CAM 196

Inflectra™ (infliximab-dyyb)

Category:Prescription Drug   Last Reviewed:June 2019
Department(s):Medical Affairs   Next Review:June 2020
Original Date:June 2018    

Policy 
Coverage of the requested drug is provided when FDA-approved indications below are met:

  • Coverage of Inflectra™ (infliximab-dyyb) is provided when the FDA-approved indications below are met and there has been a trial and failure of preferred therapy.
  • Crohn’s disease
    • Diagnosis established by or in consultation with a specialist in gastroenterology
      • Active Crohn’s disease
      • Treatment with an adequate course of systemic corticosteroid (e.g., prednisone, or prednisolone per day for 7 to 14 days) has been ineffective or is contraindicated OR
      • The patient has been unable to taper off an adequate course of systemic corticosteroids without experiencing worsening of disease OR
      • The patient is experiencing breakthrough disease (e.g., active disease flares) while stabilized for at least 2 months on immunomodulatory medication (such as azathioprine, mercaptopurine, cyclosporine, or methotrexate)
    • Fistulizing Crohn’s disease
  • Pediatric Crohn’s disease
    • Diagnosis established by or in consultation with a specialist in gastroenterology
    • The patient has had an inadequate response to conventional therapy
  • Ulcerative colitis
    • Diagnosis established by or in consultation with a specialist in gastroenterology
    • Treatment with an adequate course of systemic corticosteroid (e.g., prednisone, or prednisolone per day for 7 to 14 days) has been ineffective or is contraindicated OR
    • The patient has been unable to taper off an adequate course of systemic corticosteroids without experiencing worsening of disease 
    • The patient is experiencing breakthrough disease (e.g., active disease flares) while stabilized for at least 2 months on immunomodulatory medication (such as azathioprine, mercaptopurine, cyclosporine, or methotrexate)
  • Pediatric ulcerative colitis
    • Diagnosis established by or in consultation with a specialist in gastroenterology
    • The patient has had an inadequate response to conventional therapy
  • Rheumatoid arthritis
    • Diagnosis established by or in consultation with a specialist in rheumatology
    • There is clinical documentation that an oral DMARD (such as methotrexate) was not effective after at least a 6- to 12-week treatment course
    • Inflectra is administered with methotrexate
  • Psoriatic arthritis
    1. Diagnosis established by or in consultation with a specialist in dermatology or rheumatology
  • Plaque psoriasis
    • Diagnosis established by or in consultation with a specialist in dermatology or rheumatology
    • Diagnosis of chronic severe (i.e., extensive and/or disabling) plaque psoriasis:
      • Clinical documentation supports involvement of at least 10% of the body surface area OR
      • There is significant functional disability
    • Treatment with phototherapy (for example, UVB) or photochemotherapy was not effective, not tolerated, or is contraindicated
    • Treatment with at least one oral systemic agent for psoriasis was ineffective or not tolerated, unless all are contraindicated. Examples of systemic agents include, but are not limited to, cyclosporine, methotrexate, and acitretin
  • Ankylosing spondylitis
    • Diagnosis established by or in consultation with a specialist in rheumatology 

Infllectra is considered INVESTIGATIONAL when used for all other conditions, including, but not limited to:

  1. Behçet syndrome uveitis
  2. Celiac sprue
  3. Chronic obstructive pulmonary disease (stable)
  4. Giant cell arteritis
  5. Graft versus host disease (adults)
  6. Graft versus host disease (children/adolescents)
  7. Hidradenitis suppurativa (adults)
  8. Juvenile idiopathic arthritis
  9. Pustular psoriasis
  10. Pyoderma gangrenosum
  11. Sarcoidosis
  12. Uveitis
  13. Wegener granulomatosis

References:  

  1. Renflexis [prescribing information]. Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.; April 2017.
  2. FDA News Release. FDA approves Renflexis, a biosimilar to Remicade. FDA. Accessed from: https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&ApplNo=761054
  3. Samsung Bioepis Obtains First Drug Approval in the United States, as the U.S. Food and Drug Administration Approves RENFLEXIS™ (Infliximab-abda) Across All Eligible Indications. April 2017, Accessed from: http://www.samsungbioepis.com/en/newsroom/detail/Samsung-Bioepis-SB2-US-FDA-Approval-FINAL.html
  4. FDA approves Samsung Bioepis' copy of J&J's Remicade: company. Reuters. April 2017, Accessed from: http://www.reuters.com/article/us-samsung-bioepis-approval-usa-idUSKBN17N2LQ 
  5. Remicade [prescribing information]. Horsham, PA: Janssen Biotech Inc.; November 2015.
  6. Singh JA, Furst DE, Bharat A, et al. 2012 Update of the American College of Rheumatology 2008 Recommendations for the Use of Nonbiologic and Biologic Disease-Modifying Antirheumatic Drugs in Rheumatoid Arthritis. Arthritis Care & Research. 2012;64(5):625-39.
  7. Lichtenstein GR, Hanauer SB, Sandborn WJ, et al. American College of Gastroenterology Practice Guidelines. Management of Crohn’s Disease in Adults. Am J Gastroenterol. 2009;104(2):465-83.
  8. Lichtenstein GR, Abreu MT, Cohen R, Tremaine W. American Gastroenterological Association Institute medical position statement on corticosteroids, immunomodulators, and infliximab in inflammatory bowel disease. Gastroenterology. 2006;130(3):935-9.
  9. MCG®. Ambulatory Care 21st Edition. Infliximab. Accessed on January 23, 2016.
  10. Yee AM, Pochapin MB. Treatment of complicated sarcoidosis with infliximab anti-tumor necrosis factor-alpha therapy. Ann Intern Med. 2001;135(1):27-31.
  11. Zochling J, van der Heijde D, Burgos-Vargas R, et al. ASAS/EULAR recommendations for the management of Ankylosing Spondylitis. Ann Rheum Dis. 2006 65:442-452.
  12. Braun J, van den Berg R, Baraliakos X, et al. 2010 Update of the ASAS/EULAR Recommendations for the Management of Ankylosing Spondylitis. Ann Rheum Dis. 2011;70(6):896-904.
  13. U.S. Food and Drug Administration Information for Healthcare Professionals: Tumor Necrosis Factor (TNF) Blockers (marketed as Remicade, Enbrel, Humira, Cimzia, and Simponi). http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm124185.htm. Accessed July 1, 2013.
  14. U.S. Food and Drug Administration Drug Safety Communication: UPDATE on Tumor Necrosis Factor (TNF) blockers and risk for pediatric malignancy. http://www.fda.gov/Drugs/DrugSafety/ucm278267.htm. Accessed July 1, 2013.
  15. U.S. Food and Drug Administration Drug Safety Communication: Drug labels for the Tumor Necrosis Factor-alpha (TNFα) blockers now include warnings about infection with Legionella and Listeria bacteria. http://www.fda.gov/Drugs/DrugSafety/ucm270849.htm. Accessed July 1, 2013.
  16. Takeuchi M, Kezuka T, Sugita S, et al. Evaluation of the long-term efficacy and safety of infliximab treatment for uveitis in Behçet's disease: a multicenter study. Ophthalmology. 2014 Oct;121(10):1877-84.
  17. Kruh JN, Yang P, Suelves AM, et al. Infliximab for the treatment of refractory noninfectious Uveitis: a study of 88 patients with long-term follow-up. Ophthalmology. 2014 Jan;121(1):358-64.
  18. Levy-Clark G, Jabs DA, Read RW, et al. Expert panel recommendations for the use of anti–tumor necrosis factor biologic agents in patients with ocular inflammatory disorders. Ophthalmology. 2014 Mar;121(3):785-96.
  19. Lee FF, Foster CS. Pharmacology of uveitis. Expert Opin Pharmacother. 2010;11(7):1135-1146.
  20. Gottlieb A, Korman NJ, Gordon KB, et al. American Academy of Dermatology Guidelines for the Care and 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;58(5):851-64.
  21. Hatemi G, et al. EULAR recommendations for the management of Behcet disease. Annals of the Rheumatic Diseases 2008;67(12):1656-62.
  22. Menter A, Gottlieb A, Feldman SR, et al. American Academy of Dermatology Guidelines for the Care and Management of Psoriasis and Psoriatic Arthritis. Section 1: Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics. J Am Acad Dermatol. 2008;58(5):826-50.
  23. Gaylis N. Infliximab in the treatment of an HIV positive patient with Reiter's syndrome. J Rheumatol. 2003;30(2):407-411.   
  24. Murphy CC, Ayliffe WH, Booth A, et al. Tumor necrosis factor alpha blockade with infliximab for refractory uveitis and scleritis. Ophthalmology. 2004;111(2):352-356.
  25. Sullivan TP, Welsh E, Kerdel FA, et al. Infliximab for hidradenitis suppurativa. Br J Dermatol. 2003;149(5):1046-1049.
  26. Mariette X, Ravaud P, Steinfeld S, et al. Inefficacy of infliximab in primary Sjogren's syndrome: results of the randomized, controlled Trial of Remicade in Primary Sjogren's Syndrome (TRIPSS). Arthritis Rheum. 2004;50(4):1270-1276.
  27. Ruperto N, Lovell DJ, Cuttica R, et al. A randomized, placebo-controlled trial of infliximab plus methotrexate for the treatment of polyarticular-course juvenile rheumatoid arthritis. Arthritis Rheum. 2007;56(9):3096-106.
  28. Russo RA, Katsicas MM. Clinical remission in patients with systemic juvenile idiopathic arthritis treated with anti-tumor necrosis factor agents. J Rheumatol. 2009;36(5):1078-82.
  29. Baughman RP, Lower EE. Infliximab for refractory sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis. 2001;18(1):70-74.
  30. Kraetsch HG, Antoni C, Kalden JR, Manger B. Successful treatment of a small cohort of patients with adult onset Still's Disease with infliximab: first experiences. Ann Rheum Dis. 2001;60(suppl 3):iii55-57.
  31. Cavagna L, Caporali R, Epis O, et al. Infliximab in the treatment of adult Still's Disease refractory to conventional therapy. Clin Exp Rheumatol. 2001;19(3):329-332.
  32. Steinfeld SD, Demols P, Salmon I, et al. Infliximab in patients with primary Sjogren's Syndrome: a pilot study. Arthritis Rheum. 2001;44(10):2371-2375.
  33. Kobbe G, Schneider P, Rohr U, et al. Treatment of severe steroid refractory acute graft-vs-host disease with infliximab, a chimeric human/mouse antiTNFalpha antibody. Bone Marrow Transplant. 2001;28(1):47-49.
  34. Rivkina AM, Stump LS. Infliximab in graft-versus-host disease. Am J Health-Syst Pharm. 2002;59(13):1271-1275.
  35. Tynjälä P, Vähäsalo P, Tarkiainen M, et al. Aggressive Combination Drug Therapy in Very Early Polyarticular Juvenile Idiopathic Arthritis (ACUTE-JIA): a multicentre randomised open-label clinical trial. Ann Rheum Dis. 2011 Sep;70(9):1605-12.
  36. Lamot L, Bukovac LT, Vidovic M, et al. The 'head-to-head' comparison of etanercept and infliximab in treating children with juvenile idiopathic arthritis. Clin Exp Rheumatol. 2011 Jan-Feb;29(1):131-9.
  37. Ruperto N, Lovell DJ, Cuttica R, et al. Long-term efficacy and safety of infliximab plus methotrexate for the treatment of polyarticular-course juvenile rheumatoid arthritis: findings from an open-label treatment extension. Ann Rheum Dis. 2010 Apr;69(4):718-22.
  38. Beukelman T, Patkar NM, Saag KG, et al. 2011 American College of Rheumatology Recommendations for the Treatment of Juvenile Idiopathic Arthritis: Initiation and Safety Monitoring of Therapeutic Agents for the Treatment of Arthritis and Systemic Features. Arthritis Care & Research. 2011 April;63(4):465-82.
  39. Brandt J, Haibel H, Reddig J, et al. Successful short term treatment of severe undifferentiated spondyloarthropathy with anti-tumor necrosis factor- monoclonal antibody infliximab. J Rheumatol. 2002;29(1):118-122.
  40. De Marco G, Gerloni V, Pontikaki I, et al. Long-term evaluation of infliximab in the treatment of persistently active juvenile idiopathic arthritis refractory to conventional therapy. Reumatismo. 2007;59(1):50-6.
  41. Stasi R, Amadori S. Infliximab chimaeric anti-tumour necrosis factor alpha monoclonal antibody treatment for patients with myelodysplastic syndromes. Br J Haematol. 2002;116(2):334-337.
  42. Lamprecht P, Voswinkel J, Lilienthal T, et al. Effectiveness of TNF-alpha blockade with infliximab in refractory Wegener's granulomatosis. Rheumatology. 2002;41(11):1303-1307.
  43. Doty JD, Mazur JE, Judson MA. Treatment of sarcoidosis with infliximab. Chest. 2005;127(3):1064-71.
  44. Ulbricht KU, Stoll M, Bierwirth J, et al. Successful tumor necrosis factor alpha blockade treatment in therapy-resistant sarcoidosis. Arthritis Rheum. 2003; 48(12):3542-3.
  45. Yoshida EM. The Crohn’s Disease Activity Index, its derivatives and the Inflammatory Bowel Disease Questionnaire: A review of instruments to assess Crohn’s disease. Can J Gastroenterol. 1999;13(1):65-73.
  46. Kornbluth A. Ulcerative Colitis Practice Guidelines in Adults: American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol. 2010;105:501-523.
  47. Katsicas MM, Russo RA. Use of infliximab in patients with systemic juvenile idiopathic arthritis refractory to etanercept. Clin Exp Rheumatol. 2005;23(4):545-8.   
  48. Gerloni V, Pontikaki I, Gattinara M, et al. Efficacy of repeated intravenous infusions of an anti-tumor necrosis factor alpha monoclonal antibody, infliximab, in persistently active, refractory juvenile idiopathic arthritis: results of an open-label prospective study. Arthritis Rheum. 2005;52(2):548-53.
  49. Lahdenne P, Vahasalo P, Honkanen V. Infliximab or etanercept in the treatment of children with refractory juvenile idiopathic arthritis: an open label study. Ann Rheum Dis. 2003;62(3):245-7.
  50. Doherty CB, Rosen T. Evidence-based therapy for cutaneous sarcoidosis. Drugs. 2008;68(10):1361-83.
  51. Bartolucci P, Ramanoelina J, Cohen P, et al. Efficacy of the anti-TNF-alpha antibody infliximab against refractory systemic vasculitides: an open pilot study on 10 patients. Rheumatology (Oxford). 2002;41(10):1126-32.
  52. Kleinert J, Lorenz M, Kostler W, et al. Refractory Wegener’s granulomatosis responds to tumor necrosis factor blockade. Win Klin Wochenschr. 2004;116(9-10):334-8.
  53. Roussomoustakaki M, Dimoulios P, Chatzicostas C, et al. Hidradentis suppurativa associated with Crohn’s disease and spondyloarthropathy: response to anti-TNF therapy. J Gastroenterol. 2003;38(10):1000-4.
  54. Rosi YL, Lowe L, Kang S. Treatment of hidradenitis suppurativa with infliximab in a patient with Crohn’s disease. J Dermatolog Treat. 2005;16(1):58-61.
  55. Fardet L, Dupuy A, Kerob D, et al. Infliximab for severe hidradenitis suppurativa: transient clinical efficacy in 7 consecutive patients. J Am Acad Dermatol. 2007;56(4):624-8.
  56. Baughman RP, Drent M, Kavuru M, et al. Infliximab therapy in patients with chronic sarcoidosis and pulmonary involvement. Am J Respir Crit Care Med. 2006;174(7):795-802.
  57. Menter A, Korman NJ, Elmets CA, et al. American Academy of Dermatology Guidelines for the Care and Management of Psoriasis and Psoriatic Arthritis. Section 5: Guidelines of care for the treatment of psoriasis with phototherapy and photochemotherapy. J Am Acad Dermatol. 2010;62:114-35.
  58. Menter A, Korman NJ, Elmets CA, et al. American Academy of Dermatology Guidelines for the Care and Management of Psoriasis and Psoriatic Arthritis. Section 3: Overview of psoriasis and guidelines of care for the treatment of psoriasis with topical therapies. J Am Acad Dermatol. 2009;60:643-59.
  59. Menter A, Korman NJ, Elmets CA, et al. American Academy of Dermatology Guidelines for the Care and Management of Psoriasis and Psoriatic Arthritis. Section 4: Overview of psoriasis and guidelines of care for the treatment of psoriasis with traditional systemic agents. J Am Acad Dermatol. 2009;61:451-85.
  60. Xeljanz [prescribing information]. New York, NY: Pfizer Labs; June 2015.
  61. Inflectra [prescribing information]. New York, NY: Pfizer Labs; August 2016.
  62. Yoo DH, Hrycaj P, Miranda P, et al. A randomised, double-blind, parallel-group study to demonstrate equivalence in efficacy and safety of CT-P13 compared with innovator infliximab when coadministered with methotrexate in patients with active rheumatoid arthritis: the PLANETRA study. Ann Rheum Dis. 2013 Oct;72(10):1613-20.
  63. Park W, Hrycaj P, Jeka S, et al. A randomised, double-blind, multicentre, parallel-group, prospective study comparing the pharmacokinetics, safety, and efficacy of CT-P13 and innovator infliximab in patients with ankylosing spondylitis: the PLANETAS study. Ann Rheum Dis. 2013 Oct;72(10):1605-12.
  64. Gecse KB, Lovász BD, Farkas K et al. Efficacy and Safety of the Biosimilar Infliximab CT-P13 Treatment in Inflammatory Bowel Diseases: A Prospective, Multicentre, Nationwide Cohort . J Crohns Colitis. 2016 Feb;10(2):133-40.
  65. Ruiz-Argüello MB, Maguregui A, Ruiz Del Agua A, et al. Antibodies to infliximab in Remicade-treated rheumatic patients show identical reactivity towards biosimilars. Ann Rheum Dis. 2016 Sep;75(9):1693-6.
  66. Renflexis [prescribing information]. Kenilworth, NJ: Merck Sharp & Dohme Corp; April 2017.
  67. Choe JY, Prodanovic N, Niebrzydowski J, et al. A randomised, double-blind, phase III study comparing SB2, an infliximab biosimilar, to the infliximab reference product Remicade in patients with moderate to severe rheumatoid arthritis despite methotrexate therapy. Ann Rheum Dis. 2017 Jan;76(1):58-64.

Coding Section 

Code                    

Number

Moodifier

Description

HCPCS Q5102

ZB

Injection, infliximab, biosimilar, 10 mg (Pfizer)

 

Q5102

 ZC

Injection, infliximab, biosimilar, 10 mg (Merck)

 

Q5103 (effective 4/1/2018)

 

Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg 

 

Q5104 (effective 4/1/2018)

 

Injection, infliximab-abda, biosimilar, (renflexis), 10 mg

 

Code

Numbers

Description

ICD-10 Diagnosis Code

K50.018

Crohn's disease of small intestine with other complication

 

K50.019

Crohn's disease of small intestine with unspecified complications

 

K50.10

Crohn's disease of large intestine without complications

 

K50.111

Crohn's disease of large intestine with rectal bleeding

 

K50.112

Crohn's disease of large intestine with intestinal obstruction

 

K50.113

Crohn's disease of large intestine with fistula

 

K50.114

Crohn's disease of large intestine with abscess

 

K50.118

Crohn's disease of large intestine with other complication

 

K50.119

Crohn's disease of large intestine with unspecified complications

 

K50.80

Crohn's disease of both small and large intestine without complications

 

K50.811

Crohn's disease of both small and large intestine with rectal bleeding

 

K50.812

Crohn's disease of both small and large intestine with intestinal obstruction

 

K50.813

Crohn's disease of both small and large intestine with fistula

 

K50.814

Crohn's disease of both small and large intestine with abscess

 

K50.818

Crohn's disease of both small and large intestine with other complication

 

K50.819

Crohn's disease of both small and large intestine with unspecified complications

 

K50.90

Crohn's disease, unspecified, without complications

 

K50.911

Crohn's disease, unspecified, with rectal bleeding

 

K50.912

Crohn's disease, unspecified, with intestinal obstruction

 

K50.913

Crohn's disease, unspecified, with fistula

 

K50.914

Crohn's disease, unspecified, with abscess

 

K50.918

Crohn's disease, unspecified, with other complication

 

K50.919

Crohn's disease, unspecified, with unspecified complications

 

K51.00

Ulcerative (chronic) pancolitis without complications

 

K51.011

Ulcerative (chronic) pancolitis with rectal bleeding

 

K51.012

Ulcerative (chronic) pancolitis with intestinal obstruction

 

K51.013

Ulcerative (chronic) pancolitis with fistula

 

K51.014

Ulcerative (chronic) pancolitis with abscess

 

K51.018

Ulcerative (chronic) pancolitis with other complication

 

K51.019

Ulcerative (chronic) pancolitis with unspecified complications

 

K51.20

Ulcerative (chronic) proctitis without complications

 

K51.211

Ulcerative (chronic) proctitis with rectal bleeding

 

K51.212

Ulcerative (chronic) proctitis with intestinal obstruction

 

K51.213

Ulcerative (chronic) proctitis with fistula

 

K51.214

Ulcerative (chronic) proctitis with abscess

 

K51.218

Ulcerative (chronic) proctitis with other complication

 

K51.219

Ulcerative (chronic) proctitis with unspecified complications

 

K51.30

Ulcerative (chronic) rectosigmoiditis without complications

 

K51.311

Ulcerative (chronic) rectosigmoiditis with rectal bleeding

 

K51.312

Ulcerative (chronic) rectosigmoiditis with intestinal obstruction

 

K51.313

Ulcerative (chronic) rectosigmoiditis with fistula

 

K51.314

Ulcerative (chronic) rectosigmoiditis with abscess

 

K51.318

Ulcerative (chronic) rectosigmoiditis with other complication

 

K51.319

Ulcerative (chronic) rectosigmoiditis with unspecified complications

 

K51.40

Inflammatory polyps of colon without complications

 

K51.411

Inflammatory polyps of colon with rectal bleeding

 

K51.412

Inflammatory polyps of colon with intestinal obstruction                                    

                                   

K51.413

Inflammatory polyps of colon with fistula                                                       

 

K51.414

Inflammatory polyps of colon with abscess

 

K51.418

Inflammatory polyps of colon with other complication

 

K51.419

Inflammatory polyps of colon with unspecified complications

 

K51.50

Left sided colitis without complications

 

K51.511

Left sided colitis with rectal bleeding

 

K51.512

Left sided colitis with intestinal obstruction

 

K51.513

Left sided colitis with fistula

 

K51.514

Left sided colitis with abscess

 

K51.518

Left sided colitis with other complication

 

K51.519

Left sided colitis with unspecified complications

 

K51.80

Other ulcerative colitis without complications

 

K51.811

Other ulcerative colitis with rectal bleeding

 

K51.812

Other ulcerative colitis with intestinal obstruction

 

K51.813

Other ulcerative colitis with fistula

 

K51.814

Other ulcerative colitis with abscess

 

K51.818

Other ulcerative colitis with other complication

 

K51.819

Other ulcerative colitis with unspecified complications

 

K51.90

Ulcerative colitis, unspecified, without complications

 

K51.911

Ulcerative colitis, unspecified with rectal bleeding

 

K51.912

Ulcerative colitis, unspecified with intestinal obstruction

 

K51.913

Ulcerative colitis, unspecified with fistula

 

K51.914

Ulcerative colitis, unspecified with abscess

 

K51.918

Ulcerative colitis, unspecified with other complication

 

K51.919

Ulcerative colitis, unspecified with unspecified complications

 

K60.3

Anal fistula

 

K60.4

Rectal fistula

 

K60.5

Anorectal fistula

 

K63.2

Fistula of intestine

 

L40.0

Psoriasis vulgaris

 

L40.1

Generalized pustular psoriasis

 

L40.2

Acrodermatitis continua

 

L40.3

Pustulosis palmaris et plantaris

 

L40.4

Guttate psoriasis

 

L40.50

Arthropathic psoriasis, unspecified

 

L40.51

Distal interphalangeal psoriatic arthropathy

 

L40.52

Psoriatic arthritis mutilans

 

L40.53

Psoriatic spondylitis

 

L40.54

Psoriatic juvenile arthropathy

 

L40.59

Other psoriatic arthropathy

 

L40.8

Other psoriasis

 

L40.9

Psoriasis, unspecified

 

M05.00

Felty's syndrome, unspecified site

 

M05.011

Felty's syndrome, right shoulder

 

M05.012

Felty's syndrome, left shoulder

 

M05.019

Felty's syndrome, unspecified shoulder

 

M05.021

Felty's syndrome, right elbow

                                  

M05.022 

Felty's syndrome, left elbow                        

 

M05.029

Felty's syndrome, unspecified elbow                  

 

M05.031

Felty's syndrome, right wrist

 

M05.032

Felty's syndrome, left wrist

 

M05.039

Felty's syndrome, unspecified wrist

 

M05.041

Felty's syndrome, right hand

 

M05.042

Felty's syndrome, left hand

 

M05.049

Felty's syndrome, unspecified hand

 

M05.051

Felty's syndrome, right hip

 

M05.052

Felty's syndrome, left hip

 

M05.059

Felty's syndrome, unspecified hip

 

M05.061

Felty's syndrome, right knee

 

M05.062

Felty's syndrome, left knee

 

M05.069

Felty's syndrome, unspecified knee

 

M05.071

Felty's syndrome, right ankle and foot

 

M05.072

Felty's syndrome, left ankle and foot

 

M05.079

Felty's syndrome, unspecified ankle and foot

 

M05.09

Felty's syndrome, multiple sites

 

M05.20

Rheumatoid vasculitis with rheumatoid arthritis of unspecified site

 

M05.211

Rheumatoid vasculitis with rheumatoid arthritis of right shoulder

 

M05.212

Rheumatoid vasculitis with rheumatoid arthritis of left shoulder

 

M05.219

Rheumatoid vasculitis with rheumatoid arthritis of unspecified shoulder

 

M05.221

Rheumatoid vasculitis with rheumatoid arthritis of right elbow

 

M05.222

Rheumatoid vasculitis with rheumatoid arthritis of left elbow

 

M05.229

Rheumatoid vasculitis with rheumatoid arthritis of unspecified elbow

 

M05.231

Rheumatoid vasculitis with rheumatoid arthritis of right wrist

 

M05.232

Rheumatoid vasculitis with rheumatoid arthritis of left wrist

 

M05.239

Rheumatoid vasculitis with rheumatoid arthritis of unspecified wrist

 

M05.241

Rheumatoid vasculitis with rheumatoid arthritis of right hand

 

M05.242

Rheumatoid vasculitis with rheumatoid arthritis of left hand

 

M05.249

Rheumatoid vasculitis with rheumatoid arthritis of unspecified hand

 

M05.251

Rheumatoid vasculitis with rheumatoid arthritis of right hip

 

M05.252

Rheumatoid vasculitis with rheumatoid arthritis of left hip

 

M05.259

Rheumatoid vasculitis with rheumatoid arthritis of unspecified hip

 

M05.261

Rheumatoid vasculitis with rheumatoid arthritis of right knee

 

M05.262

Rheumatoid vasculitis with rheumatoid arthritis of left knee

 

M05.269

Rheumatoid vasculitis with rheumatoid arthritis of unspecified knee

 

M05.271

Rheumatoid vasculitis with rheumatoid arthritis of right ankle and foot

 

M05.272

Rheumatoid vasculitis with rheumatoid arthritis of left ankle and foot

 

M05.279

Rheumatoid vasculitis with rheumatoid arthritis of unspecified ankle and foot

 

M05.29

Rheumatoid vasculitis with rheumatoid arthritis of multiple sites

 

M05.30

Rheumatoid heart disease with rheumatoid arthritis of unspecified site

 

M05.311

Rheumatoid heart disease with rheumatoid arthritis of right shoulder

 

M05.312

Rheumatoid heart disease with rheumatoid arthritis of left shoulder

 

M05.319

Rheumatoid heart disease with rheumatoid arthritis of unspecified shoulder

 

M05.321

Rheumatoid heart disease with rheumatoid arthritis of right elbow

      

M05.322

Rheumatoid heart disease with rheumatoid arthritis of left elbow

                                    

M05.329   

Rheumatoid heart disease with rheumatoid arthritis of unspecified elbow

 

M05.331

Rheumatoid heart disease with rheumatoid arthritis of right wrist

 

M05.332

Rheumatoid heart disease with rheumatoid arthritis of left wrist

 

M05.339

Rheumatoid heart disease with rheumatoid arthritis of unspecified wrist

 

M05.341

Rheumatoid heart disease with rheumatoid arthritis of right hand

 

M05.342

Rheumatoid heart disease with rheumatoid arthritis of left hand

 

M05.349

Rheumatoid heart disease with rheumatoid arthritis of unspecified hand

 

M05.351

Rheumatoid heart disease with rheumatoid arthritis of right hip

 

M05.352

Rheumatoid heart disease with rheumatoid arthritis of left hip

 

M05.359

Rheumatoid heart disease with rheumatoid arthritis of unspecified hip

 

M05.361

Rheumatoid heart disease with rheumatoid arthritis of right knee

 

M05.362

Rheumatoid heart disease with rheumatoid arthritis of left knee

 

M05.369

Rheumatoid heart disease with rheumatoid arthritis of unspecified knee

 

M05.371

Rheumatoid heart disease with rheumatoid arthritis of right ankle and foot

 

M05.372

Rheumatoid heart disease with rheumatoid arthritis of left ankle and foot

 

M05.379

Rheumatoid heart disease with rheumatoid arthritis of unspecified ankle and foot

 

M05.39

Rheumatoid heart disease with rheumatoid arthritis of multiple sites

 

M05.40

Rheumatoid myopathy with rheumatoid arthritis of unspecified site

 

M05.411

Rheumatoid myopathy with rheumatoid arthritis of right shoulder

 

M05.412

Rheumatoid myopathy with rheumatoid arthritis of left shoulder

 

M05.419

Rheumatoid myopathy with rheumatoid arthritis of unspecified shoulder

 

M05.421

Rheumatoid myopathy with rheumatoid arthritis of right elbow

 

M05.422

Rheumatoid myopathy with rheumatoid arthritis of left elbow

 

M05.429

Rheumatoid myopathy with rheumatoid arthritis of unspecified elbow

 

M05.431

Rheumatoid myopathy with rheumatoid arthritis of right wrist

 

M05.432

Rheumatoid myopathy with rheumatoid arthritis of left wrist

 

M05.439

Rheumatoid myopathy with rheumatoid arthritis of unspecified wrist

 

M05.441

Rheumatoid myopathy with rheumatoid arthritis of right hand

 

M05.442

Rheumatoid myopathy with rheumatoid arthritis of left hand

 

M05.449

Rheumatoid myopathy with rheumatoid arthritis of unspecified hand

 

M05.451

Rheumatoid myopathy with rheumatoid arthritis of right hip

 

M05.452

Rheumatoid myopathy with rheumatoid arthritis of left hip

 

M05.459

Rheumatoid myopathy with rheumatoid arthritis of unspecified hip

 

M05.461

Rheumatoid myopathy with rheumatoid arthritis of right knee

 

M05.462

Rheumatoid myopathy with rheumatoid arthritis of left knee

 

M05.469

Rheumatoid myopathy with rheumatoid arthritis of unspecified knee

 

M05.471

Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot

 

M05.472

Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot

 

M05.479

Rheumatoid myopathy with rheumatoid arthritis of unspecified ankle and foot

 

M05.49

Rheumatoid myopathy with rheumatoid arthritis of multiple sites

 

M05.50

Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified site

 

M05.511

Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulder

 

M05.512

Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulder

 

M05.519

Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified shoulder

 

M05.521

Rheumatoid polyneuropathy with rheumatoid arthritis of right elbow

 

M05.522

Rheumatoid polyneuropathy with rheumatoid arthritis of left elbow

 

M05.529

Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified elbow

                                        

M05.531      

Rheumatoid polyneuropathy with rheumatoid arthritis of right wrist       

 

M05.532

Rheumatoid polyneuropathy with rheumatoid arthritis of left wrist

 

M05.539

Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified wrist

 

M05.541

Rheumatoid polyneuropathy with rheumatoid arthritis of right hand

 

M05.542

Rheumatoid polyneuropathy with rheumatoid arthritis of left hand

 

M05.549

Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hand

 

M05.551

Rheumatoid polyneuropathy with rheumatoid arthritis of right hip

 

M05.552

Rheumatoid polyneuropathy with rheumatoid arthritis of left hip

 

M05.559

Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hip

 

M05.561

Rheumatoid polyneuropathy with rheumatoid arthritis of right knee

 

M05.562

Rheumatoid polyneuropathy with rheumatoid arthritis of left knee

 

M05.569

Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified knee

 

M05.571

Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot

 

M05.572

Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot

 

M05.579

Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified ankle and foot

 

M05.59

Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites

 

M05.60

Rheumatoid arthritis of unspecified site with involvement of other organs and systems

 

M05.611

Rheumatoid arthritis of right shoulder with involvement of other organs and systems

 

M05.612

Rheumatoid arthritis of left shoulder with involvement of other organs and systems

 

M05.619

Rheumatoid arthritis of unspecified shoulder with involvement of other organs and systems

 

M05.621

Rheumatoid arthritis of right elbow with involvement of other organs and systems

 

M05.622

Rheumatoid arthritis of left elbow with involvement of other organs and systems

 

M05.629

Rheumatoid arthritis of unspecified elbow with involvement of other organs and systems

 

M05.631

Rheumatoid arthritis of right wrist with involvement of other organs and systems

 

M05.632

Rheumatoid arthritis of left wrist with involvement of other organs and systems

 

M05.639

Rheumatoid arthritis of unspecified wrist with involvement of other organs and systems

 

M05.641

Rheumatoid arthritis of right hand with involvement of other organs and systems

 

M05.642

Rheumatoid arthritis of left hand with involvement of other organs and systems

 

M05.649

Rheumatoid arthritis of unspecified hand with involvement of other organs and systems

 

M05.651

Rheumatoid arthritis of right hip with involvement of other organs and systems

 

M05.652

Rheumatoid arthritis of left hip with involvement of other organs and systems

 

M05.659

Rheumatoid arthritis of unspecified hip with involvement of other organs and systems

 

M05.661

Rheumatoid arthritis of right knee with involvement of other organs and systems

 

M05.662

Rheumatoid arthritis of left knee with involvement of other organs and systems

 

M05.669

Rheumatoid arthritis of unspecified knee with involvement of other organs and systems

 

M05.671

Rheumatoid arthritis of right ankle and foot with involvement of other organs and systems

 

M05.672

Rheumatoid arthritis of left ankle and foot with involvement of other organs and systems

 

M05.679

Rheumatoid arthritis of unspecified ankle and foot with involvement of other organs and systems

 

M05.69

Rheumatoid arthritis of multiple sites with involvement of other organs and systems

                                        

M05.70         

Rheumatoid arthritis with rheumatoid factor of unspecified site without organ or systems involvement

 

M05.711

Rheumatoid arthritis with rheumatoid factor of right shoulder without organ or systems involvement

 

M05.712

Rheumatoid arthritis with rheumatoid factor of left shoulder without organ or systems involvement

 

M05.719

Rheumatoid arthritis with rheumatoid factor of unspecified shoulder without organ or systems involvement

 

M05.721

Rheumatoid arthritis with rheumatoid factor of right elbow without organ or systems involvement

 

M05.722

Rheumatoid arthritis with rheumatoid factor of left elbow without organ or systems involvement

 

M05.729

Rheumatoid arthritis with rheumatoid factor of unspecified elbow without organ or systems involvement

 

M05.731

Rheumatoid arthritis with rheumatoid factor of right wrist without organ or systems involvement

 

M05.732

Rheumatoid arthritis with rheumatoid factor of left wrist without organ or systems involvement

 

M05.739

Rheumatoid arthritis with rheumatoid factor of unspecified wrist without organ or systems involvement

 

M05.741

Rheumatoid arthritis with rheumatoid factor of right hand without organ or systems involvement

 

M05.742

Rheumatoid arthritis with rheumatoid factor of left hand without organ or systems involvement

 

M05.749

Rheumatoid arthritis with rheumatoid factor of unspecified hand without organ or systems involvement

 

M05.751

Rheumatoid arthritis with rheumatoid factor of right hip without organ or systems involvement

 

M05.752

Rheumatoid arthritis with rheumatoid factor of left hip without organ or systems involvement

 

M05.759

Rheumatoid arthritis with rheumatoid factor of unspecified hip without organ or systems involvement

 

M05.761

Rheumatoid arthritis with rheumatoid factor of right knee without organ or systems involvement

 

M05.762

Rheumatoid arthritis with rheumatoid factor of left knee without organ or systems involvement

 

M05.769

Rheumatoid arthritis with rheumatoid factor of unspecified knee without organ or systems involvement

 

M05.771

Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systems involvement

 

M05.772

Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or systems involvement

 

M05.779

Rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot without organ or systems involvement

 

M05.79

Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement

 

M05.80

Other rheumatoid arthritis with rheumatoid factor of unspecified site

 

M05.811

Other rheumatoid arthritis with rheumatoid factor of right shoulder

 

M05.812

Other rheumatoid arthritis with rheumatoid factor of left shoulder

 

M05.819

Other rheumatoid arthritis with rheumatoid factor of unspecified shoulder

 

M05.821

Other rheumatoid arthritis with rheumatoid factor of right elbow

 

M05.822

Other rheumatoid arthritis with rheumatoid factor of left elbow

 

M05.829

Other rheumatoid arthritis with rheumatoid factor of unspecified elbow

                                    

M05.831    

Other rheumatoid arthritis with rheumatoid factor of right wrist                                  

 

M05.832

Other rheumatoid arthritis with rheumatoid factor of left wrist

 

M05.839

Other rheumatoid arthritis with rheumatoid factor of unspecified wrist

 

M05.841

Other rheumatoid arthritis with rheumatoid factor of right hand

 

M05.842

Other rheumatoid arthritis with rheumatoid factor of left hand

 

M05.849

Other rheumatoid arthritis with rheumatoid factor of unspecified hand

 

M05.851

Other rheumatoid arthritis with rheumatoid factor of right hip

 

M05.852

Other rheumatoid arthritis with rheumatoid factor of left hip

 

M05.859

Other rheumatoid arthritis with rheumatoid factor of unspecified hip

 

M05.861

Other rheumatoid arthritis with rheumatoid factor of right knee

 

M05.862

Other rheumatoid arthritis with rheumatoid factor of left knee

 

M05.869

Other rheumatoid arthritis with rheumatoid factor of unspecified knee

 

M05.871

Other rheumatoid arthritis with rheumatoid factor of right ankle and foot

 

M05.872

Other rheumatoid arthritis with rheumatoid factor of left ankle and foot

 

M05.879

Other rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot

 

M05.89

Other rheumatoid arthritis with rheumatoid factor of multiple sites

 

M05.9

Rheumatoid arthritis with rheumatoid factor, unspecified

 

M06.00

Rheumatoid arthritis without rheumatoid factor, unspecified site

 

M06.011

Rheumatoid arthritis without rheumatoid factor, right shoulder

 

M06.012

Rheumatoid arthritis without rheumatoid factor, left shoulder

 

M06.019

Rheumatoid arthritis without rheumatoid factor, unspecified shoulder

 

M06.021

Rheumatoid arthritis without rheumatoid factor, right elbow

 

M06.022

Rheumatoid arthritis without rheumatoid factor, left elbow

 

M06.029

Rheumatoid arthritis without rheumatoid factor, unspecified elbow

 

M06.031

Rheumatoid arthritis without rheumatoid factor, right wrist

 

M06.032

Rheumatoid arthritis without rheumatoid factor, left wrist

 

M06.039

Rheumatoid arthritis without rheumatoid factor, unspecified wrist

 

M06.041

Rheumatoid arthritis without rheumatoid factor, right hand

 

M06.042

Rheumatoid arthritis without rheumatoid factor, left hand

 

M06.049

Rheumatoid arthritis without rheumatoid factor, unspecified hand

 

M06.051

Rheumatoid arthritis without rheumatoid factor, right hip

 

M06.052

Rheumatoid arthritis without rheumatoid factor, left hip

 

M06.059

Rheumatoid arthritis without rheumatoid factor, unspecified hip

 

M06.061

Rheumatoid arthritis without rheumatoid factor, right knee

 

M06.062

Rheumatoid arthritis without rheumatoid factor, left knee

 

M06.069

Rheumatoid arthritis without rheumatoid factor, unspecified knee

 

M06.071

Rheumatoid arthritis without rheumatoid factor, right ankle and foot

 

M06.072

Rheumatoid arthritis without rheumatoid factor, left ankle and foot

 

M06.079

Rheumatoid arthritis without rheumatoid factor, unspecified ankle and foot

 

M06.08

Rheumatoid arthritis without rheumatoid factor, vertebrae

 

M06.09

Rheumatoid arthritis without rheumatoid factor, multiple sites

 

M06.1

Adult-onset Still's disease

 

M06.20

Rheumatoid bursitis, unspecified site

 

M06.211

Rheumatoid bursitis, right shoulder

 

M06.212

Rheumatoid bursitis, left shoulder

 

M06.219

Rheumatoid bursitis, unspecified shoulder

 

M06.221

Rheumatoid bursitis, right elbow

                                   

M06.222    

Rheumatoid bursitis, left elbow                                                                              

 

M06.229

Rheumatoid bursitis, unspecified elbow

 

M06.231

Rheumatoid bursitis, right wrist

 

M06.232

Rheumatoid bursitis, left wrist

 

M06.239

Rheumatoid bursitis, unspecified wrist

 

M06.241

Rheumatoid bursitis, right hand

 

M06.242

Rheumatoid bursitis, left hand

 

M06.249

Rheumatoid bursitis, unspecified hand

 

M06.251

Rheumatoid bursitis, right hip

 

M06.252

Rheumatoid bursitis, left hip

 

M06.259

Rheumatoid bursitis, unspecified hip

 

M06.261

Rheumatoid bursitis, right knee

 

M06.262

Rheumatoid bursitis, left knee

 

M06.269

Rheumatoid bursitis, unspecified knee

 

M06.271

Rheumatoid bursitis, right ankle and foot

 

M06.272

Rheumatoid bursitis, left ankle and foot

 

M06.279

Rheumatoid bursitis, unspecified ankle and foot

 

M06.28

Rheumatoid bursitis, vertebrae

 

M06.29

Rheumatoid bursitis, multiple sites

 

M06.30

Rheumatoid nodule, unspecified site

 

M06.311

Rheumatoid nodule, right shoulder

 

M06.312

Rheumatoid nodule, left shoulder

 

M06.319

Rheumatoid nodule, unspecified shoulder

 

M06.321

Rheumatoid nodule, right elbow

 

M06.322

Rheumatoid nodule, left elbow

 

M06.329

Rheumatoid nodule, unspecified elbow

 

M06.331

Rheumatoid nodule, right wrist

 

M06.332

Rheumatoid nodule, left wrist

 

M06.339

Rheumatoid nodule, unspecified wrist

 

M06.341

Rheumatoid nodule, right hand

 

M06.342

Rheumatoid nodule, left hand

 

M06.349

Rheumatoid nodule, unspecified hand

 

M06.351

Rheumatoid nodule, right hip

 

M06.352

Rheumatoid nodule, left hip

 

M06.359

Rheumatoid nodule, unspecified hip

 

M06.361

Rheumatoid nodule, right knee

 

M06.362

Rheumatoid nodule, left knee

 

M06.369

Rheumatoid nodule, unspecified knee

 

M06.371

Rheumatoid nodule, right ankle and foot

 

M06.372

Rheumatoid nodule, left ankle and foot

 

M06.379

Rheumatoid nodule, unspecified ankle and foot

 

M06.38

Rheumatoid nodule, vertebrae

 

M06.39

Rheumatoid nodule, multiple sites

 

M06.80

Other specified rheumatoid arthritis, unspecified site

 

M06.811

Other specified rheumatoid arthritis, right shoulder

 

M06.812

Other specified rheumatoid arthritis, left shoulder

 

M06.819

Other specified rheumatoid arthritis, unspecified shoulder

                                   

M06.821    

Other specified rheumatoid arthritis, right elbow                                                   

 

M06.822

Other specified rheumatoid arthritis, left elbow

 

M06.829

Other specified rheumatoid arthritis, unspecified elbow

 

M06.831

Other specified rheumatoid arthritis, right wrist

 

M06.832

Other specified rheumatoid arthritis, left wrist

 

M06.839

Other specified rheumatoid arthritis, unspecified wrist

 

M06.841

Other specified rheumatoid arthritis, right hand

 

M06.842

Other specified rheumatoid arthritis, left hand

 

M06.849

Other specified rheumatoid arthritis, unspecified hand

 

M06.851

Other specified rheumatoid arthritis, right hip

 

M06.852

Other specified rheumatoid arthritis, left hip

 

M06.859

Other specified rheumatoid arthritis, unspecified hip

 

M06.861

Other specified rheumatoid arthritis, right knee

 

M06.862

Other specified rheumatoid arthritis, left knee

 

M06.869

Other specified rheumatoid arthritis, unspecified knee

 

M06.871

Other specified rheumatoid arthritis, right ankle and foot

 

M06.872

Other specified rheumatoid arthritis, left ankle and foot

 

M06.879

Other specified rheumatoid arthritis, unspecified ankle and foot

 

M06.88

Other specified rheumatoid arthritis, vertebrae

 

M06.89

Other specified rheumatoid arthritis, multiple sites

 

M06.9

Rheumatoid arthritis, unspecified

 

M08.1

Juvenile ankylosing spondylitis

 

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

 

M48.8X1

Other specified spondylopathies, occipito-atlanto-axial region

 

M48.8X2

Other specified spondylopathies, cervical region

 

M48.8X3

Other specified spondylopathies, cervicothoracic region

 

M48.8X4

Other specified spondylopathies, thoracic region

 

M48.8X5

Other specified spondylopathies, thoracolumbar region

 

M48.8X6

Other specified spondylopathies, lumbar region

 

M48.8X7

Other specified spondylopathies, lumbosacral region

 

M48.8X8

Other specified spondylopathies, sacral and sacrococcygeal region

 

M48.8X9

Other specified spondylopathies, site unspecified

 

N82.2

Fistula of vagina to small intestine

 

N82.3

Fistula of vagina to large intestine

 

N82.4

Other female intestinal-genital tract fistulae

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each Policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association.  All Rights Reserved" 

History From 2018 Forward     

06/04/2019 

Annual review, no change to policy intent. 

06//04/2018

New Policy


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