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Simponi ARIA® (golimumab)
Policy Number: PH-0176
Intravenous
Last Review Date: 10/03/2023
Date of Origin: 09/05/2013
Dates Reviewed: 12/2013, 08/2014, 03/2015, 06/2015, 09/2015, 12/2015, 03/2016, 06/2016, 09/2016, 12/2016, 03/2017, 06/2017, 09/2017, 10/2017, 03/2018, 06/2018, 10/2018, 10/2019, 07/2020, 11/2020, 08/2021, 10/2022, 10/2023
FOR PEEHIP Members Only -Coverage excludes the provider-administered medication(s) outlined in this drug policy from being accessed through a specialty pharmacy. It must be obtained through buy and bill. |
- Length of Authorization
Coverage will be provided for 6 months and may be renewed, unless otherwise specified.
- Therapy for the Management of Immunotherapy-Related Toxicity may not be renewed.
- Dosing Limits
- Quantity Limit (max daily dose) [NDC Unit]:
- Simponi Aria 50 mg/4 mL single-dose vial for injection: 10 vials first 28 days, then 5 vials per 56 days
- Max Units (per dose and over time) [HCPCS Unit]:
- Management of Immune-Checkpoint Inhibitor Related Toxicity
- 250 billable units x 1 dose
- All other indications
- Loading Dose: 250 billable units on weeks 0 and 4
- Maintenance: 250 billable units every 8 weeks
- Initial Approval Criteria 1
Depending on member benefits, additional criteria may apply for coverage of this drug in an outpatient facility setting. Verify any Site of Service requirements with the member’s plan and refer to the Voluntary Site of Service Policy or the Mandatory Site of Service Policy for additional information. |
Coverage is provided in the following conditions:
- Patient is at least 18 years of age, unless otherwise specified; AND
- Patient has been evaluated and screened for the presence hepatitis B virus (HBV) infection prior to initiating treatment; AND
Universal Criteria 1
- Patient has been evaluated and screened for the presence of latent tuberculosis (TB) infection prior to initiating treatment and will receive ongoing monitoring for presence of TB during treatment; AND
- Patient does not have an active infection, including clinically important localized infections; AND
- Patient will not receive live vaccines while on therapy; AND
- Patient is not on concurrent treatment with another TNF inhibitor, IL-inhibitor, biologic response modifier or other non-biologic agent (e.g., apremilast, abrocitinib, tofacitinib, baricitinib, upadacitinib, deucravacitinib etc.); AND
Rheumatoid Arthritis (RA) † 1,17,20
- Physician has assessed baseline disease severity utilizing an objective measure/tool; AND
- Documented moderate to severe active disease; AND
- Patient has had at least a 3 month trial and failed of previous therapy with ONE oral disease modifying anti-rheumatic drug (DMARD) such as methotrexate, azathioprine, auranofin, hydroxychloroquine, penicillamine, sulfasalazine, leflunomide, etc.; AND
- Prescribed in combination with methotrexate unless contraindicated
Psoriatic Arthritis (PsA) † 1,18,22,23,27
- Patient is at least 2 years of age; AND
- Physician has assessed baseline disease severity utilizing an objective measure/tool; AND
- Documented moderate to severe active disease; AND
- For patients with predominantly axial disease, a trial and failure of at least a 4-week trial of ONE non-steroidal anti-inflammatory drug (NSAIDs), unless use is contraindicated; OR
- For patients with peripheral arthritis, dactylitis, OR active enthesitis, a trial and failure of at least a 3-month trial of ONE oral disease-modifying anti-rheumatic drug (DMARD) such as methotrexate, azathioprine, sulfasalazine, or hydroxychloroquine
Ankylosing Spondylitis (AS) † 1,7,19,28
- Physician has assessed baseline disease severity utilizing an objective measure/tool; AND
- Documented active disease; AND
- Patient had an adequate trial and failure of at least TWO (2) non-steroidal anti-inflammatory drugs (NSAIDs) over 4 weeks (in total), unless use is contraindicated
Polyarticular Juvenile Idiopathic Arthritis (pJIA) † Ф 1,14,21
- Patient is at least 2 years of age; AND
- Physician has assessed baseline disease severity utilizing an objective measure/tool; AND
- Documented moderate to severe active polyarticular disease; AND
- May be used alone or in combination with methotrexate; AND
- Patient has had at least a 1-month trial and failure (unless contraindicated or intolerant) of previous therapy with either oral non-steroidal anti-inflammatory drugs (NSAIDs) OR an oral disease-modifying anti-rheumatic drug (DMARD) (e.g., methotrexate, leflunomide, sulfasalazine, etc.)
Management of Immune Checkpoint Inhibitor-Related Toxicities ‡ 29,30
- Patient has been receiving therapy with an immune checkpoint inhibitor (e.g., nivolumab, pembrolizumab, atezolizumab, avelumab, durvalumab, cemiplimab, ipilimumab, tremelimumab, dostarlimab, etc.); AND
- Patient has moderate or severe immunotherapy-related inflammatory arthritis; AND
- Used as additional disease modifying antirheumatic drug (DMARD) therapy; AND
- Patient’s symptoms have not improved after holding immunotherapy AND one of the following:
- Patient has not responded to oral corticosteroids; OR
- Patient is unable to taper corticosteroids; OR
- Patient has not had response to conventional synthetic (cs) DMARDs (i.e., methotrexate, hydroxychloroquine, leflunomide, or sulfasalazine)
† FDA Approved Indication(s); ‡ Compendia Recommended Indication(s); Ф Orphan Drug
- Renewal Criteria 1
Coverage can be renewed based upon the following criteria:
- Patient continues to meet 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: serious infections, congestive heart failure, malignancy, demyelinating disorders, lupus-like syndrome, severe hypersensitivity reactions (including anaphylaxis), severe hematologic cytopenias (e.g., pancytopenia, leukopenia, neutropenia, agranulocytosis, aplastic anemia, thrombocytopenia), etc.; AND
Rheumatoid Arthritis (RA) 9-11
- Disease response as indicated by improvement in signs and symptoms compared to baseline such as the number of tender and swollen joint counts, reduction of C-reactive protein, improvement of patient global assessment, and/or an improvement on a disease activity scoring tool [e.g. an improvement on a composite scoring index such as Disease Activity Score-28 (DAS28) of 1.2 points or more or a ≥20% improvement on the American College of Rheumatology-20 (ACR20) criteria].
Psoriatic Arthritis (PsA) 8,25
- Disease response as indicated by improvement in signs and symptoms compared to baseline such as the number of tender and swollen joint counts and/or an improvement on a disease activity scoring tool [e.g., defined as an improvement in at least 2 of the 4 Psoriatic Arthritis Response Criteria (PsARC), 1 of which must be joint tenderness or swelling score, with no worsening in any of the 4 criteria].
Ankylosing Spondylitis (AS) 7,24,28
- Disease response as indicated by improvement in signs and symptoms compared to baseline such as total back pain, physical function, morning stiffness, and/or an improvement on a disease activity scoring tool [e.g. ≥ 1.1 improvement on the Ankylosing Spondylitis Disease Activity Score (ASDAS) or an improvement of ≥ 2 on the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)].
Polyarticular Juvenile Idiopathic Arthritis (pJIA) 15,16
- Disease response as indicated by improvement in signs and symptoms compared to baseline such as the number of tender and swollen joint counts, reduction of C-reactive protein, improvement of patient global assessment, and/or an improvement on a disease activity scoring tool [e.g., an improvement on a composite scoring index such as Juvenile Arthritis Disease Activity Score (JADAS) or the American College of Rheumatology (ACR) Pediatric (ACR-Pedi 30) of at least 30% improvement from baseline in three of six variables].
Management of Immunotherapy-Related Toxicity 29,30
- May not be renewed
- Dosage/Administration 1,13
Indication |
Dose |
Rheumatoid Arthritis, Ankylosing Spondylitis |
|
Psoriatic Arthritis |
Adult
Pediatric
|
Polyarticular Juvenile Idiopathic Arthritis |
|
Management of Immunotherapy-Related Toxicity |
|
- Billing Code/Availability Information
HCPCS Code:
- J1602 - Injection, golimumab, 1 mg, for intravenous use; 1mg = 1 billable unit
NDC:
- Simponi ARIA 50 mg/4 mL injection, single-dose vial: 57894-0350-xx
- References
- Simponi ARIA [package insert]. Horsham, PA; Janssen Biotech Inc; July 2023. Accessed September 2023.
- Singh JA, Saag KG, Bridges SL Jr, et al. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care Res (Hoboken). 2015 Nov 6. doi: 10.1002/acr.22783.
- Weinblatt ME, Bingham CO 3rd, Mendelsohn AM, et al. Intravenous golimumab is effective in patients with active rheumatoid arthritis despite methotrexate therapy with responses as early as week 2: results of the phase 3, randomised, multicentre, double-blind, placebo-controlled GO-FURTHER trial. Ann Rheum Dis. 2013 Mar;72(3):381-9. doi: 10.1136/annrheumdis-2012-201411. Epub 2012 Jun 1.
- Smolen JS, Landewé R, Bijlsma J, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update. Ann Rheum Dis. 2017 Mar 6. pii: annrheumdis-2016-210715.
- Gottlieb A, Korman NJ, Gordon KB, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 2. Psoriatic arthritis: overview and guidelines of care for treatment with an emphasis on the biologics. J Am Acad Dermatol 2008 May; 58(5):851-64.
- Ramiro S, Smolen JS, Landewé R, et al. Pharmacological treatment of psoriatic arthritis: a systematic literature review for the 2015 update of the EULAR recommendations for the management of psoriatic arthritis. Ann Rheum Dis 2016;75:490-498 doi:10.1136/annrheumdis-2015-208466
- Van Der Heijde D, Ramiro S, Landewe R, et al. 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Annals of the Rheumatic Diseases Published Online First: 13 January 2017. Doi: 10.1136/annrheumdis-2016-210770.
- National Institute for Health and Care Excellence. NICE 2017. Certolizumab pegol and secukinumab for treating active psoriatic arthritis after inadequate response to DMARDs. Published 24 May 2017. Technology Appraisal Guidance [TA445]. https://www.nice.org.uk/guidance/ta445. Accessed September 2023.
- National Institute for Health and Care Excellence. NICE 2018. Rheumatoid Arthritis in Adults: Management. Published 11th July 2018. NICE Guideline [NG100]. https://www.nice.org.uk/guidance/ng100/chapter/Recommendations.
- National Institute for Health and Care Excellence. NICE 2010. Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after failure of a TNF inhibitor. Published 10 October 2012. Clinical Guideline [TA195]. https://www.nice.org.uk/guidance/ta195/resources/adalimumab-etanercept-infliximab-rituximab-and-abatacept-for-the-treatment-of-rheumatoid-arthritis-after-the-failure-of-a-tnf-inhibitor-pdf-82598558287813.
- Ward MM, Guthri LC, Alba MI. Rheumatoid Arthritis Response Criteria And Patient-Reported Improvement in Arthritis Activity: Is an ACR20 Response Meaningful to Patients”. Arthritis Rheumatol. 2014 Sep; 66(9): 2339–2343. doi: 10.1002/art.38705.
- Ward M, Deodhar A, Gensler L, et al. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. 2019 Aug; Arthritis Care Res. doi: 10.1002/acr.24025.
- Fahrenbruch R, Kintzel P, Bott AM, et al. Dose Rounding of Biologic and Cytotoxic Anticancer Agents: A Position Statement of the Hematology/Oncology Pharmacy Association. J Oncol Pract. 2018 Mar;14(3):e130-e136.
- Ringold S, Angeles‐Han ST, Beukelman T, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Treatment of Juvenile Idiopathic Arthritis: Therapeutic Approaches for Non-Systemic Polyarthritis, Sacroiliitis, and Enthesitis. Arthritis Care & Research, Vol. 71, No. 6, June 2019, pp 717–734 DOI 10.1002/acr.23870.
- Ringold S, Bittner R, Neggi T, et al. Performance of rheumatoid arthritis disease activity measures and juvenile arthritis disease activity scores in polyarticular-course juvenile idiopathic arthritis: Analysis of their ability to classify the American College of Rheumatology pediatric measures of response and the preliminary criteria for flare and inactive disease. Arthritis Care Res (Hoboken). 2010 Aug;62(8):1095-102.
- Consolaro A, Giancane G, Schiappapietra B, et al. Clinical outcome measures in juvenile idiopathic arthritis. Pediatric Rheumatology 18 April 2016 14:23.
- Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care Res (Hoboken). 2021 Jun 8. doi: 10.1002/acr.24596.
- Gossec L, Baraliakos X, Kerschbaumer A, et al. EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2019 update. Ann Rheum Dis. 2020 Jun;79(6):700-712. doi: 10.1136/annrheumdis-2020-217159.
- Ward MM, Deodhar A, Gensler LS, et al. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol. 2019 Oct;71(10):1599-1613. doi: 10.1002/art.41042.
- Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Annals of the Rheumatic Diseases 2020;79:685-699.
- Ringold S, Weiss PF, Beukelman T, et al. 2013 update of the 2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis: recommendations for the medical therapy of children with systemic juvenile idiopathic arthritis and tuberculosis screening among children receiving biologic medications. Arthritis Rheum. 2013 Oct;65(10):2499-512.
- Singh JA, Guyatt G, Ogdie A, et al. 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis. Arthritis Rheumatol. 2019 Jan;71(1):5-32. Doi: 10.1002/art.40726.
- American Academy of Dermatology Work Group. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 6. Guidelines of care for the treatment of psoriasis and psoriatic arthritis: case-based presentations and evidence-based conclusions. J Am Acad Dermatol. 2011 Jul;65(1):137-74. Doi: 10.1016/j.jaad.2010.11.055.
- National Institute for Health and Care Excellence (NICE). Spondyloarthritis. Quality standard [QS170]. Published: 28 June 2018 https://www.nice.org.uk/guidance/qs170/chapter/Quality-statements. Accessed September 2023.
- Mease PJ. Measures of psoriatic arthritis: Tender and Swollen Joint Assessment, Psoriasis Area and Severity Index (PASI), Nail Psoriasis Severity Index (NAPSI), Modified Nail Psoriasis Severity Index (mNAPSI), Mander/Newcastle Enthesitis Index (MEI), Leeds Enthesitis Index (LEI), Spondyloarthritis Research Consortium of Canada (SPARCC), Maastricht Ankylosing Spondylitis Enthesis Score (MASES), Leeds Dactylitis Index (LDI), Patient Global for Psoriatic Arthritis, Dermatology Life Quality Index (DLQI), Psoriatic Arthritis Quality of Life (PsAQOL), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Psoriatic Arthritis Response Criteria (PsARC), Psoriatic Arthritis Joint Activity Index (PsAJAI), Disease Activity in Psoriatic Arthritis (DAPSA), and Composite Psoriatic Disease Activity Index (CPDAI). Arthritis Care Res (Hoboken). 2011 Nov;63 Suppl 11:S64-85. doi: 10.1002/acr.20577.
- Elmets CA, Korman NL, Prater EF, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures. J Am Acad Dermatol 2021 Feb; 84(2):432-470. Doi: 10.1016/j.jaad.2020.07.087
- Tucker L, Allen A, Chandler D, et al. The 2022 British Society for Rheumatology guideline for the treatment of psoriatic arthritis with biologic and targeted synthetic DMARDs. Rheum 2022 Sept; 61(9): e255–e266. Doi: 10.1093/rheumatology/keac295.
- Ramiro S, Nikiphorou E, Sepriano A, et al. ASAS-EULAR recommendations for the management of axial spondyloarthritis: 2022 update. Ann Rheum Dis. 2023 Jan; 82(1):19–34. doi:10.1136/ard-2022-223296
- Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) golimumab. National Comprehensive Cancer Network, 2023. The NCCN Compendium® is a derivative work of the NCCN Guidelines®. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed September 2023.
- Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) Management of Immunotherapy-Related Toxicities. Version 2.2023. National Comprehensive Cancer Network, 2023. The NCCN Compendium® is a derivative work of the NCCN Guidelines®. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed September 2023.
Appendix 1 – Covered Diagnosis Codes
ICD-10 |
ICD-10 Description |
L40.50 |
Arthropathic psoriasis, unspecified |
L40.51 |
Distal interphalangeal psoriatic arthropathy |
L40.52 |
Psoriatic arthritis mutilans |
L40.53 |
Psoriatic spondylitis |
L40.59 |
Other psoriatic arthropathy |
M05.10 |
Rheumatoid lung disease with rheumatoid arthritis of unspecified site |
M05.111 |
Rheumatoid lung disease with rheumatoid arthritis of right shoulder |
M05.112 |
Rheumatoid lung disease with rheumatoid arthritis of left shoulder |
M05.119 |
Rheumatoid lung disease with rheumatoid arthritis of unspecified shoulder |
M05.121 |
Rheumatoid lung disease with rheumatoid arthritis of right elbow |
M05.122 |
Rheumatoid lung disease with rheumatoid arthritis of left elbow |
M05.129 |
Rheumatoid lung disease with rheumatoid arthritis of unspecified elbow |
M05.131 |
Rheumatoid lung disease with rheumatoid arthritis of right wrist |
M05.132 |
Rheumatoid lung disease with rheumatoid arthritis of left wrist |
M05.139 |
Rheumatoid lung disease with rheumatoid arthritis of unspecified wrist |
M05.141 |
Rheumatoid lung disease with rheumatoid arthritis of right hand |
M05.142 |
Rheumatoid lung disease with rheumatoid arthritis of left hand |
M05.149 |
Rheumatoid lung disease with rheumatoid arthritis of unspecified hand |
M05.151 |
Rheumatoid lung disease with rheumatoid arthritis of right hip |
M05.152 |
Rheumatoid lung disease with rheumatoid arthritis of left hip |
M05.159 |
Rheumatoid lung disease with rheumatoid arthritis of unspecified hip |
M05.161 |
Rheumatoid lung disease with rheumatoid arthritis of right knee |
M05.162 |
Rheumatoid lung disease with rheumatoid arthritis of left knee |
M05.169 |
Rheumatoid lung disease with rheumatoid arthritis of unspecified knee |
M05.171 |
Rheumatoid lung disease with rheumatoid arthritis of right ankle and foot |
M05.172 |
Rheumatoid lung disease with rheumatoid arthritis of left ankle and foot |
M05.179 |
Rheumatoid lung disease with rheumatoid arthritis of unspecified ankle and foot |
M05.19 |
Rheumatoid lung disease with rheumatoid arthritis of multiple sites |
M05.20 |
Rheumatoid vasculitis with rheumatoid arthritis of unspecified site |
M05.211 |
Rheumatoid vasculitis with rheumatoid arthritis of right shoulder |
M05.212 |
Rheumatoid vasculitis with rheumatoid arthritis of left shoulder |
M05.219 |
Rheumatoid vasculitis with rheumatoid arthritis of unspecified shoulder |
M05.221 |
Rheumatoid vasculitis with rheumatoid arthritis of right elbow |
M05.222 |
Rheumatoid vasculitis with rheumatoid arthritis of left elbow |
M05.229 |
Rheumatoid vasculitis with rheumatoid arthritis of unspecified elbow |
M05.231 |
Rheumatoid vasculitis with rheumatoid arthritis of right wrist |
M05.232 |
Rheumatoid vasculitis with rheumatoid arthritis of left wrist |
M05.239 |
Rheumatoid vasculitis with rheumatoid arthritis of unspecified wrist |
M05.241 |
Rheumatoid vasculitis with rheumatoid arthritis of right hand |
M05.242 |
Rheumatoid vasculitis with rheumatoid arthritis of left hand |
M05.249 |
Rheumatoid vasculitis with rheumatoid arthritis of unspecified hand |
M05.251 |
Rheumatoid vasculitis with rheumatoid arthritis of right hip |
M05.252 |
Rheumatoid vasculitis with rheumatoid arthritis of left hip |
M05.259 |
Rheumatoid vasculitis with rheumatoid arthritis of unspecified hip |
M05.261 |
Rheumatoid vasculitis with rheumatoid arthritis of right knee |
M05.262 |
Rheumatoid vasculitis with rheumatoid arthritis of left knee |
M05.269 |
Rheumatoid vasculitis with rheumatoid arthritis of unspecified knee |
M05.271 |
Rheumatoid vasculitis with rheumatoid arthritis of right ankle and foot |
M05.272 |
Rheumatoid vasculitis with rheumatoid arthritis of left ankle and foot |
M05.279 |
Rheumatoid vasculitis with rheumatoid arthritis of unspecified ankle and foot |
M05.29 |
Rheumatoid vasculitis with rheumatoid arthritis of multiple sites |
M05.30 |
Rheumatoid heart disease with rheumatoid arthritis of unspecified site |
M05.311 |
Rheumatoid heart disease with rheumatoid arthritis of right shoulder |
M05.312 |
Rheumatoid heart disease with rheumatoid arthritis of left shoulder |
M05.319 |
Rheumatoid heart disease with rheumatoid arthritis of unspecified shoulder |
M05.321 |
Rheumatoid heart disease with rheumatoid arthritis of right elbow |
M05.322 |
Rheumatoid heart disease with rheumatoid arthritis of left elbow |
M05.329 |
Rheumatoid heart disease with rheumatoid arthritis of unspecified elbow |
M05.331 |
Rheumatoid heart disease with rheumatoid arthritis of right wrist |
M05.332 |
Rheumatoid heart disease with rheumatoid arthritis of left wrist |
M05.339 |
Rheumatoid heart disease with rheumatoid arthritis of unspecified wrist |
M05.341 |
Rheumatoid heart disease with rheumatoid arthritis of right hand |
M05.342 |
Rheumatoid heart disease with rheumatoid arthritis of left hand |
M05.349 |
Rheumatoid heart disease with rheumatoid arthritis of unspecified hand |
M05.351 |
Rheumatoid heart disease with rheumatoid arthritis of right hip |
M05.352 |
Rheumatoid heart disease with rheumatoid arthritis of left hip |
M05.359 |
Rheumatoid heart disease with rheumatoid arthritis of unspecified hip |
M05.361 |
Rheumatoid heart disease with rheumatoid arthritis of right knee |
M05.362 |
Rheumatoid heart disease with rheumatoid arthritis of left knee |
M05.369 |
Rheumatoid heart disease with rheumatoid arthritis of unspecified knee |
M05.371 |
Rheumatoid heart disease with rheumatoid arthritis of right ankle and foot |
M05.372 |
Rheumatoid heart disease with rheumatoid arthritis of left ankle and foot |
M05.379 |
Rheumatoid heart disease with rheumatoid arthritis of unspecified ankle and foot |
M05.39 |
Rheumatoid heart disease with rheumatoid arthritis of multiple sites |
M05.40 |
Rheumatoid myopathy with rheumatoid arthritis of unspecified site |
M05.411 |
Rheumatoid myopathy with rheumatoid arthritis of right shoulder |
M05.412 |
Rheumatoid myopathy with rheumatoid arthritis of left shoulder |
M05.419 |
Rheumatoid myopathy with rheumatoid arthritis of unspecified shoulder |
M05.421 |
Rheumatoid myopathy with rheumatoid arthritis of right elbow |
M05.422 |
Rheumatoid myopathy with rheumatoid arthritis of left elbow |
M05.429 |
Rheumatoid myopathy with rheumatoid arthritis of unspecified elbow |
M05.431 |
Rheumatoid myopathy with rheumatoid arthritis of right wrist |
M05.432 |
Rheumatoid myopathy with rheumatoid arthritis of left wrist |
M05.439 |
Rheumatoid myopathy with rheumatoid arthritis of unspecified wrist |
M05.441 |
Rheumatoid myopathy with rheumatoid arthritis of right hand |
M05.442 |
Rheumatoid myopathy with rheumatoid arthritis of left hand |
M05.449 |
Rheumatoid myopathy with rheumatoid arthritis of unspecified hand |
M05.451 |
Rheumatoid myopathy with rheumatoid arthritis of right hip |
M05.452 |
Rheumatoid myopathy with rheumatoid arthritis of left hip |
M05.459 |
Rheumatoid myopathy with rheumatoid arthritis of unspecified hip |
M05.461 |
Rheumatoid myopathy with rheumatoid arthritis of right knee |
M05.462 |
Rheumatoid myopathy with rheumatoid arthritis of left knee |
M05.469 |
Rheumatoid myopathy with rheumatoid arthritis of unspecified knee |
M05.471 |
Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot |
M05.472 |
Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot |
M05.479 |
Rheumatoid myopathy with rheumatoid arthritis of unspecified ankle and foot |
M05.49 |
Rheumatoid myopathy with rheumatoid arthritis of multiple sites |
M05.50 |
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified site |
M05.511 |
Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulder |
M05.512 |
Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulder |
M05.519 |
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified shoulder |
M05.521 |
Rheumatoid polyneuropathy with rheumatoid arthritis of right elbow |
M05.522 |
Rheumatoid polyneuropathy with rheumatoid arthritis of left elbow |
M05.529 |
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified elbow |
M05.531 |
Rheumatoid polyneuropathy with rheumatoid arthritis of right wrist |
M05.532 |
Rheumatoid polyneuropathy with rheumatoid arthritis of left wrist |
M05.539 |
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified wrist |
M05.541 |
Rheumatoid polyneuropathy with rheumatoid arthritis of right hand |
M05.542 |
Rheumatoid polyneuropathy with rheumatoid arthritis of left hand |
M05.549 |
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hand |
M05.551 |
Rheumatoid polyneuropathy with rheumatoid arthritis of right hip |
M05.552 |
Rheumatoid polyneuropathy with rheumatoid arthritis of left hip |
M05.559 |
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hip |
M05.561 |
Rheumatoid polyneuropathy with rheumatoid arthritis of right knee |
M05.562 |
Rheumatoid polyneuropathy with rheumatoid arthritis of left knee |
M05.569 |
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified knee |
M05.571 |
Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot |
M05.572 |
Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot |
M05.579 |
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified ankle and foot |
M05.59 |
Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites |
M05.60 |
Rheumatoid arthritis of unspecified site with involvement of other organs and systems |
M05.611 |
Rheumatoid arthritis of right shoulder with involvement of other organs and systems |
M05.612 |
Rheumatoid arthritis of left shoulder with involvement of other organs and systems |
M05.619 |
Rheumatoid arthritis of unspecified shoulder with involvement of other organs and systems |
M05.621 |
Rheumatoid arthritis of right elbow with involvement of other organs and systems |
M05.622 |
Rheumatoid arthritis of left elbow with involvement of other organs and systems |
M05.629 |
Rheumatoid arthritis of unspecified elbow with involvement of other organs and systems |
M05.631 |
Rheumatoid arthritis of right wrist with involvement of other organs and systems |
M05.632 |
Rheumatoid arthritis of left wrist with involvement of other organs and systems |
M05.639 |
Rheumatoid arthritis of unspecified wrist with involvement of other organs and systems |
M05.641 |
Rheumatoid arthritis of right hand with involvement of other organs and systems |
M05.642 |
Rheumatoid arthritis of left hand with involvement of other organs and systems |
M05.649 |
Rheumatoid arthritis of unspecified hand with involvement of other organs and systems |
M05.651 |
Rheumatoid arthritis of right hip with involvement of other organs and systems |
M05.652 |
Rheumatoid arthritis of left hip with involvement of other organs and systems |
M05.659 |
Rheumatoid arthritis of unspecified hip with involvement of other organs and systems |
M05.661 |
Rheumatoid arthritis of right knee with involvement of other organs and systems |
M05.662 |
Rheumatoid arthritis of left knee with involvement of other organs and systems |
M05.669 |
Rheumatoid arthritis of unspecified knee with involvement of other organs and systems |
M05.671 |
Rheumatoid arthritis of right ankle and foot with involvement of other organs and systems |
M05.672 |
Rheumatoid arthritis of left ankle and foot with involvement of other organs and systems |
M05.679 |
Rheumatoid arthritis of unspecified ankle and foot with involvement of other organs and systems |
M05.69 |
Rheumatoid arthritis of multiple sites with involvement of other organs and systems |
M05.7A |
Rheumatoid arthritis with rheumatoid factor of other specified site without organ or systems involvement |
M05.711 |
Rheumatoid arthritis with rheumatoid factor of right shoulder without organ or systems involvement |
M05.712 |
Rheumatoid arthritis with rheumatoid factor of left shoulder without organ or systems involvement |
M05.719 |
Rheumatoid arthritis with rheumatoid factor of unspecified shoulder without organ or systems involvement |
M05.721 |
Rheumatoid arthritis with rheumatoid factor of right elbow without organ or systems involvement |
M05.722 |
Rheumatoid arthritis with rheumatoid factor of left elbow without organ or systems involvement |
M05.729 |
Rheumatoid arthritis with rheumatoid factor of unspecified elbow without organ or systems involvement |
M05.731 |
Rheumatoid arthritis with rheumatoid factor of right wrist without organ or systems involvement |
M05.732 |
Rheumatoid arthritis with rheumatoid factor of left wrist without organ or systems involvement |
M05.739 |
Rheumatoid arthritis with rheumatoid factor of unspecified wrist without organ or systems involvement |
M05.741 |
Rheumatoid arthritis with rheumatoid factor of right hand without organ or systems involvement |
M05.742 |
Rheumatoid arthritis with rheumatoid factor of left hand without organ or systems involvement |
M05.749 |
Rheumatoid arthritis with rheumatoid factor of unspecified hand without organ or systems involvement |
M05.751 |
Rheumatoid arthritis with rheumatoid factor of right hip without organ or systems involvement |
M05.752 |
Rheumatoid arthritis with rheumatoid factor of left hip without organ or systems involvement |
M05.759 |
Rheumatoid arthritis with rheumatoid factor of unspecified hip without organ or systems involvement |
M05.761 |
Rheumatoid arthritis with rheumatoid factor of right knee without organ or systems involvement |
M05.762 |
Rheumatoid arthritis with rheumatoid factor of left knee without organ or systems involvement |
M05.769 |
Rheumatoid arthritis with rheumatoid factor of unspecified knee without organ or systems involvement |
M05.771 |
Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systems involvement |
M05.772 |
Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or systems involvement |
M05.779 |
Rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot without organ or systems involvement |
M05.79 |
Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement |
M05.8A |
Other rheumatoid arthritis with rheumatoid factor of other specified site |
M05.811 |
Other rheumatoid arthritis with rheumatoid factor of right shoulder |
M05.812 |
Other rheumatoid arthritis with rheumatoid factor of left shoulder |
M05.819 |
Other rheumatoid arthritis with rheumatoid factor of unspecified shoulder |
M05.821 |
Other rheumatoid arthritis with rheumatoid factor of right elbow |
M05.822 |
Other rheumatoid arthritis with rheumatoid factor of left elbow |
M05.829 |
Other rheumatoid arthritis with rheumatoid factor of unspecified elbow |
M05.831 |
Other rheumatoid arthritis with rheumatoid factor of right wrist |
M05.832 |
Other rheumatoid arthritis with rheumatoid factor of left wrist |
M05.839 |
Other rheumatoid arthritis with rheumatoid factor of unspecified wrist |
M05.841 |
Other rheumatoid arthritis with rheumatoid factor of right hand |
M05.842 |
Other rheumatoid arthritis with rheumatoid factor of left hand |
M05.849 |
Other rheumatoid arthritis with rheumatoid factor of unspecified hand |
M05.851 |
Other rheumatoid arthritis with rheumatoid factor of right hip |
M05.852 |
Other rheumatoid arthritis with rheumatoid factor of left hip |
M05.859 |
Other rheumatoid arthritis with rheumatoid factor of unspecified hip |
M05.861 |
Other rheumatoid arthritis with rheumatoid factor of right knee |
M05.862 |
Other rheumatoid arthritis with rheumatoid factor of left knee |
M05.869 |
Other rheumatoid arthritis with rheumatoid factor of unspecified knee |
M05.871 |
Other rheumatoid arthritis with rheumatoid factor of right ankle and foot |
M05.872 |
Other rheumatoid arthritis with rheumatoid factor of left ankle and foot |
M05.879 |
Other rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot |
M05.89 |
Other rheumatoid arthritis with rheumatoid factor of multiple sites |
M05.9 |
Rheumatoid arthritis with rheumatoid factor, unspecified |
M06.0A |
Rheumatoid arthritis without rheumatoid factor, other specified site |
M06.011 |
Rheumatoid arthritis without rheumatoid factor, right shoulder |
M06.012 |
Rheumatoid arthritis without rheumatoid factor, left shoulder |
M06.019 |
Rheumatoid arthritis without rheumatoid factor, unspecified shoulder |
M06.021 |
Rheumatoid arthritis without rheumatoid factor, right elbow |
M06.022 |
Rheumatoid arthritis without rheumatoid factor, left elbow |
M06.029 |
Rheumatoid arthritis without rheumatoid factor, unspecified elbow |
M06.031 |
Rheumatoid arthritis without rheumatoid factor, right wrist |
M06.032 |
Rheumatoid arthritis without rheumatoid factor, left wrist |
M06.039 |
Rheumatoid arthritis without rheumatoid factor, unspecified wrist |
M06.041 |
Rheumatoid arthritis without rheumatoid factor, right hand |
M06.042 |
Rheumatoid arthritis without rheumatoid factor, left hand |
M06.049 |
Rheumatoid arthritis without rheumatoid factor, unspecified hand |
M06.051 |
Rheumatoid arthritis without rheumatoid factor, right hip |
M06.052 |
Rheumatoid arthritis without rheumatoid factor, left hip |
M06.059 |
Rheumatoid arthritis without rheumatoid factor, unspecified hip |
M06.061 |
Rheumatoid arthritis without rheumatoid factor, right knee |
M06.062 |
Rheumatoid arthritis without rheumatoid factor, left knee |
M06.069 |
Rheumatoid arthritis without rheumatoid factor, unspecified knee |
M06.071 |
Rheumatoid arthritis without rheumatoid factor, right ankle and foot |
M06.072 |
Rheumatoid arthritis without rheumatoid factor, left ankle and foot |
M06.079 |
Rheumatoid arthritis without rheumatoid factor, unspecified ankle and foot |
M06.08 |
Rheumatoid arthritis without rheumatoid factor, vertebrae |
M06.09 |
Rheumatoid arthritis without rheumatoid factor, multiple sites |
M06.4 |
Inflammatory polyarthropathy |
M06.8A |
Other specified rheumatoid arthritis, other specified site |
M06.811 |
Other specified rheumatoid arthritis, right shoulder |
M06.812 |
Other specified rheumatoid arthritis, left shoulder |
M06.819 |
Other specified rheumatoid arthritis, unspecified shoulder |
M06.821 |
Other specified rheumatoid arthritis, right elbow |
M06.822 |
Other specified rheumatoid arthritis, left elbow |
M06.829 |
Other specified rheumatoid arthritis, unspecified elbow |
M06.831 |
Other specified rheumatoid arthritis, right wrist |
M06.832 |
Other specified rheumatoid arthritis, left wrist |
M06.839 |
Other specified rheumatoid arthritis, unspecified wrist |
M06.841 |
Other specified rheumatoid arthritis, right hand |
M06.842 |
Other specified rheumatoid arthritis, left hand |
M06.849 |
Other specified rheumatoid arthritis, unspecified hand |
M06.851 |
Other specified rheumatoid arthritis, right hip |
M06.852 |
Other specified rheumatoid arthritis, left hip |
M06.859 |
Other specified rheumatoid arthritis, unspecified hip |
M06.861 |
Other specified rheumatoid arthritis, right knee |
M06.862 |
Other specified rheumatoid arthritis, left knee |
M06.869 |
Other specified rheumatoid arthritis, unspecified knee |
M06.871 |
Other specified rheumatoid arthritis, right ankle and foot |
M06.872 |
Other specified rheumatoid arthritis, left ankle and foot |
M06.879 |
Other specified rheumatoid arthritis, unspecified ankle and foot |
M06.88 |
Other specified rheumatoid arthritis, vertebrae |
M06.89 |
Other specified rheumatoid arthritis, multiple sites |
M06.9 |
Rheumatoid arthritis, unspecified |
M08.0A |
Unspecified juvenile rheumatoid arthritis, other specified site |
M08.011 |
Unspecified juvenile rheumatoid arthritis, right shoulder |
M08.012 |
Unspecified juvenile rheumatoid arthritis, left shoulder |
M08.019 |
Unspecified juvenile rheumatoid arthritis, unspecified shoulder |
M08.021 |
Unspecified juvenile rheumatoid arthritis, right elbow |
M08.022 |
Unspecified juvenile rheumatoid arthritis, left elbow |
M08.029 |
Unspecified juvenile rheumatoid arthritis, unspecified elbow |
M08.031 |
Unspecified juvenile rheumatoid arthritis, right wrist |
M08.032 |
Unspecified juvenile rheumatoid arthritis, left wrist |
M08.039 |
Unspecified juvenile rheumatoid arthritis, unspecified wrist |
M08.041 |
Unspecified juvenile rheumatoid arthritis, right hand |
M08.042 |
Unspecified juvenile rheumatoid arthritis, left hand |
M08.049 |
Unspecified juvenile rheumatoid arthritis, unspecified hand |
M08.051 |
Unspecified juvenile rheumatoid arthritis, right hip |
M08.052 |
Unspecified juvenile rheumatoid arthritis, left hip |
M08.059 |
Unspecified juvenile rheumatoid arthritis, unspecified hip |
M08.061 |
Unspecified juvenile rheumatoid arthritis, right knee |
M08.062 |
Unspecified juvenile rheumatoid arthritis, left knee |
M08.069 |
Unspecified juvenile rheumatoid arthritis, unspecified knee |
M08.071 |
Unspecified juvenile rheumatoid arthritis, right ankle and foot |
M08.072 |
Unspecified juvenile rheumatoid arthritis, left ankle and foot |
M08.079 |
Unspecified juvenile rheumatoid arthritis, unspecified ankle and foot |
M08.08 |
Unspecified juvenile rheumatoid arthritis, vertebrae |
M08.09 |
Unspecified juvenile rheumatoid arthritis, multiple sites |
M08.2A |
Juvenile rheumatoid arthritis with systemic onset, other specified site |
M08.211 |
Juvenile rheumatoid arthritis with systemic onset, right shoulder |
M08.212 |
Juvenile rheumatoid arthritis with systemic onset, left shoulder |
M08.219 |
Juvenile rheumatoid arthritis with systemic onset, unspecified shoulder |
M08.221 |
Juvenile rheumatoid arthritis with systemic onset, right elbow |
M08.222 |
Juvenile rheumatoid arthritis with systemic onset, left elbow |
M08.229 |
Juvenile rheumatoid arthritis with systemic onset, unspecified elbow |
M08.231 |
Juvenile rheumatoid arthritis with systemic onset, right wrist |
M08.232 |
Juvenile rheumatoid arthritis with systemic onset, left wrist |
M08.239 |
Juvenile rheumatoid arthritis with systemic onset, unspecified wrist |
M08.241 |
Juvenile rheumatoid arthritis with systemic onset, right hand |
M08.242 |
Juvenile rheumatoid arthritis with systemic onset, left hand |
M08.249 |
Juvenile rheumatoid arthritis with systemic onset, unspecified hand |
M08.251 |
Juvenile rheumatoid arthritis with systemic onset, right hip |
M08.252 |
Juvenile rheumatoid arthritis with systemic onset, left hip |
M08.259 |
Juvenile rheumatoid arthritis with systemic onset, unspecified hip |
M08.261 |
Juvenile rheumatoid arthritis with systemic onset, right knee |
M08.262 |
Juvenile rheumatoid arthritis with systemic onset, left knee |
M08.269 |
Juvenile rheumatoid arthritis with systemic onset, unspecified knee |
M08.271 |
Juvenile rheumatoid arthritis with systemic onset, right ankle and foot |
M08.272 |
Juvenile rheumatoid arthritis with systemic onset, left ankle and foot |
M08.279 |
Juvenile rheumatoid arthritis with systemic onset, unspecified ankle and foot |
M08.28 |
Juvenile rheumatoid arthritis with systemic onset, vertebrae |
M08.29 |
Juvenile rheumatoid arthritis with systemic onset, multiple sites |
M08.3 |
Juvenile rheumatoid polyarthritis (seronegative) |
M08.4A |
Pauciarticular juvenile rheumatoid arthritis, other specified site |
M08.411 |
Pauciarticular juvenile rheumatoid arthritis, right shoulder |
M08.412 |
Pauciarticular juvenile rheumatoid arthritis, left shoulder |
M08.419 |
Pauciarticular juvenile rheumatoid arthritis, unspecified shoulder |
M08.421 |
Pauciarticular juvenile rheumatoid arthritis, right elbow |
M08.422 |
Pauciarticular juvenile rheumatoid arthritis, left elbow |
M08.429 |
Pauciarticular juvenile rheumatoid arthritis, unspecified elbow |
M08.431 |
Pauciarticular juvenile rheumatoid arthritis, right wrist |
M08.432 |
Pauciarticular juvenile rheumatoid arthritis, left wrist |
M08.439 |
Pauciarticular juvenile rheumatoid arthritis, unspecified wrist |
M08.441 |
Pauciarticular juvenile rheumatoid arthritis, right hand |
M08.442 |
Pauciarticular juvenile rheumatoid arthritis, left hand |
M08.449 |
Pauciarticular juvenile rheumatoid arthritis, unspecified hand |
M08.451 |
Pauciarticular juvenile rheumatoid arthritis, right hip |
M08.452 |
Pauciarticular juvenile rheumatoid arthritis, left hip |
M08.459 |
Pauciarticular juvenile rheumatoid arthritis, unspecified hip |
M08.461 |
Pauciarticular juvenile rheumatoid arthritis, right knee |
M08.462 |
Pauciarticular juvenile rheumatoid arthritis, left knee |
M08.469 |
Pauciarticular juvenile rheumatoid arthritis, unspecified knee |
M08.471 |
Pauciarticular juvenile rheumatoid arthritis, right ankle and foot |
M08.472 |
Pauciarticular juvenile rheumatoid arthritis, left ankle and foot |
M08.479 |
Pauciarticular juvenile rheumatoid arthritis, unspecified ankle and foot |
M08.48 |
Pauciarticular juvenile rheumatoid arthritis, vertebrae |
M08.80 |
Other juvenile arthritis, unspecified site |
M08.811 |
Other juvenile arthritis, right shoulder |
M08.812 |
Other juvenile arthritis, left shoulder |
M08.819 |
Other juvenile arthritis, unspecified shoulder |
M08.821 |
Other juvenile arthritis, right elbow |
M08.822 |
Other juvenile arthritis, left elbow |
M08.829 |
Other juvenile arthritis, unspecified elbow |
M08.831 |
Other juvenile arthritis, right wrist |
M08.832 |
Other juvenile arthritis, left wrist |
M08.839 |
Other juvenile arthritis, unspecified wrist |
M08.841 |
Other juvenile arthritis, right hand |
M08.842 |
Other juvenile arthritis, left hand |
M08.849 |
Other juvenile arthritis, unspecified hand |
M08.851 |
Other juvenile arthritis, right hip |
M08.852 |
Other juvenile arthritis, left hip |
M08.859 |
Other juvenile arthritis, unspecified hip |
M08.861 |
Other juvenile arthritis, right knee |
M08.862 |
Other juvenile arthritis, left knee |
M08.869 |
Other juvenile arthritis, unspecified knee |
M08.871 |
Other juvenile arthritis, right ankle and foot |
M08.872 |
Other juvenile arthritis, left ankle and foot |
M08.879 |
Other juvenile arthritis, unspecified ankle and foot |
M08.88 |
Other juvenile arthritis, other specified site |
M08.89 |
Other juvenile arthritis, multiple sites |
M08.9A |
Juvenile arthritis, unspecified, other specified site |
M08.911 |
Juvenile arthritis, unspecified, right shoulder |
M08.912 |
Juvenile arthritis, unspecified, left shoulder |
M08.919 |
Juvenile arthritis, unspecified, unspecified shoulder |
M08.921 |
Juvenile arthritis, unspecified, right elbow |
M08.922 |
Juvenile arthritis, unspecified, left elbow |
M08.929 |
Juvenile arthritis, unspecified, unspecified elbow |
M08.931 |
Juvenile arthritis, unspecified, right wrist |
M08.932 |
Juvenile arthritis, unspecified, left wrist |
M08.939 |
Juvenile arthritis, unspecified, unspecified wrist |
M08.941 |
Juvenile arthritis, unspecified, right hand |
M08.942 |
Juvenile arthritis, unspecified, left hand |
M08.949 |
Juvenile arthritis, unspecified, unspecified hand |
M08.951 |
Juvenile arthritis, unspecified, right hip |
M08.952 |
Juvenile arthritis, unspecified, left hip |
M08.959 |
Juvenile arthritis, unspecified, unspecified hip |
M08.961 |
Juvenile arthritis, unspecified, right knee |
M08.962 |
Juvenile arthritis, unspecified, left knee |
M08.969 |
Juvenile arthritis, unspecified, unspecified knee |
M08.971 |
Juvenile arthritis, unspecified, right ankle and foot |
M08.972 |
Juvenile arthritis, unspecified, left ankle and foot |
M08.979 |
Juvenile arthritis, unspecified, unspecified ankle and foot |
M08.98 |
Juvenile arthritis, unspecified, vertebrae |
M08.99 |
Juvenile arthritis, unspecified, multiple sites |
M45.0 |
Ankylosing spondylitis of multiple sites in spine |
M45.1 |
Ankylosing spondylitis of occipito-atlanto-axial region |
M45.2 |
Ankylosing spondylitis of cervical region |
M45.3 |
Ankylosing spondylitis of cervicothoracic region |
M45.4 |
Ankylosing spondylitis of thoracic region |
M45.5 |
Ankylosing spondylitis of thoracolumbar region |
M45.6 |
Ankylosing spondylitis lumbar region |
M45.7 |
Ankylosing spondylitis of lumbosacral region |
M45.8 |
Ankylosing spondylitis sacral and sacrococcygeal region |
M45.9 |
Ankylosing spondylitis of unspecified sites in spine |
Appendix 2 – Centers for Medicare and Medicaid Services (CMS)
Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determination (NCD), Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs) may exist and compliance with these policies is required where applicable. They can be found at: https://www.cms.gov/medicare-coverage-database/search.aspx. Additional indications may be covered at the discretion of the health plan.
Medicare Part B Covered Diagnosis Codes (applicable to existing NCD/LCD/LCA): N/A
Medicare Part B Administrative Contractor (MAC) Jurisdictions |
||
Jurisdiction |
Applicable State/US Territory |
Contractor |
E (1) |
CA, HI, NV, AS, GU, CNMI |
Noridian Healthcare Solutions, LLC |
F (2 & 3) |
AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ |
Noridian Healthcare Solutions, LLC |
5 |
KS, NE, IA, MO |
Wisconsin Physicians Service Insurance Corp (WPS) |
6 |
MN, WI, IL |
National Government Services, Inc. (NGS) |
H (4 & 7) |
LA, AR, MS, TX, OK, CO, NM |
Novitas Solutions, Inc. |
8 |
MI, IN |
Wisconsin Physicians Service Insurance Corp (WPS) |
N (9) |
FL, PR, VI |
First Coast Service Options, Inc. |
J (10) |
TN, GA, AL |
Palmetto GBA, LLC |
M (11) |
NC, SC, WV, VA (excluding below) |
Palmetto GBA, LLC |
L (12) |
DE, MD, PA, NJ, DC (includes Arlington & Fairfax counties and the city of Alexandria in VA) |
Novitas Solutions, Inc. |
K (13 & 14) |
NY, CT, MA, RI, VT, ME, NH |
National Government Services, Inc. (NGS) |
15 |
KY, OH |
CGS Administrators, LLC |