Local Coverage Determination for Drugs and Biologics (Non ...

Contractor Name ContractType

ContractNumber Jurisdiction State(s)

Wisconsin Physicians Service InsuranceCorporation MAC - Part A 05101 - MAC A J - 05 Iowa

Wisconsin Physicians Service InsuranceCorporation MAC - Part B 05102 - MAC B J - 05 Iowa

Wisconsin Physicians Service InsuranceCorporation MAC - Part A 05201 - MAC A J - 05 Kansas

Wisconsin Physicians Service InsuranceCorporation MAC - Part B 05202 - MAC B J - 05 Kansas

Wisconsin Physicians Service InsuranceCorporation MAC - Part A 05301 - MAC A J - 05 Missouri - Entire

StateWisconsin Physicians Service InsuranceCorporation MAC - Part B 05302 - MAC B J - 05 Missouri - Entire

StateWisconsin Physicians Service InsuranceCorporation MAC - Part A 05401 - MAC A J - 05 Nebraska

Wisconsin Physicians Service InsuranceCorporation MAC - Part B 05402 - MAC B J - 05 Nebraska

Wisconsin Physicians Service InsuranceCorporation MAC - Part A 05901 - MAC A J - 05

AlaskaAlabamaArkansasArizonaConnecticutFloridaGeorgiaIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMaineMichiganMinnesotaMissouri - EntireStateMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyOhioOregonRhode IslandSouth CarolinaSouth DakotaTennesseeUtah

Local Coverage Determination (LCD):Drugs and Biologics (Non-chemotherapy) (L34741)

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Contractor Information

Printed on 8/29/2017. of 40

https://www.cms.gov/medicare-coverage-database/staticpages/contractor-details.aspx?ContrId=143&ver=1



















Contractor Name ContractType

ContractNumber Jurisdiction State(s)

VirginiaVirgin IslandsVermontWashingtonWisconsinWest VirginiaWyoming

Wisconsin Physicians Service InsuranceCorporation MAC - Part A 08101 - MAC A J - 08 Indiana

Wisconsin Physicians Service InsuranceCorporation MAC - Part B 08102 - MAC B J - 08 Indiana

Wisconsin Physicians Service InsuranceCorporation MAC - Part A 08201 - MAC A J - 08 Michigan

Wisconsin Physicians Service InsuranceCorporation MAC - Part B 08202 - MAC B J - 08 Michigan

LCD IDL34741

Original ICD-9 LCD IDL32013

LCD TitleDrugs and Biologics (Non-chemotherapy)

Proposed LCD in Comment PeriodN/A

Source Proposed LCDN/A

AMA CPT / ADA CDT / AHA NUBC Copyright StatementCPT only copyright 2002-2017 American MedicalAssociation. All Rights Reserved. CPT is a registeredtrademark of the American Medical Association.Applicable FARS/DFARS Apply to Government Use. Feeschedules, relative value units, conversion factorsand/or related components are not assigned by theAMA, are not part of CPT, and the AMA is notrecommending their use. The AMA does not directly orindirectly practice medicine or dispense medicalservices. The AMA assumes no liability for datacontained or not contained herein.

The Code on Dental Procedures and Nomenclature(Code) is published in Current Dental Terminology(CDT). Copyright © American Dental Association. Allrights reserved. CDT and CDT-2016 are trademarks ofthe American Dental Association.

Original Effective DateFor services performed on or after 10/01/2015

Revision Effective DateFor services performed on or after 07/01/2017

Revision Ending DateN/A

Retirement DateN/A

Notice Period Start DateN/A

Notice Period End DateN/A

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LCD InformationDocument Information










http://localcoverage.cms.gov/mcd_archive/m_d.asp?id=32013

UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONSMANUAL, 2014, is copyrighted by American HospitalAssociation (“AHA”), Chicago, Illinois. No portion ofOFFICIAL UB-04 MANUAL may be reproduced, sorted ina retrieval system, or transmitted, in any form or byany means, electronic, mechanical, photocopying,recording or otherwise, without prior express, writtenconsent of AHA.” Health Forum reserves the right tochange the copyright notice from time to time uponwritten notice to Company.

◦ Be of a form that is not usually self-administered;

◦ Must be furnished by a physician; and

CMS National Coverage PolicyItalicized font represents CMS national language/wording copied directly from CMS Manuals or CMS transmittals.Contractors are prohibited from changing national language

Title XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessaryfor the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1862(a)(1)(D) investigational or experimental.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process theclaim.

CMS Publication Pub 100-02, Medicare Benefit Policy Manual, Chapter 15-Covered Medical and Other HealthServices, Section 50-Drugs and Biologicals

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 17-Drugs and Biologicals, Section 10-Payment Rules for Drugs and Biologicals

CMS Publication Pub 100-03, National Coverage Determinations Manual, Chapter 1-Covered Determinations, PartI Section 80.3.1-Verteporfin

CR9636 Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes- July2016 Update.

CMS 100-04, Medicare Benefit Policy Manual, Chapter 17, Section 40: Discarded Drugs and Biologicals.

CR9603 JW Modifier: Drug amount discarded/not administered to any patient June 2016 Update

Coverage GuidanceCoverage Indications, Limitations, and/or Medical Necessity

The LCD has been promulgated to establish the clinical conditions for which the included drugs are considered tobe medically reasonable and necessary and thus, covered by Medicare. The agents discussed in no way constitutea complete list of drugs and biologicals covered by Medicare. This document does not include chemotherapydrugs (See our Chemotherapy LCD). The contractor expects the use of those drugs and biologicals not listed hereto be medically necessary and used according to their FDA indications.

The Medicare program provides limited benefits for outpatient prescription drugs. The program covers drugs thatare furnished “incident to” a physician’s service provided that the drugs are not usually self-administered by thepatients who take them.

In order to meet all the general requirements for coverage under the incident-to provision, an FDA approved drugor biological must:


• Must be administered by the physician, or by auxiliary personnel employed by the physician under thephysician’s direct supervision.

◦ It was injected on or after the date of the FDA’s approval;

◦ It is reasonable and necessary for the individual patient; and

• All other applicable coverage requirements are met.

The charge, if any, for the drug or biological must be included in the physician’s bill and the cost of the drug orbiological must represent an expense to the physician.

Use of the drug or biological must be safe and effective and otherwise reasonable and necessary. Drugs orbiologicals approved for marketing by the Food and Drug Administration (FDA) are considered safe and effectivefor purposes of this requirement when used for indications specified on the labeling. Therefore, the program maypay for the use of an FDA approved drug or biological, if:

An unlabeled use of a drug is a use that is not included as an indication on the drug’s label as approved by theFDA. FDA approved drugs used for indications other than what is indicated on the official label may be coveredunder Medicare if the Contractor determines the use to be medically accepted, taking into consideration themajor drug compendia, authoritative medical literature and/or accepted standards of medical practice. An LCDreconsideration request with supporting documentation should be submitted via [email protected] torequest off label use of a drug.Please utilize WPS instructions for submitting a formal reconsideration as described on the WPS GHA Medicarewebsite.

Limitations:The following guidelines identify three categories with specific examples of situations in which medications wouldnot be reasonable and necessary according to accepted standards of medical practice:Medications given for a purpose other than the treatment of a particular condition, illness, or injury are notcovered.

Medication given by injection (parenterally) is not covered if standard medical practice indicates that theadministration of the medication by mouth (orally) is effective and is an accepted or preferred method ofadministration. For example, the accepted standard of medical practice for the treatment of certain diseases is toinitiate therapy with parenteral penicillin and to complete therapy with oral penicillin. Contractors exclude theentire charge for penicillin injections given after the initiation of therapy if oral penicillin is indicated unless thereare special medical circumstances that justify additional injections.

Medications administered for treatment of a disease and which exceed the frequency or duration of injectionsindicated by accepted standards of medical practice are not covered.

If a medication is determined not to be reasonable and necessary for diagnosis or treatment of an illness or injuryaccording to these guidelines, the entire charge (i.e., for both the drug and its administration) is not consideredmedically necessary.

This is not an all-inclusive list and will not be updated to include every newly FDA approved drug.

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Coding InformationBill Type Codes:


C9257 INJECTION, BEVACIZUMAB, 0.25 MG

J0129 INJECTION, ABATACEPT, 10 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTEREDUNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED)

J0178 INJECTION, AFLIBERCEPT, 1 MGJ0180 INJECTION, AGALSIDASE BETA, 1 MGJ0256 INJECTION, ALPHA 1 PROTEINASE INHIBITOR (HUMAN), NOT OTHERWISE SPECIFIED, 10 MGJ0257 INJECTION, ALPHA 1 PROTEINASE INHIBITOR (HUMAN), (GLASSIA), 10 MGJ0364 INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MGJ0490 INJECTION, BELIMUMAB, 10 MGJ1300 INJECTION, ECULIZUMAB, 10 MGJ1745 INJECTION, INFLIXIMAB, EXCLUDES BIOSIMILAR, 10 MGJ1931 INJECTION, LARONIDASE, 0.1 MGJ2001 INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INFUSION, 10 MGJ2323 INJECTION, NATALIZUMAB, 1 MGJ2357 INJECTION, OMALIZUMAB, 5 MGJ2503 INJECTION, PEGAPTANIB SODIUM, 0.3 MGJ2562 INJECTION, PLERIXAFOR, 1 MGJ2778 INJECTION, RANIBIZUMAB, 0.1 MGJ2796 INJECTION, ROMIPLOSTIM, 10 MICROGRAMSJ3396 INJECTION, VERTEPORFIN, 0.1 MGQ5102 INJECTION, INFLIXIMAB, BIOSIMILAR, 10 MG

J3590 UNCLASSIFIED BIOLOGICS

67028 INTRAVITREAL INJECTION OF A PHARMACOLOGIC AGENT (SEPARATE PROCEDURE)

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of allBill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equallyto all claims.

N/ARevenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to reportthis service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, servicesreported under other Revenue Codes are equally subject to this coverage determination. Complete absence of allRevenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed toapply equally to all Revenue Codes.

N/ACPT/HCPCS CodesGroup 1 Paragraph: N/A

Group 1 Codes:

Group 2 Paragraph: Use J3590 for Bevacizumab (Avastin™) 1-3 mg

Group 2 Codes:

Group 3 Paragraph:

CPT codes 67028 is not restricted to the diagnosis codes in this policy.

Group 3 Codes:

ICD-10 Codes that Support Medical NecessityGroup 1 Paragraph:


ICD-10Codes Description

M05.011 Felty's syndrome, right shoulderM05.012 Felty's syndrome, left shoulderM05.021 Felty's syndrome, right elbowM05.022 Felty's syndrome, left elbowM05.031 Felty's syndrome, right wristM05.032 Felty's syndrome, left wristM05.041 Felty's syndrome, right handM05.042 Felty's syndrome, left handM05.051 Felty's syndrome, right hipM05.052 Felty's syndrome, left hipM05.061 Felty's syndrome, right kneeM05.062 Felty's syndrome, left kneeM05.071 Felty's syndrome, right ankle and footM05.072 Felty's syndrome, left ankle and footM05.09 Felty's syndrome, multiple sitesM05.211 Rheumatoid vasculitis with rheumatoid arthritis of right shoulderM05.212 Rheumatoid vasculitis with rheumatoid arthritis of left shoulderM05.221 Rheumatoid vasculitis with rheumatoid arthritis of right elbowM05.222 Rheumatoid vasculitis with rheumatoid arthritis of left elbowM05.231 Rheumatoid vasculitis with rheumatoid arthritis of right wristM05.232 Rheumatoid vasculitis with rheumatoid arthritis of left wristM05.241 Rheumatoid vasculitis with rheumatoid arthritis of right handM05.242 Rheumatoid vasculitis with rheumatoid arthritis of left handM05.251 Rheumatoid vasculitis with rheumatoid arthritis of right hipM05.252 Rheumatoid vasculitis with rheumatoid arthritis of left hipM05.261 Rheumatoid vasculitis with rheumatoid arthritis of right kneeM05.262 Rheumatoid vasculitis with rheumatoid arthritis of left kneeM05.271 Rheumatoid vasculitis with rheumatoid arthritis of right ankle and footM05.272 Rheumatoid vasculitis with rheumatoid arthritis of left ankle and footM05.29 Rheumatoid vasculitis with rheumatoid arthritis of multiple sitesM05.311 Rheumatoid heart disease with rheumatoid arthritis of right shoulderM05.312 Rheumatoid heart disease with rheumatoid arthritis of left shoulderM05.321 Rheumatoid heart disease with rheumatoid arthritis of right elbowM05.322 Rheumatoid heart disease with rheumatoid arthritis of left elbowM05.331 Rheumatoid heart disease with rheumatoid arthritis of right wristM05.332 Rheumatoid heart disease with rheumatoid arthritis of left wristM05.341 Rheumatoid heart disease with rheumatoid arthritis of right handM05.342 Rheumatoid heart disease with rheumatoid arthritis of left handM05.351 Rheumatoid heart disease with rheumatoid arthritis of right hipM05.352 Rheumatoid heart disease with rheumatoid arthritis of left hipM05.361 Rheumatoid heart disease with rheumatoid arthritis of right kneeM05.362 Rheumatoid heart disease with rheumatoid arthritis of left kneeM05.371 Rheumatoid heart disease with rheumatoid arthritis of right ankle and footM05.372 Rheumatoid heart disease with rheumatoid arthritis of left ankle and footM05.39 Rheumatoid heart disease with rheumatoid arthritis of multiple sitesM05.411 Rheumatoid myopathy with rheumatoid arthritis of right shoulderM05.412 Rheumatoid myopathy with rheumatoid arthritis of left shoulderM05.421 Rheumatoid myopathy with rheumatoid arthritis of right elbowM05.422 Rheumatoid myopathy with rheumatoid arthritis of left elbowM05.431 Rheumatoid myopathy with rheumatoid arthritis of right wrist

J0129 Abatacept (Orencia™), 10 mg(CODE MAY BE USED FOR MEDICARE WHEN DRUG IS ADMINISTERED UNDER THE DIRECT SUPERVISION OF APHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED)J0129 should only be used when administering intravenously.

Group 1 Codes:



M05.432 Rheumatoid myopathy with rheumatoid arthritis of left wristM05.441 Rheumatoid myopathy with rheumatoid arthritis of right handM05.442 Rheumatoid myopathy with rheumatoid arthritis of left handM05.451 Rheumatoid myopathy with rheumatoid arthritis of right hipM05.452 Rheumatoid myopathy with rheumatoid arthritis of left hipM05.461 Rheumatoid myopathy with rheumatoid arthritis of right kneeM05.462 Rheumatoid myopathy with rheumatoid arthritis of left kneeM05.471 Rheumatoid myopathy with rheumatoid arthritis of right ankle and footM05.472 Rheumatoid myopathy with rheumatoid arthritis of left ankle and footM05.49 Rheumatoid myopathy with rheumatoid arthritis of multiple sitesM05.511 Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulderM05.512 Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulderM05.521 Rheumatoid polyneuropathy with rheumatoid arthritis of right elbowM05.522 Rheumatoid polyneuropathy with rheumatoid arthritis of left elbowM05.531 Rheumatoid polyneuropathy with rheumatoid arthritis of right wristM05.532 Rheumatoid polyneuropathy with rheumatoid arthritis of left wristM05.541 Rheumatoid polyneuropathy with rheumatoid arthritis of right handM05.542 Rheumatoid polyneuropathy with rheumatoid arthritis of left handM05.551 Rheumatoid polyneuropathy with rheumatoid arthritis of right hipM05.552 Rheumatoid polyneuropathy with rheumatoid arthritis of left hipM05.561 Rheumatoid polyneuropathy with rheumatoid arthritis of right kneeM05.562 Rheumatoid polyneuropathy with rheumatoid arthritis of left kneeM05.571 Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and footM05.572 Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and footM05.59 Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sitesM05.611 Rheumatoid arthritis of right shoulder with involvement of other organs and systemsM05.612 Rheumatoid arthritis of left shoulder with involvement of other organs and systemsM05.621 Rheumatoid arthritis of right elbow with involvement of other organs and systemsM05.622 Rheumatoid arthritis of left elbow with involvement of other organs and systemsM05.631 Rheumatoid arthritis of right wrist with involvement of other organs and systemsM05.632 Rheumatoid arthritis of left wrist with involvement of other organs and systemsM05.641 Rheumatoid arthritis of right hand with involvement of other organs and systemsM05.642 Rheumatoid arthritis of left hand with involvement of other organs and systemsM05.651 Rheumatoid arthritis of right hip with involvement of other organs and systemsM05.652 Rheumatoid arthritis of left hip with involvement of other organs and systemsM05.661 Rheumatoid arthritis of right knee with involvement of other organs and systemsM05.662 Rheumatoid arthritis of left knee with involvement of other organs and systemsM05.671 Rheumatoid arthritis of right ankle and foot with involvement of other organs and systemsM05.672 Rheumatoid arthritis of left ankle and foot with involvement of other organs and systemsM05.69 Rheumatoid arthritis of multiple sites with involvement of other organs and systems

M05.711 Rheumatoid arthritis with rheumatoid factor of right shoulder without organ or systemsinvolvement

M05.712 Rheumatoid arthritis with rheumatoid factor of left shoulder without organ or systems involvementM05.721 Rheumatoid arthritis with rheumatoid factor of right elbow without organ or systems involvementM05.722 Rheumatoid arthritis with rheumatoid factor of left elbow without organ or systems involvementM05.731 Rheumatoid arthritis with rheumatoid factor of right wrist without organ or systems involvementM05.732 Rheumatoid arthritis with rheumatoid factor of left wrist without organ or systems involvementM05.741 Rheumatoid arthritis with rheumatoid factor of right hand without organ or systems involvementM05.742 Rheumatoid arthritis with rheumatoid factor of left hand without organ or systems involvementM05.751 Rheumatoid arthritis with rheumatoid factor of right hip without organ or systems involvementM05.752 Rheumatoid arthritis with rheumatoid factor of left hip without organ or systems involvementM05.761 Rheumatoid arthritis with rheumatoid factor of right knee without organ or systems involvementM05.762 Rheumatoid arthritis with rheumatoid factor of left knee without organ or systems involvement

M05.771 Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systemsinvolvement

M05.772 Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or systemsinvolvement

M05.79



Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systemsinvolvement

M05.811 Other rheumatoid arthritis with rheumatoid factor of right shoulderM05.812 Other rheumatoid arthritis with rheumatoid factor of left shoulderM05.821 Other rheumatoid arthritis with rheumatoid factor of right elbowM05.822 Other rheumatoid arthritis with rheumatoid factor of left elbowM05.831 Other rheumatoid arthritis with rheumatoid factor of right wristM05.832 Other rheumatoid arthritis with rheumatoid factor of left wristM05.841 Other rheumatoid arthritis with rheumatoid factor of right handM05.842 Other rheumatoid arthritis with rheumatoid factor of left handM05.851 Other rheumatoid arthritis with rheumatoid factor of right hipM05.852 Other rheumatoid arthritis with rheumatoid factor of left hipM05.861 Other rheumatoid arthritis with rheumatoid factor of right kneeM05.862 Other rheumatoid arthritis with rheumatoid factor of left kneeM05.871 Other rheumatoid arthritis with rheumatoid factor of right ankle and footM05.872 Other rheumatoid arthritis with rheumatoid factor of left ankle and footM05.89 Other rheumatoid arthritis with rheumatoid factor of multiple sitesM06.011 Rheumatoid arthritis without rheumatoid factor, right shoulderM06.012 Rheumatoid arthritis without rheumatoid factor, left shoulderM06.021 Rheumatoid arthritis without rheumatoid factor, right elbowM06.022 Rheumatoid arthritis without rheumatoid factor, left elbowM06.031 Rheumatoid arthritis without rheumatoid factor, right wristM06.032 Rheumatoid arthritis without rheumatoid factor, left wristM06.041 Rheumatoid arthritis without rheumatoid factor, right handM06.042 Rheumatoid arthritis without rheumatoid factor, left handM06.051 Rheumatoid arthritis without rheumatoid factor, right hipM06.052 Rheumatoid arthritis without rheumatoid factor, left hipM06.061 Rheumatoid arthritis without rheumatoid factor, right kneeM06.062 Rheumatoid arthritis without rheumatoid factor, left kneeM06.071 Rheumatoid arthritis without rheumatoid factor, right ankle and footM06.072 Rheumatoid arthritis without rheumatoid factor, left ankle and footM06.08 Rheumatoid arthritis without rheumatoid factor, vertebraeM06.09 Rheumatoid arthritis without rheumatoid factor, multiple sitesM06.211 Rheumatoid bursitis, right shoulderM06.212 Rheumatoid bursitis, left shoulderM06.221 Rheumatoid bursitis, right elbowM06.222 Rheumatoid bursitis, left elbowM06.231 Rheumatoid bursitis, right wristM06.232 Rheumatoid bursitis, left wristM06.241 Rheumatoid bursitis, right handM06.242 Rheumatoid bursitis, left handM06.251 Rheumatoid bursitis, right hipM06.252 Rheumatoid bursitis, left hipM06.261 Rheumatoid bursitis, right kneeM06.262 Rheumatoid bursitis, left kneeM06.271 Rheumatoid bursitis, right ankle and footM06.272 Rheumatoid bursitis, left ankle and footM06.28 Rheumatoid bursitis, vertebraeM06.29 Rheumatoid bursitis, multiple sitesM06.311 Rheumatoid nodule, right shoulderM06.312 Rheumatoid nodule, left shoulderM06.321 Rheumatoid nodule, right elbowM06.322 Rheumatoid nodule, left elbowM06.331 Rheumatoid nodule, right wristM06.332 Rheumatoid nodule, left wristM06.341 Rheumatoid nodule, right handM06.342 Rheumatoid nodule, left handM06.351 Rheumatoid nodule, right hipPrinted on 8/29/2017. of 40


M06.352 Rheumatoid nodule, left hipM06.361 Rheumatoid nodule, right kneeM06.362 Rheumatoid nodule, left kneeM06.371 Rheumatoid nodule, right ankle and footM06.372 Rheumatoid nodule, left ankle and footM06.38 Rheumatoid nodule, vertebraeM06.39 Rheumatoid nodule, multiple sitesM06.811 Other specified rheumatoid arthritis, right shoulderM06.812 Other specified rheumatoid arthritis, left shoulderM06.821 Other specified rheumatoid arthritis, right elbowM06.822 Other specified rheumatoid arthritis, left elbowM06.831 Other specified rheumatoid arthritis, right wristM06.832 Other specified rheumatoid arthritis, left wristM06.841 Other specified rheumatoid arthritis, right handM06.842 Other specified rheumatoid arthritis, left handM06.851 Other specified rheumatoid arthritis, right hipM06.852 Other specified rheumatoid arthritis, left hipM06.861 Other specified rheumatoid arthritis, right kneeM06.862 Other specified rheumatoid arthritis, left kneeM06.871 Other specified rheumatoid arthritis, right ankle and footM06.872 Other specified rheumatoid arthritis, left ankle and footM06.88 Other specified rheumatoid arthritis, vertebraeM06.89 Other specified rheumatoid arthritis, multiple sitesM08.011 Unspecified juvenile rheumatoid arthritis, right shoulderM08.012 Unspecified juvenile rheumatoid arthritis, left shoulderM08.021 Unspecified juvenile rheumatoid arthritis, right elbowM08.022 Unspecified juvenile rheumatoid arthritis, left elbowM08.031 Unspecified juvenile rheumatoid arthritis, right wristM08.032 Unspecified juvenile rheumatoid arthritis, left wristM08.041 Unspecified juvenile rheumatoid arthritis, right handM08.042 Unspecified juvenile rheumatoid arthritis, left handM08.051 Unspecified juvenile rheumatoid arthritis, right hipM08.052 Unspecified juvenile rheumatoid arthritis, left hipM08.061 Unspecified juvenile rheumatoid arthritis, right kneeM08.062 Unspecified juvenile rheumatoid arthritis, left kneeM08.071 Unspecified juvenile rheumatoid arthritis, right ankle and footM08.072 Unspecified juvenile rheumatoid arthritis, left ankle and footM08.08 Unspecified juvenile rheumatoid arthritis, vertebraeM08.09 Unspecified juvenile rheumatoid arthritis, multiple sitesM08.211 Juvenile rheumatoid arthritis with systemic onset, right shoulderM08.212 Juvenile rheumatoid arthritis with systemic onset, left shoulderM08.221 Juvenile rheumatoid arthritis with systemic onset, right elbowM08.222 Juvenile rheumatoid arthritis with systemic onset, left elbowM08.231 Juvenile rheumatoid arthritis with systemic onset, right wristM08.232 Juvenile rheumatoid arthritis with systemic onset, left wristM08.241 Juvenile rheumatoid arthritis with systemic onset, right handM08.242 Juvenile rheumatoid arthritis with systemic onset, left handM08.251 Juvenile rheumatoid arthritis with systemic onset, right hipM08.252 Juvenile rheumatoid arthritis with systemic onset, left hipM08.261 Juvenile rheumatoid arthritis with systemic onset, right kneeM08.262 Juvenile rheumatoid arthritis with systemic onset, left kneeM08.271 Juvenile rheumatoid arthritis with systemic onset, right ankle and footM08.272 Juvenile rheumatoid arthritis with systemic onset, left ankle and footM08.28 Juvenile rheumatoid arthritis with systemic onset, vertebraeM08.29 Juvenile rheumatoid arthritis with systemic onset, multiple sitesM08.3 Juvenile rheumatoid polyarthritis (seronegative)M08.411 Pauciarticular juvenile rheumatoid arthritis, right shoulderM08.412 Pauciarticular juvenile rheumatoid arthritis, left shoulderPrinted on 8/29/2017. of 40


M08.421 Pauciarticular juvenile rheumatoid arthritis, right elbowM08.422 Pauciarticular juvenile rheumatoid arthritis, left elbowM08.431 Pauciarticular juvenile rheumatoid arthritis, right wristM08.432 Pauciarticular juvenile rheumatoid arthritis, left wristM08.441 Pauciarticular juvenile rheumatoid arthritis, right handM08.442 Pauciarticular juvenile rheumatoid arthritis, left handM08.451 Pauciarticular juvenile rheumatoid arthritis, right hipM08.452 Pauciarticular juvenile rheumatoid arthritis, left hipM08.461 Pauciarticular juvenile rheumatoid arthritis, right kneeM08.462 Pauciarticular juvenile rheumatoid arthritis, left kneeM08.471 Pauciarticular juvenile rheumatoid arthritis, right ankle and footM08.472 Pauciarticular juvenile rheumatoid arthritis, left ankle and footM08.48 Pauciarticular juvenile rheumatoid arthritis, vertebraeM08.811 Other juvenile arthritis, right shoulderM08.812 Other juvenile arthritis, left shoulderM08.821 Other juvenile arthritis, right elbowM08.822 Other juvenile arthritis, left elbowM08.831 Other juvenile arthritis, right wristM08.832 Other juvenile arthritis, left wristM08.841 Other juvenile arthritis, right handM08.842 Other juvenile arthritis, left handM08.851 Other juvenile arthritis, right hipM08.852 Other juvenile arthritis, left hipM08.861 Other juvenile arthritis, right kneeM08.862 Other juvenile arthritis, left kneeM08.871 Other juvenile arthritis, right ankle and footM08.872 Other juvenile arthritis, left ankle and footM08.88 Other juvenile arthritis, other specified siteM08.89 Other juvenile arthritis, multiple sitesM08.911 Juvenile arthritis, unspecified, right shoulderM08.912 Juvenile arthritis, unspecified, left shoulderM08.921 Juvenile arthritis, unspecified, right elbowM08.922 Juvenile arthritis, unspecified, left elbowM08.931 Juvenile arthritis, unspecified, right wristM08.932 Juvenile arthritis, unspecified, left wristM08.941 Juvenile arthritis, unspecified, right handM08.942 Juvenile arthritis, unspecified, left handM08.951 Juvenile arthritis, unspecified, right hipM08.952 Juvenile arthritis, unspecified, left hipM08.961 Juvenile arthritis, unspecified, right kneeM08.962 Juvenile arthritis, unspecified, left kneeM08.971 Juvenile arthritis, unspecified, right ankle and footM08.972 Juvenile arthritis, unspecified, left ankle and footM08.98 Juvenile arthritis, unspecified, vertebraeM08.99 Juvenile arthritis, unspecified, multiple sites

• Neovascular (Wet) Age-Related Macular Degeneration• Diabetic macular edema• Proliferative diabetic retinopathy in patients with or without diabetic macular edema

Group 2 Paragraph:

J2778 Ranibizumab (Lucentis™), 0.1 mg;



E08.3211 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy withmacular edema, right eye

E08.3212 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy withmacular edema, left eye

E08.3213 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy withmacular edema, bilateral

E08.3311 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathywith macular edema, right eye

E08.3312 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathywith macular edema, left eye

E08.3313 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathywith macular edema, bilateral

E08.3411 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy withmacular edema, right eye

E08.3412 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy withmacular edema, left eye

E08.3413 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy withmacular edema, bilateral

E08.3511 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macularedema, right eye

E08.3512 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macularedema, left eye

E08.3513 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macularedema, bilateral

E09.3211 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy withmacular edema, right eye

E09.3212 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy withmacular edema, left eye

E09.3213 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy withmacular edema, bilateral

E09.3311 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathywith macular edema, right eye

E09.3312 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathywith macular edema, left eye

E09.3313 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathywith macular edema, bilateral

E09.3411 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy withmacular edema, right eye

E09.3412 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy withmacular edema, left eye

E09.3413 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy withmacular edema, bilateral

E09.3511 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macularedema, right eye

E09.3512 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macularedema, left eye

E09.3513 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macularedema, bilateral

E10.3211 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, righteye

E10.3212 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, lefteye

E10.3213 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema,bilateral

E10.3291 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema,right eye

E10.3292 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema,left eye

E10.3293 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema,bilateral

Group 2 Codes:



E10.3311 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema,right eye

E10.3312 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema,left eye

E10.3313 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema,bilateral

E10.3391 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macularedema, right eye

E10.3392 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macularedema, left eye

E10.3393 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macularedema, bilateral

E10.3411 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema,right eye

E10.3412 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, lefteye

E10.3413 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema,bilateral

E10.3491 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema,right eye

E10.3492 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema,left eye

E10.3493 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema,bilateral

E10.3511 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eyeE10.3512 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eyeE10.3513 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral




E11.3291 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema,right eye

E11.3292 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema,left eye

E11.3293 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema,bilateral




E11.3391 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macularedema, right eye

E11.3392 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macularedema, left eye

E11.3393 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macularedema, bilateral




E11.3491 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema,right eye

E11.3492 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema,left eye



E11.3493 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema,bilateral


E13.3211 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macularedema, right eye

E13.3212 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macularedema, left eye

E13.3213 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macularedema, bilateral

E13.3291 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macularedema, right eye

E13.3292 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macularedema, left eye

E13.3293 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macularedema, bilateral

E13.3311 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macularedema, right eye

E13.3312 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macularedema, left eye

E13.3313 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macularedema, bilateral

E13.3391 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy withoutmacular edema, right eye

E13.3392 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy withoutmacular edema, left eye

E13.3393 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy withoutmacular edema, bilateral

E13.3411 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macularedema, right eye

E13.3412 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macularedema, left eye

E13.3413 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macularedema, bilateral

E13.3491 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macularedema, right eye

E13.3492 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macularedema, left eye

E13.3493 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macularedema, bilateral

E13.3511 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, righteye

E13.3512 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, lefteye

E13.3513 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema,bilateral

H35.051 Retinal neovascularization, unspecified, right eyeH35.052 Retinal neovascularization, unspecified, left eyeH35.053 Retinal neovascularization, unspecified, bilateralH35.3210 Exudative age-related macular degeneration, right eye, stage unspecifiedH35.3211 Exudative age-related macular degeneration, right eye, with active choroidal neovascularizationH35.3212 Exudative age-related macular degeneration, right eye, with inactive choroidal neovascularizationH35.3213 Exudative age-related macular degeneration, right eye, with inactive scarH35.3220 Exudative age-related macular degeneration, left eye, stage unspecifiedH35.3221 Exudative age-related macular degeneration, left eye, with active choroidal neovascularizationH35.3222 Exudative age-related macular degeneration, left eye, with inactive choroidal neovascularizationH35.3223 Exudative age-related macular degeneration, left eye, with inactive scarH35.3230 Exudative age-related macular degeneration, bilateral, stage unspecifiedH35.3231 Exudative age-related macular degeneration, bilateral, with active choroidal neovascularization



H35.3232 Exudative age-related macular degeneration, bilateral, with inactive choroidal neovascularizationH35.3233 Exudative age-related macular degeneration, bilateral, with inactive scar

























Group 3 Paragraph: Group 3 Paragraph: J0178 Aflibercept (Eylea), 1 mg• Neovascular (Wet) Age-Related Macular Degeneration• Diabetic macular edema• Proliferative diabetic retinopathy in patients with diabetic macular edema

Group 3 Codes:
































E13.3413Printed on 8/29/2017. of 40


Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macularedema, bilateral




H35.051 Retinal neovascularization, unspecified, right eyeH35.052 Retinal neovascularization, unspecified, left eyeH35.053 Retinal neovascularization, unspecified, bilateralH35.3210 Exudative age-related macular degeneration, right eye, stage unspecifiedH35.3211 Exudative age-related macular degeneration, right eye, with active choroidal neovascularizationH35.3212 Exudative age-related macular degeneration, right eye, with inactive choroidal neovascularizationH35.3213 Exudative age-related macular degeneration, right eye, with inactive scarH35.3220 Exudative age-related macular degeneration, left eye, stage unspecifiedH35.3221 Exudative age-related macular degeneration, left eye, with active choroidal neovascularizationH35.3222 Exudative age-related macular degeneration, left eye, with inactive choroidal neovascularizationH35.3223 Exudative age-related macular degeneration, left eye, with inactive scarH35.3230 Exudative age-related macular degeneration, bilateral, stage unspecifiedH35.3231 Exudative age-related macular degeneration, bilateral, with active choroidal neovascularizationH35.3232 Exudative age-related macular degeneration, bilateral, with inactive choroidal neovascularizationH35.3233 Exudative age-related macular degeneration, bilateral, with inactive scar

ICD-10 Codes DescriptionH34.8110 Central retinal vein occlusion, right eye, with macular edemaH34.8120 Central retinal vein occlusion, left eye, with macular edemaH34.8130 Central retinal vein occlusion, bilateral, with macular edemaH34.8310 Tributary (branch) retinal vein occlusion, right eye, with macular edemaH34.8320 Tributary (branch) retinal vein occlusion, left eye, with macular edemaH34.8330 Tributary (branch) retinal vein occlusion, bilateral, with macular edema

ICD-10 Codes DescriptionH35.051 Retinal neovascularization, unspecified, right eyeH35.052 Retinal neovascularization, unspecified, left eyeH35.053 Retinal neovascularization, unspecified, bilateralH44.21 Degenerative myopia, right eyeH44.22 Degenerative myopia, left eyeH44.23 Degenerative myopia, bilateral

Group 4 Paragraph:

J2778 Ranibizumab (Lucentis™), 0.1mg; J0178 Aflibercept (Eylea), 1 mg Macular Edema following eithercentral retinal vein occlusion (CRVO) or venous tributary branch occlusion (BRVO).

Group 4 Codes:

Group 5 Paragraph: J2778 Ranibizumab (Lucentis™), 0.1 mgMyopic Choroidal Neovascularization (mCNV) FDA approval 01/05/2017

Group 5 Codes:

Group 6 Paragraph:


ICD-10 Codes DescriptionE75.21 Fabry (-Anderson) disease

ICD-10 Codes DescriptionE88.01 Alpha-1-antitrypsin deficiency

ICD-10 Codes DescriptionE88.01 Alpha-1-antitrypsin deficiency

ICD-10 Codes DescriptionG20 Parkinson's disease

• Treatment of patients with paroxysmal nocturnal hemoglobinuria (PNH) to reduce hemolysis. • For the treatment of patients with atypical hemolytic uremic syndrome (aHUS) to inhibit complement

mediated thrombotic microangiopathy. Effective 09/23/2011-FDA approval date.

ICD-10 Codes DescriptionD59.3 Hemolytic-uremic syndromeD59.5 Paroxysmal nocturnal hemoglobinuria [Marchiafava-Micheli]

J0180 Agalsidase Beta (Fabrazyme™), 1 mg

Group 6 Codes:

Group 7 Paragraph:

J0256 Alpha 1 Proteinase Inhibitor (Human), not otherwise specified, 10 mg

Group 7 Codes:

Group 8 Paragraph:

J0257 Alpha 1 Protease Inhibitor (Human), (Glassia), 10 MG

Group 8 Codes:

Group 9 Paragraph: J0364 Apomorphine hydrochloride (Apokyn™), 1 mgAcute, intermittent treatment of hypomobility associated with advanced Parkinson's disease.

Group 9 Codes:

Group 10 Paragraph:

J1300 Eculizumab (Soliris™), 10 mg

Group 10 Codes:

Group 11 Paragraph:


• Other rheumatoid arthritis with visceral or systemic involvement. • Sarcoidosis: will be considered for treating patients with persistent symptomatic sarcoidosis despite

corticosteroid and immunosuppressive treatment. • Iridocyclitis: Infliximab will be covered for uveitis that is refractory to other immunosuppressive agents. • Failure of previously used agents must be documented in the medical record.


A18.54 Tuberculous iridocyclitisD86.0 Sarcoidosis of lungD86.1 Sarcoidosis of lymph nodesD86.2 Sarcoidosis of lung with sarcoidosis of lymph nodesD86.3 Sarcoidosis of skinD86.81 Sarcoid meningitisD86.82 Multiple cranial nerve palsies in sarcoidosisD86.83 Sarcoid iridocyclitisD86.84 Sarcoid pyelonephritisD86.85 Sarcoid myocarditisD86.86 Sarcoid arthropathyD86.87 Sarcoid myositisD86.89 Sarcoidosis of other sitesH20.00 Unspecified acute and subacute iridocyclitisH20.011 Primary iridocyclitis, right eyeH20.012 Primary iridocyclitis, left eyeH20.013 Primary iridocyclitis, bilateralH20.021 Recurrent acute iridocyclitis, right eyeH20.022 Recurrent acute iridocyclitis, left eyeH20.023 Recurrent acute iridocyclitis, bilateralH20.031 Secondary infectious iridocyclitis, right eyeH20.032 Secondary infectious iridocyclitis, left eyeH20.033 Secondary infectious iridocyclitis, bilateralH20.041 Secondary noninfectious iridocyclitis, right eyeH20.042 Secondary noninfectious iridocyclitis, left eyeH20.043 Secondary noninfectious iridocyclitis, bilateralH20.051 Hypopyon, right eyeH20.052 Hypopyon, left eyeH20.053 Hypopyon, bilateralH20.11 Chronic iridocyclitis, right eyeH20.12 Chronic iridocyclitis, left eyeH20.13 Chronic iridocyclitis, bilateralH20.21 Lens-induced iridocyclitis, right eyeH20.22 Lens-induced iridocyclitis, left eyeH20.23 Lens-induced iridocyclitis, bilateralH20.811 Fuchs' heterochromic cyclitis, right eyeH20.812 Fuchs' heterochromic cyclitis, left eyeH20.813 Fuchs' heterochromic cyclitis, bilateralH20.821 Vogt-Koyanagi syndrome, right eyeH20.822 Vogt-Koyanagi syndrome, left eyeH20.823 Vogt-Koyanagi syndrome, bilateralH20.9 Unspecified iridocyclitisJ99 Respiratory disorders in diseases classified elsewhereK50.00 Crohn's disease of small intestine without complicationsK50.011 Crohn's disease of small intestine with rectal bleeding

J1745 Infliximab (Remicade™), 10 mg & Q5102 Infliximab, Biosimilar

Group 11 Codes:



K50.012 Crohn's disease of small intestine with intestinal obstructionK50.013 Crohn's disease of small intestine with fistulaK50.014 Crohn's disease of small intestine with abscessK50.018 Crohn's disease of small intestine with other complicationK50.019 Crohn's disease of small intestine with unspecified complicationsK50.10 Crohn's disease of large intestine without complicationsK50.111 Crohn's disease of large intestine with rectal bleedingK50.112 Crohn's disease of large intestine with intestinal obstructionK50.113 Crohn's disease of large intestine with fistulaK50.114 Crohn's disease of large intestine with abscessK50.118 Crohn's disease of large intestine with other complicationK50.119 Crohn's disease of large intestine with unspecified complicationsK50.80 Crohn's disease of both small and large intestine without complicationsK50.811 Crohn's disease of both small and large intestine with rectal bleedingK50.812 Crohn's disease of both small and large intestine with intestinal obstructionK50.813 Crohn's disease of both small and large intestine with fistulaK50.814 Crohn's disease of both small and large intestine with abscessK50.818 Crohn's disease of both small and large intestine with other complicationK50.819 Crohn's disease of both small and large intestine with unspecified complicationsK51.00 Ulcerative (chronic) pancolitis without complicationsK51.011 Ulcerative (chronic) pancolitis with rectal bleedingK51.012 Ulcerative (chronic) pancolitis with intestinal obstructionK51.013 Ulcerative (chronic) pancolitis with fistulaK51.014 Ulcerative (chronic) pancolitis with abscessK51.018 Ulcerative (chronic) pancolitis with other complicationK51.019 Ulcerative (chronic) pancolitis with unspecified complicationsK51.20 Ulcerative (chronic) proctitis without complicationsK51.211 Ulcerative (chronic) proctitis with rectal bleedingK51.212 Ulcerative (chronic) proctitis with intestinal obstructionK51.213 Ulcerative (chronic) proctitis with fistulaK51.214 Ulcerative (chronic) proctitis with abscessK51.218 Ulcerative (chronic) proctitis with other complicationK51.219 Ulcerative (chronic) proctitis with unspecified complicationsK51.30 Ulcerative (chronic) rectosigmoiditis without complicationsK51.311 Ulcerative (chronic) rectosigmoiditis with rectal bleedingK51.312 Ulcerative (chronic) rectosigmoiditis with intestinal obstructionK51.313 Ulcerative (chronic) rectosigmoiditis with fistulaK51.314 Ulcerative (chronic) rectosigmoiditis with abscessK51.318 Ulcerative (chronic) rectosigmoiditis with other complicationK51.319 Ulcerative (chronic) rectosigmoiditis with unspecified complicationsK51.40 Inflammatory polyps of colon without complicationsK51.411 Inflammatory polyps of colon with rectal bleedingK51.412 Inflammatory polyps of colon with intestinal obstructionK51.413 Inflammatory polyps of colon with fistulaK51.414 Inflammatory polyps of colon with abscessK51.418 Inflammatory polyps of colon with other complicationK51.419 Inflammatory polyps of colon with unspecified complicationsK51.50 Left sided colitis without complicationsK51.511 Left sided colitis with rectal bleedingK51.512 Left sided colitis with intestinal obstructionK51.513 Left sided colitis with fistulaK51.514 Left sided colitis with abscessK51.518 Left sided colitis with other complicationK51.519 Left sided colitis with unspecified complicationsK51.80 Other ulcerative colitis without complicationsK51.811 Other ulcerative colitis with rectal bleedingK51.812 Other ulcerative colitis with intestinal obstructionK51.813 Other ulcerative colitis with fistulaPrinted on 8/29/2017. of 40


K51.814 Other ulcerative colitis with abscessK51.818 Other ulcerative colitis with other complicationK51.819 Other ulcerative colitis with unspecified complicationsK51.90 Ulcerative colitis, unspecified, without complicationsK51.911 Ulcerative colitis, unspecified with rectal bleedingK51.912 Ulcerative colitis, unspecified with intestinal obstructionK51.913 Ulcerative colitis, unspecified with fistulaK51.914 Ulcerative colitis, unspecified with abscessK51.918 Ulcerative colitis, unspecified with other complicationL40.0 Psoriasis vulgarisL40.1 Generalized pustular psoriasisL40.2 Acrodermatitis continuaL40.3 Pustulosis palmaris et plantarisL40.4 Guttate psoriasisL40.50 Arthropathic psoriasis, unspecifiedL40.51 Distal interphalangeal psoriatic arthropathyL40.52 Psoriatic arthritis mutilansL40.53 Psoriatic spondylitisL40.54 Psoriatic juvenile arthropathyL40.59 Other psoriatic arthropathyL40.8 Other psoriasisL40.9 Psoriasis, unspecifiedM05.011 Felty's syndrome, right shoulderM05.012 Felty's syndrome, left shoulderM05.021 Felty's syndrome, right elbowM05.022 Felty's syndrome, left elbowM05.031 Felty's syndrome, right wristM05.032 Felty's syndrome, left wristM05.041 Felty's syndrome, right handM05.042 Felty's syndrome, left handM05.051 Felty's syndrome, right hipM05.052 Felty's syndrome, left hipM05.061 Felty's syndrome, right kneeM05.062 Felty's syndrome, left kneeM05.071 Felty's syndrome, right ankle and footM05.072 Felty's syndrome, left ankle and footM05.09 Felty's syndrome, multiple sitesM05.211 Rheumatoid vasculitis with rheumatoid arthritis of right shoulderM05.212 Rheumatoid vasculitis with rheumatoid arthritis of left shoulderM05.221 Rheumatoid vasculitis with rheumatoid arthritis of right elbowM05.222 Rheumatoid vasculitis with rheumatoid arthritis of left elbowM05.231 Rheumatoid vasculitis with rheumatoid arthritis of right wristM05.232 Rheumatoid vasculitis with rheumatoid arthritis of left wristM05.241 Rheumatoid vasculitis with rheumatoid arthritis of right handM05.242 Rheumatoid vasculitis with rheumatoid arthritis of left handM05.251 Rheumatoid vasculitis with rheumatoid arthritis of right hipM05.252 Rheumatoid vasculitis with rheumatoid arthritis of left hipM05.261 Rheumatoid vasculitis with rheumatoid arthritis of right kneeM05.262 Rheumatoid vasculitis with rheumatoid arthritis of left kneeM05.271 Rheumatoid vasculitis with rheumatoid arthritis of right ankle and footM05.272 Rheumatoid vasculitis with rheumatoid arthritis of left ankle and footM05.29 Rheumatoid vasculitis with rheumatoid arthritis of multiple sitesM05.311 Rheumatoid heart disease with rheumatoid arthritis of right shoulderM05.312 Rheumatoid heart disease with rheumatoid arthritis of left shoulderM05.321 Rheumatoid heart disease with rheumatoid arthritis of right elbowM05.322 Rheumatoid heart disease with rheumatoid arthritis of left elbowM05.331 Rheumatoid heart disease with rheumatoid arthritis of right wrist



M05.332 Rheumatoid heart disease with rheumatoid arthritis of left wristM05.341 Rheumatoid heart disease with rheumatoid arthritis of right handM05.342 Rheumatoid heart disease with rheumatoid arthritis of left handM05.351 Rheumatoid heart disease with rheumatoid arthritis of right hipM05.352 Rheumatoid heart disease with rheumatoid arthritis of left hipM05.361 Rheumatoid heart disease with rheumatoid arthritis of right kneeM05.362 Rheumatoid heart disease with rheumatoid arthritis of left kneeM05.371 Rheumatoid heart disease with rheumatoid arthritis of right ankle and footM05.372 Rheumatoid heart disease with rheumatoid arthritis of left ankle and footM05.39 Rheumatoid heart disease with rheumatoid arthritis of multiple sitesM05.411 Rheumatoid myopathy with rheumatoid arthritis of right shoulderM05.412 Rheumatoid myopathy with rheumatoid arthritis of left shoulderM05.421 Rheumatoid myopathy with rheumatoid arthritis of right elbowM05.422 Rheumatoid myopathy with rheumatoid arthritis of left elbowM05.431 Rheumatoid myopathy with rheumatoid arthritis of right wristM05.432 Rheumatoid myopathy with rheumatoid arthritis of left wristM05.441 Rheumatoid myopathy with rheumatoid arthritis of right handM05.442 Rheumatoid myopathy with rheumatoid arthritis of left handM05.451 Rheumatoid myopathy with rheumatoid arthritis of right hipM05.452 Rheumatoid myopathy with rheumatoid arthritis of left hipM05.461 Rheumatoid myopathy with rheumatoid arthritis of right kneeM05.462 Rheumatoid myopathy with rheumatoid arthritis of left kneeM05.471 Rheumatoid myopathy with rheumatoid arthritis of right ankle and footM05.472 Rheumatoid myopathy with rheumatoid arthritis of left ankle and footM05.49 Rheumatoid myopathy with rheumatoid arthritis of multiple sitesM05.511 Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulderM05.512 Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulderM05.521 Rheumatoid polyneuropathy with rheumatoid arthritis of right elbowM05.522 Rheumatoid polyneuropathy with rheumatoid arthritis of left elbowM05.531 Rheumatoid polyneuropathy with rheumatoid arthritis of right wristM05.532 Rheumatoid polyneuropathy with rheumatoid arthritis of left wristM05.541 Rheumatoid polyneuropathy with rheumatoid arthritis of right handM05.542 Rheumatoid polyneuropathy with rheumatoid arthritis of left handM05.551 Rheumatoid polyneuropathy with rheumatoid arthritis of right hipM05.552 Rheumatoid polyneuropathy with rheumatoid arthritis of left hipM05.561 Rheumatoid polyneuropathy with rheumatoid arthritis of right kneeM05.562 Rheumatoid polyneuropathy with rheumatoid arthritis of left kneeM05.571 Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and footM05.572 Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and footM05.59 Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sitesM05.611 Rheumatoid arthritis of right shoulder with involvement of other organs and systemsM05.612 Rheumatoid arthritis of left shoulder with involvement of other organs and systemsM05.621 Rheumatoid arthritis of right elbow with involvement of other organs and systemsM05.622 Rheumatoid arthritis of left elbow with involvement of other organs and systemsM05.631 Rheumatoid arthritis of right wrist with involvement of other organs and systemsM05.632 Rheumatoid arthritis of left wrist with involvement of other organs and systemsM05.641 Rheumatoid arthritis of right hand with involvement of other organs and systemsM05.642 Rheumatoid arthritis of left hand with involvement of other organs and systemsM05.651 Rheumatoid arthritis of right hip with involvement of other organs and systemsM05.652 Rheumatoid arthritis of left hip with involvement of other organs and systemsM05.661 Rheumatoid arthritis of right knee with involvement of other organs and systemsM05.662 Rheumatoid arthritis of left knee with involvement of other organs and systemsM05.671 Rheumatoid arthritis of right ankle and foot with involvement of other organs and systemsM05.672 Rheumatoid arthritis of left ankle and foot with involvement of other organs and systemsM05.69 Rheumatoid arthritis of multiple sites with involvement of other organs and systems

M05.711 Rheumatoid arthritis with rheumatoid factor of right shoulder without organ or systemsinvolvement

M05.712 Rheumatoid arthritis with rheumatoid factor of left shoulder without organ or systems involvementPrinted on 8/29/2017. of 40


M05.721 Rheumatoid arthritis with rheumatoid factor of right elbow without organ or systems involvementM05.722 Rheumatoid arthritis with rheumatoid factor of left elbow without organ or systems involvementM05.731 Rheumatoid arthritis with rheumatoid factor of right wrist without organ or systems involvementM05.732 Rheumatoid arthritis with rheumatoid factor of left wrist without organ or systems involvementM05.741 Rheumatoid arthritis with rheumatoid factor of right hand without organ or systems involvementM05.742 Rheumatoid arthritis with rheumatoid factor of left hand without organ or systems involvementM05.751 Rheumatoid arthritis with rheumatoid factor of right hip without organ or systems involvementM05.752 Rheumatoid arthritis with rheumatoid factor of left hip without organ or systems involvementM05.761 Rheumatoid arthritis with rheumatoid factor of right knee without organ or systems involvementM05.762 Rheumatoid arthritis with rheumatoid factor of left knee without organ or systems involvement

M05.771 Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systemsinvolvement

M05.772 Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or systemsinvolvement

M05.79 Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systemsinvolvement

M05.811 Other rheumatoid arthritis with rheumatoid factor of right shoulderM05.812 Other rheumatoid arthritis with rheumatoid factor of left shoulderM05.821 Other rheumatoid arthritis with rheumatoid factor of right elbowM05.822 Other rheumatoid arthritis with rheumatoid factor of left elbowM05.831 Other rheumatoid arthritis with rheumatoid factor of right wristM05.832 Other rheumatoid arthritis with rheumatoid factor of left wristM05.841 Other rheumatoid arthritis with rheumatoid factor of right handM05.842 Other rheumatoid arthritis with rheumatoid factor of left handM05.851 Other rheumatoid arthritis with rheumatoid factor of right hipM05.852 Other rheumatoid arthritis with rheumatoid factor of left hipM05.861 Other rheumatoid arthritis with rheumatoid factor of right kneeM05.862 Other rheumatoid arthritis with rheumatoid factor of left kneeM05.871 Other rheumatoid arthritis with rheumatoid factor of right ankle and footM05.872 Other rheumatoid arthritis with rheumatoid factor of left ankle and footM05.89 Other rheumatoid arthritis with rheumatoid factor of multiple sitesM06.011 Rheumatoid arthritis without rheumatoid factor, right shoulderM06.012 Rheumatoid arthritis without rheumatoid factor, left shoulderM06.021 Rheumatoid arthritis without rheumatoid factor, right elbowM06.022 Rheumatoid arthritis without rheumatoid factor, left elbowM06.031 Rheumatoid arthritis without rheumatoid factor, right wristM06.032 Rheumatoid arthritis without rheumatoid factor, left wristM06.041 Rheumatoid arthritis without rheumatoid factor, right handM06.042 Rheumatoid arthritis without rheumatoid factor, left handM06.051 Rheumatoid arthritis without rheumatoid factor, right hipM06.052 Rheumatoid arthritis without rheumatoid factor, left hipM06.061 Rheumatoid arthritis without rheumatoid factor, right kneeM06.062 Rheumatoid arthritis without rheumatoid factor, left kneeM06.071 Rheumatoid arthritis without rheumatoid factor, right ankle and footM06.072 Rheumatoid arthritis without rheumatoid factor, left ankle and footM06.08 Rheumatoid arthritis without rheumatoid factor, vertebraeM06.09 Rheumatoid arthritis without rheumatoid factor, multiple sitesM06.211 Rheumatoid bursitis, right shoulderM06.212 Rheumatoid bursitis, left shoulderM06.221 Rheumatoid bursitis, right elbowM06.222 Rheumatoid bursitis, left elbowM06.231 Rheumatoid bursitis, right wristM06.232 Rheumatoid bursitis, left wristM06.241 Rheumatoid bursitis, right handM06.242 Rheumatoid bursitis, left handM06.251 Rheumatoid bursitis, right hipM06.252 Rheumatoid bursitis, left hipM06.261 Rheumatoid bursitis, right knee



M06.262 Rheumatoid bursitis, left kneeM06.271 Rheumatoid bursitis, right ankle and footM06.272 Rheumatoid bursitis, left ankle and footM06.28 Rheumatoid bursitis, vertebraeM06.29 Rheumatoid bursitis, multiple sitesM06.311 Rheumatoid nodule, right shoulderM06.312 Rheumatoid nodule, left shoulderM06.321 Rheumatoid nodule, right elbowM06.322 Rheumatoid nodule, left elbowM06.331 Rheumatoid nodule, right wristM06.332 Rheumatoid nodule, left wristM06.341 Rheumatoid nodule, right handM06.342 Rheumatoid nodule, left handM06.351 Rheumatoid nodule, right hipM06.352 Rheumatoid nodule, left hipM06.361 Rheumatoid nodule, right kneeM06.362 Rheumatoid nodule, left kneeM06.371 Rheumatoid nodule, right ankle and footM06.372 Rheumatoid nodule, left ankle and footM06.38 Rheumatoid nodule, vertebraeM06.39 Rheumatoid nodule, multiple sitesM06.811 Other specified rheumatoid arthritis, right shoulderM06.812 Other specified rheumatoid arthritis, left shoulderM06.821 Other specified rheumatoid arthritis, right elbowM06.822 Other specified rheumatoid arthritis, left elbowM06.831 Other specified rheumatoid arthritis, right wristM06.832 Other specified rheumatoid arthritis, left wristM06.841 Other specified rheumatoid arthritis, right handM06.842 Other specified rheumatoid arthritis, left handM06.851 Other specified rheumatoid arthritis, right hipM06.852 Other specified rheumatoid arthritis, left hipM06.861 Other specified rheumatoid arthritis, right kneeM06.862 Other specified rheumatoid arthritis, left kneeM06.871 Other specified rheumatoid arthritis, right ankle and footM06.872 Other specified rheumatoid arthritis, left ankle and footM06.88 Other specified rheumatoid arthritis, vertebraeM06.89 Other specified rheumatoid arthritis, multiple sitesM08.011 Unspecified juvenile rheumatoid arthritis, right shoulderM08.012 Unspecified juvenile rheumatoid arthritis, left shoulderM08.021 Unspecified juvenile rheumatoid arthritis, right elbowM08.022 Unspecified juvenile rheumatoid arthritis, left elbowM08.031 Unspecified juvenile rheumatoid arthritis, right wristM08.032 Unspecified juvenile rheumatoid arthritis, left wristM08.041 Unspecified juvenile rheumatoid arthritis, right handM08.042 Unspecified juvenile rheumatoid arthritis, left handM08.051 Unspecified juvenile rheumatoid arthritis, right hipM08.052 Unspecified juvenile rheumatoid arthritis, left hipM08.061 Unspecified juvenile rheumatoid arthritis, right kneeM08.062 Unspecified juvenile rheumatoid arthritis, left kneeM08.071 Unspecified juvenile rheumatoid arthritis, right ankle and footM08.072 Unspecified juvenile rheumatoid arthritis, left ankle and footM08.08 Unspecified juvenile rheumatoid arthritis, vertebraeM08.09 Unspecified juvenile rheumatoid arthritis, multiple sitesM08.1 Juvenile ankylosing spondylitisM08.211 Juvenile rheumatoid arthritis with systemic onset, right shoulderM08.212 Juvenile rheumatoid arthritis with systemic onset, left shoulderM08.221 Juvenile rheumatoid arthritis with systemic onset, right elbowM08.222 Juvenile rheumatoid arthritis with systemic onset, left elbowPrinted on 8/29/2017. of 40


M08.231 Juvenile rheumatoid arthritis with systemic onset, right wristM08.232 Juvenile rheumatoid arthritis with systemic onset, left wristM08.241 Juvenile rheumatoid arthritis with systemic onset, right handM08.242 Juvenile rheumatoid arthritis with systemic onset, left handM08.251 Juvenile rheumatoid arthritis with systemic onset, right hipM08.252 Juvenile rheumatoid arthritis with systemic onset, left hipM08.261 Juvenile rheumatoid arthritis with systemic onset, right kneeM08.262 Juvenile rheumatoid arthritis with systemic onset, left kneeM08.271 Juvenile rheumatoid arthritis with systemic onset, right ankle and footM08.272 Juvenile rheumatoid arthritis with systemic onset, left ankle and footM08.28 Juvenile rheumatoid arthritis with systemic onset, vertebraeM08.29 Juvenile rheumatoid arthritis with systemic onset, multiple sitesM08.3 Juvenile rheumatoid polyarthritis (seronegative)M08.411 Pauciarticular juvenile rheumatoid arthritis, right shoulderM08.412 Pauciarticular juvenile rheumatoid arthritis, left shoulderM08.421 Pauciarticular juvenile rheumatoid arthritis, right elbowM08.422 Pauciarticular juvenile rheumatoid arthritis, left elbowM08.431 Pauciarticular juvenile rheumatoid arthritis, right wristM08.432 Pauciarticular juvenile rheumatoid arthritis, left wristM08.441 Pauciarticular juvenile rheumatoid arthritis, right handM08.442 Pauciarticular juvenile rheumatoid arthritis, left handM08.451 Pauciarticular juvenile rheumatoid arthritis, right hipM08.452 Pauciarticular juvenile rheumatoid arthritis, left hipM08.461 Pauciarticular juvenile rheumatoid arthritis, right kneeM08.462 Pauciarticular juvenile rheumatoid arthritis, left kneeM08.471 Pauciarticular juvenile rheumatoid arthritis, right ankle and footM08.472 Pauciarticular juvenile rheumatoid arthritis, left ankle and footM08.48 Pauciarticular juvenile rheumatoid arthritis, vertebraeM08.811 Other juvenile arthritis, right shoulderM08.812 Other juvenile arthritis, left shoulderM08.821 Other juvenile arthritis, right elbowM08.822 Other juvenile arthritis, left elbowM08.831 Other juvenile arthritis, right wristM08.832 Other juvenile arthritis, left wristM08.841 Other juvenile arthritis, right handM08.842 Other juvenile arthritis, left handM08.851 Other juvenile arthritis, right hipM08.852 Other juvenile arthritis, left hipM08.861 Other juvenile arthritis, right kneeM08.862 Other juvenile arthritis, left kneeM08.871 Other juvenile arthritis, right ankle and footM08.872 Other juvenile arthritis, left ankle and footM08.88 Other juvenile arthritis, other specified siteM08.89 Other juvenile arthritis, multiple sitesM08.911 Juvenile arthritis, unspecified, right shoulderM08.912 Juvenile arthritis, unspecified, left shoulderM08.921 Juvenile arthritis, unspecified, right elbowM08.922 Juvenile arthritis, unspecified, left elbowM08.931 Juvenile arthritis, unspecified, right wristM08.932 Juvenile arthritis, unspecified, left wristM08.941 Juvenile arthritis, unspecified, right handM08.942 Juvenile arthritis, unspecified, left handM08.951 Juvenile arthritis, unspecified, right hipM08.952 Juvenile arthritis, unspecified, left hipM08.961 Juvenile arthritis, unspecified, right kneeM08.962 Juvenile arthritis, unspecified, left kneeM08.971 Juvenile arthritis, unspecified, right ankle and foot



M08.972 Juvenile arthritis, unspecified, left ankle and footM08.98 Juvenile arthritis, unspecified, vertebraeM08.99 Juvenile arthritis, unspecified, multiple sitesM35.2 Behcet's diseaseM45.0 Ankylosing spondylitis of multiple sites in spineM45.1 Ankylosing spondylitis of occipito-atlanto-axial regionM45.2 Ankylosing spondylitis of cervical regionM45.3 Ankylosing spondylitis of cervicothoracic regionM45.4 Ankylosing spondylitis of thoracic regionM45.5 Ankylosing spondylitis of thoracolumbar regionM45.6 Ankylosing spondylitis lumbar regionM45.7 Ankylosing spondylitis of lumbosacral regionM45.8 Ankylosing spondylitis sacral and sacrococcygeal regionM45.9 Ankylosing spondylitis of unspecified sites in spineM48.8X1 Other specified spondylopathies, occipito-atlanto-axial regionM48.8X2 Other specified spondylopathies, cervical regionM48.8X3 Other specified spondylopathies, cervicothoracic regionM48.8X4 Other specified spondylopathies, thoracic regionM48.8X5 Other specified spondylopathies, thoracolumbar regionM48.8X6 Other specified spondylopathies, lumbar regionM48.8X7 Other specified spondylopathies, lumbosacral regionM48.8X8 Other specified spondylopathies, sacral and sacrococcygeal region

• Indicated for patients with Hurler and Hurler-Scheie forms of Mucopolysaccharidosis I (MPS I) and • For patients with the Scheie form who have moderate to severe symptoms.

ICD-10 Codes DescriptionE76.01 Hurler's syndromeE76.02 Hurler-Scheie syndromeE76.03 Scheie's syndrome

ICD-10 Codes DescriptionI46.2 Cardiac arrest due to underlying cardiac conditionI46.8 Cardiac arrest due to other underlying conditionI46.9 Cardiac arrest, cause unspecifiedI47.0 Re-entry ventricular arrhythmiaI47.2 Ventricular tachycardiaI49.01 Ventricular fibrillationI49.02 Ventricular flutterI49.3 Ventricular premature depolarization

Group 12 Paragraph:

J1931 Laronidase (Aldurazyme™), 0.1 mg

Group 12 Codes:

Group 13 Paragraph:

J2001 Lidocaine HCL, 10 mg

Group 13 Codes:


ICD-10 Codes DescriptionI49.49 Other premature depolarizationI49.9 Cardiac arrhythmia, unspecified

ICD-10 Codes DescriptionG35 Multiple sclerosisK50.00 Crohn's disease of small intestine without complicationsK50.011 Crohn's disease of small intestine with rectal bleedingK50.012 Crohn's disease of small intestine with intestinal obstructionK50.013 Crohn's disease of small intestine with fistulaK50.014 Crohn's disease of small intestine with abscessK50.018 Crohn's disease of small intestine with other complicationK50.019 Crohn's disease of small intestine with unspecified complicationsK50.10 Crohn's disease of large intestine without complicationsK50.111 Crohn's disease of large intestine with rectal bleedingK50.112 Crohn's disease of large intestine with intestinal obstructionK50.113 Crohn's disease of large intestine with fistulaK50.114 Crohn's disease of large intestine with abscessK50.118 Crohn's disease of large intestine with other complicationK50.119 Crohn's disease of large intestine with unspecified complicationsK50.80 Crohn's disease of both small and large intestine without complicationsK50.811 Crohn's disease of both small and large intestine with rectal bleedingK50.812 Crohn's disease of both small and large intestine with intestinal obstructionK50.813 Crohn's disease of both small and large intestine with fistulaK50.814 Crohn's disease of both small and large intestine with abscessK50.818 Crohn's disease of both small and large intestine with other complicationK50.819 Crohn's disease of both small and large intestine with unspecified complicationsK50.90 Crohn's disease, unspecified, without complicationsK50.911 Crohn's disease, unspecified, with rectal bleedingK50.912 Crohn's disease, unspecified, with intestinal obstructionK50.913 Crohn's disease, unspecified, with fistulaK50.914 Crohn's disease, unspecified, with abscessK50.918 Crohn's disease, unspecified, with other complication

• Moderate to severe persistent asthma in patients with a positive skin test or in vitro reactivity to aperennial aeroallergen and symptoms that are inadequately controlled with inhaled corticosteroids.Includes moderate to severe extrinsic or intrinsic asthma.

• Chronic Idiopathic Urticaria adults and adolescents (12 years and above) who remain symptomatic despiteH1 antihistamine treatment. Effective 03/21/2014-FDA approval date.

ICD-10 Codes DescriptionJ45.40 Moderate persistent asthma, uncomplicatedJ45.50 Severe persistent asthma, uncomplicated

Group 14 Paragraph: J2323 Natalizumab (Tysabri™), 1 mgCrohn’s disease will be covered for moderate to severe active Crohn’s disease (CD) with evidence of inflammationfor patients who have had an inadequate response to, or are unable to tolerate, conventional CD therapies andinhibitors of TNF-a.

Group 14 Codes:

Group 15 Paragraph:

J2357 Omalizumab (Xolair™), 5 mg

Group 15 Codes:


ICD-10 Codes DescriptionL50.1 Idiopathic urticaria

• Diabetic macular edema, • Central vein occlusion, • Wet macular degeneration























E09.3511

Group 16 Paragraph:

J2503 Pegaptanib sodium (Macugen™), 0.3 mg

Group 16 Codes:



Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macularedema, right eye





























E13.3411Printed on 8/29/2017. of 40


Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macularedema, right eye






H34.8110 Central retinal vein occlusion, right eye, with macular edemaH34.8111 Central retinal vein occlusion, right eye, with retinal neovascularizationH34.8112 Central retinal vein occlusion, right eye, stableH34.8120 Central retinal vein occlusion, left eye, with macular edemaH34.8121 Central retinal vein occlusion, left eye, with retinal neovascularizationH34.8122 Central retinal vein occlusion, left eye, stableH34.8130 Central retinal vein occlusion, bilateral, with macular edemaH34.8131 Central retinal vein occlusion, bilateral, with retinal neovascularizationH34.8132 Central retinal vein occlusion, bilateral, stableH35.3210 Exudative age-related macular degeneration, right eye, stage unspecifiedH35.3211 Exudative age-related macular degeneration, right eye, with active choroidal neovascularizationH35.3212 Exudative age-related macular degeneration, right eye, with inactive choroidal neovascularizationH35.3213 Exudative age-related macular degeneration, right eye, with inactive scarH35.3220 Exudative age-related macular degeneration, left eye, stage unspecifiedH35.3221 Exudative age-related macular degeneration, left eye, with active choroidal neovascularizationH35.3222 Exudative age-related macular degeneration, left eye, with inactive choroidal neovascularizationH35.3223 Exudative age-related macular degeneration, left eye, with inactive scarH35.3230 Exudative age-related macular degeneration, bilateral, stage unspecifiedH35.3231 Exudative age-related macular degeneration, bilateral, with active choroidal neovascularizationH35.3232 Exudative age-related macular degeneration, bilateral, with inactive choroidal neovascularizationH35.3233 Exudative age-related macular degeneration, bilateral, with inactive scar


C82.00 -C82.09

Follicular lymphoma grade I, unspecified site - Follicular lymphoma grade I, extranodal and solidorgan sites

C82.10 -C82.20

Follicular lymphoma grade II, unspecified site - Follicular lymphoma grade III, unspecified,unspecified site

C82.21 -C82.29

Follicular lymphoma grade III, unspecified, lymph nodes of head, face, and neck - Follicularlymphoma grade III, unspecified, extranodal and solid organ sites

C82.30 -C82.39

Follicular lymphoma grade IIIa, unspecified site - Follicular lymphoma grade IIIa, extranodal andsolid organ sites

C82.40 -C82.49

Follicular lymphoma grade IIIb, unspecified site - Follicular lymphoma grade IIIb, extranodal andsolid organ sites

C82.50 -C82.59

Diffuse follicle center lymphoma, unspecified site - Diffuse follicle center lymphoma, extranodal andsolid organ sites

C82.60 -C82.69

Cutaneous follicle center lymphoma, unspecified site - Cutaneous follicle center lymphoma,extranodal and solid organ sites

Group 17 Paragraph: J2562 Plerixafor (Mozobil™), 1 mgIndicated in combination with granulocyte-colony stimulating factor (G-CSF) to mobilize hematopoietic stem cellsto the peripheral blood for collection and subsequent autologous transplantation in patients with non-Hodgkin’slymphoma and multiple myeloma.

Group 17 Codes:


https://www.cms.gov/medicare-coverage-database/staticpages/icd10-code-range.aspx?DocType=LCD&DocID=34741&ver=47&Group=17&RangeStart=C82.00&RangeEnd=C82.09&LCDId=34741&kq=370124852&ua=highwire%7cchrome&displayPDFNote=Y&bc=AAAAAAAAIAAAAA%3d%3d&















C82.80 -C82.89

Other types of follicular lymphoma, unspecified site - Other types of follicular lymphoma,extranodal and solid organ sites

C82.90 -C82.99

Follicular lymphoma, unspecified, unspecified site - Follicular lymphoma, unspecified, extranodaland solid organ sites

C83.00 -C83.09

Small cell B-cell lymphoma, unspecified site - Small cell B-cell lymphoma, extranodal and solidorgan sites

C83.10 -C83.19 Mantle cell lymphoma, unspecified site - Mantle cell lymphoma, extranodal and solid organ sites

C83.30 -C83.39

Diffuse large B-cell lymphoma, unspecified site - Diffuse large B-cell lymphoma, extranodal andsolid organ sites

C83.50 -C83.59

Lymphoblastic (diffuse) lymphoma, unspecified site - Lymphoblastic (diffuse) lymphoma,extranodal and solid organ sites

C83.70 -C83.79 Burkitt lymphoma, unspecified site - Burkitt lymphoma, extranodal and solid organ sites

C83.80 -C83.89

Other non-follicular lymphoma, unspecified site - Other non-follicular lymphoma, extranodal andsolid organ sites

C83.90 -C83.99

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

C84.00 -C84.09 Mycosis fungoides, unspecified site - Mycosis fungoides, extranodal and solid organ sites

C84.10 -C84.19 Sezary disease, unspecified site - Sezary disease, extranodal and solid organ sites

C84.40 -C84.49

Peripheral T-cell lymphoma, not classified, unspecified site - Peripheral T-cell lymphoma, notclassified, extranodal and solid organ sites

C84.60 -C84.69

Anaplastic large cell lymphoma, ALK-positive, unspecified site - Anaplastic large cell lymphoma,ALK-positive, extranodal and solid organ sites

C84.70 -C84.79

Anaplastic large cell lymphoma, ALK-negative, unspecified site - Anaplastic large cell lymphoma,ALK-negative, extranodal and solid organ sites

C84.A0 -C84.A9

Cutaneous T-cell lymphoma, unspecified, unspecified site - Cutaneous T-cell lymphoma,unspecified, extranodal and solid organ sites

C84.Z0 -C84.Z9

Other mature T/NK-cell lymphomas, unspecified site - Other mature T/NK-cell lymphomas,extranodal and solid organ sites

C84.90 -C84.99

Mature T/NK-cell lymphomas, unspecified, unspecified site - Mature T/NK-cell lymphomas,unspecified, extranodal and solid organ sites

C85.10 -C85.20

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

C85.21 -C85.29

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

C85.80 -C85.89

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

C85.90 -C85.99

Non-Hodgkin lymphoma, unspecified, unspecified site - Non-Hodgkin lymphoma, unspecified,extranodal and solid organ sites

C86.0 -C86.6 Extranodal NK/T-cell lymphoma, nasal type - Primary cutaneous CD30-positive T-cell proliferations

C88.4 Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma]

C90.00 Multiple myeloma not having achieved remissionC90.01 Multiple myeloma in remissionC91.40 Hairy cell leukemia not having achieved remissionC91.41 Hairy cell leukemia, in remissionC91.42 Hairy cell leukemia, in relapseC96.0 Multifocal and multisystemic (disseminated) Langerhans-cell histiocytosisC96.2 Malignant mast cell tumorC96.4 Sarcoma of dendritic cells (accessory cells)C96.A Histiocytic sarcomaC96.Z Other specified malignant neoplasms of lymphoid, hematopoietic and related tissueC96.9 Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified

Group 18 Paragraph:






























https://www.cms.gov/medicare-coverage-database/staticpages/icd10-code-range.aspx?DocType=LCD&DocID=34741&ver=47&Group=17&RangeStart=C84.A0&RangeEnd=C84.A9&LCDId=34741&kq=370124852&ua=highwire%7cchrome&displayPDFNote=Y&bc=AAAAAAAAIAAAAA%3d%3d&

https://www.cms.gov/medicare-coverage-database/staticpages/icd10-code-range.aspx?DocType=LCD&DocID=34741&ver=47&Group=17&RangeStart=C84.A0&RangeEnd=C84.A9&LCDId=34741&kq=370124852&ua=highwire%7cchrome&displayPDFNote=Y&bc=AAAAAAAAIAAAAA%3d%3d&

https://www.cms.gov/medicare-coverage-database/staticpages/icd10-code-range.aspx?DocType=LCD&DocID=34741&ver=47&Group=17&RangeStart=C84.Z0&RangeEnd=C84.Z9&LCDId=34741&kq=370124852&ua=highwire%7cchrome&displayPDFNote=Y&bc=AAAAAAAAIAAAAA%3d%3d&

https://www.cms.gov/medicare-coverage-database/staticpages/icd10-code-range.aspx?DocType=LCD&DocID=34741&ver=47&Group=17&RangeStart=C84.Z0&RangeEnd=C84.Z9&LCDId=34741&kq=370124852&ua=highwire%7cchrome&displayPDFNote=Y&bc=AAAAAAAAIAAAAA%3d%3d&













ICD-10 Codes DescriptionD69.3 Immune thrombocytopenic purpura

• Verteporfin is covered with a diagnosis of neovascular age-related macular degeneration withpredominately classic subfoveal choroidal neovascular (CNV) lesions where the area of classic CNVoccupies = 50 percent of the area of the entire lesion at the initial visit.

• Additional FDA approved indications include pathologic myopia and presumed ocular histoplasmosis. • Central serous chorioretinopathy is approved effective 01/01/2016.

ICD-10 Codes DescriptionB39.4 Histoplasmosis capsulati, unspecifiedB39.5 Histoplasmosis duboisiiH32 Chorioretinal disorders in diseases classified elsewhereH35.3210 Exudative age-related macular degeneration, right eye, stage unspecifiedH35.3211 Exudative age-related macular degeneration, right eye, with active choroidal neovascularizationH35.3212 Exudative age-related macular degeneration, right eye, with inactive choroidal neovascularizationH35.3213 Exudative age-related macular degeneration, right eye, with inactive scarH35.3220 Exudative age-related macular degeneration, left eye, stage unspecifiedH35.3221 Exudative age-related macular degeneration, left eye, with active choroidal neovascularizationH35.3222 Exudative age-related macular degeneration, left eye, with inactive choroidal neovascularizationH35.3223 Exudative age-related macular degeneration, left eye, with inactive scarH35.3230 Exudative age-related macular degeneration, bilateral, stage unspecifiedH35.3231 Exudative age-related macular degeneration, bilateral, with active choroidal neovascularizationH35.3232 Exudative age-related macular degeneration, bilateral, with inactive choroidal neovascularizationH35.3233 Exudative age-related macular degeneration, bilateral, with inactive scarH35.711 Central serous chorioretinopathy, right eyeH35.712 Central serous chorioretinopathy, left eyeH35.713 Central serous chorioretinopathy, bilateralH44.21 Degenerative myopia, right eyeH44.22 Degenerative myopia, left eyeH44.23 Degenerative myopia, bilateral

• J3590 (unclassified biologics) for Bevacizumab (Avastin™), 1-3 mg (for administration in the officesetting)

• C9257 Bevaciumab (Avastin™), 0.25 mg (for hospital outpatient and ASC settings)

J2796 Romiplostim (Nplate™), 10 mcgFor the treatment of thrombocytopenia in patients with chronic immune idiopathic thrombocytopenic purpura(ITP) who have had an insufficient response to corticosteroids, immunoglobulins or splenectomy.

Group 18 Codes:

Group 19 Paragraph: J3396 Verteporfin (Visudyne™), 0.1 mgSee National Coverage Determinations Manual 100-03 Section 80.3.1

Group 19 Codes:

Group 19 Medical Necessity ICD-10 Codes Asterisk Explanation:

Group 20 Paragraph:



B39.4 Histoplasmosis capsulati, unspecifiedB39.5 Histoplasmosis duboisii













E08.3591 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy withoutmacular edema, right eye

E08.3592 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy withoutmacular edema, left eye

E08.3593 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy withoutmacular edema, bilateral













E09.3591 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macularedema, right eye

E09.3592 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macularedema, left eye

Group 20 Codes:



E09.3593 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macularedema, bilateral










E10.3511 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eyeE10.3512 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eyeE10.3513 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateralE10.3591 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eyeE10.3592 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eyeE10.3593 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral










E11.3511 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eyeE11.3512 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eyeE11.3513 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateralE11.3591 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eyeE11.3592 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eyeE11.3593 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral















E13.3591 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema,right eye

E13.3592 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, lefteye

E13.3593 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema,bilateral

H21.1X1 Other vascular disorders of iris and ciliary body, right eyeH21.1X2 Other vascular disorders of iris and ciliary body, left eyeH21.1X3 Other vascular disorders of iris and ciliary body, bilateralH32 Chorioretinal disorders in diseases classified elsewhereH34.8110 Central retinal vein occlusion, right eye, with macular edemaH34.8111 Central retinal vein occlusion, right eye, with retinal neovascularizationH34.8112 Central retinal vein occlusion, right eye, stableH34.8120 Central retinal vein occlusion, left eye, with macular edemaH34.8121 Central retinal vein occlusion, left eye, with retinal neovascularizationH34.8122 Central retinal vein occlusion, left eye, stableH34.8130 Central retinal vein occlusion, bilateral, with macular edemaH34.8131 Central retinal vein occlusion, bilateral, with retinal neovascularizationH34.8132 Central retinal vein occlusion, bilateral, stableH34.8310 Tributary (branch) retinal vein occlusion, right eye, with macular edemaH34.8311 Tributary (branch) retinal vein occlusion, right eye, with retinal neovascularizationH34.8312 Tributary (branch) retinal vein occlusion, right eye, stableH34.8320 Tributary (branch) retinal vein occlusion, left eye, with macular edemaH34.8321 Tributary (branch) retinal vein occlusion, left eye, with retinal neovascularizationH34.8322 Tributary (branch) retinal vein occlusion, left eye, stableH34.8330 Tributary (branch) retinal vein occlusion, bilateral, with macular edemaH34.8331 Tributary (branch) retinal vein occlusion, bilateral, with retinal neovascularizationH34.8332 Tributary (branch) retinal vein occlusion, bilateral, stableH35.051 Retinal neovascularization, unspecified, right eyeH35.052 Retinal neovascularization, unspecified, left eyeH35.053 Retinal neovascularization, unspecified, bilateralH35.3210 Exudative age-related macular degeneration, right eye, stage unspecifiedH35.3211 Exudative age-related macular degeneration, right eye, with active choroidal neovascularizationH35.3212 Exudative age-related macular degeneration, right eye, with inactive choroidal neovascularizationH35.3213 Exudative age-related macular degeneration, right eye, with inactive scarH35.3220 Exudative age-related macular degeneration, left eye, stage unspecifiedH35.3221 Exudative age-related macular degeneration, left eye, with active choroidal neovascularizationH35.3222 Exudative age-related macular degeneration, left eye, with inactive choroidal neovascularizationH35.3223 Exudative age-related macular degeneration, left eye, with inactive scarH35.3230 Exudative age-related macular degeneration, bilateral, stage unspecifiedH35.3231 Exudative age-related macular degeneration, bilateral, with active choroidal neovascularizationH35.3232 Exudative age-related macular degeneration, bilateral, with inactive choroidal neovascularizationH35.3233 Exudative age-related macular degeneration, bilateral, with inactive scarH35.351 Cystoid macular degeneration, right eyeH35.352 Cystoid macular degeneration, left eyePrinted on 8/29/2017. of 40


H35.353 Cystoid macular degeneration, bilateralH35.81 Retinal edemaH40.89 Other specified glaucoma

ICD-10 Codes DescriptionM32.0 Drug-induced systemic lupus erythematosusM32.10 Systemic lupus erythematosus, organ or system involvement unspecifiedM32.11 Endocarditis in systemic lupus erythematosusM32.12 Pericarditis in systemic lupus erythematosusM32.13 Lung involvement in systemic lupus erythematosusM32.14 Glomerular disease in systemic lupus erythematosusM32.15 Tubulo-interstitial nephropathy in systemic lupus erythematosusM32.19 Other organ or system involvement in systemic lupus erythematosusM32.8 Other forms of systemic lupus erythematosusM32.9 Systemic lupus erythematosus, unspecified


Group 21 Paragraph: J0490 Belimumab (Benlysta™), 10 mgB-lymphocycte stimulator (BLyS)-specific inhibitor indicated for the treatment of adult patients with active,autoantibody-positive, systemic lupus erythematosus who are receiving standard therapy.

Group 21 Codes:


ICD-10 Codes that DO NOT Support Medical Necessity Group 1 Paragraph:

N/A

Group 1 Codes: N/A

ICD-10 Additional Information

Back to Top

General InformationAssociated InformationDocumentations RequirementsThe patient's medical record must contain documentation that fully supports the medical necessity for servicesincluded within this LCD. (See the Coverage Indications,Limitations and/or Medical Necessity).This documentationincludes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostictests or procedures.

The medical record must include the following information:A physician’s order with appropriate signature;Supervising physician with appropriate signature;Medication Administration record with appropriate signature;The name of the drug or biological administered;The route of administration;The dosage (e.g., mgs, mcgs, cc's or IU's);


RevisionHistory

Date

RevisionHistoryNumber

Revision History Explanation Reason(s) forChange

07/01/2017 R20

07/01/2017: Group 2: J2778 Ranibizumab(Lucentis™), due to FDAindications, added Group 2 Codes: E10.3291, E10.3292, E10.3293,E11.3291, E11.3292, E11.3293, E13.3291, E13.3292, E13.3293,E10.3391, E10.3392, E10.3393, E11.3391, E11.3392, E11.3393,E13.3391, E13.3392, E13.3393, E10.3491, E10.3492, E10.3493,E11.3491, E11.3492, E11.3493, E13.3491, E13.3492, E13.3493. FDA approval/effective date 04/15/2017. J0178 Aflibercept (Eylea), 1 mgFDA indications no longer match Ranibizumab/Lucentis(J2778) and aseparate table (Group 3) added to include the appropriate indications andrelated diagnosis codes as previously listed in Group 2. No change incoverage: Group 3. Prior Groups 3-20 have been renumbered toaccommodate the new Group 3 for Aflibercept (Eylea).

• Other

04/01/2017 R19

The duration of the administration- start and stop time must be documented for IV infusions.When a portion of the drug or biological is discarded, the medical record must clearly document the amountadministered and the amount wasted or discarded.Effective 01/01/2017 claims for unused drugs or biologicals from single use vials or single use packages that areopened and the entire dose/quantity is not administered and the remainder is discarded shall be submitted usingthe JW modifier. See Billing & Coding Guidelines.

Utilization GuidelinesInjections of drugs that are administered at an excessive frequency are not medically necessary. Frequency isconsidered excessive when services are performed more frequently than listed in the package insert or generallyaccepted by peers and the reason for additional services is not justified by documentation.

Sources of Information and Basis for DecisionFDA labelsOther Contractors LCDs

Cunningham Jr, E.T., & et al. (2005). A phase II randomized double-masked trial of pegaptanib, an anti-vascularendothelial growth factor aptamer, for diabetic macular edema. Ophthalmology, 112(10), 1747-1757.

Adamis, A. & et al. (2006). Changes in retinal neovascularization after pegaptanib (Macugen) therapy in diabeticindividuals. American Academy of Ophthalmology, 113(1), 23-28.

Sultan, M.B., Zhou, D. & et al. (2011). A phase 2/3, multicenter, randomized, double-masked, 2-year trial ofpegaptanib sodium for the treatment of diabetic macular edema. American Academy of Ophthalmology, 118(6),1107-1118.

Tolentino, M. (2011). Systemic and ocular safety of intravitreal of anti-VEGF therapies for ocular neovasculardisease. Survey of Ophthalmology, 56(2), 95-113.

Wroblewski, J. J., Wells, J.A., & et al. (2009). Pegaptanib sodium for macular edema secondary to central retinalvein occlusion. Archives of Ophthalmology, 127(4), 374-380.

Sawa, M., Gomi, F., & et al. (2009). Long-term results of intravitreal bevacizumab injection for choroidalneovascularization secondary to angioid streaks. American Journal of Ophthalmology, 148(4), 584–590.

Mimoun, G., Tilleul, J. & et al. (2010). Intravitreal ranibizumab for choroidal neovascularization in angioid streaks.American Journal of Ophthalmology, 150(5), 692–700.

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Revision History Information


RevisionHistory

Date



04/01/2017: Annual review 03/09/2017, reformatted without change incoverage, grammatical corrections, J2778 Ranibizumab(Lucentis™) FDAindication added Group 4: H44.21, H44.22, H44.23, H35.051, H35.052,H35.053, Additional information in Documentation requirements, JWModifier information added to Policy/Billing & Coding Guidelines, addedL34741 to Billing & Coding Guideline Title.

• Other(2017ICD-10codeupdatedue tonew FDAindicationAnnualReview)

01/01/2017 R18 01/01/2017 CPT/HCPCS update: description change to Group 1 Codes:J1745.

• RevisionsDue ToCPT/HCPCSCodeChanges

• Other(2017 CPTcodeupdate)

12/01/2016 R17

12/01/2016: Group 3: J2778: removed the requirements for 2 diagnosiscodes; clarification of paragraph, removed H34.8111, H34.8112,H34.8121, H34.8122, H34.8131, H34.8132, H34.8311, H34.8312,H34.8321, H34.8322, H34.8331, H34.8332, H35.81 effective10/01/2016. Group 13: J2357: FDA indication language added toparagraph, relocated L50.1 from narrative to table. Removed J45.20 andJ45.30: not FDA indication effective 01/15/2017.

• RevisionsDue ToICD-10-CMCodeChanges

10/01/2016 R16

10/01/2016 ICD-10 CM code updates



RevisionHistory

Date



Group 2: Deleted: E08.321, E08.331, E08.341, E08.351 ,E09.321,E09.331,E09.341, E09.351, E10.321, E10.331, E10.341, E10.351,E11.321, E11.331, E11.341, E11.351, E13.321, E13.331, E13.341,E13.351, H35.32 Added: E08.3211, E08.3212, E08.3213, E08.3311,E08.3312, E08.3313, E08.3411, E08.3412, E08.3413, E08.3511,E08.3512, E08.3513, E09.3211, E09.3212, E09.3213, E09.3311,E09.3312, E09.3313, E09.3411, E09.3412, E09.3413, E09.3511,E09.3512, E09.3513, E10.3211, E10.3212, E10.3213, E10.3311,E10.3312, E10.3313, E10.3411, E10.3412, E10.3413, E10.3511,E10.3512, E10.3513, E11.3211, E11.3212, E11.3213, E11.3311,E11.3312, E11.3313, E11.3411, E11.3412, E11.3413, E11.3511,E11.3512, E11.3513, E13.3211, E13.3212, E13.3213, E13.3311,E13.3312, E13.3313, E13.3411, E13.3412, E13.3413, E13.3511,E13.3512, E13.3513, H35.3210, H35.3211, H35.3212, H35.3213,H35.3220, H35.3221, H35.3222, H35.3223, H35.3230, H35.3231,H35.3232, H35.3233 Group 3: Deleted: H34.811 H34.812, H34.813,H34.831, H34.832, H34.833 Added: H34.8110, H34.8111, H34.8112,H34.8120, H34.8121, H34.8122, H34.8130, H34.8131, H34.8132,H34.8310, H34.8311, H34.8312, H34.8320, H34.8321, H34.8322,H34.8330, H34.8331, H34.8332 Group 14: Deleted: E08.321, E08.331,E08.341, E08.351, E09.321, E09.331, E09.341, E09.351, E10.321,E10.331, E10.341, E10.351, E11.321, E11.331, E11.341, E11.351,E13.321, E13.331, E13.341, E13.351, H34.811, H34.812, H34.813,H35.32 Added: E08.3211, E08.3212, E08.3213, E08.3311, E08.3312,E08.3313, E08.3411, E08.3412, E08.3413, E08.3511, E08.3512,E08.3513, E09.3211, E09.3212, E09.3213, E09.3311, E09.3312,E09.3313, E09.3411, E09.3412, E09.3413, E09.3511, E09.3512,E09.3513, E10.3211, E10.3212, E10.3213, E10.3311, E10.3312,E10.3313, E10.3411, E10.3412, E10.3413, E10.3511, E10.3512,E10.3513, E11.3211, E11.3212, E11.3213, E11.3311, E11.3312,E11.3313, E11.3411, E11.3412, E11.3413, E11.3511, E11.3512,E11.3513, E13.3211, E13.3212, E13.3213, E13.3311, E13.3312,E13.3313, E13.3411, E13.3412, E13.3413, E13.3511, E13.3512,E13.3513, H34.8110, H34.8111, H34.8112, H34.8120, H34.8121,H34.8122, H34.8130, H34.8131, H34.8132, H35.3210, H35.3211,H35.3212, H35.3213, H35.3220, H35.3221, H35.3222, H35.3223,H35.3230, H35.3231, H35.3232, H35.3233 Group 17: Deleted: H35.32Added: H35.3210, H35.3211, H35.3212, H35.3213, H35.3220,H35.3221, H35.3222, H35.3223, H35.3230, H35.3231, H35.3232,H35.3233 Group 18: Deleted: E08.321, E08.331, E08.341, E08.351,E08.359, E09.321, E09.331, E09.341, E09.351, E09.359, E10.321,E10.331, E10.341, E10.351, E10.359, E11.321, E11.331, E11.341,E11.351, E11.359, E13.321, E13.331, E13.341, E13.351, E13.359,H34.811, H34.812, H34.813, H34.831, H34.832, H34.833, H35.32Added: E08.3211, E08.3212, E08.3213, E08.3311, E08.3312, E08.3313,E08.3411, E08.3412, E08.3413, E08.3511, E08.3512, E08.3513,E08.3591, E08.3592, E08.3593, E09.3211, E09.3212, E09.3213,E09.3311, E09.3312, E09.3313, E09.3411, E09.3412, E09.3413,E09.3511, E09.3512, E09.3513, E09.3591, E09.3592, E09.3593,E10.3211, E10.3212, E10.3213, E10.3311, E10.3312, E10.3313,E10.3411, E10.3412, E10.3413, E10.3511, E10.3512, E10.3513,E10.3591, E10.3592, E10.3593, E11.3211, E11.3212, E11.3213,E11.3311, E11.3312, E11.3313, E11.3411, E11.3412, E11.3413,E11.3511, E11.3512, E11.3513, E11.3591, E11.3592, E11.3593,E13.3211, E13.3212, E13.3213, E13.3311, E13.3312, E13.3313,E13.3411, E13.3412, E13.3413, E13.3511, E13.3512, E13.3513,E13.3591, E13.3592, E13.3593, H34.8110, H34.8111, H34.8112,H34.8120, H34.8121, H34.8122, H34.8130, H34.8131, H34.8132,H34.8310, H34.8311, H34.8312, H34.8320, H34.8321, H34.8322,H34.8330, H34.8331, H34.8332, H35.3210, H35.3211, H35.3212,H35.3213, H35.3220, H35.3221, H35.3222, H35.3223, H35.3230,H35.3231, H35.3232, H35.3233

09/15/2016 R15


RevisionHistory

Date



08/01/2016 Removed J7999-added J3590 to bill for Avastin 1-3mg Added67028 & updated Billing and coding with: RT/LT/50(bi-lateral) modifiers.Effective date 09/15/2016


07/01/2016 R1407/01/2016: Added Q5102, Infliximab, Biosimilar to Group 1 and 9Paragraphs with the same ICD-10 indications as J1745 Infliximab(Remicade™), 10 mg. Code update per CR9636 and Q5102 is effective04/05/2016.


05/16/2016 R1304/28/2016 - Corrected typo in HTML coding causing trademarksymbol(™) to appear incorrectly as a question mark(?) for "Avastin" inparagraph for Group 18 of ICD-10 codes. No other changes to policy.

• TypographicalError

05/16/2016 R12 05/01/2016: Annual review completed. Corrected typos. Placed CPT andICD 10 codes into Group Paragraph/Code tables.

• Other(annualreview)

05/16/2016 R1104/01/2016: Added J0490, Belimumab, 10mg with ICD 10 codes M32.0,M32.10, M32.11, M32.12, M32.13, M32.14, M32.15, M32.19, M32.8,M32.9; 45 day notice-with an effective date of 05/16/2016.


• RevisionsDue To ICD-10-CMCodeChanges

03/01/2016 R10

03/01/2016 for the revision of 11/01/2015 concerning J2778:reorganized layout of indications to make it clear that H35.81 requiresone of the following as a secondary diagnosis for coverage: H34.811,H34.812, H34.813, H34.831, H34.832, H34.833; this change is effectivefor services on or after 10/01/2015.

• Other(clarificationof coveragedate)

01/01/2016 R901/01/2016: Per HCPCS code updates for 2016: deleted Q9977compounded drug, noc; and added J7999 compounded drug, noc forbevacizumab/Avastin. Added H35.711, H35.712, and H35.713 to J3396.CAC information removed.


• Other• Revisions

Due To ICD-10-CMCodeChanges

11/01/2015 R8

11/01/2015-Bevacizumab: removed J3590 and added Q9977 perCR9167. J0178: added H35.051, H35.052, and H35.053. J2778: removedE08.359, E09.359, E10.359, E11.359, 13.359 as they are not per FDAindication; effective 12/15/2015 to give 45 day notice. And reorganizedlayout of indications to make it clear that H35.81 requires one of thefollowing for coverage:H34.811, H34.812, H34.813, H34.831, H34.832, H34.833. Addedlanguage under CMS section to indicate use of italicized font for languagetaken from Medicare. And, removed J8 information and table.


• RevisionsDue To ICD-10-CMCodeChanges

10/01/2015 R7

10/06/2015 - Due to CMS guidance, we have removed the Jurisdiction 8Notice and corresponding table from the CMS National Coverage Policysection. No other changes to policy or coverage. • Other

10/01/2015 R605/01/2015-Added Proliferative diabetic retinopathy in patients withdiabetic macular edema to J0178, effective 03/25/2015- FDA approvaldate; Annual Review 04/01/2015- reformatted sources of informationsection & code table for J0178.

• Other(AnnualReview)


RevisionHistory

Date




10/01/2015 R512/01/2014-Added dx code for macular edema & coding instruction toJ0178: Code macular edema a H35.81 and H34.811-H34.813 or H34.831-H34.833. Effective 01/15/2015-two dx codes are required for coverageof macular edema following Retinal vein occlusion (RVO).


10/01/2015 R411/01/2014-Added Macular Edema following retinal vein occlusion -Venous tributary (branch) occlusion -H34.831, H34.832, H34.833 toJ0178-effective 10/06/2014-FDA approval date. Reformatted andremoved underlining in source of information section.

•Other(Coveragechange/ICD-10Addition)•Revisions DueTo ICD-10-CMCode Changes

10/01/2015 R3 10/01/2014-Typo corrected-Eylea• Typographical

Error• Other

10/01/2015 R2

09/01/2014- Added Diabetic macular edema dx codes to J0178- E08.321,E08.331, E08.341, E08.351, E09.321, E09.331, E09.341, E09.351,E10.321, E10.331, E10.341, E10.351, E11.321, E11.331, E11.341,E11.351, E13.321, E13.331, E13.341, E13.351- effective 07/29/2014–FDA approval date. Removed unspecified dx codes: M05.40, M05.50,M05.70, M05.80, M05.9, M06.00, M06.20, M06.30, M06.80, M06.9,M05.00, M05.20, M05.30, M05.60, M08.00, M08.20, M08.80, M08.90,M08.40 from J0129. Removed K51.919, M05.00, M05.20, M05.30,M05.40, M05.50, M05.60, M05.70, M05.80, M05.9, M06.00, M06.20,M06.30, M06.80 M06.9, M08.00, M08.20, M08.40, M08.80, M08.90,M48.8X9 from J1745; Removed K50.919 from J2323, Removed E08.311,E09.311, E10.311, E11.311, E13.311 from J2503 & J2778, J3590/C9257

• Other(CoverageChange &ICD-10addition

)• Revisions

Due ToICD-10-CMCodeChanges

10/01/2015 R105/01/2014- - Added L50.1 to J2357, effective 03/21/2014-FDA approvaldate. Typos corrected: Removed code description for J0178- had beenlisted twice; J2562 Sezary’s disease misspelled; J2778- removed E08.351-was listed twice in the table; changed Carrier to Contractor.

• Other(Typos,Corrections)

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