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Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™
Policy Number: PH-0109
Intravenous
Last Review Date: 08/01/2024
Date of Origin: 7/20/2010
Dates Reviewed: 09/2010, 12/2010, 02/2011, 03/2011, 05/2011, 06/2011, 09/2011, 12/2011, 03/2012, 06/2012, 09/2012, 12/2012, 03/2013, 06/2013, 09/2013, 12/2013, 03/2014, 06/2014, 09/2014, 12/2014, 03/2015, 05/2015, 08/2015, 11/2015, 02/2016, 05/2016, 08/2016, 10/2016, 02/2017, 05/2017, 08/2017, 10/2017, 02/2018, 05/2018, 07/2018, 09/2018, 12/2018, 03/2019, 06/2019, 09/2019, 10/2019, 12/2019, 03/2020, 06/2020, 09/2020, 12/2020, 01/2021, 03/2021, 06/2021, 09/2021, 12/2021, 01/2022, 03/2022, 06/2022, 09/2022, 12/2022, 03/2023, 06/2023, 09/2023, 12/2023, 03/2024, 05/2024, 08/2024
FOR PEEHIP Members Only -Coverage excludes the provider-administered medication(s) outlined in this drug policy from being accessed through a specialty pharmacy. It must be obtained through buy and bill. |
- Length of Authorization 1-5,23-25,34,44,62,80,94-98,102-104,108,115-118,128-130,133-138, 153,155,170-174
Coverage will be provided for 6 months (12 months initially for pemphigus vulgaris) and may be renewed, unless otherwise specified.
- Maintenance therapy for oncology indications may be renewed for up to a maximum of 2 years, unless otherwise specified:
- Adult Acute Lymphoblastic Leukemia (ALL) may be renewed for a maximum of 18 doses.
- Mantle Cell Lymphoma may be renewed until disease progression or intolerable toxicity.
- Hairy Cell Leukemia may be renewed for up to a maximum of 12 doses.
- Induction/Consolidation of Pediatric B-Cell Acute Leukemia and Aggressive Mature B-Cell Lymphomas may NOT be renewed.
- Pediatric Hodgkin Lymphoma may NOT be renewed.
- Management of Immunotherapy-Related Toxicities:
- Myositis/Myasthenia Gravis/Encephalitis may NOT be renewed.
- Bullous Dermatitis may be renewed for a maximum of 18 months (4 total doses).
- Relapse therapy for Pemphigus Vulgaris must be at least 16 weeks past a prior infusion.
- Chronic Graft-Versus-Host Disease (cGVHD) may NOT be renewed.
- Hematopoietic Cell Transplantation may NOT be renewed.
- Lupus Nephritis and Pediatric Idiopathic Nephrotic Syndrome may be renewed ONLY in patients experiencing a disease relapse.
- Complications of Transplanted Solid Organ may NOT be renewed.
- Dosing Limits
- Quantity Limit (max daily dose) [NDC Unit]:
- Rituxan 100 mg/10 mL single-dose vial for injection: 12 vials per 28 day supply
- Rituxan 500 mg/50 mL single-dose vial for injection: 8 vials per 28 day supply
- Truxima 100 mg/10 mL single-dose vial for injection: 12 vials per 28 day supply
- Truxima 500 mg/50 mL single-dose vial for injection: 8 vials per 28 day supply
- Ruxience 100 mg/10 mL single-dose vial for injection: 12 vials per 28 day supply
- Ruxience 500 mg/50 mL single-dose vial for injection: 8 vials per 28 day supply
- Riabni 100 mg/10 mL single-dose vial for injection: 12 vials per 28 day supply
- Riabni 500 mg/50 mL single-dose vial for injection: 8 vials per 28 day supply
- Max Units (per dose and over time) [HCPCS Unit]:
Oncology Indications |
Chronic Lymphocytic Leukemia (CLL)/Small Lymphocytic Leukemia (SLL):
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ALL
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Waldenström Macroglobulinemia/Lymphoplasmacytic Lymphoma
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CNS Cancers
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Hairy Cell Leukemia
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Histiocytic Neoplasms – Rosai-Dorfman Disease
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Pediatric Hodgkin Lymphoma
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Chronic Graft-Versus-Host Disease (cGVHD)
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Hematopoietic Cell Transplantation
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All other oncology indications:
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Non-Oncology Indications |
Rheumatoid Arthritis (RA):
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Multiple Sclerosis (MS):
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Pemphigus Vulgaris (PV):
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GPA(WG)/MPA:
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All other non-oncology indications:
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- Initial Approval Criteria 1-4
Coverage is provided in the following conditions:
For PEEHIP Members Only |
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For Commercial Members Only |
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- Patient is at least 18 years of age, unless otherwise specified; AND
Universal Criteria 1-4
- Patient does not have a severe, active infection; AND
- Patient has been screened for the presence of hepatitis B (HBV) infection (i.e., HBsAg and anti-HBc) prior to initiating therapy and patients with evidence of current or prior HBV infection will be monitored for HBV reactivation during treatment; AND
- Patient has not received a live vaccine within 28 days prior to starting treatment and live vaccines will not be administered concurrently while on treatment; AND
Oncology Indications 1-5
- Patient is CD20 antigen expression positive (excluding use for cGVHD, Hematopoietic Cell Transplantation, and Management of Immunotherapy-Related Toxicity); AND
Pediatric Mature B-Cell Acute Leukemia (B-AL) † 1
- Patient is at least 6 months of age; AND
- Used in combination with chemotherapy for previously untreated disease
Adult* Acute Lymphoblastic Leukemia (ALL) ‡ 5,93
- Patient has Philadelphia chromosome-positive (Ph+) disease; AND
- Used in combination with a tyrosine kinase inhibitor (TKI)-based regimen; AND
- Patient is <65 years of age without significant comorbidities; OR
- Used in combination with MOpAD (methotrexate, vincristine, pegaspargase, dexamethasone) for TKI-refractory disease; OR
- Used in combination with a tyrosine kinase inhibitor (TKI)-based regimen; AND
- Patient has Philadelphia chromosome-negative (Ph-) disease; AND
- Used as a component of a multiagent chemotherapy
*NCCN recommendations for Adult ALL may be applicable to adolescent and young adult (AYA) patients within the age range of 15-39 years.
Central Nervous System (CNS) Cancers ‡ 5
- Patient has leptomeningeal metastases from lymphomas§; OR
- Patient has primary CNS lymphoma; AND
- Used for induction therapy; AND
- Used as a single agent OR in combination with a methotrexate-containing regimen, temozolomide, or lenalidomide; OR
- Patient has CSF positive or spinal MRI positive disease§; OR
- Used for consolidation (monthly maintenance) therapy; AND
- Used as continuation of induction regimen in patients with complete response or complete response unconfirmed (CRu) to induction therapy; AND
- Used as a single agent; OR
- Used on combination with high-dose methotrexate¥; OR
- Used as continuation of induction regimen in patients with complete response or complete response unconfirmed (CRu) to induction therapy; AND
- Used for relapsed or refractory disease; AND
- Used as a single agent OR in combination with systemic therapy in patients with prior whole brain radiation therapy§; AND
- Patient has CSF positive or spinal MRI positive disease; OR
- Used as a single agent OR in combination with temozolomide, lenalidomide, or high-dose methotrexate
- Used as a single agent OR in combination with systemic therapy in patients with prior whole brain radiation therapy§; AND
- Used for induction therapy; AND
§ For intrathecal or intraventricular administration. ¥ For intravenous administration
Adult Hodgkin Lymphoma ‡ 5
- Patient has nodular lymphocyte-predominant disease
Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL) † ‡ Ф 1-5
- Used in combination with fludarabine and cyclophosphamide (FC) †; OR
- Patient has disease without del(17p)/TP53 mutation; AND
- Used as first-line therapy in combination with bendamustine (excluding use in frail patients); OR
- Used as subsequent therapy in combination with one of the following:
- Bendamustine (patients <65 years of age without significant comorbidities; excluding use in frail patients)
- Idelalisib
- Lenalidomide
- Venetoclax; OR
- Patient has disease with del(17p)/TP53 mutation; AND
- Used as first-line therapy in combination with high-dose methylprednisolone; OR
- Used as subsequent therapy in combination with one of the following:
- Alemtuzumab
- High-dose methylprednisolone
- Idelalisib
- Lenalidomide
- Venetoclax; OR
- Used as initial therapy for histologic (Richter’s) transformation to diffuse large B-cell lymphoma; AND
- Used in combination with cyclophosphamide, doxorubicin, and vincristine-based regimens or as a component of OFAR (oxaliplatin, fludarabine, cytarabine, and rituximab)
Waldenström Macroglobulinemia/Lymphoplasmacytic Lymphoma ‡ 5
Adult B-Cell Lymphomas † ‡ Ф 1-5,44 including, but not limited to, the following:
- HIV-Related B-Cell Lymphomas ‡
- Disease is related to Burkitt lymphoma, diffuse large B-cell lymphoma (DLBCL), HHV8-positive DLBCL (not otherwise specified), or primary effusion lymphoma (PEL)
- Burkitt Lymphoma ‡
- Used in combination with chemotherapy
- Diffuse Large B-Cell Lymphoma † Ф
- Low-Grade (grade 1-2) or Follicular Lymphoma † Ф
- Extranodal Marginal Zone Lymphoma (EMZL) of the Stomach & Nongastric Sites (Noncutaneous) ‡
- Nodal & Splenic Marginal Zone Lymphoma ‡
- High-Grade B-Cell Lymphomas ‡
- Mantle Cell Lymphoma ‡
- Histologic Transformation of Indolent Lymphomas to Diffuse Large B-Cell Lymphoma ‡
- Post-Transplant Lymphoproliferative Disorders (PTLD) (B-Cell type) ‡
Castleman Disease ‡ 5
- Patient has multicentric disease; OR
- Patient has unicentric disease; AND
- Used as second-line therapy for relapsed or refractory disease; OR
- Used for unresectable disease or symptomatic disease after incomplete resection
Primary Cutaneous B-Cell Lymphomas ‡ 5
Pediatric Aggressive Mature B-Cell Lymphomas (Primary Mediastinal Large B-Cell Lymphoma, Diffuse Large B-Cell Lymphoma, Burkitt Lymphoma, & Burkitt-like Lymphoma) † ‡ Ф 1,5,50,121
- Patient is at least 6 months of age*; AND
- Used in combination with chemotherapy
*Pediatric Aggressive Mature B-Cell Lymphoma may be applicable to adolescent and young adult (AYA) patients older than 18 years of age and less than 39 years of age, who are treated in the pediatric oncology setting.
Hairy Cell Leukemia ‡ 5
- Used as a single agent; AND
- Used for less than complete response or relapsed disease in patients unable to receive purine analogs (i.e., cladribine or pentostatin); OR
- Used in combination with cladribine; OR
- Used in combination with pentostatin; AND
- Used for less than complete response or relapsed disease; OR
- Used in combination with vemurafenib; AND
- Used as initial therapy in patients unable to tolerate purine analogs (i.e., cladribine or pentostatin) including frail patients and those with active infection; OR
- Used for less than complete response or relapse within 2 years of complete response following initial treatment with cladribine or pentostatin; OR
- Used for progression after therapy for relapsed or refractory disease (if not previously given); OR
- Used in combination with venetoclax; AND
- Used for progression after therapy for relapsed or refractory disease; AND
- Patient had disease resistance to BRAF inhibitor therapy
- Used for progression after therapy for relapsed or refractory disease; AND
Histiocytic Neoplasms – Rosai-Dorfman Disease ‡ 5
- Used as a single agent for nodal, immune-cytopenia, or immunoglobulin G4 (IgG4) related diseases; AND
- Used for symptomatic unresectable unifocal disease; OR
- Used for symptomatic multifocal disease; OR
- Used for relapsed/refractory disease
Pediatric Hodgkin Lymphoma ‡ 5,128
- Patient is ≤ 18 years of age*; AND
- Patient has nodular lymphocyte-predominant disease; AND
- Used in combination with CVbP (cyclophosphamide, vinblastine, prednisolone); AND
- Used as primary treatment for stage IA or IIA disease (incomplete resection and non-bulky disease)
*Pediatric Hodgkin Lymphoma may be applicable to adolescent and young adult (AYA) patients up to the age of 39 years.
Chronic Graft-Versus-Host Disease (cGVHD) ‡ 5,22-25
- Patient is post-allogeneic hematopoietic cell transplant (generally 3 or more months); AND
- Used as additional therapy in combination with systemic corticosteroids; AND
- Patient has no response (e.g., steroid-refractory disease) to first-line therapy options
Hematopoietic Cell Transplantation (HCT) ‡ 5
- Used as conditioning for allogeneic transplant as part of a non-myeloablative regimen in combination with cyclophosphamide and fludarabine
Management of Immunotherapy-Related Toxicities ‡ 5,62
- Patient has been receiving therapy with an immune checkpoint inhibitor (e.g., cemiplimab, nivolumab, pembrolizumab, atezolizumab, avelumab, durvalumab, ipilimumab, dostarlimab, nivolumab/relatlimab, tremelimumab, retifanlimab, toripalimab, tislelizumab, etc.); AND
- Patient has encephalitis related to immunotherapy; AND
- Patient is autoimmune-encephalopathy-antibody positive; OR
- Patient has had limited to no improvement after 7 to 14 days on high-dose corticosteroids with or without intravenous immunoglobulin (IVIG); OR
- Patient has bullous dermatitis related to immunotherapy; AND
- Used as additional therapy for moderate (G2), severe (G3) or life-threatening (G4) disease; OR
- Patient has moderate, severe, or life-threatening steroid-refractory myositis (proximal muscle weakness, neck flexor weakness, with or without myalgias) related to immunotherapy; AND
- Used for significant dysphagia, life-threatening situations, or cases refractory to corticosteroids; OR
- Patient has myasthenia gravis related to immunotherapy; AND
- Used as additional therapy for severe (G3-4) disease that is refractory to plasmapheresis or IVIG
- Patient has encephalitis related to immunotherapy; AND
Non-Oncology Indications
- Patient is not on concurrent treatment with another CD20-directed therapy, biologic agents (e.g., TNF-inhibitor, IL-inhibitor, integrin receptor antagonist, T cell costimulation modulator, etc.) or targeted synthetic therapies (e.g., apremilast, abrocitinib, tofacitinib, baricitinib, upadacitinib, deucravacitnib, ritlecitinib, ruxolitinib, etrasimod, ozanimod, etc.); AND
Rheumatoid Arthritis (RA) † 1-4,46-49,112,113
- Physician has assessed baseline disease severity utilizing an objective measure/tool; AND
- Documented moderate to severe active disease; AND
- Used in combination with methotrexate unless the patient has a contraindication or intolerance; AND
- Patient tried and failed at least a 3-month trial with ONE conventional synthetic disease modifying anti-rheumatic drug (csDMARD) (e.g., methotrexate, azathioprine, auranofin, hydroxychloroquine, penicillamine, sulfasalazine, leflunomide, etc.); OR
- Patient is already established on biologic or targeted synthetic therapy for the treatment of RA; AND
- Previous failure with one or more preferred TNF antagonists at least one of which should be a self-injectable; AND
- Patient has not had treatment with rituximab in the previous 4 months
Pemphigus Vulgaris † Ф 1,10,11,35,36,38,61,80,114,139
- Patient has a diagnosis of pemphigus vulgaris as determined by the following:
- Patient has one or more of the following clinical features:
- Appearance of lesions, erosions and/or blisters
- Nikolsky sign (induction of blistering via mechanical pressure at the edge of a blister or on normal skin)
- Characteristic scarring and lesion distribution; AND
- Histopathologic confirmation by skin/mucous membrane biopsy; AND
- Positive direct immunofluorescence (DIF) microscopy result OR the presence of autoantibodies as detected by indirect immunofluorescence (IIF) or enzyme-linked immunosorbent assay (ELISA); AND
- Patient has one or more of the following clinical features:
- Patient has moderate to severe disease as assessed utilizing an objective measure/tool (e.g., PDAI, PSS, ABSIS, etc.); AND
- Used in combination with glucocorticoids (e.g., prednisone, prednisolone, etc.); AND
- Other causes of blistering or erosive skin and mucous membrane diseases have been ruled out
Granulomatosis with Polyangiitis (GPA) (Wegener’s Granulomatosis) and Microscopic Polyangiitis (MPA) † Ф 1-4,125
- Patient is at least 2 years of age; AND
- Used in combination with glucocorticoids (e.g., prednisone, methylprednisolone, etc.)
Thrombocytopenic Purpura ‡ 6-9,63,127
- Diagnosis includes one of the following:
- Primary thrombocytopenia or idiopathic (immune) thrombocytopenia purpura (ITP)
- Evans syndrome; AND
- Patient has previously failed or has a contraindication or intolerance to therapy with corticosteroids; AND
- The patient has a platelet count ≤30 x 109/L OR 30 x 109/L to < 50 x 109/L with symptomatic bleeding or with increased risk for bleeding
Thrombotic Thrombocytopenic Purpura (TTP) ‡ 16-18,20,21,126
- The patient has a platelet count ≤30 x 109/L OR 30 x 109/L to < 50 x 109/L with symptomatic bleeding or with increased risk for bleeding; AND
- Patient has immune-mediated or acquired disease with ADAMTS13-deficiency; AND
- Used in combination with corticosteroids and therapeutic plasma exchange (TPE); OR
- Used as a single agent as prophylactic therapy for patients in remission
Multiple Sclerosis (MS) ‡ 144,148
- Patient must have a confirmed diagnosis of multiple sclerosis (MS) as documented by laboratory report (i.e., MRI); AND
- Patient has a diagnosis of a relapsing form of MS [i.e., relapsing-remitting MS (RRMS)*, active secondary progressive disease (SPMS)**, or clinically isolated syndrome (CIS)***]
*Definitive diagnosis of MS with a relapsing-remitting course is based upon BOTH dissemination in time and space. Unless contraindicated, MRI should be obtained (even if criteria are met). 148 |
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Dissemination in time (Development/appearance of new CNS lesions over time) |
Dissemination in space (Development of lesions in distinct anatomical locations within the CNS; multifocal) |
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**Active secondary progressive MS (SPMS) is defined as the following: 145,148-150 |
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***Definitive diagnosis of CIS is based upon ALL of the following: 148 |
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Autoimmune Hemolytic Anemia (AIHA) ‡ 26-32
- Patient has warm-reactive disease refractory to or dependent on glucocorticoids; OR
- Patient has cold agglutinin disease with symptomatic anemia, transfusion-dependence, and/or disabling circulatory symptoms
Lupus Nephritis (LN) ‡ 115-117,132,153,155,159,166,169
- Patient has disease that is non-responsive or refractory to standard first-line therapy (i.e., mycophenolate mofetil, mycophenolic acid, cyclophosphamide, or calcineurin inhibitors [e.g., tacrolimus, voclosporin, cyclosporine etc.]); AND
- Used as a single agent OR as add-on therapy in combination with mycophenolate mofetil, mycophenolic acid, or cyclophosphamide
Myasthenia Gravis (unrelated to immunotherapy-related toxicity) ‡ 118-120,156
- Patient has muscle-specific tyrosine kinase (MuSK)-antibody positive disease; AND
- Patient is refractory to standard first-line therapy (e.g., glucocorticoids, azathioprine, mycophenolate mofetil, etc.)
Complications of Transplanted Solid Organ (kidney, liver, lung, heart, pancreas) in Adult and Pediatric* Patients 133-138
- Used for suppression of panel reactive anti-human leukocyte antigen (HLA) antibodies prior to transplantation; OR
- Used for treatment of antibody-mediated rejection of solid organ transplantation
*Note: There is no minimum age requirement for this indication
Neuromyelitis Optica Spectrum Disorder (NMOSD) ‡ 90-92,157,165
- Patient has a confirmed diagnosis based on the following:
- Patient was found to be seropositive for aquaporin-4 (AQP4) IgG antibodies; AND
- Patient has at least one core clinical characteristic § (*Note: some core clinical characteristics require both clinical and typical MRI findings); AND
- Alternative diagnoses have been excluded [e.g., myelin oligodendrocyte glycoprotein (MOG) antibody disease (MOGAD), multiple sclerosis, sarcoidosis, cancer, chronic infection, etc.]; OR
- Patient is seronegative for AQP4-IgG antibodies OR has unknown AQP4-IgG status; AND
- Patient has at least two core clinical characteristics § occurring as a result of one or more clinical attacks; AND
- Patient has experienced ALL of the following:
- At least 1 core clinical characteristic must be acute optic neuritis, acute myelitis, or area postrema syndrome
- Fulfillment of typical MRI findings requirements for each area affected ψ; AND
- Alternative diagnoses have been excluded [e.g., myelin oligodendrocyte glycoprotein (MOG) antibody disease (MOGAD), multiple sclerosis, sarcoidosis, cancer, chronic infection, etc.]; AND
- Patient was found to be seropositive for aquaporin-4 (AQP4) IgG antibodies; AND
- Used as a single agent or in combination with immunosuppressive therapy (e.g., azathioprine, methotrexate, mycophenolate, etc.)
§ Core Clinical Characteristics of NMOSD 90,157 |
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ψ Typical MRI findings in NMOSD related to clinical presentation (T2 unless noted otherwise) 157 |
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LETM = longitudinally extensive transverse myelitis lesions; VS = vertebral segments |
Antisynthetase Syndrome-Related Interstitial Lung Disease ‡ 167,168,174, 186
- Patient has antisynthetase antibody positive disease (e.g., anti-Jo-1, -PL-7, -PL-12, -OJ, -EJ, etc.); AND
- Physician has assessed baseline disease severity utilizing an objective measure (i.e., baseline glucocorticoid use, pulmonary function testing [i.e., forced vital capacity (FVC%), total lung capacity (TLC%), diffusing capacity of the lungs for carbon monoxide (DLCO%)], or chest CT scan); AND
- Patient has documented severe active disease; AND
- Patient has recurrent or progressive disease despite treatment with glucocorticoids and/or other immunosuppressive agents (e.g., azathioprine, mycophenolate mofetil, cyclophosphamide, tacrolimus, etc.); AND
- Will be used in combination with glucocorticoids or other immunosuppressive agents (e.g., azathioprine, mycophenolate mofetil, cyclophosphamide, tacrolimus, etc.), unless the patient has a contraindication or intolerance
Idiopathic Membranous Nephropathy ‡ 172, 175-177
- Patient has a documented diagnosis of idiopathic (primary) membranous nephropathy; AND
- Secondary causes of membranous nephropathy have been ruled out [e.g., infections, autoimmune diseases, malignancies, nutritional supplements (e.g., lipoic acid, etc.), nonsteroidal anti-inflammatory drugs (NSAIDs), etc.]; AND
- Used as first-line therapy in patients with any of the following moderate to high risk factors for progressive disease:
- Proteinuria > 3.5 g/day and no decrease > 50% after 6 months of therapy with an angiotensin converting enzyme inhibitor (ACEi) or angiotensin II receptor blocker (ARB); OR
- eGFR < 60 ml/min/1.73m2; OR
- Proteinuria > 8 g/d for > 6 months; OR
- Patient has experienced serious complications of nephrotic syndrome (e.g., acute kidney injury, infection, thromboembolic events, etc.); OR
- Used for initial disease relapse following remission on first-line therapy with rituximab, a calcineurin inhibitor (e.g., tacrolimus, cyclosporine, etc.) or cyclophosphamide in combination with glucocorticoids; OR
- Used for treatment-resistance to first-line therapy with rituximab, a calcineurin inhibitor (e.g., tacrolimus, cyclosporine, etc.) or cyclophosphamide in combination with glucocorticoids; AND
- Patient has a stable eGFR; AND
- Will be used in combination with a calcineurin inhibitor if previously treated with rituximab alone in the first-line setting; OR
- Used for disease recurrence following kidney transplant; AND
- Patient has proteinuria > 1 g/d
- Used as first-line therapy in patients with any of the following moderate to high risk factors for progressive disease:
Pediatric Idiopathic Nephrotic Syndrome ‡ 170-173
- Patient is 12 years of age or younger; AND
- Patient has symptomatic disease (i.e., nephrotic-range proteinuria and either hypoalbuminemia or edema when albumin level is not available); AND
- Patient has been diagnosed with one of the following:
- Frequently relapsing nephrotic syndrome (FRNS) with at least four relapses per year or at least two relapses within 6 months of initial presentation
- Steroid dependent nephrotic syndrome (SDNS) with two consecutive relapses during steroid tapering or within 14 days of cessation of therapy
- Steroid resistant nephrotic syndrome (SRNS) with failure to achieve complete remission within a 4-6 -week course of daily corticosteroids; AND
- Patient has failed an adequate trial with at least one other steroid-sparing agent (e.g., cyclophosphamide, calcineurin inhibitor [e.g., tacrolimus, cyclosporine, etc.], mycophenolate mofetil, etc.)
IgG4-Related Disease ‡ 178-182
- Physician has assessed baseline disease severity utilizing an objective measure/tool (e.g., IgG4-RD Responder Index score, physician's global assessment [PGA], amount of glucocorticoid or other immunosuppressive use, incidence of disease flares, serum IgG4 level, etc.); AND
- Other conditions that mimic IgG4-related disease have been ruled out (e.g., malignancy, infection, other autoimmune disorders, etc.); AND
- Patient has documented active disease; AND
- Documented failure or ineffective response to an adequate trial with glucocorticoids, unless there is a contraindication or intolerance to use
Systemic Lupus Erythematosus |
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† FDA Approved Indication(s); ‡ Compendia Recommended Indication(s); Ф Orphan Drug
- Renewal Criteria 1-4
Coverage may be renewed based upon the following criteria:
For PEEHIP Members Only |
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For Commercial Members Only |
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- Patient continues to meet the universal and other indication-specific relevant criteria such as concomitant therapy requirements (not including prerequisite therapy), performance status, etc. identified in section III; AND
- Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include: severe infusion-related reactions, tumor lysis syndrome (TLS), severe mucocutaneous reactions (e.g., paraneoplastic pemphigus, Stevens-Johnson syndrome, lichenoid dermatitis, etc.), progressive multifocal leukoencephalopathy (PML), hepatitis B virus reactivation, serious infections (bacterial, fungal or viral), cardiovascular adverse reactions (e.g., ventricular fibrillation, myocardial infarction, cardiogenic shock, cardiac arrhythmias), renal toxicity, bowel obstruction and perforation, etc.; AND
Oncology Indications 1-5,23-25,34,44,50,62,94-98,102-104,129,130,128
- Patient has not exceeded dosing or duration limits as defined in Sections I, II, and V; AND
Adult Acute Lymphoblastic Leukemia (ALL)
- Treatment response or stabilization of disease as indicated by CBC, bone marrow cytogenic analysis, QPCR, or FISH
Pediatric B-Cell Acute Leukemia and Aggressive Mature B-Cell Lymphomas (induction or consolidation therapy)
- Coverage may NOT be renewed
Pediatric Hodgkin Lymphoma
- Coverage may NOT be renewed
Chronic Graft-Versus-Host Disease (cGVHD)
- Coverage may NOT be renewed
Hematopoietic Cell Transplantation
- Coverage may NOT be renewed
Management of Immunotherapy-Related Toxicities
- Coverage for use in the treatment of myositis/myasthenia gravis/encephalitis may NOT be renewed
- Coverage for use in bullous dermatitis: Patient has not exceeded a maximum of 18 months of therapy (4 total doses)
All Other Oncology Indications
- Disease response with treatment as defined by stabilization of disease or decrease in size of tumor or tumor spread
Non-Oncology Indications 1-4
Rheumatoid Arthritis (RA)
- Disease response as indicated by improvement in signs and symptoms compared to baseline such as the number of tender and swollen joint counts, reduction of C-reactive protein, improvement of patient global assessment, and/or an improvement on a disease activity scoring tool [e.g. an improvement on a composite scoring index such as Disease Activity Score-28 (DAS28) of 1.2 points or more or a ≥20% improvement on the American College of Rheumatology-20 (ACR20) criteria, or improvement of disease severity on RAPID3 assessment]; AND
- Dose escalation (up to the maximum dose and frequency specified below) may occur upon clinical review on a case by case basis provided that the patient has:
- Shown an initial response to therapy; AND
- Received a minimum of one maintenance dose at the dose and interval specified below; AND
- Responded to therapy with subsequent loss of response
Thrombocytopenic Purpura (ITP or Evans Syndrome) 7-9, 63
- Disease response as indicated by the achievement and maintenance of a platelet count of at least 30 × 109/L and at least doubling the baseline platelet count
Thrombotic Thrombocytopenic Purpura (TTP)
- Disease response as indicated by an increase in ADAMTS13 activity with a reduction in thrombotic risk
Multiple Sclerosis (MS) 147,151
- Continuous monitoring of response to therapy indicates a beneficial response* [manifestations of MS disease activity include, but are not limited to, an increase in annualized relapse rate (ARR), development of new/worsening T2 hyperintensities or enhancing lesions on brain/spinal MRI, and progression of sustained impairment as evidenced by expanded disability status scale (EDSS), timed 25-foot walk (T25-FW), 9-hole peg test (9-HPT)]
*Note:
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Granulomatosis with Polyangiitis (GPA) (Wegener’s granulomatosis) and Microscopic Polyangiitis (MPA) 1-4, 125
- Disease response as indicated by disease control and improvement in signs and symptoms of condition compared to baseline; AND
- Decreased frequency in the occurrence of major relapses (defined by the reappearance of clinical and/or laboratory signs of vasculitis activity that could lead to organ failure or damage, or could be life threatening)
Pemphigus Vulgaris 10,11,35,61
- Patient is currently receiving tapering doses of corticosteroids or has discontinued use of corticosteroids; AND
- Disease response as indicated by one of the following:
- Complete epithelialization of lesions and improvement in signs and symptoms of condition compared to baseline
- Patient has not developed new lesions and established lesions begin to heal
- Disease response as indicated by one of the following:
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- For Relapses ONLY: Patient previously achieved disease control; AND
- Patient has the appearance of 3 or more new lesions a month that do not heal spontaneously within 1 week, or by the extension of established lesions
- For Relapses ONLY: Patient previously achieved disease control; AND
Autoimmune Hemolytic Anemia (AIHA) 31,152
- Disease response as indicated by improvement in signs and symptoms of anemia (e.g., dyspnea, fatigue, etc.); AND
- Patient has had an improvement in laboratory values (e.g., hemoglobin, hematocrit, etc.), reduced transfusion needs, and/or reduced glucocorticoid use
Lupus Nephritis 115-117
- Coverage may only be renewed in patients experiencing a disease relapse (e.g., increased serum creatinine, increase in protein urine excretion, decrease in eGFR, etc.)
Myasthenia Gravis (unrelated to immunotherapy-related toxicity) 118-120
- Disease response as indicated by a decrease in the daily dose of corticosteroids and/or an improvement in signs and symptoms compared to baseline.
Complications of Transplanted Solid Organ (kidney, liver, lung, heart, pancreas) 133-138
- Coverage may NOT be renewed.
NMOSD 90,91
- Disease response as indicated by stabilization/improvement in any of the following:
- Decrease in acute relapses or improvement of stability
- Reduced hospitalizations
- Reduction/discontinuation in plasma exchange treatments
- Reduction/discontinuation of corticosteroids without relapse
Antisynthetase Syndrome-Related Interstitial Lung Disease 167,168,174
- Disease response as indicated by stabilization/improvement in any of the following:
- Reduction or stabilization of glucocorticoid use from baseline
- Improvement or stabilization of pulmonary function testing (i.e., improvement defined as >10% increase in FVC%, TLC%, or DLCO%; stabilization defined as < 10% decrease in FVC%, TLC%, or DLCO%)
- Improvement or stabilization of chest CT score (i.e., improvement defined as >10% decrease in CT score; stabilization defined as a < 10% increase in CT score)
Idiopathic Membranous Nephropathy 172,175,177
- Patient experienced beneficial disease response with improvement in symptoms and/or other objective measures compared to baseline (e.g., reduction in proteinuria, increase and/or normalization of serum albumin, improvement/stability of serum creatinine and/or eGFR, decrease in anti-PLA2R antibody levels, etc.); OR
- Patient has resistant disease following first-line therapy with rituximab; AND
- Patient has stable eGFR; AND
- Will be used in combination with a calcineurin inhibitor if previously treated with rituximab alone in the first-line setting
Pediatric Idiopathic Nephrotic Syndrome ‡ 170-173
- Patient previously achieved beneficial disease response from the prior course of therapy; AND
- Patient is experiencing signs and symptoms of recurrent active disease necessitating additional doses (e.g., recurrence of nephrotic-range proteinuria with a dipstick > 3+ [>300 mg/dL] for 3 consecutive days OR urinary protein creatinine ratio [UPCR] ≥200 mg/mmol [≥2 mg/mg] on a spot urine sample on 3 consecutive days, with or without reappearance of edema in a child who had previously achieved complete remission)
IgG4-Related Disease ‡ 178-182
- Patient experienced beneficial disease response with improvement in involved organ-related symptoms and/or other objective measures compared to baseline (e.g. improvement in the IgG4-RD Responder Index score of > 2 points, improvement in the physician's global assessment [PGA], reduction in glucocorticoid or other immunosuppressive use, reduction of disease flares, reduction in serum IgG4 level, etc.); AND
- Patient meets one of the following:
- Ongoing maintenance therapy is required due to patient having a high-risk of relapse
- Patient is experiencing signs and symptoms of relapsed active disease necessitating an additional course of therapy
- Dosage/Administration 1-5,9,19,23-26,32,34,40,42,44,50,62,80,83-89,91,94-98,102-111,115-118,122-125,128-133,135-137,140,152,164,165, 167,168, 170-173,175,178-184-185, 187-190
Indication |
Dose |
|
CLL/SLL |
Initial Therapy |
375 mg/m² intravenously (IV) weekly for 12 doses; OR 375 mg/m² IV cycle 1, then 500 mg/m² every 28 days cycles 2-6 (6 total doses); OR 375 mg/m² IV cycle 1, followed by 500 mg/m² every 2 weeks for 4 doses, then 500 mg/m² every 28 days for 3 doses (8 total doses) |
Renewal Therapy |
375 mg/m² IV every 3 months; OR 500 mg/ m² IV every 8 weeks |
|
Waldenström Macroglobulinemia |
Initial Therapy |
375 mg/m² IV weekly for 12 doses |
Renewal Therapy |
375 mg/m² IV once weekly for 4 doses per 6 month period; OR 375 mg/ m² IV every 8 weeks |
|
Adult B-Cell Lymphomas, Castleman Disease, Primary Cutaneous B-Cell Lymphomas, or Adult HL |
Initial Therapy |
375 mg/m2 IV once weekly for 4 – 8 doses in a 6 month period |
Renewal Therapy |
375 mg/m² IV once weekly for 4 doses per 6 month period; OR 375 mg/ m² IV every 8 weeks |
|
Pediatric Aggressive Mature B-Cell Lymphomas |
Induction* [courses 1 and 2 (COPDAM1 and COPDAM2)] 375 mg/m2 IV, two doses during each of the induction courses (Day -2 and Day 1). During the 1st induction course, prednisone is given as part of the chemotherapy course, and should be administered prior to rituximab. Rituximab will be given 48 hours after the first infusion of rituximab. Consolidation* [courses 1 and 2 (CYM/CYVE)] 375 mg/m2 IV, one dose during each of the consolidation courses (Day 1) Relapsed/Refractory RCYVE – 375mg/m2 IV on day 1 of each 21-day cycle RICE – 375 mg/m2 IV on days 1 and 3 of courses 1 and 2, and on day 1 only of course 3 if needed. *Note: dosing and dosing schedules are highly variable and dependent on regimen used, please refer to NCCN and PI for additional protocols. |
|
Pediatric Mature B-Cell Acute Leukemia |
Induction* [courses 1 and 2 (COPDAM1 and COPDAM2)] 375 mg/m2 IV, two doses during each of the induction courses (Day -2 and Day 1). During the 1st induction course, prednisone is given as part of the chemotherapy course, and should be administered prior to rituximab. Rituximab will be given 48 hours after the first infusion of rituximab. Consolidation* [courses 1 and 2 (CYM/CYVE)] 375 mg/m2 IV, one dose during each of the consolidation courses (Day 1) *Note: dosing and dosing schedules are highly variable and dependent on regimen used, please refer to NCCN and PI for additional protocols. |
|
CNS Lymphoma |
Intravenous administration Initial Therapy: Up to 750 mg/m² weekly for 4 – 8 doses Renewal Therapy: 375 mg/m² IV once weekly for 4 doses per 6 month period; OR 375 mg/m² IV every 8 weeks Intrathecal/Intraventricular administration 25 mg weekly to twice weekly |
|
ALL |
375 mg/m2 IV up to twice weekly for a total of 16 to 18 infusions (e.g., induction [days 1 and 7], salvage reinduction when necessary [days 1 and 7], consolidation [4 infusions: blocks 1, 3, 4, and 6], late intensification [days 1 and 7], late consolidation [2 infusions: blocks 7 and 9], and maintenance [6 infusions]) |
|
Hairy Cell Leukemia |
375 mg/m2 IV once weekly for 4 – 8 doses; OR 375mg/m2 IV on days 1 and 15 every 28 days for 4 cycles, then 375mg/m2 IV every 4 weeks for 4 cycles (up to 8 total cycles) |
|
RA |
1,000 mg IV on days 1 and 15, repeated every 24 weeks. May repeat up to every 16 weeks** following the previous infusion in patients requiring more frequent dosing based on clinical evaluation.
**Dose escalation criteria detailed in section IV must be met prior to increasing dosing frequency. |
|
Pemphigus Vulgaris |
Initiation 1,000 mg IV on days 1 and 15; OR 375 mg/m² IV weekly for 4 doses Maintenance 500 mg IV at month 12 and repeat every 6 months thereafter or based on clinical evaluation Relapse 1,000 mg IV upon relapse, resumption of glucocorticoids may be considered *Subsequent infusions (maintenance and relapse) should be no sooner than 16 weeks after the previous infusion. |
|
AIHA |
Warm-reactive disease 375 mg/m² IV weekly for 4 doses in a 6 month period; OR 1,000 mg IV on days 1 and 15
Cold agglutinin disease 375 mg/m² IV weekly for 4 doses in a 6 month period |
|
Thrombocytopenic Purpura or Thrombotic Thrombocytopenic Purpura (TTP) |
375 mg/m² IV weekly for 4 doses; OR 1,000 mg IV on days 1 and 15 |
|
Management of Immunotherapy-Related Toxicities |
Bullous Dermatitis 1,000 mg IV every 2 weeks for 2 doses, then 500 mg IV at months 12 and 18 as needed Myositis Myasthenia Gravis 375 mg/m² IV weekly for 4 doses; OR 500 mg/m² IV every 2 weeks for 2 doses Encephalitis 1,000 mg IV every 2 weeks for 2 doses; OR 375 mg/m² IV weekly for 4 doses |
|
GPA (WG), MPA |
Induction (Pediatric and Adult) 375 mg/m² IV weekly for 4 doses; OR
Maintenance
*Initial MAINTENANCE infusions should be no sooner than 16 weeks and no later than 24 weeks after the previous infusion if rituximab was used for initial induction therapy. *Initial MAINTENANCE infusions should be initiated within 4 weeks following disease control when initial induction occurred with other standard of care immunosuppressants. |
|
cGVHD |
375 mg/m² IV weekly for 4 doses, then 375 mg/m² IV monthly for 4 months -OR- 375 mg/m² IV weekly for 4 doses (Note: A second course of 4 weekly doses may be administered 8 weeks after initial therapy for patients with lack of or incomplete response.) -OR- 375 mg/m² IV weekly for 4 – 8 doses |
|
Hematopoietic Cell Transplantation |
Conditioning: 375 mg/m² IV for 1 day before transplant, then 1000 mg/m² IV on days 1,8, and 15 after transplant |
|
Multiple Sclerosis |
1,000 mg IV on days 1 and 15, repeat every 6 months |
|
NMOSD |
1,000 mg IV once on days 1 and 15, repeat every 6 months -OR- 375 mg/m2 once weekly for 4 weeks, repeat every 6 months |
|
Histiocytic Neoplasms – Rosai-Dorfman Disease |
500 mg/m² IV every 1 – 2 weeks for 2 – 6 doses every 6 months
|
|
Systemic Lupus Erythematosus |
375 mg/m2 once weekly for 4 weeks |
|
Myasthenia Gravis (unrelated to immunotherapy-related toxicity) |
1,000 mg IV on days 1 and 15, may repeat a full or partial course every 6 months -OR- 375 mg/m2 IV once weekly for 4 doses, may repeat a full or partial course every 6 months |
|
Pediatric Hodgkin Lymphoma |
375 mg/m² IV on day 1 of every 2-3 week cycle for a total of 3 cycles |
|
Complications of transplanted solid organ (kidney, liver, lung, heart, pancreas) |
|
|
Antisynthetase Syndrome-Related Interstitial Lung Disease |
1,000 mg IV on days 1 and 15 repeated every 6 months -OR- 375 mg/m2 IV once weekly for 4 doses repeated every 6 months |
|
Pediatric Idiopathic Nephrotic Syndrome |
375 mg/m2 IV once weekly for 1-4 doses
|
|
Idiopathic Membranous Nephropathy |
375 mg/m2 IV once weekly for 1-4 doses every 6 months -OR- 1,000 mg IV on days 1 and 15 every 6 months |
|
IgG4-Related Disease |
Induction: 375 mg/m2 IV once weekly for 1-4 doses -OR- 1,000 mg IV on days 1 and 15 *Subsequent infusions (maintenance and relapse) may be administered at either induction schedule above and should be repeated no sooner than every 6 months. |
|
Abbreviations: COP = Cyclophosphamide, Oncovin (vincristine), Prednisone; COPDAM = Cyclophosphamide, Oncovin (vincristine), Prednisolone, Adriamycin (doxorubicin), Methotrexate; CYM = Cytarabine (Ara-C), Methotrexate; CYVE = Cytarabine (Ara-C), Vepesid (Etoposide,VP-16); RICE = Rituximab, Ifosfamide, Carboplatin, Etoposide (VP-16) |
- Billing Code/Availability Information
HCPCS Code(s):
- J9312 – Injection, rituximab, 10 mg; 1 billable unit = 10 mg (Rituxan IV only)
- Q5115 – Injection, rituximab-abbs, biosimilar, (truxima), 10 mg; 1 billable unit = 10 mg
- Q5119 – Injection, rituximab-pvvr, biosimilar, (ruxience), 10 mg; 1 billable unit = 10 mg
- Q5123 – Injection, rituximab-arrx, biosimilar, (riabni), 10 mg; 1 billable unit = 10 mg
NDC(s):
- Rituxan 100 mg/10 mL single-dose vial for injection: 50242-0051-xx
- Rituxan 500 mg/50 mL single-dose vial for injection: 50242-0053-xx
- Truxima 100 mg/10 mL single-dose vial for injection: 63459-0103-xx
- Truxima 500 mg/50 mL single-dose vial for injection: 63459-0104-xx
- Ruxience 100 mg/10 mL single-dose vial for injection: 00069-0238-xx
- Ruxience 500 mg/50 mL single-dose vial for injection: 00069-0249-xx
- Riabni 100 mg/10 mL single-dose vial for injection: 55513-0224-xx
- Riabni 500 mg/50 mL single-dose vial for injection: 55513-0326-xx
- References
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Appendix 1 – Covered Diagnosis Codes
ICD-10 |
Description |
C79.32 |
Secondary malignant neoplasm of cerebral meninges |
C81.00 |
Nodular lymphocyte predominant Hodgkin lymphoma, unspecified site |
C81.01 |
Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of head, face, and neck |
C81.02 |
Nodular lymphocyte predominant Hodgkin lymphoma, intrathoracic lymph nodes |
C81.03 |
Nodular lymphocyte predominant Hodgkin lymphoma, intra-abdominal lymph nodes |
C81.04 |
Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of axilla and upper limb |
C81.05 |
Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
C81.06 |
Nodular lymphocyte predominant Hodgkin lymphoma, intrapelvic lymph nodes |
C81.07 |
Nodular lymphocyte predominant Hodgkin lymphoma, spleen |
C81.08 |
Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of multiple sites |
C81.09 |
Nodular lymphocyte predominant Hodgkin lymphoma, extranodal and solid organ sites |
C81.19 |
Nodular sclerosis Hodgkin lymphoma, extranodal and solid organ sites |
C81.29 |
Mixed cellularity Hodgkin lymphoma, extranodal and solid organ sites |
C81.39 |
Lymphocyte depleted Hodgkin lymphoma, extranodal and solid organ sites |
C81.49 |
Lymphocyte-rich Hodgkin lymphoma, extranodal and solid organ sites |
C81.79 |
Other Hodgkin lymphoma, extranodal and solid organ sites |
C81.99 |
Hodgkin lymphoma, unspecified, extranodal and solid organ sites |
C82.00 |
Follicular lymphoma grade I, unspecified site |
C82.01 |
Follicular lymphoma grade I, lymph nodes of head, face and neck |
C82.02 |
Follicular lymphoma, grade I, intrathoracic lymph nodes |
C82.03 |
Follicular lymphoma grade I, intra-abdominal lymph nodes |
C82.04 |
Follicular lymphoma grade I, lymph nodes of axilla and upper limb |
C82.05 |
Follicular lymphoma grade I, lymph nodes of inguinal regional and lower limb |
C82.06 |
Follicular lymphoma grade I, intrapelvic lymph nodes |
C82.07 |
Follicular lymphoma grade I, spleen |
C82.08 |
Follicular lymphoma grade I, lymph nodes of multiple sites |
C82.09 |
Follicular lymphoma grade I, extranodal and solid organ sites |
C82.10 |
Follicular lymphoma grade II, unspecified site |
C82.11 |
Follicular lymphoma grade II, lymph nodes of head, face and neck |
C82.12 |
Follicular lymphoma, grade II, intrathoracic lymph nodes |
C82.13 |
Follicular lymphoma grade II, intra-abdominal lymph nodes |
C82.14 |
Follicular lymphoma grade II, lymph nodes of axilla and upper limb |
C82.15 |
Follicular lymphoma grade II, lymph nodes of inguinal region and lower limb |
C82.16 |
Follicular lymphoma grade II, intrapelvic lymph nodes |
C82.17 |
Follicular lymphoma grade II, spleen |
C82.18 |
Follicular lymphoma grade II, lymph nodes of multiple sites |
C82.19 |
Follicular lymphoma grade II, extranodal and solid organ sites |
C82.20 |
Follicular lymphoma grade III, unspecified, unspecified site |
C82.21 |
Follicular lymphoma grade III, unspecified, lymph nodes of head, face and neck |
C82.22 |
Follicular lymphoma, grade III, unspecified, intrathoracic lymph nodes |
C82.23 |
Follicular lymphoma grade III, unspecified, intra-abdominal lymph nodes |
C82.24 |
Follicular lymphoma grade III, unspecified, lymph nodes of axilla and upper limb |
C82.25 |
Follicular lymphoma grade III, unspecified, lymph nodes of inguinal region and lower limb |
C82.26 |
Follicular lymphoma grade III, unspecified, intrapelvic lymph nodes |
C82.27 |
Follicular lymphoma grade III, unspecified, spleen |
C82.28 |
Follicular lymphoma grade III, unspecified, lymph nodes of multiple sites |
C82.29 |
Follicular lymphoma grade III, unspecified, extranodal and solid organ sites |
C82.30 |
Follicular lymphoma grade IIIa, unspecified site |
C82.31 |
Follicular lymphoma grade IIIa, lymph nodes of head, face and neck |
C82.32 |
Follicular lymphoma, grade IIIa, intrathoracic lymph nodes |
C82.33 |
Follicular lymphoma grade IIIa, intra-abdominal lymph nodes |
C82.34 |
Follicular lymphoma grade IIIa, lymph nodes of axilla and upper limb |
C82.35 |
Follicular lymphoma grade IIIa, lymph nodes of inguinal region and lower limb |
C82.36 |
Follicular lymphoma grade IIIa, intrapelvic lymph nodes |
C82.37 |
Follicular lymphoma grade IIIa, spleen |
C82.38 |
Follicular lymphoma grade IIIa, lymph nodes of multiple sites |
C82.39 |
Follicular lymphoma grade IIIa, extranodal and solid organ sites |
C82.40 |
Follicular lymphoma grade IIIb, unspecified site |
C82.41 |
Follicular lymphoma grade IIIb, lymph nodes of head, face and neck |
C82.42 |
Follicular lymphoma, grade IIIb, intrathoracic lymph nodes |
C82.43 |
Follicular lymphoma grade IIIb, intra-abdominal lymph nodes |
C82.44 |
Follicular lymphoma grade IIIb, lymph nodes of axilla and upper limb |
C82.45 |
Follicular lymphoma grade IIIb, lymph nodes of inguinal region and lower limb |
C82.46 |
Follicular lymphoma grade IIIb, intrapelvic lymph nodes |
C82.47 |
Follicular lymphoma grade IIIb, spleen |
C82.48 |
Follicular lymphoma grade IIIb, lymph nodes of multiple sites |
C82.49 |
Follicular lymphoma grade IIIb, extranodal and solid organ sites |
C82.50 |
Diffuse follicle center lymphoma, unspecified site |
C82.51 |
Diffuse follicle center lymphoma, lymph nodes of head, face and neck |
C82.52 |
Diffuse follicle center lymphoma, intrathoracic lymph nodes |
C82.53 |
Diffuse follicle center lymphoma, intra-abdominal lymph nodes |
C82.54 |
Diffuse follicle center lymphoma, lymph nodes of axilla and upper limb |
C82.55 |
Diffuse follicle center lymphoma, lymph nodes of inguinal region and lower limb |
C82.56 |
Diffuse follicle center lymphoma, intrapelvic lymph nodes |
C82.57 |
Diffuse follicle center lymphoma, spleen |
C82.58 |
Diffuse follicle center lymphoma, lymph nodes of multiple sites |
C82.59 |
Diffuse follicle center lymphoma, extranodal and solid organ sites |
C82.60 |
Cutaneous follicle center lymphoma, unspecified site |
C82.61 |
Cutaneous follicle center lymphoma, lymph nodes of head, face and neck |
C82.62 |
Cutaneous follicle center lymphoma, intrathoracic lymph nodes |
C82.63 |
Cutaneous follicle center lymphoma, intra-abdominal lymph nodes |
C82.64 |
Cutaneous follicle center lymphoma, lymph nodes of axilla and upper limb |
C82.65 |
Cutaneous follicle center lymphoma, lymph nodes of inguinal region and lower limb |
C82.66 |
Cutaneous follicle center lymphoma, intrapelvic lymph nodes |
C82.67 |
Cutaneous follicle center lymphoma, spleen |
C82.68 |
Cutaneous follicle center lymphoma, lymph nodes of multiple sites |
C82.69 |
Cutaneous follicle center lymphoma, extranodal and solid organ sites |
C82.80 |
Other types of follicular lymphoma, unspecified site |
C82.81 |
Other types of follicular lymphoma, lymph nodes of head, face and neck |
C82.82 |
Other types of follicular lymphoma, intrathoracic lymph nodes |
C82.83 |
Other types of follicular lymphoma, intra-abdominal lymph nodes |
C82.84 |
Other types of follicular lymphoma, lymph nodes of axilla and upper limb |
C82.85 |
Other types of follicular lymphoma, lymph nodes of inguinal region and lower limb |
C82.86 |
Other types of follicular lymphoma, intrapelvic lymph nodes |
C82.87 |
Other types of follicular lymphoma, spleen |
C82.88 |
Other types of follicular lymphoma, lymph nodes of multiple sites |
C82.89 |
Other types of follicular lymphoma, extranodal and solid organ sites |
C82.90 |
Follicular lymphoma, unspecified, unspecified site |
C82.91 |
Follicular lymphoma, unspecified, lymph nodes of head, face and neck |
C82.92 |
Follicular lymphoma, unspecified, intrathoracic lymph nodes |
C82.93 |
Follicular lymphoma, unspecified, intra-abdominal lymph nodes |
C82.94 |
Follicular lymphoma, unspecified, lymph nodes of axilla and upper limb |
C82.95 |
Follicular lymphoma, unspecified lymph nodes of inguinal region and lower limb |
C82.96 |
Follicular lymphoma, unspecified, intrapelvic lymph nodes |
C82.97 |
Follicular lymphoma, unspecified, spleen |
C82.98 |
Follicular lymphoma, unspecified, lymph nodes of multiple sites |
C82.99 |
Follicular lymphoma, unspecified, extranodal and solid organ sites |
C83.00 |
Small cell B-cell lymphoma, unspecified site |
C83.01 |
Small cell B-cell lymphoma, lymph nodes of head, face and neck |
C83.02 |
Small cell B-cell lymphoma, intrathoracic lymph nodes |
C83.03 |
Small cell B-cell lymphoma, intra-abdominal lymph nodes |
C83.04 |
Small cell B-cell lymphoma, lymph nodes of axilla and upper limb |
C83.05 |
Small cell B-cell lymphoma, lymph nodes of inguinal region and lower limb |
C83.06 |
Small cell B-cell lymphoma, intrapelvic lymph nodes |
C83.07 |
Small cell B-cell lymphoma, spleen |
C83.08 |
Small cell B-cell lymphoma, lymph nodes of multiple sites |
C83.09 |
Small cell B-cell lymphoma, extranodal and solid organ sites |
C83.10 |
Mantle cell lymphoma, unspecified site |
C83.11 |
Mantle cell lymphoma, lymph nodes of head, face and neck |
C83.12 |
Mantle cell lymphoma, intrathoracic lymph nodes |
C83.13 |
Mantle cell lymphoma, intra-abdominal lymph nodes |
C83.14 |
Mantle cell lymphoma, lymph nodes of axilla and upper limb |
C83.15 |
Mantle cell lymphoma, lymph nodes of inguinal region and lower limb |
C83.16 |
Mantle cell lymphoma, intrapelvic lymph nodes |
C83.17 |
Mantle cell lymphoma, spleen |
C83.18 |
Mantle cell lymphoma, lymph nodes of multiple sites |
C83.19 |
Mantle cell lymphoma, extranodal and solid organ sites |
C83.30 |
Diffuse large B-cell lymphoma unspecified site |
C83.31 |
Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck |
C83.32 |
Diffuse large B-cell lymphoma intrathoracic lymph nodes |
C83.33 |
Diffuse large B-cell lymphoma intra-abdominal lymph nodes |
C83.34 |
Diffuse large B-cell lymphoma lymph nodes of axilla and upper limb |
C83.35 |
Diffuse large B-cell lymphoma, lymph nodes of inguinal region and lower limb |
C83.36 |
Diffuse large B-cell lymphoma intrapelvic lymph nodes |
C83.37 |
Diffuse large B-cell lymphoma, spleen |
C83.38 |
Diffuse large B-cell lymphoma lymph nodes of multiple sites |
C83.39 |
Diffuse large B-cell lymphoma extranodal and solid organ sites |
C83.50 |
Lymphoblastic (diffuse) lymphoma, unspecified site |
C83.51 |
Lymphoblastic (diffuse) lymphoma, lymph nodes of head, face, and neck |
C83.52 |
Lymphoblastic (diffuse) lymphoma, intrathoracic lymph nodes |
C83.53 |
Lymphoblastic (diffuse) lymphoma, intra-abdominal lymph nodes |
C83.54 |
Lymphoblastic (diffuse) lymphoma, lymph nodes of axilla and upper limb |
C83.55 |
Lymphoblastic (diffuse) lymphoma, lymph nodes of inguinal region and lower limb |
C83.56 |
Lymphoblastic (diffuse) lymphoma, intrapelvic lymph nodes |
C83.57 |
Lymphoblastic (diffuse) lymphoma, spleen |
C83.58 |
Lymphoblastic (diffuse) lymphoma, lymph nodes of multiple sites |
C83.59 |
Lymphoblastic (diffuse) lymphoma, extranodal and solid organ sites |
C83.70 |
Burkitt lymphoma, unspecified site |
C83.71 |
Burkitt lymphoma, lymph nodes of head, face, and neck |
C83.72 |
Burkitt lymphoma, intrathoracic lymph nodes |
C83.73 |
Burkitt lymphoma, intra-abdominal lymph nodes |
C83.74 |
Burkitt lymphoma, lymph nodes of axilla and upper limb |
C83.75 |
Burkitt lymphoma, lymph nodes of inguinal region and lower limb |
C83.76 |
Burkitt lymphoma, intrapelvic lymph nodes |
C83.77 |
Burkitt lymphoma, spleen |
C83.78 |
Burkitt lymphoma, lymph nodes of multiple sites |
C83.79 |
Burkitt lymphoma, extranodal and solid organ sites |
C83.80 |
Other non-follicular lymphoma, unspecified site |
C83.81 |
Other non-follicular lymphoma, lymph nodes of head, face and neck |
C83.82 |
Other non-follicular lymphoma, intrathoracic lymph nodes |
C83.83 |
Other non-follicular lymphoma, intra-abdominal lymph nodes |
C83.84 |
Other non-follicular lymphoma, lymph nodes of axilla and upper limb |
C83.85 |
Other non-follicular lymphoma, lymph nodes of inguinal region and lower limb |
C83.86 |
Other non-follicular lymphoma, intrapelvic lymph nodes |
C83.87 |
Other non-follicular lymphoma, spleen |
C83.88 |
Other non-follicular lymphoma, lymph nodes of multiple sites |
C83.89 |
Other non-follicular lymphoma, extranodal and solid organ sites |
C83.90 |
Non-follicular (diffuse) lymphoma, unspecified site |
C83.91 |
Non-follicular (diffuse) lymphoma, unspecified lymph nodes of head, face, and neck |
C83.92 |
Non-follicular (diffuse) lymphoma, unspecified intrathoracic lymph nodes |
C83.93 |
Non-follicular (diffuse) lymphoma, unspecified intra-abdominal lymph nodes |
C83.94 |
Non-follicular (diffuse) lymphoma, unspecified lymph nodes of axilla and upper limb |
C83.95 |
Non-follicular (diffuse) lymphoma, unspecified lymph nodes of inguinal region and lower limb |
C83.96 |
Non-follicular (diffuse) lymphoma, unspecified intrapelvic lymph nodes |
C83.97 |
Non-follicular (diffuse) lymphoma, unspecified spleen |
C83.98 |
Non-follicular (diffuse) lymphoma, unspecified lymph nodes of multiple sites |
C83.99 |
Non-follicular (diffuse) lymphoma, unspecified extranodal and solid organ sites |
C84.09 |
Mycosis fungoides, extranodal and solid organ sites |
C84.19 |
Sézary disease, extranodal and solid organ sites |
C84.49 |
Peripheral T-cell lymphoma, not classified, extranodal and solid organ sites |
C84.69 |
Anaplastic large cell lymphoma, ALK-positive, extranodal and solid organ sites |
C84.79 |
Anaplastic large cell lymphoma, ALK-negative, extranodal and solid organ sites |
C84.99 |
Mature T/NK-cell lymphomas, unspecified, extranodal and solid organ sites |
C84.A9 |
Cutaneous T-cell lymphoma, unspecified, extranodal and solid organ sites |
C84.Z9 |
Other mature T/NK-cell lymphomas, extranodal and solid organ sites |
C85.10 |
Unspecified B-cell lymphoma, unspecified site |
C85.11 |
Unspecified B-cell lymphoma, lymph nodes of head, face, and neck |
C85.12 |
Unspecified B-cell lymphoma, intrathoracic lymph nodes |
C85.13 |
Unspecified B-cell lymphoma, intra-abdominal lymph nodes |
C85.14 |
Unspecified B-cell lymphoma, lymph nodes of axilla and upper limb |
C85.15 |
Unspecified B-cell lymphoma, lymph nodes of inguinal region and lower limb |
C85.16 |
Unspecified B-cell lymphoma, intrapelvic lymph nodes |
C85.17 |
Unspecified B-cell lymphoma, spleen |
C85.18 |
Unspecified B-cell lymphoma, lymph nodes of multiple sites |
C85.19 |
Unspecified B-cell lymphoma, extranodal and solid organ sites |
C85.20 |
Mediastinal (thymic) large B-cell lymphoma, unspecified site |
C85.21 |
Mediastinal (thymic) large B-cell lymphoma, lymph nodes of head, face and neck |
C85.22 |
Mediastinal (thymic) large B-cell lymphoma, intrathoracic lymph nodes |
C85.23 |
Mediastinal (thymic) large B-cell lymphoma, intra-abdominal lymph nodes |
C85.24 |
Mediastinal (thymic) large B-cell lymphoma, lymph nodes of axilla and upper limb |
C85.25 |
Mediastinal (thymic) large B-cell lymphoma, lymph nodes of inguinal region and lower limb |
C85.26 |
Mediastinal (thymic) large B-cell lymphoma, intrapelvic lymph nodes |
C85.27 |
Mediastinal (thymic) large B-cell lymphoma, spleen |
C85.28 |
Mediastinal (thymic) large B-cell lymphoma, lymph nodes of multiple sites |
C85.29 |
Mediastinal (thymic) large B-cell lymphoma, extranodal and solid organ sites |
C85.80 |
Other specified types of non-Hodgkin lymphoma, unspecified site |
C85.81 |
Other specified types of non-Hodgkin lymphoma, lymph nodes of head, face and neck |
C85.82 |
Other specified types of non-Hodgkin lymphoma, intrathoracic lymph nodes |
C85.83 |
Other specified types of non-Hodgkin lymphoma, intra-abdominal lymph nodes |
C85.84 |
Other specified types of non-Hodgkin lymphoma, lymph nodes of axilla and upper limb |
C85.85 |
Other specified types of non-Hodgkin lymphoma, lymph nodes of inguinal region of lower limb |
C85.86 |
Other specified types of non-Hodgkin lymphoma, intrapelvic lymph nodes |
C85.87 |
Other specified types of non-Hodgkin lymphoma, spleen |
C85.88 |
Other specified types of non-Hodgkin lymphoma, lymph nodes of multiple sites |
C85.89 |
Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites |
C85.99 |
Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites |
C88.0 |
Waldenström macroglobulinemia |
C88.4 |
Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT-lymphoma) |
C91.00 |
Acute lymphoblastic leukemia not having achieved remission |
C91.01 |
Acute lymphoblastic leukemia, in remission |
C91.02 |
Acute lymphoblastic leukemia, in relapse |
C91.10 |
Chronic lymphocytic leukemia of B-cell type not having achieved remission |
C91.12 |
Chronic lymphocytic leukemia of B-cell type in relapse |
C91.40 |
Hairy cell leukemia not having achieved remission |
C91.42 |
Hairy cell leukemia, in relapse |
D47.Z1 |
Post-transplant lymphoproliferative disorder (PTLD) |
D47.Z2 |
Other neoplasms of uncertain behavior of lymphoid, hematopoietic and related tissue-Castleman disease |
D59.10 |
Autoimmune hemolytic anemia, unspecified |
D59.11 |
Warm autoimmune hemolytic anemia |
D59.12 |
Cold autoimmune hemolytic anemia |
D59.13 |
Mixed type autoimmune hemolytic anemia |
D59.19 |
Other autoimmune hemolytic anemia |
D69.3 |
Immune thrombocytopenic purpura |
D69.41 |
Evans Syndrome |
D69.42 |
Congenital and hereditary thrombocytopenia purpura |
D69.49 |
Other primary thrombocytopenia |
D76.3 |
Other histiocytosis syndromes |
D89.811 |
Chronic graft-versus-host disease |
D89.812 |
Acute on chronic graft-versus-host disease |
D89.813 |
Graft-versus-host disease unspecified |
D89.84 |
IgG4-related disease |
G04.81 |
Other encephalitis and encephalomyelitis |
G04.89 |
Other myelitis |
G04.90 |
Encephalitis and encephalomyelitis, unspecified |
G35 |
Multiple sclerosis |
G36.0 |
Neuromyelitis optica [Devic] |
G70.0 |
Myasthenia gravis |
G70.00 |
Myasthenia gravis without (acute) exacerbation |
G70.01 |
Myasthenia gravis with (acute) exacerbation |
J84.9 |
Interstitial pulmonary disease, unspecified |
L10.0 |
Pemphigus vulgaris |
L13.8 |
Other specified bullous disorders |
L13.9 |
Bullous disorder, unspecified |
M05.10 |
Rheumatoid lung disease with rheumatoid arthritis of unspecified site |
M05.111 |
Rheumatoid lung disease with rheumatoid arthritis of right shoulder |
M05.112 |
Rheumatoid lung disease with rheumatoid arthritis of left shoulder |
M05.119 |
Rheumatoid lung disease with rheumatoid arthritis of unspecified shoulder |
M05.121 |
Rheumatoid lung disease with rheumatoid arthritis of right elbow |
M05.122 |
Rheumatoid lung disease with rheumatoid arthritis of left elbow |
M05.129 |
Rheumatoid lung disease with rheumatoid arthritis of unspecified elbow |
M05.131 |
Rheumatoid lung disease with rheumatoid arthritis of right wrist |
M05.132 |
Rheumatoid lung disease with rheumatoid arthritis of left wrist |
M05.139 |
Rheumatoid lung disease with rheumatoid arthritis of unspecified wrist |
M05.141 |
Rheumatoid lung disease with rheumatoid arthritis of right hand |
M05.142 |
Rheumatoid lung disease with rheumatoid arthritis of left hand |
M05.149 |
Rheumatoid lung disease with rheumatoid arthritis of unspecified hand |
M05.151 |
Rheumatoid lung disease with rheumatoid arthritis of right hip |
M05.152 |
Rheumatoid lung disease with rheumatoid arthritis of left hip |
M05.159 |
Rheumatoid lung disease with rheumatoid arthritis of unspecified hip |
M05.161 |
Rheumatoid lung disease with rheumatoid arthritis of right knee |
M05.162 |
Rheumatoid lung disease with rheumatoid arthritis of left knee |
M05.169 |
Rheumatoid lung disease with rheumatoid arthritis of unspecified knee |
M05.171 |
Rheumatoid lung disease with rheumatoid arthritis of right ankle and foot |
M05.172 |
Rheumatoid lung disease with rheumatoid arthritis of left ankle and foot |
M05.179 |
Rheumatoid lung disease with rheumatoid arthritis of unspecified ankle and foot |
M05.19 |
Rheumatoid lung disease with rheumatoid arthritis of multiple sites |
M05.20 |
Rheumatoid vasculitis with rheumatoid arthritis of unspecified site |
M05.211 |
Rheumatoid vasculitis with rheumatoid arthritis of right shoulder |
M05.212 |
Rheumatoid vasculitis with rheumatoid arthritis of left shoulder |
M05.219 |
Rheumatoid vasculitis with rheumatoid arthritis of unspecified shoulder |
M05.221 |
Rheumatoid vasculitis with rheumatoid arthritis of right elbow |
M05.222 |
Rheumatoid vasculitis with rheumatoid arthritis of left elbow |
M05.229 |
Rheumatoid vasculitis with rheumatoid arthritis of unspecified elbow |
M05.231 |
Rheumatoid vasculitis with rheumatoid arthritis of right wrist |
M05.232 |
Rheumatoid vasculitis with rheumatoid arthritis of left wrist |
M05.239 |
Rheumatoid vasculitis with rheumatoid arthritis of unspecified wrist |
M05.241 |
Rheumatoid vasculitis with rheumatoid arthritis of right hand |
M05.242 |
Rheumatoid vasculitis with rheumatoid arthritis of left hand |
M05.249 |
Rheumatoid vasculitis with rheumatoid arthritis of unspecified hand |
M05.251 |
Rheumatoid vasculitis with rheumatoid arthritis of right hip |
M05.252 |
Rheumatoid vasculitis with rheumatoid arthritis of left hip |
M05.259 |
Rheumatoid vasculitis with rheumatoid arthritis of unspecified hip |
M05.261 |
Rheumatoid vasculitis with rheumatoid arthritis of right knee |
M05.262 |
Rheumatoid vasculitis with rheumatoid arthritis of left knee |
M05.269 |
Rheumatoid vasculitis with rheumatoid arthritis of unspecified knee |
M05.271 |
Rheumatoid vasculitis with rheumatoid arthritis of right ankle and foot |
M05.272 |
Rheumatoid vasculitis with rheumatoid arthritis of left ankle and foot |
M05.279 |
Rheumatoid vasculitis with rheumatoid arthritis of unspecified ankle and foot |
M05.29 |
Rheumatoid vasculitis with rheumatoid arthritis of multiple sites |
M05.30 |
Rheumatoid heart disease with rheumatoid arthritis of unspecified site |
M05.311 |
Rheumatoid heart disease with rheumatoid arthritis of right shoulder |
M05.312 |
Rheumatoid heart disease with rheumatoid arthritis of left shoulder |
M05.319 |
Rheumatoid heart disease with rheumatoid arthritis of unspecified shoulder |
M05.321 |
Rheumatoid heart disease with rheumatoid arthritis of right elbow |
M05.322 |
Rheumatoid heart disease with rheumatoid arthritis of left elbow |
M05.329 |
Rheumatoid heart disease with rheumatoid arthritis of unspecified elbow |
M05.331 |
Rheumatoid heart disease with rheumatoid arthritis of right wrist |
M05.332 |
Rheumatoid heart disease with rheumatoid arthritis of left wrist |
M05.339 |
Rheumatoid heart disease with rheumatoid arthritis of unspecified wrist |
M05.341 |
Rheumatoid heart disease with rheumatoid arthritis of right hand |
M05.342 |
Rheumatoid heart disease with rheumatoid arthritis of left hand |
M05.349 |
Rheumatoid heart disease with rheumatoid arthritis of unspecified hand |
M05.351 |
Rheumatoid heart disease with rheumatoid arthritis of right hip |
M05.352 |
Rheumatoid heart disease with rheumatoid arthritis of left hip |
M05.359 |
Rheumatoid heart disease with rheumatoid arthritis of unspecified hip |
M05.361 |
Rheumatoid heart disease with rheumatoid arthritis of right knee |
M05.362 |
Rheumatoid heart disease with rheumatoid arthritis of left knee |
M05.369 |
Rheumatoid heart disease with rheumatoid arthritis of unspecified knee |
M05.371 |
Rheumatoid heart disease with rheumatoid arthritis of right ankle and foot |
M05.372 |
Rheumatoid heart disease with rheumatoid arthritis of left ankle and foot |
M05.379 |
Rheumatoid heart disease with rheumatoid arthritis of unspecified ankle and foot |
M05.39 |
Rheumatoid heart disease with rheumatoid arthritis of multiple sites |
M05.40 |
Rheumatoid myopathy with rheumatoid arthritis of unspecified site |
M05.411 |
Rheumatoid myopathy with rheumatoid arthritis of right shoulder |
M05.412 |
Rheumatoid myopathy with rheumatoid arthritis of left shoulder |
M05.419 |
Rheumatoid myopathy with rheumatoid arthritis of unspecified shoulder |
M05.421 |
Rheumatoid myopathy with rheumatoid arthritis of right elbow |
M05.422 |
Rheumatoid myopathy with rheumatoid arthritis of left elbow |
M05.429 |
Rheumatoid myopathy with rheumatoid arthritis of unspecified elbow |
M05.431 |
Rheumatoid myopathy with rheumatoid arthritis of right wrist |
M05.432 |
Rheumatoid myopathy with rheumatoid arthritis of left wrist |
M05.439 |
Rheumatoid myopathy with rheumatoid arthritis of unspecified wrist |
M05.441 |
Rheumatoid myopathy with rheumatoid arthritis of right hand |
M05.442 |
Rheumatoid myopathy with rheumatoid arthritis of left hand |
M05.449 |
Rheumatoid myopathy with rheumatoid arthritis of unspecified hand |
M05.451 |
Rheumatoid myopathy with rheumatoid arthritis of right hip |
M05.452 |
Rheumatoid myopathy with rheumatoid arthritis of left hip |
M05.459 |
Rheumatoid myopathy with rheumatoid arthritis of unspecified hip |
M05.461 |
Rheumatoid myopathy with rheumatoid arthritis of right knee |
M05.462 |
Rheumatoid myopathy with rheumatoid arthritis of left knee |
M05.469 |
Rheumatoid myopathy with rheumatoid arthritis of unspecified knee |
M05.471 |
Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot |
M05.472 |
Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot |
M05.479 |
Rheumatoid myopathy with rheumatoid arthritis of unspecified ankle and foot |
M05.49 |
Rheumatoid myopathy with rheumatoid arthritis of multiple sites |
M05.50 |
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified site |
M05.511 |
Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulder |
M05.512 |
Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulder |
M05.519 |
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified shoulder |
M05.521 |
Rheumatoid polyneuropathy with rheumatoid arthritis of right elbow |
M05.522 |
Rheumatoid polyneuropathy with rheumatoid arthritis of left elbow |
M05.529 |
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified elbow |
M05.531 |
Rheumatoid polyneuropathy with rheumatoid arthritis of right wrist |
M05.532 |
Rheumatoid polyneuropathy with rheumatoid arthritis of left wrist |
M05.539 |
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified wrist |
M05.541 |
Rheumatoid polyneuropathy with rheumatoid arthritis of right hand |
M05.542 |
Rheumatoid polyneuropathy with rheumatoid arthritis of left hand |
M05.549 |
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hand |
M05.551 |
Rheumatoid polyneuropathy with rheumatoid arthritis of right hip |
M05.552 |
Rheumatoid polyneuropathy with rheumatoid arthritis of left hip |
M05.559 |
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hip |
M05.561 |
Rheumatoid polyneuropathy with rheumatoid arthritis of right knee |
M05.562 |
Rheumatoid polyneuropathy with rheumatoid arthritis of left knee |
M05.569 |
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified knee |
M05.571 |
Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot |
M05.572 |
Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot |
M05.579 |
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified ankle and foot |
M05.59 |
Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites |
M05.60 |
Rheumatoid arthritis of unspecified site with involvement of other organs and systems |
M05.611 |
Rheumatoid arthritis of right shoulder with involvement of other organs and systems |
M05.612 |
Rheumatoid arthritis of left shoulder with involvement of other organs and systems |
M05.619 |
Rheumatoid arthritis of unspecified shoulder with involvement of other organs and systems |
M05.621 |
Rheumatoid arthritis of right elbow with involvement of other organs and systems |
M05.622 |
Rheumatoid arthritis of left elbow with involvement of other organs and systems |
M05.629 |
Rheumatoid arthritis of unspecified elbow with involvement of other organs and systems |
M05.631 |
Rheumatoid arthritis of right wrist with involvement of other organs and systems |
M05.632 |
Rheumatoid arthritis of left wrist with involvement of other organs and systems |
M05.639 |
Rheumatoid arthritis of unspecified wrist with involvement of other organs and systems |
M05.641 |
Rheumatoid arthritis of right hand with involvement of other organs and systems |
M05.642 |
Rheumatoid arthritis of left hand with involvement of other organs and systems |
M05.649 |
Rheumatoid arthritis of unspecified hand with involvement of other organs and systems |
M05.651 |
Rheumatoid arthritis of right hip with involvement of other organs and systems |
M05.652 |
Rheumatoid arthritis of left hip with involvement of other organs and systems |
M05.659 |
Rheumatoid arthritis of unspecified hip with involvement of other organs and systems |
M05.661 |
Rheumatoid arthritis of right knee with involvement of other organs and systems |
M05.662 |
Rheumatoid arthritis of left knee with involvement of other organs and systems |
M05.669 |
Rheumatoid arthritis of unspecified knee with involvement of other organs and systems |
M05.671 |
Rheumatoid arthritis of right ankle and foot with involvement of other organs and systems |
M05.672 |
Rheumatoid arthritis of left ankle and foot with involvement of other organs and systems |
M05.679 |
Rheumatoid arthritis of unspecified ankle and foot with involvement of other organs and systems |
M05.69 |
Rheumatoid arthritis of multiple sites with involvement of other organs and systems |
M05.7A |
Rheumatoid arthritis with rheumatoid factor of other specified site without organ or systems involvement |
M05.711 |
Rheumatoid arthritis with rheumatoid factor of right shoulder without organ or systems involvement |
M05.712 |
Rheumatoid arthritis with rheumatoid factor of left shoulder without organ or systems involvement |
M05.719 |
Rheumatoid arthritis with rheumatoid factor of unspecified shoulder without organ or systems involvement |
M05.721 |
Rheumatoid arthritis with rheumatoid factor of right elbow without organ or systems involvement |
M05.722 |
Rheumatoid arthritis with rheumatoid factor of left elbow without organ or systems involvement |
M05.729 |
Rheumatoid arthritis with rheumatoid factor of unspecified elbow without organ or systems involvement |
M05.731 |
Rheumatoid arthritis with rheumatoid factor of right wrist without organ or systems involvement |
M05.732 |
Rheumatoid arthritis with rheumatoid factor of left wrist without organ or systems involvement |
M05.739 |
Rheumatoid arthritis with rheumatoid factor of unspecified wrist without organ or systems involvement |
M05.741 |
Rheumatoid arthritis with rheumatoid factor of right hand without organ or systems involvement |
M05.742 |
Rheumatoid arthritis with rheumatoid factor of left hand without organ or systems involvement |
M05.749 |
Rheumatoid arthritis with rheumatoid factor of unspecified hand without organ or systems involvement |
M05.751 |
Rheumatoid arthritis with rheumatoid factor of right hip without organ or systems involvement |
M05.752 |
Rheumatoid arthritis with rheumatoid factor of left hip without organ or systems involvement |
M05.759 |
Rheumatoid arthritis with rheumatoid factor of unspecified hip without organ or systems involvement |
M05.761 |
Rheumatoid arthritis with rheumatoid factor of right knee without organ or systems involvement |
M05.762 |
Rheumatoid arthritis with rheumatoid factor of left knee without organ or systems involvement |
M05.769 |
Rheumatoid arthritis with rheumatoid factor of unspecified knee without organ or systems involvement |
M05.771 |
Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systems involvement |
M05.772 |
Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or systems involvement |
M05.779 |
Rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot without organ or systems involvement |
M05.79 |
Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement |
M05.8A |
Other rheumatoid arthritis with rheumatoid factor of other specified site |
M05.811 |
Other rheumatoid arthritis with rheumatoid factor of right shoulder |
M05.812 |
Other rheumatoid arthritis with rheumatoid factor of left shoulder |
M05.819 |
Other rheumatoid arthritis with rheumatoid factor of unspecified shoulder |
M05.821 |
Other rheumatoid arthritis with rheumatoid factor of right elbow |
M05.822 |
Other rheumatoid arthritis with rheumatoid factor of left elbow |
M05.829 |
Other rheumatoid arthritis with rheumatoid factor of unspecified elbow |
M05.831 |
Other rheumatoid arthritis with rheumatoid factor of right wrist |
M05.832 |
Other rheumatoid arthritis with rheumatoid factor of left wrist |
M05.839 |
Other rheumatoid arthritis with rheumatoid factor of unspecified wrist |
M05.841 |
Other rheumatoid arthritis with rheumatoid factor of right hand |
M05.842 |
Other rheumatoid arthritis with rheumatoid factor of left hand |
M05.849 |
Other rheumatoid arthritis with rheumatoid factor of unspecified hand |
M05.851 |
Other rheumatoid arthritis with rheumatoid factor of right hip |
M05.852 |
Other rheumatoid arthritis with rheumatoid factor of left hip |
M05.859 |
Other rheumatoid arthritis with rheumatoid factor of unspecified hip |
M05.861 |
Other rheumatoid arthritis with rheumatoid factor of right knee |
M05.862 |
Other rheumatoid arthritis with rheumatoid factor of left knee |
M05.869 |
Other rheumatoid arthritis with rheumatoid factor of unspecified knee |
M05.871 |
Other rheumatoid arthritis with rheumatoid factor of right ankle and foot |
M05.872 |
Other rheumatoid arthritis with rheumatoid factor of left ankle and foot |
M05.879 |
Other rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot |
M05.89 |
Other rheumatoid arthritis with rheumatoid factor of multiple sites |
M05.9 |
Rheumatoid arthritis with rheumatoid factor, unspecified |
M06.0A |
Rheumatoid arthritis without rheumatoid factor, other specified site |
M06.011 |
Rheumatoid arthritis without rheumatoid factor, right shoulder |
M06.012 |
Rheumatoid arthritis without rheumatoid factor, left shoulder |
M06.019 |
Rheumatoid arthritis without rheumatoid factor, unspecified shoulder |
M06.021 |
Rheumatoid arthritis without rheumatoid factor, right elbow |
M06.022 |
Rheumatoid arthritis without rheumatoid factor, left elbow |
M06.029 |
Rheumatoid arthritis without rheumatoid factor, unspecified elbow |
M06.031 |
Rheumatoid arthritis without rheumatoid factor, right wrist |
M06.032 |
Rheumatoid arthritis without rheumatoid factor, left wrist |
M06.039 |
Rheumatoid arthritis without rheumatoid factor, unspecified wrist |
M06.041 |
Rheumatoid arthritis without rheumatoid factor, right hand |
M06.042 |
Rheumatoid arthritis without rheumatoid factor, left hand |
M06.049 |
Rheumatoid arthritis without rheumatoid factor, unspecified hand |
M06.051 |
Rheumatoid arthritis without rheumatoid factor, right hip |
M06.052 |
Rheumatoid arthritis without rheumatoid factor, left hip |
M06.059 |
Rheumatoid arthritis without rheumatoid factor, unspecified hip |
M06.061 |
Rheumatoid arthritis without rheumatoid factor, right knee |
M06.062 |
Rheumatoid arthritis without rheumatoid factor, left knee |
M06.069 |
Rheumatoid arthritis without rheumatoid factor, unspecified knee |
M06.071 |
Rheumatoid arthritis without rheumatoid factor, right ankle and foot |
M06.072 |
Rheumatoid arthritis without rheumatoid factor, left ankle and foot |
M06.079 |
Rheumatoid arthritis without rheumatoid factor, unspecified ankle and foot |
M06.08 |
Rheumatoid arthritis without rheumatoid factor, vertebrae |
M06.09 |
Rheumatoid arthritis without rheumatoid factor, multiple sites |
M06.8A |
Other specified rheumatoid arthritis, other specified site |
M06.811 |
Other specified rheumatoid arthritis, right shoulder |
M06.812 |
Other specified rheumatoid arthritis, left shoulder |
M06.819 |
Other specified rheumatoid arthritis, unspecified shoulder |
M06.821 |
Other specified rheumatoid arthritis, right elbow |
M06.822 |
Other specified rheumatoid arthritis, left elbow |
M06.829 |
Other specified rheumatoid arthritis, unspecified elbow |
M06.831 |
Other specified rheumatoid arthritis, right wrist |
M06.832 |
Other specified rheumatoid arthritis, left wrist |
M06.839 |
Other specified rheumatoid arthritis, unspecified wrist |
M06.841 |
Other specified rheumatoid arthritis, right hand |
M06.842 |
Other specified rheumatoid arthritis, left hand |
M06.849 |
Other specified rheumatoid arthritis, unspecified hand |
M06.851 |
Other specified rheumatoid arthritis, right hip |
M06.852 |
Other specified rheumatoid arthritis, left hip |
M06.859 |
Other specified rheumatoid arthritis, unspecified hip |
M06.861 |
Other specified rheumatoid arthritis, right knee |
M06.862 |
Other specified rheumatoid arthritis, left knee |
M06.869 |
Other specified rheumatoid arthritis, unspecified knee |
M06.871 |
Other specified rheumatoid arthritis, right ankle and foot |
M06.872 |
Other specified rheumatoid arthritis, left ankle and foot |
M06.879 |
Other specified rheumatoid arthritis, unspecified ankle and foot |
M06.88 |
Other specified rheumatoid arthritis, vertebrae |
M06.89 |
Other specified rheumatoid arthritis, multiple sites |
M06.9 |
Rheumatoid arthritis, unspecified |
M31.10 |
Thrombotic microangiopathy, unspecified |
M31.30 |
Wegener’s granulomatosis without renal involvement |
M31.31 |
Wegener’s granulomatosis with renal involvement |
M31.7 |
Microscopic polyangiitis |
M32.10 |
Systemic lupus erythematosus organ or system involvement unspecified |
M32.11 |
Endocarditis in systemic lupus erythematosus |
M32.12 |
Pericarditis in systemic lupus erythematosus |
M32.13 |
Lung involvement in systemic lupus erythematosus |
M32.14 |
Glomerular disease in systemic lupus erythematosus |
M32.15 |
Tubulo-interstitial nephropathy in systemic lupus erythematosus |
M32.19 |
Other organ or system involvement in systemic lupus erythematosus |
M32.8 |
Other forms of systemic lupus erythematosus |
M32.9 |
Systemic lupus erythematosus, unspecified |
M60.80 |
Other myositis, unspecified site |
M60.811 |
Other myositis, right shoulder |
M60.812 |
Other myositis, left shoulder |
M60.819 |
Other myositis, unspecified shoulder |
M60.821 |
Other myositis, right upper arm |
M60.822 |
Other myositis, left upper arm |
M60.829 |
Other myositis, unspecified upper arm |
M60.831 |
Other myositis, right forearm |
M60.832 |
Other myositis, left forearm |
M60.839 |
Other myositis, unspecified forearm |
M60.841 |
Other myositis, right hand |
M60.842 |
Other myositis, left hand |
M60.849 |
Other myositis, unspecified hand |
M60.851 |
Other myositis, right thigh |
M60.852 |
Other myositis, left thigh |
M60.859 |
Other myositis, unspecified thigh |
M60.861 |
Other myositis, right lower leg |
M60.862 |
Other myositis, left lower leg |
M60.869 |
Other myositis, unspecified lower leg |
M60.871 |
Other myositis, right ankle and foot |
M60.872 |
Other myositis, left ankle and foot |
M60.879 |
Other myositis, unspecified ankle and foot |
M60.88 |
Other myositis, other site |
M60.89 |
Other myositis, multiple sites |
M79.10 |
Myalgia, unspecified site |
M79.11 |
Myalgia of mastication muscle |
M79.12 |
Myalgia of auxiliary muscles, head and neck |
M79.18 |
Myalgia, other site |
N04.0 |
Nephrotic syndrome with minor glomerular abnormality |
N04.1 |
Nephrotic syndrome with focal and segmental glomerular lesions |
N04.2 |
Nephrotic syndrome with diffuse membranous glomerulonephritis |
N04.21 |
Primary membranous nephropathy with nephrotic syndrome |
N04.3 |
Nephrotic syndrome with diffuse mesangial proliferative glomerulonephritis |
N04.4 |
Nephrotic syndrome with diffuse endocapillary proliferative glomerulonephritis |
N04.5 |
Nephrotic syndrome with diffuse mesangiocapillary glomerulonephritis |
N04.6 |
Nephrotic syndrome with dense deposit disease |
N04.621 |
Primary membranous nephropathy with isolated proteinuria |
N04.7 |
Nephrotic syndrome with diffuse crescentic glomerulonephritis |
N04.8 |
Nephrotic syndrome with other morphologic changes |
N04.9 |
Nephrotic syndrome with unspecified morphologic changes |
T86.09 |
Other complications of bone marrow transplant |
Z85.71 |
Personal history of Hodgkin lymphoma |
Z85.72 |
Personal history of non-Hodgkin lymphomas |
Z85.79 |
Personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues |
Z94.81 |
Bone marrow transplant status |
Z94.89 |
Other transplanted organ and tissue status |
Z94.9 |
Transplanted organ and tissue status, unspecified |
Appendix 2 – Centers for Medicare and Medicaid Services (CMS)
The preceding information is intended for non-Medicare coverage determinations. Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs) may exist and compliance with these policies is required where applicable. Local Coverage Articles (LCAs) may also exist for claims payment purposes or to clarify benefit eligibility under Part B for drugs which may be self-administered. The following link may be used to search for NCD, LCD, or LCA documents: https://www.cms.gov/medicare-coverage-database/search.aspx. Additional indications, including any preceding information, may be applied at the discretion of the health plan.
Medicare Part B Covered Diagnosis Codes |
||
Jurisdiction |
NCD/LCA/LCD Document (s) |
Contractor |
5,8 |
A55639 |
Wisconsin Physicians Service Insurance Corp (WPS) |
15 |
A57160, A58582 |
CGS Administrators, LLC |
6,K |
A59101 |
National Government Services, Inc |
J,M |
A56380 |
Palmetto GBA |
Medicare Part B Administrative Contractor (MAC) Jurisdictions |
||
Jurisdiction |
Applicable State/US Territory |
Contractor |
E (1) |
CA, HI, NV, AS, GU, CNMI |
Noridian Healthcare Solutions, LLC |
F (2 & 3) |
AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ |
Noridian Healthcare Solutions, LLC |
5 |
KS, NE, IA, MO |
Wisconsin Physicians Service Insurance Corp (WPS) |
6 |
MN, WI, IL |
National Government Services, Inc. (NGS) |
H (4 & 7) |
LA, AR, MS, TX, OK, CO, NM |
Novitas Solutions, Inc. |
8 |
MI, IN |
Wisconsin Physicians Service Insurance Corp (WPS) |
N (9) |
FL, PR, VI |
First Coast Service Options, Inc. |
J (10) |
TN, GA, AL |
Palmetto GBA |
M (11) |
NC, SC, WV, VA (excluding below) |
Palmetto GBA |
L (12) |
DE, MD, PA, NJ, DC (includes Arlington & Fairfax counties and the city of Alexandria in VA) |
Novitas Solutions, Inc. |
K (13 & 14) |
NY, CT, MA, RI, VT, ME, NH |
National Government Services, Inc. (NGS) |
15 |
KY, OH |
CGS Administrators, LLC |