lymph nodes

C83.93

Non-follicular (diffuse) lymphoma, unspecified intra-abdominal lymph nodes

C83.94

Non-follicular (diffuse) lymphoma, unspecified lymph nodes of axilla and upper limb

C83.95

Non-follicular (diffuse) lymphoma, unspecified lymph nodes of inguinal region and lower limb

C83.96

Non-follicular (diffuse) lymphoma, unspecified intrapelvic lymph nodes

C83.97

Non-follicular (diffuse) lymphoma, unspecified spleen

C83.98

Non-follicular (diffuse) lymphoma, unspecified lymph nodes of multiple sites

C83.99

Non-follicular (diffuse) lymphoma, unspecified extranodal and solid organ sites

C85.10

Unspecified B-cell lymphoma, unspecified site

C85.11

Unspecified B-cell lymphoma, lymph nodes of head, face, and neck

C85.12

Unspecified B-cell lymphoma, intrathoracic lymph nodes

C85.13

Unspecified B-cell lymphoma, intra-abdominal lymph nodes

C85.14

Unspecified B-cell lymphoma, lymph nodes of axilla and upper limb

C85.15

Unspecified B-cell lymphoma, lymph nodes of inguinal region and lower limb

C85.16

Unspecified B-cell lymphoma, intrapelvic lymph nodes

C85.17

Unspecified B-cell lymphoma, spleen

C85.18

Unspecified B-cell lymphoma, lymph nodes of multiple sites

C85.19

Unspecified B-cell lymphoma, extranodal and solid organ sites

C85.20

Mediastinal (thymic) large B-cell lymphoma, unspecified site

C85.21

Mediastinal (thymic) large B-cell lymphoma, lymph nodes of head, face and neck

C85.22

Mediastinal (thymic) large B-cell lymphoma, intrathoracic lymph nodes

C85.23

Mediastinal (thymic) large B-cell lymphoma, intra-abdominal lymph nodes

C85.24

Mediastinal (thymic) large B-cell lymphoma, lymph nodes of axilla and upper limb

C85.25

Mediastinal (thymic) large B-cell lymphoma, lymph nodes of inguinal region and lower limb

C85.26

Mediastinal (thymic) large B-cell lymphoma, intrapelvic lymph nodes

C85.27

Mediastinal (thymic) large B-cell lymphoma, spleen

C85.28

Mediastinal (thymic) large B-cell lymphoma, lymph nodes of multiple sites

C85.29

Mediastinal (thymic) large B-cell lymphoma, extranodal and solid organ sites

C85.80

Other specified types of non-Hodgkin lymphoma, unspecified site

C85.81

Other specified types of non-Hodgkin lymphoma, lymph nodes of head, face and neck

C85.82

Other specified types of non-Hodgkin lymphoma, intrathoracic lymph nodes

C85.83

Other specified types of non-Hodgkin lymphoma, intra-abdominal lymph nodes

C85.84

Other specified types of non-Hodgkin lymphoma, lymph nodes of axilla and upper limb

C85.85

Other specified types of non-Hodgkin lymphoma, lymph nodes of inguinal region of lower limb

C85.86

Other specified types of non-Hodgkin lymphoma, intrapelvic lymph nodes

C85.87

Other specified types of non-Hodgkin lymphoma, spleen

C85.88

Other specified types of non-Hodgkin lymphoma, lymph nodes of multiple sites

C85.89

Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites

C88.0

Waldenström macroglobulinemia

C88.4

Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT-lymphoma)

C91.00

Acute lymphoblastic leukemia not having achieved remission

C91.01

Acute lymphoblastic leukemia, in remission

C91.02

Acute lymphoblastic leukemia, in relapse

C91.10

Chronic lymphocytic leukemia of B-cell type not having achieved remission

C91.12

Chronic lymphocytic leukemia of B-cell type in relapse

C91.40

Hairy cell leukemia not having achieved remission

C91.42

Hairy cell leukemia, in relapse

D36.0

Benign neoplasm of lymph nodes

D47.Z1

Post-transplant lymphoproliferative disorder (PTLD)

D47.Z2

Other neoplasms of uncertain behavior of lymphoid, hematopoietic and related tissue-Castleman disease

D59.1

Other autoimmune hemolytic anemias

D69.3

Immune thrombocytopenic purpura

D69.41

Evans Syndrome

D69.42

Congenital and hereditary thrombocytopenia purpura

D69.49

Other primary thrombocytopenia

D89.811

Chronic graft-versus-host disease

D89.812

Acute on chronic graft-versus-host disease

D89.813

Graft-versus-host disease unspecified

G04.81

Other encephalitis and encephalomyelitis

G70.00

Myasthenia gravis without (acute) exacerbation

G70.01

Myasthenia gravis with (acute) exacerbation

L10.0

Pemphigus vulgaris

L13.8

Other specified bullous disorders

L13.9

Bullous disorder, unspecified

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

M05.70

Rheumatoid arthritis with rheumatoid factor of unspecified 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

M05.80

Other rheumatoid arthritis with rheumatoid factor of unspecified 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

M06.00

Rheumatoid arthritis without rheumatoid factor, unspecified 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

M06.80

Other specified rheumatoid arthritis, unspecified 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

M31.1

Thrombotic microangiopathy

M31.30

Wegener’s granulomatosis without renal involvement

M31.31

Wegener’s granulomatosis with renal involvement

M31.7

Microscopic polyangiitis

R59.0

Localized enlarged lymph nodes

R59.1

Generalized enlarged lymph nodes

R59.9

Enlarged lymph nodes, unspecified

T86.09

Other complications of bone marrow transplant

Z85.71

Personal history of Hodgkin lymphoma

Z85.72

Personal history of non-Hodgkin lymphomas

Z85.79

Personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues

Z94.81

Bone marrow transplant status

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 Articles (LCAs) and Local Coverage Determinations (LCDs) 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):

Jurisdiction(s): 6, K

NCD/LCD/LCA Document (s): A52452

https://www.cms.gov/medicare-coverage-database/search/article-date-search.aspx?DocID=A52452&bc=gAAAAAAAAAAAAA==

Jurisdiction(s): 5,8

NCD/LCD/LCA Document (s): A55639

https://www.cms.gov/medicare-coverage-database/search/article-date-search.aspx?DocID=A55639&bc=gAAAAAAAAAAA

Jurisdiction(s): 15

NCD/LCD/LCA Document (s): A57321

https://www.cms.gov/medicare-coverage-database/search/article-date-search.aspx?DocID=A57321&bc=gAAAAAAAAAAA

Jurisdiction(s): J,M

NCD/LCD/LCA Document (s): A56380

https://www.cms.gov/medicare-coverage-database/search/article-date-search.aspx?DocID=A56380&bc=gAAAAAAAAAAA

Jurisdiction(s): 15

NCD/LCD/LCA Document (s): A57160

https://www.cms.gov/medicare-coverage-database/search/document-id-search-results.aspx?DocID=A57160&bc=gAAAAAAAAAAA&

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

 

 

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