Colony Stimulating Factors: Neupogen® (filgrastim ... · Neupogen® (filgrastim), Neulasta®...

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I. Medication Description:

Colony stimulating factors (CSFs) act on hematopoietic cells by binding to specific cell surface receptors thereby stimulating proliferation, differentiation, commitment, and end cell functional activation. CSFs are biosynthetic products that stimulate the development of white blood cells such as neutrophils and macrophages (infection fighting cells).

Neutropenia is defined as an absolute neutrophil count (ANC) of less than 1500/microL. The ANC is equal to the product of the white blood cell count (WBC) and the fraction of polymorphonuclear cells (PMNs) and band forms: ANC = WBC (cells/microL) x percent (PMNs + bands) ÷ 100

Fever in a neutropenic patient is usually defined as a single temperature >38.3⁰C (101.3⁰F), or a temperature >38⁰C (100.4⁰F) sustained for more than one hour.

Colony Stimulating Factors: Neupogen® (filgrastim), Neulasta® (pegfilgrastim), Leukine® (sargramostim), Granix (tbo-filgrastim)

Last Review Date: 03/25/2014 Date of Origin: 10/17/2008

Dates Reviewed: 6/17/2009, 12/22/2009, 06/15/2010/ 7/20/2010, 09/2010, 12/2010, 03/2011, 06/2011, 09/2011, 12/2011, 03/2012, 6/19/2012, 09/06/2012, 12/06/2012, 03/07/2013, 06/06/2013, 09/05/2013, 12/05/2013, 03/25/2014

Prior Auth Available: √ Post-Service edit: √ Medical Necessity Criteria Number: IC-0049

The medical necessity criteria was developed by ICORE Healthcare for the purpose of making clinical review determinations for requests for medications commonly used in various diseases. The clinical disciplines of oncology, hematology, rheumatology, neurology, internal medicine, pharmacy and nursing were consulted as part of the criteria development. The development followed an extensive literature search pertaining to established clinical guidelines and accepted prescribing patterns for each individual drug. The indications for the medications are consistent with FDA approved indications, CMS coverage guidelines, National Comprehensive Cancer Network (NCCN) guidelines and/or other published peer reviewed research literature.

Absolute neutrophil count/microL Risk management

>1500 None

1000-1500 No significant risk of infection; fever can be managed on an outpatient basis

500-1000 Some risk of infection; fever can occasionally be managed on an outpatient basis

<500 Significant risk of infection; fever should always be managed on an inpatient basis with parenteral antibiotics; few clinical signs of infection

<200 Very significant risk of infection; fever should always be managed on an inpatient basis with parenteral antibiotics; few or no clinical signs of infection

Colony Stimulating Factors: Neupogen® (filgrastim), Neulasta® (pegfilgrastim), Leukine® (sargramostim), Granix (tbo-filgrastim) Last Review Date: 03/25/2014

Medical Necessity Criteria Number: IC-0049

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II. Length of Authorization:

Coverage is provided for 4 months and may be renewed

III. Review Criteria:

Coverage for Leukine® (sargramostim) is provided in the following conditions: Myeloid reconstitution after autologous or allogeneic Bone marrow transplant (BMT)† Peripheral Blood Progenitor Cell (PBPC) mobilizaton and transplant† Patient with non-myeloid malignancy

o Patient is undergoing myelosuppressive chemotherapy and/or radiotherapy with an expected incidence of febrile neutropenia of 20% or greater‡; OR

o Patient is undergoing myelosuppressive chemotherapy with an expected incidence of febrile neutropenia of 10% or greater ‡ AND one or more of the following co-morbidities: • Elderly patients (age 65 or older) • History of recurrent febrile neutropenia from chemotherapy • Extensive prior exposure to chemotherapy • Previous exposure of pelvis, or other areas of large amounts of bone marrow, to radiation • Pre-existing neutropenia (ANC ≤ 1000/mm3) or bone marrow involvement with tumor • Patient has a condition that can potentially increase the risk of serious infection (i.e. HIV/AIDS)

Infection/open wounds • Recent surgery • Poor performance status • Poor renal function • Liver dysfunction (elevated bilirubin)

Patient who experienced a neutropenic complication from a prior cycle of the same chemotherapy

Acute Myeloid Leukemia (AML) following induction or consolidation chemotherapy†

Bone Marrow Transplantation (BMT) failure or Engraftment Delay† Coverage for Granix® (tbo-filgrastim) is provided in the following conditions: Patient with non-myeloid malignancy†



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o Patient is undergoing myelosuppressive chemotherapy with an expected incidence of febrile neutropenia of 10% or greater‡ AND one or more of the following co-morbidities: • Elderly patients (age 65 or older) • History of recurrent febrile neutropenia from chemotherapy • Extensive prior exposure to chemotherapy • Previous exposure of pelvis, or other areas of large amounts of bone marrow, to radiation • Pre-existing neutropenia (ANC ≤ 1000/mm3) or bone marrow involvement with tumor • Patient has a condition that can potentially increase the risk of serious infection (i.e. HIV/AIDS)


Coverage for Neulasta® (pegfilgrastim) is provided in the following conditions: Patient with non-myeloid malignancy†


o Patient is undergoing myelosuppressive chemotherapy with an expected incidence of febrile neutropenia of 10% or greater ‡ AND one or more of the following co-morbidities: • Elderly patients (age 65 or older) • History of recurrent febrile neutropenia from chemotherapy • Extensive prior exposure to chemotherapy • Previous exposure of pelvis, or other areas of large amounts of bone marrow, to radiation • Pre-existing neutropenia (ANC ≤ 1000/mm3) or bone marrow involvement with tumor • Patient has a condition that can potentially increase the risk of serious infection (i.e. HIV/AIDS)


o In all cases patients must weigh at least 45 kg to receive Neulasta®pegfilgrastim




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Coverage for Neupogen® (filgrastim) is provided in the following conditions: Bone marrow transplant (BMT) † Peripheral Blood Progenitor Cell (PBPC) mobilization and transplant†

Patient with non-myeloid malignancy†


o Patient is undergoing myelosuppressive chemotherapy with an expected incidence of febrile neutropenia of 10% or greater‡ AND one or more of the following co-morbidities: • Elderly patients (age 65 or older) • History of recurrent febrile neutropenia from chemotherapy • Extensive prior exposure to chemotherapy • Previous exposure of pelvis, or other areas of large amounts of bone marrow, to radiation • Pre-existing neutropenia (ANC ≤ 1000/mm3) or bone marrow involvement with tumor • Patient has a condition that can potentially increase the risk of serious infection (i.e. HIV/AIDS)



Acute Myeloid Leukemia (AML) patient following induction or consolidation chemotherapy†

Bone Marrow Transplantation (BMT) failure or Engraftment Delay Severe chronic neutropenia (ANC<500)†

Myelodysplastic Syndrome

†FDA-labeled indication(s) ‡ expected incidence of febrile neutropenia percentages for myelosuppressive chemotherapy regimens can be found in the NCCN Myeloid Growth Factors Clinical Practice Guideline at NCCN.org.

IV. Renewal Criteria:

Same as initial prior authorization policy criteria



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V. Dosage/Administration:

Indication (Drug) Dose Leukine – all indications 250mcg/m2 daily for up to 14 days Granix 5mcg/kg daily for up to 14 days Neupogen 5mcg/kg daily for up to 14 days for non-BMT/PBPC indications

10mcg/kg daily for up to 14 days for BMT/PBPC/Severe Neutropenia indications Neulasta – all indications Up to 6mg every 14 days

• Do not administer within 14 days before or 24 hours after administration of a cytotoxic chemotherapy

VI. Billing/Coding Information: JCode:

J2820 – Leukine (Bayer) 250, 500 mcg injection: 1 billable unit = 50 mcg J1442 - Neupogen (Amgen) 300 mcg, 480 mcg injection: 1 billable unit = 1 mcg J2505 – Neulasta (Amgen) 6 mg injection: 1 billable unit = 6 mg J1446 – Granix (Teva) 300 mcg, 480 mcg injection: 1 billable unit = 5 mcg NDC: Leukine 250 mcg vial– 00024-5843-xx (Bayer) Leukine 500 mcg vial– 00024-5844-xx (Bayer) Neupogen 300 mcg vial– 55513-0530-xx (Amgen) Neupogen 300 mcg prefilled syringe – 55513-0924-xx (Amgen) Neupogen 480 mcg vial – 55513-0546-xx (Amgen) Neupogen 480 mcg prefilled syringe – 55513-0209-xx (Amgen) Neulasta 6 mg prefilled syringe – 55513-0190-xx (Amgen) Granix 300 mcg prefilled syringe – 63459-0910-xx (Teva) Granix 400 mcg prefilled syringe – 63459-0912-xx (Teva) Max Units (per dose and over time): Leukine (J2820) Male 10 billable units per day Female 10 billable units per day Neupogen (J1442) Severe Chronic Neutropenia: Male 1380 billable units per day Female 1200 billable units per day



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BMT or PBPC: Male 1200 billable units per day Female 960 billable units per day All other indications: Male 600 billable units per day Female 480 billable units per day Granix (J1446) Male 120 billable units per day Female 96 billable units per day Neulasta (J2505) Male 1 billable unit per 14 days Female 1 billable unit per 14 days Quantity Limits Leukine 250 mcg vial: 28 vials per 14 days Leukine 500 mcg vial: 14 vials per 14 days Neupogen 300 mcg vial: 90 vials per 30 days Neupogen 300 mcg prefilled syringe: 90 syringes per 30 days Neupogen 480 mcg vial: 90 vials per 30 days Neupogen 480 mcg prefilled syringe: 90 syringes per 30 days Neulasta 6 mg prefilled syringe: 1 syringe per 14 days Granix 300 mcg: 28 syringes per 14 days Granix 480 mcg; 14 syringes per 14 days Covered Diagnosis:

Leukine

288.03 Drug induced neutropenia

996.85 Complications of transplanted bone marrow

V07.8 Other specified prophylactic or treatment measure

V42.81 Bone marrow replaced by transplant

V42.82 Peripheral stem cells replaced by transplant

V58.11 Encounter for antineoplastic chemotherapy

V66.2 Convalescence following chemotherapy



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Granix 288.03 Drug induced neutropenia




Neulasta





Neupogen

042 Human immunodeficiency virus (HIV)

205.10 Chronic myeloid leukemia, without mention of achieving remission

238.72 Low grade myelodysplastic syndrome (MDS) lesions

238.73 High grade myelodysplastic syndrome lesions 238.74 Myelodysplastic syndrome with 5q deletion 238.75 Myelodysplastic syndrome (MDS) unspecified

284.89 Other specified aplastic anemias

288.00 Neutropenia, unspecified

288.01

Congenital neutropenia

288.02 Cyclic neutropenia


996.85 Complications of transplanted bone marrow


V42.81 Bone marrow replaced by transplant

V42.82 Peripheral stem cells replaced by transplant



VII. 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) 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.

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



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Medicare Part B Covered Diagnosis Codes (applicable to existing NCD/LCD): Leukine (J2820), Neupogen (J1442), Neulasta (J2505), Granix (J1446)

Jurisdiction(s): 15 NCD/LCD Document (s): L31851 ICD-9 Codes Diagnosis

140.0 MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER 140.1 MALIGNANT NEOPLASM OF LOWER LIP VERMILION BORDER 140.3 MALIGNANT NEOPLASM OF UPPER LIP INNER ASPECT 140.4 MALIGNANT NEOPLASM OF LOWER LIP INNER ASPECT 140.5 MALIGNANT NEOPLASM OF LIP UNSPECIFIED INNER ASPECT 140.6 MALIGNANT NEOPLASM OF COMMISSURE OF LIP 140.8 MALIGNANT NEOPLASM OF OTHER SITES OF LIP 140.9 MALIGNANT NEOPLASM OF LIP UNSPECIFIED VERMILION BORDER 141.0 MALIGNANT NEOPLASM OF BASE OF TONGUE 141.1 MALIGNANT NEOPLASM OF DORSAL SURFACE OF TONGUE 141.2 MALIGNANT NEOPLASM OF TIP AND LATERAL BORDER OF TONGUE 141.3 MALIGNANT NEOPLASM OF VENTRAL SURFACE OF TONGUE

141.4 MALIGNANT NEOPLASM OF ANTERIOR TWO-THIRDS OF TONGUE PART UNSPECIFIED

141.5 MALIGNANT NEOPLASM OF JUNCTIONAL ZONE OF TONGUE 141.6 MALIGNANT NEOPLASM OF LINGUAL TONSIL 141.8 MALIGNANT NEOPLASM OF OTHER SITES OF TONGUE 141.9 MALIGNANT NEOPLASM OF TONGUE UNSPECIFIED 142.0 MALIGNANT NEOPLASM OF PAROTID GLAND 142.1 MALIGNANT NEOPLASM OF SUBMANDIBULAR GLAND 142.2 MALIGNANT NEOPLASM OF SUBLINGUAL GLAND 142.8 MALIGNANT NEOPLASM OF OTHER MAJOR SALIVARY GLANDS 142.9 MALIGNANT NEOPLASM OF SALIVARY GLAND UNSPECIFIED 143.0 MALIGNANT NEOPLASM OF UPPER GUM 143.1 MALIGNANT NEOPLASM OF LOWER GUM 143.8 MALIGNANT NEOPLASM OF OTHER SITES OF GUM 143.9 MALIGNANT NEOPLASM OF GUM UNSPECIFIED 144.0 MALIGNANT NEOPLASM OF ANTERIOR PORTION OF FLOOR OF MOUTH 144.1 MALIGNANT NEOPLASM OF LATERAL PORTION OF FLOOR OF MOUTH 144.8 MALIGNANT NEOPLASM OF OTHER SITES OF FLOOR OF MOUTH



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144.9 MALIGNANT NEOPLASM OF FLOOR OF MOUTH PART UNSPECIFIED 145.0 MALIGNANT NEOPLASM OF CHEEK MUCOSA 145.1 MALIGNANT NEOPLASM OF VESTIBULE OF MOUTH 145.2 MALIGNANT NEOPLASM OF HARD PALATE 145.3 MALIGNANT NEOPLASM OF SOFT PALATE 145.4 MALIGNANT NEOPLASM OF UVULA 145.5 MALIGNANT NEOPLASM OF PALATE UNSPECIFIED 145.6 MALIGNANT NEOPLASM OF RETROMOLAR AREA 145.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED PARTS OF MOUTH 145.9 MALIGNANT NEOPLASM OF MOUTH UNSPECIFIED 146.0 MALIGNANT NEOPLASM OF TONSIL 146.1 MALIGNANT NEOPLASM OF TONSILLAR FOSSA

146.2 MALIGNANT NEOPLASM OF TONSILLAR PILLARS (ANTERIOR) (POSTERIOR)

146.3 MALIGNANT NEOPLASM OF VALLECULA EPIGLOTTICA 146.4 MALIGNANT NEOPLASM OF ANTERIOR ASPECT OF EPIGLOTTIS 146.5 MALIGNANT NEOPLASM OF JUNCTIONAL REGION OF OROPHARYNX 146.6 MALIGNANT NEOPLASM OF LATERAL WALL OF OROPHARYNX 146.7 MALIGNANT NEOPLASM OF POSTERIOR WALL OF OROPHARYNX 146.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF OROPHARYNX 146.9 MALIGNANT NEOPLASM OF OROPHARYNX UNSPECIFIED SITE 147.0 MALIGNANT NEOPLASM OF SUPERIOR WALL OF NASOPHARYNX 147.1 MALIGNANT NEOPLASM OF POSTERIOR WALL OF NASOPHARYNX 147.2 MALIGNANT NEOPLASM OF LATERAL WALL OF NASOPHARYNX 147.3 MALIGNANT NEOPLASM OF ANTERIOR WALL OF NASOPHARYNX 147.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF NASOPHARYNX 147.9 MALIGNANT NEOPLASM OF NASOPHARYNX UNSPECIFIED SITE 148.0 MALIGNANT NEOPLASM OF POSTCRICOID REGION OF HYPOPHARYNX 148.1 MALIGNANT NEOPLASM OF PYRIFORM SINUS

148.2 MALIGNANT NEOPLASM OF ARYEPIGLOTTIC FOLD HYPOPHARYNGEAL ASPECT

148.3 MALIGNANT NEOPLASM OF POSTERIOR HYPOPHARYNGEAL WALL 148.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF HYPOPHARYNX 148.9 MALIGNANT NEOPLASM OF HYPOPHARYNX UNSPECIFIED SITE 149.0 MALIGNANT NEOPLASM OF PHARYNX UNSPECIFIED 149.1 MALIGNANT NEOPLASM OF WALDEYER'S RING



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149.8 MALIGNANT NEOPLASM OF OTHER SITES WITHIN THE LIP AND ORAL CAVITY

149.9 MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE LIP AND ORAL CAVITY

150.0 MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS 150.1 MALIGNANT NEOPLASM OF THORACIC ESOPHAGUS 150.2 MALIGNANT NEOPLASM OF ABDOMINAL ESOPHAGUS 150.3 MALIGNANT NEOPLASM OF UPPER THIRD OF ESOPHAGUS 150.4 MALIGNANT NEOPLASM OF MIDDLE THIRD OF ESOPHAGUS 150.5 MALIGNANT NEOPLASM OF LOWER THIRD OF ESOPHAGUS 150.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED PART OF ESOPHAGUS 150.9 MALIGNANT NEOPLASM OF ESOPHAGUS UNSPECIFIED SITE 151.0 MALIGNANT NEOPLASM OF CARDIA 151.1 MALIGNANT NEOPLASM OF PYLORUS 151.2 MALIGNANT NEOPLASM OF PYLORIC ANTRUM 151.3 MALIGNANT NEOPLASM OF FUNDUS OF STOMACH 151.4 MALIGNANT NEOPLASM OF BODY OF STOMACH

151.5 MALIGNANT NEOPLASM OF LESSER CURVATURE OF STOMACH UNSPECIFIED

151.6 MALIGNANT NEOPLASM OF GREATER CURVATURE OF STOMACH UNSPECIFIED

151.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF STOMACH 151.9 MALIGNANT NEOPLASM OF STOMACH UNSPECIFIED SITE 152.0 MALIGNANT NEOPLASM OF DUODENUM 152.1 MALIGNANT NEOPLASM OF JEJUNUM 152.2 MALIGNANT NEOPLASM OF ILEUM 152.3 MALIGNANT NEOPLASM OF MECKEL'S DIVERTICULUM

152.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SMALL INTESTINE

152.9 MALIGNANT NEOPLASM OF SMALL INTESTINE UNSPECIFIED SITE 153.0 MALIGNANT NEOPLASM OF HEPATIC FLEXURE 153.1 MALIGNANT NEOPLASM OF TRANSVERSE COLON 153.2 MALIGNANT NEOPLASM OF DESCENDING COLON 153.3 MALIGNANT NEOPLASM OF SIGMOID COLON 153.4 MALIGNANT NEOPLASM OF CECUM 153.5 MALIGNANT NEOPLASM OF APPENDIX VERMIFORMIS 153.6 MALIGNANT NEOPLASM OF ASCENDING COLON



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153.7 MALIGNANT NEOPLASM OF SPLENIC FLEXURE

153.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARGE INTESTINE

153.9 MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE 154.0 MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION 154.1 MALIGNANT NEOPLASM OF RECTUM 154.2 MALIGNANT NEOPLASM OF ANAL CANAL 154.3 MALIGNANT NEOPLASM OF ANUS UNSPECIFIED SITE

154.8 MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM RECTOSIGMOID JUNCTION AND ANUS

155.0 MALIGNANT NEOPLASM OF LIVER PRIMARY 155.1 MALIGNANT NEOPLASM OF INTRAHEPATIC BILE DUCTS

155.2 MALIGNANT NEOPLASM OF LIVER NOT SPECIFIED AS PRIMARY OR SECONDARY

156.0 MALIGNANT NEOPLASM OF GALLBLADDER 156.1 MALIGNANT NEOPLASM OF EXTRAHEPATIC BILE DUCTS 156.2 MALIGNANT NEOPLASM OF AMPULLA OF VATER

156.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF GALLBLADDER AND EXTRAHEPATIC BILE DUCTS

156.9 MALIGNANT NEOPLASM OF BILIARY TRACT PART UNSPECIFIED SITE 157.0 MALIGNANT NEOPLASM OF HEAD OF PANCREAS 157.1 MALIGNANT NEOPLASM OF BODY OF PANCREAS 157.2 MALIGNANT NEOPLASM OF TAIL OF PANCREAS 157.3 MALIGNANT NEOPLASM OF PANCREATIC DUCT 157.4 MALIGNANT NEOPLASM OF ISLETS OF LANGERHANS 157.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF PANCREAS 157.9 MALIGNANT NEOPLASM OF PANCREAS PART UNSPECIFIED 158.0 MALIGNANT NEOPLASM OF RETROPERITONEUM 158.8 MALIGNANT NEOPLASM OF SPECIFIED PARTS OF PERITONEUM 158.9 MALIGNANT NEOPLASM OF PERITONEUM UNSPECIFIED 159.0 MALIGNANT NEOPLASM OF INTESTINAL TRACT PART UNSPECIFIED 159.1 MALIGNANT NEOPLASM OF SPLEEN NOT ELSEWHERE CLASSIFIED

159.8 MALIGNANT NEOPLASM OF OTHER SITES OF DIGESTIVE SYSTEM AND INTRA-ABDOMINAL ORGANS

159.9 MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE DIGESTIVE ORGANS AND PERITONEUM

160.0 MALIGNANT NEOPLASM OF NASAL CAVITIES



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160.1 MALIGNANT NEOPLASM OF AUDITORY TUBE MIDDLE EAR AND MASTOID AIR CELLS

160.2 MALIGNANT NEOPLASM OF MAXILLARY SINUS 160.3 MALIGNANT NEOPLASM OF ETHMOIDAL SINUS 160.4 MALIGNANT NEOPLASM OF FRONTAL SINUS 160.5 MALIGNANT NEOPLASM OF SPHENOIDAL SINUS 160.8 MALIGNANT NEOPLASM OF OTHER ACCESSORY SINUSES 160.9 MALIGNANT NEOPLASM OF ACCESSORY SINUS UNSPECIFIED 161.0 MALIGNANT NEOPLASM OF GLOTTIS 161.1 MALIGNANT NEOPLASM OF SUPRAGLOTTIS 161.2 MALIGNANT NEOPLASM OF SUBGLOTTIS 161.3 MALIGNANT NEOPLASM OF LARYNGEAL CARTILAGES 161.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARYNX 161.9 MALIGNANT NEOPLASM OF LARYNX UNSPECIFIED 162.0 MALIGNANT NEOPLASM OF TRACHEA 162.2 MALIGNANT NEOPLASM OF MAIN BRONCHUS 162.3 MALIGNANT NEOPLASM OF UPPER LOBE BRONCHUS OR LUNG 162.4 MALIGNANT NEOPLASM OF MIDDLE LOBE BRONCHUS OR LUNG 162.5 MALIGNANT NEOPLASM OF LOWER LOBE BRONCHUS OR LUNG 162.8 MALIGNANT NEOPLASM OF OTHER PARTS OF BRONCHUS OR LUNG 162.9 MALIGNANT NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED 163.0 MALIGNANT NEOPLASM OF PARIETAL PLEURA 163.1 MALIGNANT NEOPLASM OF VISCERAL PLEURA 163.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF PLEURA 163.9 MALIGNANT NEOPLASM OF PLEURA UNSPECIFIED 164.0 MALIGNANT NEOPLASM OF THYMUS 164.1 MALIGNANT NEOPLASM OF HEART 164.2 MALIGNANT NEOPLASM OF ANTERIOR MEDIASTINUM 164.3 MALIGNANT NEOPLASM OF POSTERIOR MEDIASTINUM 164.8 MALIGNANT NEOPLASM OF OTHER PARTS OF MEDIASTINUM 164.9 MALIGNANT NEOPLASM OF MEDIASTINUM PART UNSPECIFIED

165.0 MALIGNANT NEOPLASM OF UPPER RESPIRATORY TRACT PART UNSPECIFIED

165.8 MALIGNANT NEOPLASM OF OTHER SITES WITHIN THE RESPIRATORY SYSTEM AND INTRATHORACIC ORGANS

165.9 MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE RESPIRATORY SYSTEM



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170.0 MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE EXCEPT MANDIBLE

170.1 MALIGNANT NEOPLASM OF MANDIBLE

170.2 MALIGNANT NEOPLASM OF VERTEBRAL COLUMN EXCLUDING SACRUM AND COCCYX

170.3 MALIGNANT NEOPLASM OF RIBS STERNUM AND CLAVICLE 170.4 MALIGNANT NEOPLASM OF SCAPULA AND LONG BONES OF UPPER LIMB 170.5 MALIGNANT NEOPLASM OF SHORT BONES OF UPPER LIMB 170.6 MALIGNANT NEOPLASM OF PELVIC BONES SACRUM AND COCCYX 170.7 MALIGNANT NEOPLASM OF LONG BONES OF LOWER LIMB 170.8 MALIGNANT NEOPLASM OF SHORT BONES OF LOWER LIMB

170.9 MALIGNANT NEOPLASM OF BONE AND ARTICULAR CARTILAGE SITE UNSPECIFIED

171.0 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF HEAD FACE AND NECK

171.2 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF UPPER LIMB INCLUDING SHOULDER

171.3 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF LOWER LIMB INCLUDING HIP

171.4 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF THORAX

171.5 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF ABDOMEN

171.6 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF PELVIS

171.7 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF TRUNK UNSPECIFIED

171.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF CONNECTIVE AND OTHER SOFT TISSUE

171.9 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE SITE UNSPECIFIED

172.0 MALIGNANT MELANOMA OF SKIN OF LIP 172.1 MALIGNANT MELANOMA OF SKIN OF EYELID INCLUDING CANTHUS

172.2 MALIGNANT MELANOMA OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL

172.3 MALIGNANT MELANOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE

172.4 MALIGNANT MELANOMA OF SKIN OF SCALP AND NECK 172.5 MALIGNANT MELANOMA OF SKIN OF TRUNK EXCEPT SCROTUM

172.6 MALIGNANT MELANOMA OF SKIN OF UPPER LIMB INCLUDING SHOULDER



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172.7 MALIGNANT MELANOMA OF SKIN OF LOWER LIMB INCLUDING HIP 172.8 MALIGNANT MELANOMA OF OTHER SPECIFIED SITES OF SKIN 172.9 MELANOMA OF SKIN SITE UNSPECIFIED 174.0 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST 174.1 MALIGNANT NEOPLASM OF CENTRAL PORTION OF FEMALE BREAST

174.2 MALIGNANT NEOPLASM OF UPPER-INNER QUADRANT OF FEMALE BREAST

174.3 MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF FEMALE BREAST

174.4 MALIGNANT NEOPLASM OF UPPER-OUTER QUADRANT OF FEMALE BREAST

174.5 MALIGNANT NEOPLASM OF LOWER-OUTER QUADRANT OF FEMALE BREAST

174.6 MALIGNANT NEOPLASM OF AXILLARY TAIL OF FEMALE BREAST 174.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE BREAST 174.9 MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE 175.0 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST

175.9 MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST

176.0 KAPOSI'S SARCOMA SKIN 176.1 KAPOSI'S SARCOMA SOFT TISSUE 176.2 KAPOSI'S SARCOMA PALATE 176.3 KAPOSI'S SARCOMA GASTROINTESTINAL SITES 176.4 KAPOSI'S SARCOMA LUNG 176.5 KAPOSI'S SARCOMA LYMPH NODES 176.8 KAPOSI'S SARCOMA OTHER SPECIFIED SITES 176.9 KAPOSI'S SARCOMA UNSPECIFIED SITE 179 MALIGNANT NEOPLASM OF UTERUS-PART UNS

180.0 MALIGNANT NEOPLASM OF ENDOCERVIX 180.1 MALIGNANT NEOPLASM OF EXOCERVIX 180.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF CERVIX 180.9 MALIGNANT NEOPLASM OF CERVIX UTERI UNSPECIFIED SITE 181 MALIGNANT NEOPLASM OF PLACENTA

182.0 MALIGNANT NEOPLASM OF CORPUS UTERI EXCEPT ISTHMUS 182.1 MALIGNANT NEOPLASM OF ISTHMUS

182.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF BODY OF UTERUS



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183.0 MALIGNANT NEOPLASM OF OVARY 183.2 MALIGNANT NEOPLASM OF FALLOPIAN TUBE 183.3 MALIGNANT NEOPLASM OF BROAD LIGAMENT OF UTERUS 183.4 MALIGNANT NEOPLASM OF PARAMETRIUM 183.5 MALIGNANT NEOPLASM OF ROUND LIGAMENT OF UTERUS

183.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF UTERINE ADNEXA

183.9 MALIGNANT NEOPLASM OF UTERINE ADNEXA UNSPECIFIED SITE 184.0 MALIGNANT NEOPLASM OF VAGINA 184.1 MALIGNANT NEOPLASM OF LABIA MAJORA 184.2 MALIGNANT NEOPLASM OF LABIA MINORA 184.3 MALIGNANT NEOPLASM OF CLITORIS 184.4 MALIGNANT NEOPLASM OF VULVA UNSPECIFIED SITE

184.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE GENITAL ORGANS

184.9 MALIGNANT NEOPLASM OF FEMALE GENITAL ORGAN SITE UNSPECIFIED 185 MALIGNANT NEOPLASM OF PROSTATE

186.0 MALIGNANT NEOPLASM OF UNDESCENDED TESTIS 186.9 MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED TESTIS 187.1 MALIGNANT NEOPLASM OF PREPUCE 187.2 MALIGNANT NEOPLASM OF GLANS PENIS 187.3 MALIGNANT NEOPLASM OF BODY OF PENIS 187.4 MALIGNANT NEOPLASM OF PENIS PART UNSPECIFIED 187.5 MALIGNANT NEOPLASM OF EPIDIDYMIS 187.6 MALIGNANT NEOPLASM OF SPERMATIC CORD 187.7 MALIGNANT NEOPLASM OF SCROTUM

187.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF MALE GENITAL ORGANS

187.9 MALIGNANT NEOPLASM OF MALE GENITAL ORGAN SITE UNSPECIFIED 188.0 MALIGNANT NEOPLASM OF TRIGONE OF URINARY BLADDER 188.1 MALIGNANT NEOPLASM OF DOME OF URINARY BLADDER 188.2 MALIGNANT NEOPLASM OF LATERAL WALL OF URINARY BLADDER 188.3 MALIGNANT NEOPLASM OF ANTERIOR WALL OF URINARY BLADDER 188.4 MALIGNANT NEOPLASM OF POSTERIOR WALL OF URINARY BLADDER 188.5 MALIGNANT NEOPLASM OF BLADDER NECK 188.6 MALIGNANT NEOPLASM OF URETERIC ORIFICE



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188.7 MALIGNANT NEOPLASM OF URACHUS 188.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF BLADDER 188.9 MALIGNANT NEOPLASM OF BLADDER PART UNSPECIFIED 189.0 MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS 189.1 MALIGNANT NEOPLASM OF RENAL PELVIS 189.2 MALIGNANT NEOPLASM OF URETER 189.3 MALIGNANT NEOPLASM OF URETHRA 189.4 MALIGNANT NEOPLASM OF PARAURETHRAL GLANDS

189.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF URINARY ORGANS

189.9 MALIGNANT NEOPLASM OF URINARY ORGAN SITE UNSPECIFIED

190.0 MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID

190.1 MALIGNANT NEOPLASM OF ORBIT 190.2 MALIGNANT NEOPLASM OF LACRIMAL GLAND 190.3 MALIGNANT NEOPLASM OF CONJUNCTIVA 190.4 MALIGNANT NEOPLASM OF CORNEA 190.5 MALIGNANT NEOPLASM OF RETINA 190.6 MALIGNANT NEOPLASM OF CHOROID 190.7 MALIGNANT NEOPLASM OF LACRIMAL DUCT 190.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF EYE 190.9 MALIGNANT NEOPLASM OF EYE PART UNSPECIFIED 191.0 MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES 191.1 MALIGNANT NEOPLASM OF FRONTAL LOBE 191.2 MALIGNANT NEOPLASM OF TEMPORAL LOBE 191.3 MALIGNANT NEOPLASM OF PARIETAL LOBE 191.4 MALIGNANT NEOPLASM OF OCCIPITAL LOBE 191.5 MALIGNANT NEOPLASM OF VENTRICLES 191.6 MALIGNANT NEOPLASM OF CEREBELLUM NOS 191.7 MALIGNANT NEOPLASM OF BRAIN STEM 191.8 MALIGNANT NEOPLASM OF OTHER PARTS OF BRAIN 191.9 MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE 192.0 MALIGNANT NEOPLASM OF CRANIAL NERVES 192.1 MALIGNANT NEOPLASM OF CEREBRAL MENINGES 192.2 MALIGNANT NEOPLASM OF SPINAL CORD 192.3 MALIGNANT NEOPLASM OF SPINAL MENINGES



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192.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF NERVOUS SYSTEM

192.9 MALIGNANT NEOPLASM OF NERVOUS SYSTEM PART UNSPECIFIED 193 MALIGNANT NEOPLASM OF THYROID GLAND

194.0 MALIGNANT NEOPLASM OF ADRENAL GLAND 194.1 MALIGNANT NEOPLASM OF PARATHYROID GLAND

194.3 MALIGNANT NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT

194.4 MALIGNANT NEOPLASM OF PINEAL GLAND 194.5 MALIGNANT NEOPLASM OF CAROTID BODY 194.6 MALIGNANT NEOPLASM OF AORTIC BODY AND OTHER PARAGANGLIA

194.8 MALIGNANT NEOPLASM OF OTHER ENDOCRINE GLANDS AND RELATED STRUCTURES

194.9 MALIGNANT NEOPLASM OF ENDOCRINE GLAND SITE UNSPECIFIED 195.0 MALIGNANT NEOPLASM OF HEAD FACE AND NECK 195.1 MALIGNANT NEOPLASM OF THORAX 195.2 MALIGNANT NEOPLASM OF ABDOMEN 195.3 MALIGNANT NEOPLASM OF PELVIS 195.4 MALIGNANT NEOPLASM OF UPPER LIMB 195.5 MALIGNANT NEOPLASM OF LOWER LIMB 195.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES

196.0 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF HEAD FACE AND NECK

196.1 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INTRATHORACIC LYMPH NODES

196.2 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INTRA-ABDOMINAL LYMPH NODES

196.3 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF AXILLA AND UPPER LIMB

196.5 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

196.6 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INTRAPELVIC LYMPH NODES

196.8 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF MULTIPLE SITES

196.9 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES SITE UNSPECIFIED

197.0 SECONDARY MALIGNANT NEOPLASM OF LUNG 197.1 SECONDARY MALIGNANT NEOPLASM OF MEDIASTINUM



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197.2 SECONDARY MALIGNANT NEOPLASM OF PLEURA 197.3 SECONDARY MALIGNANT NEOPLASM OF OTHER RESPIRATORY ORGANS

197.4 SECONDARY MALIGNANT NEOPLASM OF SMALL INTESTINE INCLUDING DUODENUM

197.5 SECONDARY MALIGNANT NEOPLASM OF LARGE INTESTINE AND RECTUM

197.6 SECONDARY MALIGNANT NEOPLASM OF RETROPERITONEUM AND PERITONEUM

197.7 MALIGNANT NEOPLASM OF LIVER SECONDARY

197.8 SECONDARY MALIGNANT NEOPLASM OF OTHER DIGESTIVE ORGANS AND SPLEEN

198.0 SECONDARY MALIGNANT NEOPLASM OF KIDNEY 198.1 SECONDARY MALIGNANT NEOPLASM OF OTHER URINARY ORGANS 198.2 SECONDARY MALIGNANT NEOPLASM OF SKIN 198.3 SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD

198.4 SECONDARY MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM

198.5 SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW 198.6 SECONDARY MALIGNANT NEOPLASM OF OVARY 198.7 SECONDARY MALIGNANT NEOPLASM OF ADRENAL GLAND

198.81 SECONDARY MALIGNANT NEOPLASM OF BREAST 198.82 SECONDARY MALIGNANT NEOPLASM OF GENITAL ORGANS 198.89 SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES 199.0 DISSEMINATED MALIGNANT NEOPLASM 199.1 OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE 199.2 MALIGNANT NEOPLASM ASSOCIATED WITH TRANSPLANT ORGAN

200.00 RETICULOSARCOMA UNSPECIFIED SITE

200.01 RETICULOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

200.02 RETICULOSARCOMA INVOLVING INTRATHORACIC LYMPH NODES 200.03 RETICULOSARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES

200.04 RETICULOSARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

200.05 RETICULOSARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

200.06 RETICULOSARCOMA INVOLVING INTRAPELVIC LYMPH NODES 200.07 RETICULOSARCOMA INVOLVING SPLEEN 200.08 RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES



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200.10 LYMPHOSARCOMA UNSPECIFIED SITE 200.11 LYMPHOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK 200.12 LYMPHOSARCOMA INVOLVING INTRATHORACIC LYMPH NODES 200.13 LYMPHOSARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES

200.14 LYMPHOSARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

200.15 LYMPHOSARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

200.16 LYMPHOSARCOMA INVOLVING INTRAPELVIC LYMPH NODES 200.17 LYMPHOSARCOMA INVOLVING SPLEEN 200.18 LYMPHOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES 200.20 BURKITT'S TUMOR OR LYMPHOMA UNSPECIFIED SITE

200.21 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

200.22 BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRATHORACIC LYMPH NODES

200.23 BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES

200.24 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

200.25 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

200.26 BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRAPELVIC LYMPH NODES

200.27 BURKITT'S TUMOR OR LYMPHOMA INVOLVING SPLEEN

200.28 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

200.30 MARGINAL ZONE LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES

200.31 MARGINAL ZONE LYMPHOMA,LYMPH NODES OF HEAD, FACE, AND NECK

200.32 MARGINAL ZONE LYMPHOMA,INTRATHORACIC LYMPH NODES 200.33 MARGINAL ZONE LYMPHOMA, INTRAABDOMINAL LYMPH NODES

200.34 MARGINAL ZONE LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB

200.35 MARGINAL ZONE LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

200.36 MARGINAL ZONE LYMPHOMA, INTRAPELVIC LYMPH NODES 200.37 MARGINAL ZONE LYMPHOMA, SPLEEN 200.38 MARGINAL ZONE LYMPHOMA, LYMPH NODES OF MULTIPLE SITES



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200.40 MANTLE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES

200.41 MANTLE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 200.42 MANTLE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES 200.43 MANTLE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES 200.44 MANTLE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB

200.45 MANTLE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

200.46 MANTLE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES 200.47 MANTLE CELL LYMPHOMA, SPLEEN 200.48 MANTLE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES

200.50 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES

200.51 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK

200.52 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRATHORACIC LYMPH NODES

200.53 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES

200.54 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB

200.55 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

200.56 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRAPELVIC LYMPH NODES

200.57 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, SPLEEN

200.58 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF MULTIPLE SITES

200.60 ANAPLASTIC LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES

200.61 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK

200.62 ANAPLASTIC LARGE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES

200.63 ANAPLASTIC LARGE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES

200.64 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB

200.65 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

200.66 ANAPLASTIC LARGE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES 200.67 ANAPLASTIC LARGE CELL LYMPHOMA, SPLEEN



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200.68 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES

200.70 LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES

200.71 LARGE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 200.72 LARGE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES 200.73 LARGE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES 200.74 LARGE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB

200.75 LARGE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

200.76 LARGE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES 200.77 LARGE CELL LYMPHOMA, SPLEEN 200.78 LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES

200.80 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA UNSPECIFIED SITE

200.81 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

200.82 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING INTRATHORACIC LYMPH NODES

200.83 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES

200.84 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

200.85 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

200.86 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING INTRAPELVIC LYMPH NODES

200.87 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING SPLEEN

200.88 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

201.00 HODGKIN'S PARAGRANULOMA UNSPECIFIED SITE

201.01 HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.02 HODGKIN'S PARAGRANULOMA INVOLVING INTRATHORACIC LYMPH NODES

201.03 HODGKIN'S PARAGRANULOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES

201.04 HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF AXILLA



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AND UPPER LIMB

201.05 HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

201.06 HODGKIN'S PARAGRANULOMA INVOLVING INTRAPELVIC LYMPH NODES 201.07 HODGKIN'S PARAGRANULOMA INVOLVING SPLEEN

201.08 HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

201.10 HODGKIN'S GRANULOMA UNSPECIFIED SITE

201.11 HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.12 HODGKIN'S GRANULOMA INVOLVING INTRATHORACIC LYMPH NODES

201.13 HODGKIN'S GRANULOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES

201.14 HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

201.15 HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

201.16 HODGKIN'S GRANULOMA INVOLVING INTRAPELVIC LYMPH NODES 201.17 HODGKIN'S GRANULOMA INVOLVING SPLEEN

201.18 HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

201.20 HODGKIN'S SARCOMA UNSPECIFIED SITE

201.21 HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.22 HODGKIN'S SARCOMA INVOLVING INTRATHORACIC LYMPH NODES 201.23 HODGKIN'S SARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES

201.24 HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

201.25 HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

201.26 HODGKIN'S SARCOMA INVOLVING INTRAPELVIC LYMPH NODES 201.27 HODGKIN'S SARCOMA INVOLVING SPLEEN 201.28 HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

201.40 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE UNSPECIFIED SITE

201.41 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.42 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING INTRATHORACIC LYMPH NODES

201.43 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING INTRA-ABDOMINAL LYMPH NODES



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201.44 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

201.45 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

201.46 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING INTRAPELVIC LYMPH NODES

201.47 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING SPLEEN

201.48 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF MULTIPLE SITES

201.50 HODGKIN'S DISEASE NODULAR SCLEROSIS UNSPECIFIED SITE

201.51 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.52 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING INTRATHORACIC LYMPH NODES

201.53 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES

201.54 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

201.55 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

201.56 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING INTRAPELVIC LYMPH NODES

201.57 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING SPLEEN

201.58 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF MULTIPLE SITES

201.60 HODGKIN'S DISEASE MIXED CELLULARITY UNSPECIFIED SITE

201.61 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.62 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING INTRATHORACIC LYMPH NODES

201.63 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING INTRA-ABDOMINAL LYMPH NODES

201.64 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

201.65 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

201.66 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING INTRAPELVIC LYMPH NODES

201.67 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING SPLEEN

201.68 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF MULTIPLE SITES

201.70 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION UNSPECIFIED SITE



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201.71 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.72 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING INTRATHORACIC LYMPH NODES

201.73 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING INTRA-ABDOMINAL LYMPH NODES

201.74 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

201.75 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

201.76 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING INTRAPELVIC LYMPH NODES

201.77 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING SPLEEN

201.78 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF MULTIPLE SITES

201.90 HODGKIN'S DISEASE UNSPECIFIED TYPE UNSPECIFIED SITE

201.91 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.92 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING INTRATHORACIC LYMPH NODES

201.93 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING INTRA-ABDOMINAL LYMPH NODES

201.94 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

201.95 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

201.96 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING INTRAPELVIC LYMPH NODES

201.97 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING SPLEEN

201.98 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF MULTIPLE SITES

202.00 NODULAR LYMPHOMA UNSPECIFIED SITE

202.01 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.02 NODULAR LYMPHOMA INVOLVING INTRATHORACIC LYMPH NODES 202.03 NODULAR LYMPHOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.04 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.05 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.06 NODULAR LYMPHOMA INVOLVING INTRAPELVIC LYMPH NODES 202.07 NODULAR LYMPHOMA INVOLVING SPLEEN



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202.08 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES 202.10 MYCOSIS FUNGOIDES UNSPECIFIED SITE

202.11 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.12 MYCOSIS FUNGOIDES INVOLVING INTRATHORACIC LYMPH NODES 202.13 MYCOSIS FUNGOIDES INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.14 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.15 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.16 MYCOSIS FUNGOIDES INVOLVING INTRAPELVIC LYMPH NODES 202.17 MYCOSIS FUNGOIDES INVOLVING SPLEEN 202.18 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF MULTIPLE SITES 202.20 SEZARY'S DISEASE UNSPECIFIED SITE 202.21 SEZARY'S DISEASE INVOLVING LYMPH NODES OF HEAD FACE AND NECK 202.22 SEZARY'S DISEASE INVOLVING INTRATHORACIC LYMPH NODES 202.23 SEZARY'S DISEASE INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.24 SEZARY'S DISEASE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.25 SEZARY'S DISEASE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.26 SEZARY'S DISEASE INVOLVING INTRAPELVIC LYMPH NODES 202.27 SEZARY'S DISEASE INVOLVING SPLEEN 202.28 SEZARY'S DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES 202.30 MALIGNANT HISTIOCYTOSIS UNSPECIFIED SITE

202.31 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.32 MALIGNANT HISTIOCYTOSIS INVOLVING INTRATHORACIC LYMPH NODES

202.33 MALIGNANT HISTIOCYTOSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.34 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.35 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.36 MALIGNANT HISTIOCYTOSIS INVOLVING INTRAPELVIC LYMPH NODES 202.37 MALIGNANT HISTIOCYTOSIS INVOLVING SPLEEN

202.38 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES

202.40 LEUKEMIC RETICULOENDOTHELIOSIS UNSPECIFIED SITE



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202.41 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.42 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRATHORACIC LYMPH NODES

202.43 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.44 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER ARM

202.45 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.46 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRAPELVIC LYMPH NODES

202.47 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING SPLEEN

202.48 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES

202.50 LETTERER-SIWE DISEASE UNSPECIFIED SITE

202.51 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.52 LETTERER-SIWE DISEASE INVOLVING INTRATHORACIC LYMPH NODES 202.53 LETTERER-SIWE DISEASE INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.54 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.55 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.56 LETTERER-SIWE DISEASE INVOLVING INTRAPELVIC LYMPH NODES 202.57 LETTERER-SIWE DISEASE INVOLVING SPLEEN 202.58 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES 202.60 MALIGNANT MAST CELL TUMORS UNSPECIFIED SITE

202.61 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.62 MALIGNANT MAST CELL TUMORS INVOLVING INTRATHORACIC LYMPH NODES

202.63 MALIGNANT MAST CELL TUMORS INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.64 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.65 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.66 MALIGNANT MAST CELL TUMORS INVOLVING INTRAPELVIC LYMPH NODES

202.67 MALIGNANT MAST CELL TUMORS INVOLVING SPLEEN



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202.68 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF MULTIPLE SITES

202.70 PERIPHERAL T CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES

202.71 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK

202.72 PERIPHERAL T CELL LYMPHOMA, INTRATHORACIC LYMPH NODES 202.73 PERIPHERAL T CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES

202.74 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB

202.75 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.76 PERIPHERAL T CELL LYMPHOMA, INTRAPELVIC LYMPH NODES 202.77 PERIPHERAL T CELL LYMPHOMA, SPLEEN 202.78 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES 202.80 OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE

202.81 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.82 OTHER MALIGNANT LYMPHOMAS INVOLVING INTRATHORACIC LYMPH NODES

202.83 OTHER MALIGNANT LYMPHOMAS INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.84 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.85 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.86 OTHER MALIGNANT LYMPHOMAS INVOLVING INTRAPELVIC LYMPH NODES

202.87 OTHER MALIGNANT LYMPHOMAS INVOLVING SPLEEN

202.88 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF MULTIPLE SITES

202.90 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE UNSPECIFIED SITE

202.91 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.92 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRATHORACIC LYMPH NODES

202.93 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.94 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF AXILLA AND UPPER



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LIMB

202.95 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.96 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRAPELVIC LYMPH NODES

202.97 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING SPLEEN

202.98 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF MULTIPLE SITES

203.00 MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

203.01 MULTIPLE MYELOMA IN REMISSION 203.02 MULTIPLE MYELOMA, IN RELAPSE

203.10 PLASMA CELL LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

203.11 PLASMA CELL LEUKEMIA IN REMISSION 203.12 PLASMA CELL LEUKEMIA, IN RELAPSE

203.80 OTHER IMMUNOPROLIFERATIVE NEOPLASMS, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

203.81 OTHER IMMUNOPROLIFERATIVE NEOPLASMS IN REMISSION 203.82 OTHER IMMUNOPROLIFERATIVE NEOPLASMS, IN RELAPSE

204.00 ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

204.01 LYMPHOID LEUKEMIA ACUTE IN REMISSION 204.02 ACUTE LYMPHOID LEUKEMIA, IN RELAPSE

204.10 CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

204.11 LYMPHOID LEUKEMIA CHRONIC IN REMISSION 204.12 CHRONIC LYMPHOID LEUKEMIA, IN RELAPSE

204.20 SUBACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

204.21 LYMPHOID LEUKEMIA SUBACUTE IN REMISSION 204.22 SUBACUTE LYMPHOID LEUKEMIA, IN RELAPSE

204.80 OTHER LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

204.81 OTHER LYMPHOID LEUKEMIA IN REMISSION 204.82 OTHER LYMPHOID LEUKEMIA, IN RELAPSE

204.90 UNSPECIFIED LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION



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204.91 UNSPECIFIED LYMPHOID LEUKEMIA IN REMISSION 204.92 UNSPECIFIED LYMPHOID LEUKEMIA, IN RELAPSE

205.00 - 205.02

ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - ACUTE MYELOID LEUKEMIA, IN RELAPSE

205.10 CHRONIC MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

205.12 CHRONIC MYELOID LEUKEMIA, IN RELAPSE

209.00 - 209.36

MALIGNANT CARCINOID TUMOR OF THE SMALL INTESTINE, UNSPECIFIED PORTION - MERKEL CELL CARCINOMA OF OTHER SITES

209.70 - 209.79

SECONDARY NEUROENDOCRINE TUMOR, UNSPECIFIED SITE - SECONDARY NEUROENDOCRINE TUMOR OF OTHER SITES

230.0 - 238.9

CARCINOMA IN SITU OF LIP ORAL CAVITY AND PHARYNX - NEOPLASM OF UNCERTAIN BEHAVIOR SITE UNSPECIFIED

239.81 NEOPLASMS OF UNSPECIFIED NATURE, RETINA AND CHOROID 239.89 NEOPLASMS OF UNSPECIFIED NATURE, OTHER SPECIFIED SITES 285.3 ANTINEOPLASTIC CHEMOTHERAPY INDUCED ANEMIA

288.00 - 288.09 NEUTROPENIA, UNSPECIFIED - OTHER NEUTROPENIA 714.1 FELTY'S SYNDROME

V42.81 BONE MARROW REPLACED BY TRANSPLANT V42.82 PERIPHERAL STEM CELLS REPLACED BY TRANSPLANT V58.11 ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY V58.12 ENCOUNTER FOR IMMUNOTHERAPY FOR NEOPLASTIC CONDITION V59.3 BONE MARROW DONORS

Leukine (J2820), Neupogen (J1442), Neulasta (J2505), Granix (J1446) Jurisdiction(s): 11(M) NCD/LCD Document (s): L31799

ICD-9 Codes Diagnosis

140.0 - 173.89 MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER - OTHER SPECIFIED MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SKIN

174.0 - 204.92 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST - UNSPECIFIED LYMPHOID LEUKEMIA, IN RELAPSE

205.00 - 205.02 ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - ACUTE MYELOID LEUKEMIA, IN RELAPSE


205.12 CHRONIC MYELOID LEUKEMIA, IN RELAPSE

209.00 - 209.36 MALIGNANT CARCINOID TUMOR OF THE SMALL INTESTINE, UNSPECIFIED PORTION - MERKEL CELL CARCINOMA OF OTHER SITES

209.70 - 209.79 SECONDARY NEUROENDOCRINE TUMOR, UNSPECIFIED SITE - SECONDARY NEUROENDOCRINE TUMOR OF OTHER SITES

http://www.cms.gov/medicare-coverage-database/staticpages/icd9-code-range.aspx?DocType=LCD&DocID=31851&ver=12&Group=1&RangeStart=205.00&RangeEnd=205.02�







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230.0 - 238.9 CARCINOMA IN SITU OF LIP ORAL CAVITY AND PHARYNX - NEOPLASM OF UNCERTAIN BEHAVIOR SITE UNSPECIFIED

239.81 NEOPLASMS OF UNSPECIFIED NATURE, RETINA AND CHOROID 239.89 NEOPLASMS OF UNSPECIFIED NATURE, OTHER SPECIFIED SITES 285.3 ANTINEOPLASTIC CHEMOTHERAPY INDUCED ANEMIA

288.00 - 288.09 NEUTROPENIA, UNSPECIFIED - OTHER NEUTROPENIA 714.1 FELTY'S SYNDROME

V42.81 BONE MARROW REPLACED BY TRANSPLANT V42.82 PERIPHERAL STEM CELLS REPLACED BY TRANSPLANT V58.11 ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY V58.12 ENCOUNTER FOR IMMUNOTHERAPY FOR NEOPLASTIC CONDITION V59.3 BONE MARROW DONORS

Neupogen (J1442) ONLY

Jurisdiction(s): 5,8 NCD/LCD Document (s): L30306 ICD-9 Codes Diagnosis

042 HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE 202.40 LEUKEMIC RETICULOENDOTHELIOSIS UNSPECIFIED SITE

205.00 ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

205.02 ACUTE MYELOID LEUKEMIA, IN RELAPSE 238.72 LOW GRADE MYELODYSPLASTIC SYNDROME LESIONS 238.73 HIGH GRADE MYELODYSPLASTIC SYNDROME LESIONS 238.74 MYELODYSPLASTIC SYNDROME WITH 5Q DELETION 238.75 MYELODYSPLASTIC SYNDROME, UNSPECIFIED 238.76 MYELOFIBROSIS WITH MYELOID METAPLASIA 284.89 OTHER SPECIFIED APLASTIC ANEMIAS 288.00 NEUTROPENIA, UNSPECIFIED 288.01 CONGENITAL NEUTROPENIA 288.02 CYCLIC NEUTROPENIA 288.03 DRUG INDUCED NEUTROPENIA V07.8 OTHER SPECIFIED PROPHYLACTIC OR TREATMENT MEASURE V15.3 PERSONAL HISTORY OF IRRADIATION PRESENTING HAZARDS TO HEALTH V15.9 UNSPECIFIED PERSONAL HISTORY PRESENTING HAZARDS TO HEALTH

V42.81 BONE MARROW REPLACED BY TRANSPLANT V42.82 PERIPHERAL STEM CELLS REPLACED BY TRANSPLANT



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V49.83 AWAITING ORGAN TRANSPLANT STATUS V87.41 PERSONAL HISTORY OF ANTINEOPLASTIC CHEMOTHERAPY

Leukine (J2820)


042 HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE

172.0 - 172.9 MALIGNANT MELANOMA OF SKIN OF LIP - MELANOMA OF SKIN SITE UNSPECIFIED

201.40 - 201.98* HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE UNSPECIFIED SITE - HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF MULTIPLE SITES

202.00 - 202.08* NODULAR LYMPHOMA UNSPECIFIED SITE - NODULAR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

202.40 - 202.48 LEUKEMIC RETICULOENDOTHELIOSIS UNSPECIFIED SITE - LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES

202.80 - 202.88* OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE - OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF MULTIPLE SITES

204.00 – 204.02* ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - ACUTE LYMPHOID LEUKEMIA, IN RELAPSE

205.00** ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

205.02** ACUTE MYELOID LEUKEMIA, IN RELAPSE 238.72 LOW GRADE MYELODYSPLASTIC SYNDROME LESIONS 238.73 HIGH GRADE MYELODYSPLASTIC SYNDROME LESIONS 238.74 MYELODYSPLASTIC SYNDROME WITH 5Q DELETION 238.75 MYELODYSPLASTIC SYNDROME, UNSPECIFIED 238.76 MYELOFIBROSIS WITH MYELOID METAPLASIA 284.89 OTHER SPECIFIED APLASTIC ANEMIAS 288.00 NEUTROPENIA, UNSPECIFIED 288.01 CONGENITAL NEUTROPENIA 288.02 CYCLIC NEUTROPENIA 288.03 DRUG INDUCED NEUTROPENIA 996.85 COMPLICATIONS OF TRANSPLANTED BONE MARROW V07.8 OTHER SPECIFIED PROPHYLACTIC OR TREATMENT MEASURE

V42.81 BONE MARROW REPLACED BY TRANSPLANT V42.82 PERIPHERAL STEM CELLS REPLACED BY TRANSPLANT



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*Must be used with primary code V42.81 ** Must be used with primary code 288.03 Neulasta (J2505)


288.03 DRUG INDUCED NEUTROPENIA V07.8 OTHER SPECIFIED PROPHYLACTIC OR TREATMENT MEASURE V15.9 UNSPECIFIED PERSONAL HISTORY PRESENTING HAZARDS TO HEALTH

Granix (J1446)


288.03 DRUG INDUCED NEUTROPENIA V07.8 OTHER SPECIFIED PROPHYLACTIC OR TREATMENT MEASURE V15.9 UNSPECIFIED PERSONAL HISTORY PRESENTING HAZARDS TO HEALTH

Leukine (J2820), Neupogen (J1442) ONLY Jurisdiction(s): 10(J) NCD/LCD Document (s): L30026


042 HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE

202.00 - 202.90 NODULAR LYMPHOMA UNSPECIFIED SITE - OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE UNSPECIFIED SITE

203.00 MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

203.02 MULTIPLE MYELOMA, IN RELAPSE


205.02 ACUTE MYELOID LEUKEMIA, IN RELAPSE

238.71 - 238.77 ESSENTIAL THROMBOCYTHEMIA - POST-TRANSPLANT LYMPHOPROLIFERATIVE DISORDER (PTLD)

238.79 OTHER LYMPHATIC AND HEMATOPOIETIC TISSUES 288.00 - 288.04 NEUTROPENIA, UNSPECIFIED - NEUTROPENIA DUE TO INFECTION

288.09 OTHER NEUTROPENIA 288.50 LEUKOCYTOPENIA, UNSPECIFIED



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288.51 LYMPHOCYTOPENIA 288.59 OTHER DECREASED WHITE BLOOD CELL COUNT 363.20 CHORIORETINITIS UNSPECIFIED V07.8 OTHER SPECIFIED PROPHYLACTIC OR TREATMENT MEASURE

V42.81 BONE MARROW REPLACED BY TRANSPLANT V42.82 PERIPHERAL STEM CELLS REPLACED BY TRANSPLANT V42.9 UNSPECIFIED ORGAN OR TISSUE REPLACED BY TRANSPLANT

V59.02 BLOOD DONORS STEM CELLS V59.3 BONE MARROW DONORS V66.2 CONVALESCENCE FOLLOWING CHEMOTHERAPY V66.5 CONVALESCENCE FOLLOWING OTHER TREATMENT

Neulasta (J2505) ONLY Jurisdiction(s): 10(J) NCD/LCD Document (s): L30026


288.00 - 288.04 NEUTROPENIA, UNSPECIFIED - NEUTROPENIA DUE TO INFECTION 288.09 OTHER NEUTROPENIA 288.50 LEUKOCYTOPENIA, UNSPECIFIED 288.51 LYMPHOCYTOPENIA 288.59 OTHER DECREASED WHITE BLOOD CELL COUNT V07.8 OTHER SPECIFIED PROPHYLACTIC OR TREATMENT MEASURE V66.2 CONVALESCENCE FOLLOWING CHEMOTHERAPY

Granix (J1446) ONLY Jurisdiction(s): 10(J) NCD/LCD Document (s): L30026


288.00 NEUTROPENIA, UNSPECIFIED 288.03 - 288.09 DRUG INDUCED NEUTROPENIA - OTHER NEUTROPENIA

Neupogen (J1442) Granix (J1446) Jurisdiction(s): 9 (N) NCD/LCD Document (s): L29180; L29431


238.72 LOW GRADE MYELODYSPLASTIC SYNDROME LESIONS 238.73 HIGH GRADE MYELODYSPLASTIC SYNDROME LESIONS 238.74 MYELODYSPLASTIC SYNDROME WITH 5Q DELETION 238.75 MYELODYSPLASTIC SYNDROME, UNSPECIFIED



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238.77 POST-TRANSPLANT LYMPHOPROLIFERATIVE DISORDER (PTLD) 288.00 - 288.09 NEUTROPENIA, UNSPECIFIED - OTHER NEUTROPENIA

995.20 UNSPECIFIED ADVERSE EFFECT OF UNSPECIFIED DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE

995.29 UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE

V42.81* BONE MARROW REPLACED BY TRANSPLANT V42.82* PERIPHERAL STEM CELLS REPLACED BY TRANSPLANT

V42.9 UNSPECIFIED ORGAN OR TISSUE REPLACED BY TRANSPLANT V58.11 ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY

V58.69* LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS V59.8 DONORS OF OTHER SPECIFIED ORGAN OR TISSUE

*V42.81, V42.82, V58.69 is a secondary diagnosis code and should not be billed as the primary diagnosis Neupogen (J1442) ONLY

Jurisdiction(s):6, K NCD/LCD Document (s): A48208 ICD-9 Codes Diagnosis

042* HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE 202.40 LEUKEMIC RETICULOENDOTHELIOSIS UNSPECIFIED SITE

202.41 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.42 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRATHORACIC LYMPH NODES

202.43 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.44 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER ARM

202.45 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.46 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRAPELVIC LYMPH NODES

202.47 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING SPLEEN

202.48 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES

203.10 PLASMA CELL LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

203.11 PLASMA CELL LEUKEMIA IN REMISSION

203.80 OTHER IMMUNOPROLIFERATIVE NEOPLASMS, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

203.81 OTHER IMMUNOPROLIFERATIVE NEOPLASMS IN REMISSION 204.00 ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING



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ACHIEVED REMISSION 204.01 LYMPHOID LEUKEMIA ACUTE IN REMISSION 204.02 ACUTE LYMPHOID LEUKEMIA, IN RELAPSE

204.10 CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

204.11 LYMPHOID LEUKEMIA CHRONIC IN REMISSION 204.12 CHRONIC LYMPHOID LEUKEMIA, IN RELAPSE

204.20 SUBACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

204.21 LYMPHOID LEUKEMIA SUBACUTE IN REMISSION 204.22 SUBACUTE LYMPHOID LEUKEMIA, IN RELAPSE

204.80 OTHER LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

204.81 OTHER LYMPHOID LEUKEMIA IN REMISSION 204.82 OTHER LYMPHOID LEUKEMIA, IN RELAPSE

204.90 UNSPECIFIED LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

204.91 UNSPECIFIED LYMPHOID LEUKEMIA IN REMISSION 204.92 UNSPECIFIED LYMPHOID LEUKEMIA, IN RELAPSE


205.01 MYELOID LEUKEMIA ACUTE IN REMISSION 205.02 ACUTE MYELOID LEUKEMIA, IN RELAPSE


205.11 MYELOID LEUKEMIA CHRONIC IN REMISSION 205.12 CHRONIC MYELOID LEUKEMIA, IN RELAPSE

205.20 SUBACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

205.21 MYELOID LEUKEMIA SUBACUTE IN REMISSION 205.22 SUBACUTE MYELOID LEUKEMIA, IN RELAPSE

205.30 MYELOID SARCOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

205.31 MYELOID SARCOMA IN REMISSION 205.32 MYELOID SARCOMA, IN RELAPSE

205.80 OTHER MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

205.81 OTHER MYELOID LEUKEMIA IN REMISSION 205.82 OTHER MYELOID LEUKEMIA, IN RELAPSE

205.90 UNSPECIFIED MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

205.91 UNSPECIFIED MYELOID LEUKEMIA IN REMISSION 205.92 UNSPECIFIED MYELOID LEUKEMIA, IN RELAPSE



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238.72 LOW GRADE MYELODYSPLASTIC SYNDROME LESIONS 238.73 HIGH GRADE MYELODYSPLASTIC SYNDROME LESIONS 238.74 MYELODYSPLASTIC SYNDROME WITH 5Q DELETION 238.75 MYELODYSPLASTIC SYNDROME, UNSPECIFIED 238.76 MYELOFIBROSIS WITH MYELOID METAPLASIA 238.79 OTHER LYMPHATIC AND HEMATOPOIETIC TISSUES 284.11 ANTINEOPLASTIC CHEMOTHERAPY INDUCED PANCYTOPENIA 284.12 OTHER DRUG INDUCED PANCYTOPENIA 284.19 OTHER PANCYTOPENIA 284.2 MYELOPHTHISIS

284.89 OTHER SPECIFIED APLASTIC ANEMIAS 284.9 APLASTIC ANEMIA UNSPECIFIED

288.00** NEUTROPENIA, UNSPECIFIED 288.01 CONGENITAL NEUTROPENIA 288.02 CYCLIC NEUTROPENIA 288.03 DRUG INDUCED NEUTROPENIA

288.04** NEUTROPENIA DUE TO INFECTION 288.09 OTHER NEUTROPENIA

288.50** LEUKOCYTOPENIA, UNSPECIFIED 288.59** OTHER DECREASED WHITE BLOOD CELL COUNT

528.01 MUCOSITIS (ULCERATIVE) DUE TO ANTINEOPLASTIC THERAPY

642.40* MILD OR UNSPECIFIED PRE-ECLAMPSIA UNSPECIFIED AS TO EPISODE OF CARE

642.41* MILD OR UNSPECIFIED PRE-ECLAMPSIA WITH DELIVERY

642.42* MILD OR UNSPECIFIED PRE-ECLAMPSIA WITH DELIVERY WITH POSTPARTUM COMPLICATION

642.43* MILD OR UNSPECIFIED PRE-ECLAMPSIA ANTEPARTUM 642.44* MILD OR UNSPECIFIED PRE-ECLAMPSIA POSTPARTUM 642.50* SEVERE PRE-ECLAMPSIA UNSPECIFIED AS TO EPISODE OF CARE 642.51* SEVERE PRE-ECLAMPSIA WITH DELIVERY

642.52* SEVERE PRE-ECLAMPSIA WITH DELIVERY WITH POSTPARTUM COMPLICATION

642.53* SEVERE PRE-ECLAMPSIA ANTEPARTUM 642.54* SEVERE PRE-ECLAMPSIA POSTPARTUM 780.61* FEVER PRESENTING WITH CONDITIONS CLASSIFIED ELSEWHERE

V07.8 OTHER SPECIFIED PROPHYLACTIC OR TREATMENT MEASURE V15.9 UNSPECIFIED PERSONAL HISTORY PRESENTING HAZARDS TO HEALTH

V42.81 BONE MARROW REPLACED BY TRANSPLANT V42.82 PERIPHERAL STEM CELLS REPLACED BY TRANSPLANT V49.83 AWAITING ORGAN TRANSPLANT STATUS V58.11 ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY V58.12 ENCOUNTER FOR IMMUNOTHERAPY FOR NEOPLASTIC CONDITION V59.02 BLOOD DONORS STEM CELLS



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V66.2 CONVALESCENCE FOLLOWING CHEMOTHERAPY V66.5 CONVALESCENCE FOLLOWING OTHER TREATMENT

*Must be billed along with a primary code of 288.00**, 288.04**, 288.50**, or 288.59**. Neulasta (J2505) ONLY

Jurisdiction(s): 6, K NCD/LCD Document (s): A48208 ICD-9 Codes Diagnosis

284.11 ANTINEOPLASTIC CHEMOTHERAPY INDUCED PANCYTOPENIA 288.03 DRUG INDUCED NEUTROPENIA V07.8 OTHER SPECIFIED PROPHYLACTIC OR TREATMENT MEASURE V15.9 UNSPECIFIED PERSONAL HISTORY PRESENTING HAZARDS TO HEALTH

V42.82 PERIPHERAL STEM CELLS REPLACED BY TRANSPLANT V58.11 ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY V58.12 ENCOUNTER FOR IMMUNOTHERAPY FOR NEOPLASTIC CONDITION V66.2 CONVALESCENCE FOLLOWING CHEMOTHERAPY

Granix (J1446) ONLY

Jurisdiction(s): 6, K NCD/LCD Document (s): A48208 ICD-9 Codes Diagnosis

288.00 NEUTROPENIA, UNSPECIFIED 288.03 DRUG INDUCED NEUTROPENIA - 288.04 NEUTROPENIA DUE TO INFECTION 288.09 OTHER NEUTROPENIA

Neulasta (J2505) ONLY Jurisdiction(s): 9 (N) NCD/LCD Document (s): L29254; L29463


140.0 - 149.9 MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER - MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE LIP AND ORAL CAVITY

150.0 - 159.9 MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS - MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE DIGESTIVE ORGANS AND PERITONEUM

160.0 - 165.9 MALIGNANT NEOPLASM OF NASAL CAVITIES - MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE RESPIRATORY SYSTEM

170.0 - 176.9 MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE EXCEPT MANDIBLE - KAPOSI'S SARCOMA UNSPECIFIED SITE

179 - 189.9 MALIGNANT NEOPLASM OF UTERUS-PART UNS - MALIGNANT



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NEOPLASM OF URINARY ORGAN SITE UNSPECIFIED

190.0 - 199.2 MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID - MALIGNANT NEOPLASM ASSOCIATED WITH TRANSPLANT ORGAN

200.00 - 200.88 RETICULOSARCOMA UNSPECIFIED SITE - OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

201.00 - 201.98 HODGKIN'S PARAGRANULOMA UNSPECIFIED SITE - HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF MULTIPLE SITES

202.00 - 202.08 NODULAR LYMPHOMA UNSPECIFIED SITE - NODULAR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

202.10 - 202.18 MYCOSIS FUNGOIDES UNSPECIFIED SITE - MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF MULTIPLE SITES

202.20 - 202.28 SEZARY'S DISEASE UNSPECIFIED SITE - SEZARY'S DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES

202.30 - 202.38 MALIGNANT HISTIOCYTOSIS UNSPECIFIED SITE - MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES

202.40 - 202.48 LEUKEMIC RETICULOENDOTHELIOSIS UNSPECIFIED SITE - LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES

202.50 - 202.58 LETTERER-SIWE DISEASE UNSPECIFIED SITE - LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES

202.60 - 202.68 MALIGNANT MAST CELL TUMORS UNSPECIFIED SITE - MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF MULTIPLE SITES

202.70 - 202.78 PERIPHERAL T CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES

202.80 - 202.88 OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE - OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF MULTIPLE SITES

203.00 - 203.82 MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - OTHER IMMUNOPROLIFERATIVE NEOPLASMS, IN RELAPSE

204.00 - 204.02 ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - ACUTE LYMPHOID LEUKEMIA, IN RELAPSE

204.10 - 204.12 CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - CHRONIC LYMPHOID LEUKEMIA, IN RELAPSE

204.20 - 204.22 SUBACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - SUBACUTE LYMPHOID LEUKEMIA, IN RELAPSE

204.80 - 204.82 OTHER LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - OTHER LYMPHOID LEUKEMIA, IN RELAPSE

209.31 MERKEL CELL CARCINOMA OF THE FACE 209.32 MERKEL CELL CARCINOMA OF THE SCALP AND NECK 209.33 MERKEL CELL CARCINOMA OF THE UPPER LIMB



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209.34 MERKEL CELL CARCINOMA OF THE LOWER LIMB 209.35 MERKEL CELL CARCINOMA OF THE TRUNK 209.36 MERKEL CELL CARCINOMA OF OTHER SITES 209.75 SECONDARY MERKEL CELL CARCINOMA 273.3 MACROGLOBULINEMIA



V07.8 OTHER SPECIFIED PROPHYLACTIC OR TREATMENT MEASURE V66.2 CONVALESCENCE FOLLOWING CHEMOTHERAPY

Leukine (J2820) ONLY Jurisdiction(s): 9(N) NCD/LCD Document (s): L29391; L29275


205.00 - 205.92 ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - UNSPECIFIED MYELOID LEUKEMIA, IN RELAPSE

238.71 - 238.79 ESSENTIAL THROMBOCYTHEMIA - OTHER LYMPHATIC AND HEMATOPOIETIC TISSUES

288.00 - 288.09 NEUTROPENIA, UNSPECIFIED - OTHER NEUTROPENIA



996.85 COMPLICATIONS OF TRANSPLANTED BONE MARROW 996.88 COMPLICATIONS OF TRANSPLANTED ORGAN, STEM CELL

V42.81* BONE MARROW REPLACED BY TRANSPLANT V42.82* PERIPHERAL STEM CELLS REPLACED BY TRANSPLANT V42.9* UNSPECIFIED ORGAN OR TISSUE REPLACED BY TRANSPLANT V58.11 ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY V58.44 AFTERCARE FOLLOWING ORGAN TRANSPLANT

V58.69* LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS V59.02 BLOOD DONORS STEM CELLS V59.3 BONE MARROW DONORS V59.8 DONORS OF OTHER SPECIFIED ORGAN OR TISSUE

*V42.81, V42.82, V42.9 and V58.69 are secondary diagnosis codes and should not be billed as the primary diagnosis.



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VIII. Policy Exclusions: o Treatment for diagnoses not FDA approved o All indications not described in Section III Review criteria are not covered and may be considered

experimental or investigational

IX. Black Box Warnings/Contraindications: Neupogen® (filgrastim) and Neulasta® (pegfilgrastim) Contraindications o Known hypersensitivity to E. coli protein o Hypersensitivity to pegfilgrastim or filgrastim

Leukine® (sargramostim) Contraindications o Chemotherapy and radiation therapy o Do not administer Leukine within 24 hours (before or after) chemotherapy or radiation therapy because of

the potential sensitivity of rapidly dividing hematopoietic progenitor cells. o Hypersensitivity to GM-CSF, yeast-derived productsor any component of the product

X. References:

1. Leukine [package insert]. Seattle, WA; Bayer Pharmaceuticals, Inc; June 2012. Accessed February 2014. 2. Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®)

sargramostim. National Comprehensive Cancer Network, 2014. 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 February 2014.

3. Granix [package insert]. North Wales, PA; Teva Pharmaceuticals USA, Inc.; July 2013. Accessed February 2014.

4. Neulasta [package insert]. Thousand Oaks, CA; Amgen Inc; May 2012. Accessed February 2014. 5. Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®)

pegfigrastim. National Comprehensive Cancer Network, 2014. 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 February 2014.

6. Neupogen [package insert]. Thousand Oaks, CA; Amgen Inc; September 2013. Accessed February 2014. 7. Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®)

filgrastim. National Comprehensive Cancer Network, 2014. 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 February 2014.



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8. Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) Myeloid Growth Factors. Version 2.2014. National Comprehensive Cancer Network, 2013. 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 February 2014.

9. Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) tbo-filgrastim. National Comprehensive Cancer Network, 2013. 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 February 2014

10. Smith TJ, Khatcheressian J, Lyman GH, Ozer H, Armitage JO, Balducci L, Bennett CL, Cantor SB, Crawford J, Cross SJ, Demetri G, Desch CE, Pizzo PA, Schiffer CA, Schwartzberg L, Somerfield MR, Somlo G, Wade JC, Wade JL, Winn RJ, Wozniak AJ, Wolff AC. 2006 update of recommendations for the use of white blood cell growth factors: an evidence-based clinical practice guideline. J Clin Oncol. 2006;24(19):3187-205.

11. Framptom JE, et al. Filgrastim: a review of its pharmacological properties and therapeutic efficacy in neutropenia. Drugs 1994;49(5):731-760

12. Ozer H, et al. 2000 Update of recommendations for the use of hematopoietic colony-stimulating factors: evidence-based, clinical practice guidelines. J Clin Oncol 200;18(20):3558-3585.

13. CGS, Administrators, LLC. Local Coverage Determination (LCD): White Cell Colony Stimulating Factors (L31851). Centers for Medicare & Medicaid Services, Inc. Updated on 01/02/2014 with effective date 01/01/2014. Accessed March 2014.

14. Palmetto GBA. Local Coverage Determination (LCD): White Cell Colony Stimulating Factors (L31799). Centers for Medicare & Medicaid Services, Inc. Updated on 01/10/2014 with effective date 01/16/2014. Accessed March 2014.

15. First Coast Service Options, Inc. Local Coverage Determination (LCD): Sargramostim (GM-CSF, Leukine®) (L29391; L29275). Centers for Medicare & Medicaid Services, Inc. Updated on 09/14/2011 with effective date 10/01/2011. Accessed March.

16. Wisconsin Physicians Service Insurance Corporation. Local Coverage Determination (LCD): Human Granulocyte/Macrophage Colony Stimulating Factors (L30306). Centers for Medicare & Medicaid Services, Inc. Updated on 02/19/2014 with effective date 03/01/2014. Accessed March 2014.

17. Cahaba Government Benefit Administrators, LLC. Local Coverage Determination (LCD): Drugs and Biologicals: Colony Stimulating Factors (L30026). Centers for Medicare & Medicaid Services, Inc. Updated on 01/28/2014 with effective date 01/01/2014. Accessed March 2014.

18. First Coast Service Options, Inc. Local Coverage Determination (LCD): G-CSF (Neupogen®, Granix™) (L29180; L29431). Centers for Medicare & Medicaid Services, Inc. Updated on 01/09/2014 with effective date 01/01/2014. Accessed March 2014.

19. First Coast Service Options, Inc. Local Coverage Determination (LCD): Pegfilgrastim (Neulasta®) (L29254; L29463). Centers for Medicare & Medicaid Services, Inc. Updated on 02/17/2013 with effective date 02/07/2013. Accessed March 2014.



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20. National Government Services, Inc . Local Coverage Article: Filgrastim, Pegfilgrastim, Tbo-filgrastim (e.g., Neupogen®, Neulasta TM, Granix TM) - Related to LCD L25820 (A48208). Centers for Medicare & Medicaid Services, Inc. Updated on 01/10/2014 with effective date 01/16/2014. Accessed March 2014.

XI.

Appendix:

Medicare Part B Administrative Contractor (MAC) Jurisdictions Jurisdiction Applicable State/US Territory Contractor

E CA,HI, NV, AS, GU, CNMI Noridian Administrative Services (NAS) F AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ Noridian Administrative Services (NAS) 5 KS, NE, IA, MO Wisconsin Physicians Service (WPS) 6 MN, WI, IL National Government Services (NGS) H LA, AR, MS, TX, OK, CO, NM Novitas Solutions 8 MI, IN Wisconsin Physicians Service (WPS)

9 (N) FL, PR, VI First Coast Service Options 10 (J) TN, GA, AL Cahaba Government Benefit Administrators

11 (M) NC, SC, VA, WV Palmetto GBA 12 (L) DE, MD, PA, NJ, DC Novitas Solutions

K NY, CT, MA, RI, VT, ME, NH National Government Services (NGS) 15 KY, OH CGS Administrators, LLC

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