IMMUNE GLOBULIN (IVIG AND SCIG)

Transcription

1 Oxfrd IMMUNE GLOBULIN (IVIG AND SCIG) UnitedHealthcare Oxfrd Clinical Plicy Plicy Number: PHARMACY T2 Effective Date: April 1, 2019 Instructins fr Use Table f Cntents Page CONDITIONS OF COVERAGE... 1 COVERAGE RATIONALE... 1 APPLICABLE CODES DESCRIPTION OF SERVICES BENEFIT CONSIDERATIONS CLINICAL EVIDENCE U.S. FOOD AND DRUG ADMINISTRATION REFERENCES POLICY HISTORY/REVISION INFORMATION INSTRUCTIONS FOR USE Related Plicies Acquired Rare Disease Drug Therapy Exceptin Prcess Experimental/Investigatinal Treatment Experimental/Investigatinal Treatment fr NJ Plans Immune Glbulin Site f Care Review Guidelines fr Medical Necessity f Hspital Outpatient Facility Infusin CONDITIONS OF COVERAGE Applicable Lines f Business/Prducts Benefit Type Referral Required (Des nt apply t nn-gatekeeper prducts) Authrizatin Required (Precertificatin always required fr inpatient admissin) Precertificatin with Medical Directr Review Required Yes 1 Applicable Site(s) f Service (If site f service is nt listed, Medical Directr review is required) Special Cnsideratins COVERAGE RATIONALE This plicy applies t Oxfrd Cmmercial plan membership. General Benefits Package N Yes - Hme Yes 2 - Outpatient Yes 2,3 - Office Hme, Outpatient, Office 1 Precertificatin with review by a Medical Directr r their designee thrugh Oxfrd s Medical Management is required. 2 Precertificatin is nt required fr Rh(D) immune glbulin prducts ( , J2788, and J2790- J2792). 3 Participating Prviders in the Office Setting: Precertificatin is required fr services perfrmed in the ffice f a participating prvider. Nn-Participating/ Out-f-Netwrk Prviders in the Office Setting: Precertificatin is nt required, but encuraged fr utf-netwrk services perfrmed in the ffice. If precertificatin is nt btained, Oxfrd will review fr ut-f-netwrk benefits and medical necessity after the service is rendered. See Benefit Cnsideratins This plicy refers t the fllwing intravenus (IV) and subcutaneus (SC) immune glbulin (IG) prducts (list nt all inclusive): Immune Glbulin (IVIG and SCIG) Page 1 f 34

2 Bivigam (IV) Carimune NF (IV) Cuvitru (SC) Flebgamma DIF (IV) Gammagard Liquid (IV, SC) Gammagard S/D (IV) Gammaked (IV, SC) Gammaplex (IV) Gamunex -C (IV, SC) Hizentra (SC) HyQvia (SC) Octagam (IV) Panzyga (IV) Privigen (IV) In absence f a prduct listed and in additin t applicable criteria utlined within the drug plicy, prescribing and dsing infrmatin frm the package insert is the clinical infrmatin used t determine benefit cverage. The term IVIG will be used in this plicy where prescribing and dsing infrmatin is specific t the intravenus frmulatin. At all ther times, the term immune glbulin will be used. Diagnses Addressed in this Plicy Asthma (severe, persistent, highdse sterid-dependent) Bne marrw transplantatin (BMT) Cytmegalvirus (CMV) induced pneumnitis in slid rgan transplants Enterviral meningencephalitis Guillain-Barré syndrme (GBS) IgM antimyelin-assciated glycprtein paraprtein-assciated peripheral neurpathy Lennx Gastaut syndrme Diagnses Autimmune bullus diseases Chrnic inflammatry demyelinating plyneurpathy Dermatmysitis r plymysitis Fetmaternal allimmune thrmbcytpenia HIV-infectin, preventin f bacterial infectin in pediatric HIV Kawasaki disease Lymphprliferative disease, treatment f bacterial infectins Autimmune uveitis Chrnic lymphcytic leukemia (CLL), preventin f infectin in B-cell CLL Diabetes mellitus Graves phthalmpathy Immune thrmbcytpenia Lambert-Eatn myasthenic syndrme (LEMS) Mnclnal gammpathy Multifcal mtr neurpathy (MMN) Multiple sclersis, relapsing frms Myasthenic exacerbatin Neurmyelitis ptica Paraprteinemic neurpathy Psttransfusin purpura Pst B-Cell Targeted Therapies Renal transplantatin, preventin f acute humral rejectin Primary immundeficiency syndrmes Rheumatid arthritis, severe Rasmussen syndrme Rtaviral enterclitis Staphylcccal txic shck Stiff-persn syndrme Thrmbcytpenia, secndary t HCV, HIV, r pregnancy Txic epidermal necrlysis r Stevens-Jhnsn syndrme Urticaria, delayed pressure The fllwing infrmatin pertains t medical necessity review: Unprven uses General Requirements (Applicable t All Medical Necessity Requests) Fr initial therapy bth f the fllwing: Diagnsis; and Medical recrds dcumenting bth f the fllwing: Histry and physical examinatin, dcumenting the severity f the cnditin, including frequency and severity f infectins where applicable; and Labratry results r diagnstic evidence supprting the indicatin fr which immune glbulin is requested Fr cntinuatin f therapy, all f the fllwing: Dcumentatin f psitive clinical respnse t immune glbulin therapy; and Statement f expected frequency and duratin f prpsed immune glbulin treatment; and Fr lng term treatment, dcumentatin f titratin t the minimum effective dse and frequency needed t maintain a sustained clinical respnse. Immune Glbulin (IVIG and SCIG) Page 2 f 34

3 Diagnsis-Specific Requirements The infrmatin belw indicates additinal requirements fr thse indicatins having specific medical necessity criteria in the list f prven indicatins. Immune glbulin is prven and medically necessary fr: Asthma (severe, persistent, high-dse sterid-dependent) 64,66 Immune glbulin is medically necessary fr the treatment f severe, persistent, high-dse steriddependent asthma when all f the fllwing criteria are met: Patient is receiving ptimal cnventinal asthma therapy (e.g., high-dse inhaled gluccrticids, shrt- and lng-acting inhaled β agnists); and Patient has required cntinuus ral gluccrticid therapy fr a minimum f 2 mnths prir t the decisin t initiate Immune glbulin therapy; and Fr lng term treatment, dcumentatin f titratin t the minimum dse and frequency needed t maintain a sustained clinical effect. Autimmune bullus diseases [pemphigus vulgaris, pemphigus fliaceus, bullus pemphigid, mucus membrane (cicatricial) pemphigid, epidermlysis bullsa acquisita, pemphigid gestatinis, linear IgA bullus dermatsis] 3,24,59 Immune glbulin is medically necessary fr the treatment f autimmune bullus diseases when all f the fllwing criteria are met: Diagnsis f an autimmune bullus disease; and Extensive and debilitating disease; and Histry f failure, cntraindicatin, r intlerance t systemic crticsterids with cncurrent immunsuppressive treatment (e.g., azathiprine, cyclphsphamide, mycphenlate mfetil); and IVIG dse des nt exceed 1,000 t 2,000 mg/kg per mnth divided int 3 equal dses each given n 3 cnsecutive days r 400 mg/kg per day given ver 5 cnsecutive days per mnth. IVIG administratin may be repeated mnthly as needed fr patients requiring maintenance therapy. Dsing interval may need t be adjusted in patients with severe cmrbidities 3 ; and Fr lng term treatment, dcumentatin f titratin t the minimum dse and frequency needed t maintain a sustained clinical effect. Autimmune uveitis 59 Bne marrw transplantatin (BMT) 9,14,37,59 Immune glbulin is medically necessary after allgeneic BMT when all f the fllwing criteria are met: One f the fllwing uses: Preventin f acute graft vs. hst disease (GVHD); r Preventin f infectin and Cnfirmed allgeneic bne marrw transplant within the last 100 days; and Dcumented severe hypgammaglbulinemia (IgG < 400 mg/dl); and IVIG dse des nt exceed 500 mg/kg nce weekly fr the first 90 days f therapy, then mnthly up t 360 days after transplantatin. Chrnic inflammatry demyelinating plyneurpathy 8,17,30,35,37,40,59 Immune glbulin is medically necessary fr the treatment f chrnic inflammatry demyelinating plyneurpathy when all f the fllwing criteria are met: Initial treatment: Diagnsis f chrnic inflammatry demyelinating plyneurpathy as cnfirmed by all f the fllwing: - Prgressive symptms present fr at least 2 mnths; and - Symptmatic plyradiculneurpathy as indicated by prgressive r relapsing mtr r sensry impairment f mre than ne limb; and - Electrdiagnstic findings (cnsistent with EFNS/PNS guidelines fr definite CIDP) indicating at least ne f the fllwing criteria are present: 68 Mtr distal latency prlngatin in 2 nerves Reductin f mtr cnductin velcity in 2 nerves Prlngatin f F-wave latency in 2 nerves Absence f F-waves in at least 1 nerve Immune Glbulin (IVIG and SCIG) Page 3 f 34

4 Partial mtr cnductin blck f at least 1 mtr nerve Abnrmal tempral dispersin in at least 2 nerves Distal CMAP duratin increase in at least 1 nerve and IVIG dse des nt exceed 2,000 mg/kg per mnth given ver 2 t 5 days administered in up t three mnthly infusins. Dsing interval may need t be adjusted in patients with severe cmrbidities. Cntinuatin f treatment: Dcumentatin f psitive clinical respnse t therapy as measured by an bjective scale (e.g., Rankin, Mdified Rankin r Medical Research Cuncil (MRC) scale); and Fr lng-term treatment, dcumentatin f titratin t the minimum dse and frequency needed t maintain a sustained clinical effect; and IVIG dse des nt exceed 2,000 mg/kg per mnth given ver 2 t 5 cnsecutive days. IVIG administratin may be repeated mnthly as needed t prevent exacerbatin. Dsing interval may need t be adjusted in patients with severe cmrbidities. Chrnic lymphcytic leukemia (CLL), preventin f infectin in B-cell CLL 15,16,27,37 Immune Glbulin is medically necessary fr the preventin f infectin in B-cell chrnic lymphcytic leukemia when all f the fllwing criteria are met: Diagnsis f B-cell chrnic lymphcytic leukemia (CLL); and One f the fllwing: - Dcumented hypgammaglbulinemia (IgG < 500 mg/dl) - Histry f bacterial infectin(s) assciated with B-cell CLL and IVIG dse des nt exceed 400 mg/kg every 3 t 4 weeks. Cytmegalvirus (CMV) induced pneumnitis in slid rgan transplants Dermatmysitis r plymysitis 8,9,30,59,62 Immune glbulin is medically necessary fr the treatment f dermatmysitis r plymysitis when all f the fllwing criteria are met: Diagnsis f dermatmysitis r plymysitis; and Histry f failure, cntraindicatin, r intlerance t immunsuppressive therapy (e.g., azathiprine, crticsterids, cyclphsphamide, methtrexate); and IVIG dse des nt exceed 2,000 mg/kg per mnth given ver 2 t 5 days administered as mnthly infusins. Dsing interval may need t be adjusted in patients with severe cmrbidities; and Fr lng term treatment, dcumentatin f titratin t the minimum des and frequency needed t maintain a sustained clinical effect. Diabetes mellitus 66,67 Immune glbulin is medically necessary fr the treatment f autimmune diabetes mellitus when bth f the fllwing criteria are met: Patient is newly diagnsed with insulin dependent (type 1) diabetes mellitus; and Patient is nt a candidate fr r is refractry t insulin therapy. Enterviral meningencephalitis 59 Fet-nenatal allimmune thrmbcytpenia 1,32 Immune glbulin is medically necessary fr the treatment f fet-nenatal allimmune thrmbcytpenia when all f the fllwing criteria are met: Fr pregnant wmen: Diagnsis f fet-nenatal allimmune thrmbcytpenia; and One r mre f the fllwing: - Previusly affected pregnancy - Family histry f the disease - Platelet allantibdies fund n screening and IVIG dse des nt exceed 1,000 mg/kg nce weekly until delivery r Fr newbrns: Immune Glbulin (IVIG and SCIG) Page 4 f 34

5 Diagnsis f fet-nenatal allimmune thrmbcytpenia; and Thrmbcytpenia that persists after transfusin f antigen-negative cmpatible platelets. Graves phthalmpathy 59 Guillain-Barré syndrme (GBS) 8,30,40,59,62 Immune glbulin is medically necessary fr the treatment f Guillain-Barré syndrme when all f the fllwing criteria are met: Diagnsis f Guillain-Barré Syndrme; and Severe disease requiring aid t walk; and Onset f neurpathic symptms within the last fur weeks; and IVIG dse des nt exceed 2,000 mg/kg per mnth given ver 2 t 5 cnsecutive days. IVIG administratin may be repeated in up t three mnthly infusins. Dsing interval may need t be adjusted in patients with severe cmrbidities; and Fr lng term treatment, dcumentatin f titratin t the minimum dse and frequency needed t maintain a sustained clinical effect. HIV-infectin, preventin f bacterial infectin in pediatric HIV 14,23,37 Immune glbulin is medically necessary fr the preventin f bacterial infectin in pediatric HIV when all f the fllwing criteria are met: Diagnsis f HIV disease; and Patient age 13 years; and One f the fllwing criteria: Dcumented hypgammaglbulinemia (IgG < 400 mg/dl); r Functinal antibdy deficiency as demnstrated by either pr specific antibdy titers r recurrent bacterial infectins and IVIG dse des nt exceed 400 mg/kg every 28 days. Immune thrmbcytpenia [Idipathic thrmbcytpenic purpura (ITP)] 6,14,16,17,31,36,37,59 Immune glbulin is medically necessary fr the treatment f immune thrmbcytpenic purpura when at least ne f the fllwing criteria are met: All f the fllwing: Diagnsis f acute idipathic thrmbcytpenic purpura (ITP); and Dcumented platelet cunt <50 x 10 9 / L (btained within the past 30 days) 36 ; and IVIG dse des nt exceed 1,000 mg/kg/day fr 1 t 2 days r All f the fllwing: Diagnsis f chrnic thrmbcytpenic purpura (ITP); and Histry f failure, cntraindicatin, r intlerance t at least ne f the fllwing: - Crticsterids - Splenectmy and IVIG dse des nt exceed 2,000 mg/kg per mnth given ver 2 t 5 cnsecutive days. IVIG administratin may be repeated mnthly as needed t prevent exacerbatin. Dsing interval shuld be adjusted depending upn respnse and titrated t the minimum effective dse that can be given at maximum intervals t maintain safe platelet levels. IgM antimyelin-assciated glycprtein paraprtein-assciated peripheral neurpathy 8,59 Kawasaki disease 16,37,59 Immune glbulin is medically necessary fr the treatment f Kawasaki disease when bth f the fllwing criteria are met: Diagnsis f Kawasaki disease; and IVIG dse des nt exceed 400 mg/kg fr five cnsecutive days r a single dse f 2,000 mg/kg. Lambert-Eatn myasthenic syndrme (LEMS) 8,9,30, Immune Glbulin (IVIG and SCIG) Page 5 f 34

6 Immune glbulin is medically necessary fr the treatment f Lambert-Eatn myasthenic syndrme when all f the fllwing criteria are met: Diagnsis f Lambert-Eatn myasthenic syndrme (LEMS); and Histry f failure, cntraindicatin, r intlerance t immunmdulatr mntherapy (e.g., azathiprine, crticsterids); and Cncmitant immunmdulatr therapy (e.g., azathiprine, crticsterids), unless cntraindicated, will be used fr lng-term management f LEMS; and IVIG dse des nt exceed 2,000 mg/kg per mnth given ver 2 t 5 cnsecutive days. 62 IVIG administratin may be repeated mnthly as needed t prevent exacerbatin. Dsing interval may need t be adjusted in patients with severe cmrbidities; and Fr lng term treatment, dcumentatin f titratin t the minimum dse and frequency needed t maintain a sustained clinical effect. Lennx Gastaut syndrme 9,62 Immune glbulin is medically necessary fr the treatment f Lennx Gastaut syndrme when all f the fllwing criteria are met: Histry f failure, cntraindicatin r intlerance t initial treatment with traditinal anti-epileptic pharmactherapy (e.g., lamtrigine, phenytin, valpric acid); and IVIG dse des nt exceed 400 mg/kg/day given fr 4 t 5 cnsecutive days. IVIG administratin may be repeated mnthly as needed in patients requiring maintenance therapy. Dsing interval may need t be adjusted in patients with severe cmrbidities; and Fr lng term treatment, dcumentatin f titratin t the minimum dse and frequency needed t maintain a sustained clinical effect. Lymphprliferative disease, treatment f bacterial infectins 59 Mnclnal gammpathy 59 Multifcal mtr neurpathy (MMN) 8,9,15,30,48,59,62 Immune glbulin is medically necessary fr the treatment f multifcal mtr neurpathy when bth f the fllwing criteria are met: Initial treatment: Diagnsis f multifcal mtr neurpathy as cnfirmed by all f the fllwing: 48 - Weakness with slwly prgressive r stepwise prgressive curse ver at least ne mnth; and - Asymmetric invlvement f tw r mre nerves; and - Absence f mtr neurn signs and bulbar signs and IVIG dse des nt exceed 2,400 mg/kg per mnth given ver 2 t 5 days. IVIG administratin may be repeated mnthly as needed t prevent exacerbatin. Dsing interval may need t be adjusted in patients with severe cmrbidities. 8,9,48,62 Cntinuatin f treatment: Dcumentatin f psitive clinical respnse t therapy as measured by an bjective scale [e.g., Rankin, Mdified Rankin, Medical Research Cuncil (MRC) scale]; and IVIG dse des nt exceed 2,400 mg/kg per mnth given ver 2 t 5 cnsecutive days. Dsing interval may need t be adjusted in patients with severe cmrbidities. 8,9,48,62 ; and Fr lng term treatment, dcumentatin f titratin t the minimum dse and frequency needed t maintain a sustained clinical effect. Multiple sclersis, relapsing frms 9,11,18,59,62 Nte: Treatment f any ther type f multiple sclersis with immune glbulin is nt supprted by clinical evidence. Immune glbulin is medically necessary fr the treatment f relapsing frms f multiple sclersis when all f the fllwing criteria are met: Initial treatment: Diagnsis f relapsing frms f multiple sclersis (MS) (e.g., relapsing-remitting MS, secndaryprgressive MS with relapses, prgressive-relapsing MS with relapses; and Dcumentatin f an MS exacerbatin r prgressin (wrsening) f the patient s clinical status frm the visit prir t the ne prmpting the decisin t initiate immune glbulin therapy; and Histry f failure, cntraindicatin, r intlerance t at least tw f the fllwing agents: - Aubagi (teriflunmide) Immune Glbulin (IVIG and SCIG) Page 6 f 34

7 - Avnex (interfern beta-1a), - Betasern (interfern beta-1b), - Cpaxne/Glatpa (glatiramer acetate), - Extavia (interfern beta-1b), - Gilenya (finglimd), - Lemtrada (alemtuzumab) - Ocrevus (crelizumab) - Plegridy (peginterfern beta-1a) - Rebif (interfern beta-1a), - Tecfidera (dimethyl fumarate) - Tysabri (natalizumab) and Inductin, when indicated, des nt exceed a dse f 400 mg/kg daily fr up t five days. Cntinuatin f treatment: Medical recrds, including findings f interval examinatin including neurlgical deficits incurred and assessment f disability [e.g., Expanded Disability Status Scale (EDSS) Scre, Functinal Systems Scre (FSS), Multiple Sclersis Functinal Cmpsite (MSFC), Disease Steps (DS)]; and Stable r imprved disability scre (e.g., EDSS, FSS, MSFC, DS); and Dcumentatin f decreased number f relapses since starting immune glbulin therapy; and Diagnsis cntinues t be the relapsing frms f MS ; and IVIG dse des nt exceed 1,000 mg/kg mnthly; and Fr lng term treatment, dcumentatin f titratin t the minimum dse and frequency needed t maintain a sustained clinical effect. Myasthenia Gravis 8,9,13,20,30,39,59,62,39,69 Nte: Evidence des nt supprt the use f immune glbulin maintenance therapy fr cular myasthenia. Myasthenia Exacerbatin Immune glbulin is medically necessary fr the treatment f myasthenic exacerbatin when all f the fllwing criteria are met: Diagnsis f generalized myasthenia gravis; and Evidence f myasthenic exacerbatin, defined by at least ne f the fllwing symptms in the last mnth: Difficulty swallwing Acute respiratry failure Majr functinal disability respnsible fr the discntinuatin f physical activity Recent immuntherapy treatment with a checkpint inhibitr [e.g., Keytruda (pembrlizumab), Opdiv (nivlumab), Tecentriq (atezlizumab)] and One f the fllwing: Histry f failure, cntraindicatin, r intlerance t immunmdulatr therapy (e.g., azathiprine, cyclsprine, mycphenlate mfetil) fr lng-term management f myasthenia gravis Cncurrently receiving immunmdulatr therapy (e.g., azathiprine, cyclsprine, mycphenlate mfetil), fr lng-term management f myasthenia gravis and IVIG dse des nt exceed 2,000 mg/kg per mnth given ver 2 t 5 days administered in up t three mnthly infusins. Dsing interval may need t be adjusted in patients with severe cmrbidities. Refractry Myasethenia Gravis Immune glbulin is medically necessary fr the treatment f refractry myasthenia gravis when ALL f the fllwing criteria are met: Diagnsis f refractry generalized myasthenia gravis by r in cnsultatin with a physician r center with expertise in management f myasthenia gravis; and Dcumentatin that the disease status is unchanged r wrsening (persistent r wrsening symptms that limit functining) despite failure, cntraindicatin, r intlerance t BOTH f the fllwing (used in adequate dses and duratin): Crticsterids; and TWO immunmdulatr therapies (e.g., azathiprine, mycphenlate mfetil, cyclsprine, methtrexate, tacrlimus) and Immune Glbulin (IVIG and SCIG) Page 7 f 34

8 Currently receiving immunmdulatr therapy (e.g., crticsterids, azathiprine, mycphenlate mfetil, cyclsprine, methtrexate, tacrlimus), used in adequate dses, fr lng-term management f myasthenia gravis; and IVIG dse des nt exceed 2,000 mg/kg per mnth given ver 2 t 5 days. Dsing interval may need t be adjusted in patients with severe cmrbidities. Neurmyelitis ptica 22,55,56 Immune glbulin is medically necessary fr the treatment f neurmyelitis ptica when all f the fllwing criteria are met: Diagnsis f neurmyelitis ptica; and Histry f failure, cntraindicatin, r intlerance t at least tw f the fllwing: Azathiprine Crticsterids Mycphenlate mfetil Rituximab and IVIG dse des nt exceed 2,000 mg/kg per mnth given ver 2 t 5 days administered in up t six mnthly infusins. Dsing interval may need t be adjusted in patients with severe cmrbidities. Paraprteinemic neurpathy 59 Psttransfusin purpura 3,59 Immune glbulin is medically necessary fr the treatment f psttransfusin purpura when bth f the fllwing criteria are met: Diagnsis f psttransfusin purpura; and IVIG dse des nt exceed 1,000 mg/kg fr 2 days. Pst B-cell targeted therapies Immune glbulin is medically necessary fr the preventin f infectin secndary t B-cell targeted therapy when all f the fllwing criteria are met: Dcumentatin cnfirming previus treatment f B-cell targeted therapy within the last 100 days [e.g., CAR-T (e.g., Kymriah), Rituxan (rituximab), Bespnsa (intuzumab zgamicin)]; and Bth f the fllwing: Dcumented hypgammaglbulinemia (IgG < 500 mg/dl) Histry f bacterial infectin(s) assciated with B-cell depletin and IVIG dse des nt exceed 400 mg/kg every 4 weeks, up t 360 days after discntinuatin f B-cell depleting therapy. Primary immundeficiency syndrmes 3,6,12,14-17,21,28,31,37,42,43,48-54,59 (See disease list) Immune glbulin is medically necessary fr the treatment f primary immundeficiency syndrmes when all f the fllwing criteria are met: Diagnsis f primary immundeficiency; and Clinically significant functinal deficiency f humral immunity as evidenced by ne f the fllwing: Dcumented failure t prduce antibdies t specific antigens; r Histry f significant recurrent infectins and Initial IVIG dse is 200 t 800 mg/kg every 3 t 4 weeks, based n prduct prescribing infrmatin, and titrated based upn patient respnse. 28,51-2,57-61,76,118,133 (Fr SCIG prducts, FDA-labeled dsing and cnversin guidelines will used t determine benefit cverage.) Rasmussen syndrme 59,62 Immune glbulin is medically necessary fr the treatment f Rasmussen syndrme when bth f the fllwing criteria are met: Dcumentatin that shrt term ameliratin f encephalitis is needed prir t definitive surgical therapy; and IVIG dse des nt exceed 2,000 mg/kg per mnth given ver 2 t 5 days. IVIG is nt recmmended fr lng-term therapy fr Rasmussen s encephalitis as surgical treatment is the current standard f care. 62 Immune Glbulin (IVIG and SCIG) Page 8 f 34

9 Renal transplantatin, preventin r treatment f acute humral rejectin 59 Rheumatid arthritis, severe 59 Rtaviral enterclitis 59 Staphylcccal txic shck 59 Stiff-persn syndrme 8,9,46,59,62 Immune glbulin is medically necessary fr the treatment f stiff-persn syndrme when all f the fllwing criteria are met: Diagnsis f stiff-persn syndrme; and Histry f failure, cntraindicatin r intlerance t GABAnergic medicatin (e.g., baclfen, benzdiazepines) 9,59,62 ; and IVIG dse des nt exceed 2,000 mg/kg per mnth given ver 2 t 5 days. IVIG administratin may be repeated mnthly as needed fr patients requiring maintenance therapy. Dsing interval may need t be adjusted in patients with severe cmrbidities. 62 ; and Fr lng term treatment, dcumentatin f titratin t the minimum dse and frequency needed t maintain a sustained clinical effect. Thrmbcytpenia, secndary t Hepatitis C Virus (HCV), Human Immundeficiency Virus (HIV), r pregnancy 57 Immune glbulin is medically necessary fr the treatment f thrmbcytpenia when ne f the fllwing criteria is met: Fr initial therapy, all f the fllwing: One f the fllwing: - Bth f the fllwing: Diagnsis f thrmbcytpenia secndary t HCV infectin Patient is receiving cncurrent antiviral therapy, unless cntraindicated r - Bth f the fllwing: Diagnsis f thrmbcytpenia secndary HIV infectin Patient is receiving cncurrent antiviral therapy, unless cntraindicated r - Diagnsis f thrmbcytpenia secndary t pregnancy and Dcumented platelet cunt < 50 x 109 / L (btained within the past 30 days) 36 ; and IVIG dse des nt exceed 1,000 mg/kg/day fr 1 t 2 days r Fr cntinuatin f therapy, bth f the fllwing: One f the fllwing: - Bth f the fllwing: Diagnsis f thrmbcytpenia secndary t HCV infectin Patient is receiving cncurrent antiviral therapy, unless cntraindicated r - Bth f the fllwing: Diagnsis f thrmbcytpenia secndary t HIV infectin Patient is receiving cncurrent antiviral therapy, unless cntraindicated r - Diagnsis f thrmbcytpenia secndary t pregnancy and IVIG dse des nt exceed 2,000 mg/kg per mnth given ver 2 t 5 cnsecutive days. IVIG administratin may be repeated mnthly as needed t prevent exacerbatin. Dsing interval shuld be adjusted depending upn respnse and titrated t the minimum effective dse that can be given at maximum intervals t maintain safe platelet levels. Txic epidermal necrlysis r Stevens-Jhnsn syndrme 59 Urticaria, delayed pressure 59 Immune Glbulin (IVIG and SCIG) Page 9 f 34

10 Immune glbulin is unprven and nt medically necessary fr: Acquired hemphilia Acute disseminated encephalmyelitis (ADEM) Adrenleukdystrphy Alzheimer s disease Amytrphic lateral sclersis (ALS) Antiphsphlipid antibdy syndrme (APS) in pregnancy Asthma, nn-sterid dependent Atpic dermatitis Autism spectrum disrders Autimmune liver disease Autimmune neutrpenia Bne marrw transplantatin (BMT), preventin f acute graft vs. hst disease (GVHD) after autlgus BMT Bne marrw transplantatin (BMT), preventin f chrnic graft vs. hst disease (GVHD) after autlgus BMT Bne marrw transplantatin (BMT), preventin f infectin after autlgus BMT Campylbacter species-induced enteritis Cerebral infarctins with antiphsphlipid antibdies Chrnic fatigue syndrme Demyelinating neurpathy assciated with mnclnal IgM Demyelinative brain stem encephalitis Dilated cardimypathy HIV infectin, t reduce viral lad HTLV-1-assciated myelpathy Idipathic dysautnmia, acute Inclusin bdy mysitis Islated IgA deficiency Islated IgG4 deficiency Lumbsacral r brachial plexitis Mycarditis, acute Nenatal isimmune hemlytic jaundice Nenatal sepsis, preventin Ocular myasthenia Opsclnus myclnus Paraneplastic cerebellar degeneratin, sensry neurpathy, r encephalpathy Pediatric autimmune neurpsychiatric disrders assciated with streptcccal infectins (PANDAS) POEMS syndrme Pstinfectius cerebellar ataxia Pstperative sepsis Pseudmembranus clitis Respiratry syncytial virus (RSV) lwer respiratry tract infectin Rheumatic fever, acute Sjgren's syndrme Spntaneus recurrent abrtins, preventin Urticaria, chrnic Vasculitides and antineutrphil antibdy syndrmes Efficacy fr these cnditins has nt been described in adequately designed studies. The available evidence is limited t case reprts r case series, anecdtal reprts, and pen-label trials, r the available studies have failed t demnstrate a psitive treatment effect. Further well-designed studies are needed t establish the rle f immune glbulin in these cnditins. APPLICABLE CODES The fllwing list(s) f prcedure and/r diagnsis cdes is prvided fr reference purpses nly and may nt be all inclusive. Listing f a cde in this plicy des nt imply that the service described by the cde is a cvered r nncvered health service. Benefit cverage fr health services is determined by the member specific benefit plan dcument and applicable laws that may require cverage fr a specific service. The inclusin f a cde des nt imply any right t reimbursement r guarantee claim payment. Other Plicies may apply. CPT Cde Descriptin Immune glbulin (IgIV), human, fr intravenus use Immune glbulin (SCIg), human, fr use in subcutaneus infusins, 100 mg, each CPT is a registered trademark f the American Medical Assciatin Immune Glbulin (IVIG and SCIG) Page 10 f 34

11 HCPCS Cde J1459 J1555 J1556 J1557 J1559 J1561 J1566 J1568 J1569 J1572 J1575 J1599 Descriptin Injectin, immune glbulin (Privigen), intravenus, nnlyphilized (e.g., liquid), 500 mg Injectin, immune glbulin (cuvitru), 100 mg Injectin, immune glbulin (bivigam), 500 mg Injectin, immune glbulin, (Gammaplex), intravenus, nn-lyphilized (e.g., liquid), 500 mg Injectin, immune glbulin (Hizentra), 100 mg Injectin, immune glbulin, (Gamunex-C/Gammaked), intravenus, nnlyphilized (e.g., liquid), 500 mg Injectin, immune glbulin, intravenus, lyphilized (e.g., pwder), nt therwise specified, 500 mg Injectin, immune glbulin, (Octagam), intravenus, nnlyphilized (e.g., liquid), 500 mg Injectin, immune glbulin, (Gammagard liquid), intravenus, nnlyphilized, (e.g., liquid), 500 mg Injectin, immune glbulin, (Flebgamma/Flebgamma DIF), intravenus, nnlyphilized (e.g., liquid), 500 mg Injectin, immune glbulin/hyalurnidase, (hyqvia), 100 mg immuneglbulin Injectin, immune glbulin, intravenus, nnlyphilized (e.g., liquid), nt therwise specified, 500 mg ICD-10 Diagnsis Cde A08.0 Rtaviral enteritis A48.3 Txic shck syndrme A49.9 Bacterial infectin, unspecified A87.0 Enterviral meningitis A87.8 Other viral meningitis A87.9 Viral meningitis, unspecified Descriptin A88.0 Enterviral exanthematus fever [Bstn exanthem] A88.8 Other specified viral infectins f central nervus system B20 Human immundeficiency virus [HIV] disease B25.0 Cytmegalviral pneumnitis C91.10 Chrnic lymphcytic leukemia f B-cell type nt having achieved remissin C91.11 Chrnic lymphcytic leukemia f B-cell type in remissin C91.12 Chrnic lymphcytic leukemia f B-cell type in relapse D47.2 Mnclnal gammpathy D47.9 Neplasm f uncertain behavir f lymphid, hematpietic and related tissue, unspecified D69.3 Immune thrmbcytpenic purpura D69.51 Psttransfusin purpura D69.59 Other secndary thrmbcytpenia D80.0 Hereditary hypgammaglbulinemia D80.1 Nnfamilial hypgammaglbulinemia D80.3 Selective deficiency f immunglbulin G [IgG] subclasses D80.4 Selective deficiency f immunglbulin M [IgM] D80.5 Immundeficiency with increased immunglbulin M [IgM] D80.6 Antibdy deficiency with near-nrmal immunglbulins r with hyperimmunglbulinemia D80.7 Transient hypgammaglbulinemia f infancy Immune Glbulin (IVIG and SCIG) Page 11 f 34

12 ICD-10 Diagnsis Cde Descriptin D81.0 Severe cmbined immundeficiency [SCID] with reticular dysgenesis D81.1 Severe cmbined immundeficiency [SCID] with lw T- and B-cell numbers D81.2 Severe cmbined immundeficiency [SCID] with lw r nrmal B-cell numbers D81.6 Majr histcmpatibility cmplex class I deficiency D81.7 Majr histcmpatibility cmplex class II deficiency D81.89 Other cmbined immundeficiencies D81.9 Cmbined immundeficiency, unspecified D82.0 Wisktt-Aldrich syndrme D82.1 Di Gerge's syndrme D82.4 Hyperimmunglbulin E [IgE] syndrme D83.0 D83.1 Cmmn variable immundeficiency with predminant abnrmalities f B-cell numbers and functin Cmmn variable immundeficiency with predminant immunregulatry T-cell disrders D83.2 Cmmn variable immundeficiency with autantibdies t B- r T-cells D83.8 Other cmmn variable immundeficiencies D83.9 Cmmn variable immundeficiency, unspecified D84.8 Other specified immundeficiencies D89.2 Hypergammaglbulinemia, unspecified D Acute graft-versus-hst disease D Acute n chrnic graft-versus-hst disease D89.82 Autimmune lymphprliferative syndrme [ALPS] D89.9 Disrder invlving the immune mechanism, unspecified E05.00 Thyrtxicsis with diffuse giter withut thyrtxic crisis r strm E05.01 Thyrtxicsis with diffuse giter with thyrtxic crisis r strm E10.10 Type 1 diabetes mellitus with ketacidsis withut cma E10.11 Type 1 diabetes mellitus with ketacidsis with cma E10.21 Type 1 diabetes mellitus with diabetic nephrpathy E10.22 Type 1 diabetes mellitus with diabetic chrnic kidney disease E10.29 Type 1 diabetes mellitus with ther diabetic kidney cmplicatin E Type 1 diabetes mellitus with unspecified diabetic retinpathy with macular edema E E E E E E E E E Type 1 diabetes mellitus with unspecified diabetic retinpathy withut macular edema Type 1 diabetes mellitus with mild nnprliferative diabetic retinpathy with macular edema, right eye Type 1 diabetes mellitus with mild nnprliferative diabetic retinpathy with macular edema, left eye Type 1 diabetes mellitus with mild nnprliferative diabetic retinpathy with macular edema, bilateral Type 1 diabetes mellitus with mild nnprliferative diabetic retinpathy with macular edema, unspecified eye Type 1 diabetes mellitus with mild nnprliferative diabetic retinpathy withut macular edema, right eye Type 1 diabetes mellitus with mild nnprliferative diabetic retinpathy withut macular edema, left eye Type 1 diabetes mellitus with mild nnprliferative diabetic retinpathy withut macular edema, bilateral Type 1 diabetes mellitus with mild nnprliferative diabetic retinpathy withut macular edema, unspecified eye Immune Glbulin (IVIG and SCIG) Page 12 f 34

13 ICD-10 Diagnsis Cde E E E E E E E E E E E E E E E E E E E E E E E E E E E Descriptin Type 1 diabetes mellitus with mderate nnprliferative diabetic retinpathy with macular edema, right eye Type 1 diabetes mellitus with mderate nnprliferative diabetic retinpathy with macular edema, left eye Type 1 diabetes mellitus with mderate nnprliferative diabetic retinpathy with macular edema, bilateral Type 1 diabetes mellitus with mderate nnprliferative diabetic retinpathy with macular edema, unspecified eye Type 1 diabetes mellitus with mderate nnprliferative diabetic retinpathy withut macular edema, right eye Type 1 diabetes mellitus with mderate nnprliferative diabetic retinpathy withut macular edema, left eye Type 1 diabetes mellitus with mderate nnprliferative diabetic retinpathy withut macular edema, bilateral Type 1 diabetes mellitus with mderate nnprliferative diabetic retinpathy withut macular edema, unspecified eye Type 1 diabetes mellitus with severe nnprliferative diabetic retinpathy with macular edema, right eye Type 1 diabetes mellitus with severe nnprliferative diabetic retinpathy with macular edema, left eye Type 1 diabetes mellitus with severe nnprliferative diabetic retinpathy with macular edema, bilateral Type 1 diabetes mellitus with severe nnprliferative diabetic retinpathy with macular edema, unspecified eye Type 1 diabetes mellitus with severe nnprliferative diabetic retinpathy withut macular edema, right eye Type 1 diabetes mellitus with severe nnprliferative diabetic retinpathy withut macular edema, left eye Type 1 diabetes mellitus with severe nnprliferative diabetic retinpathy withut macular edema, bilateral Type 1 diabetes mellitus with severe nnprliferative diabetic retinpathy withut macular edema, unspecified eye Type 1 diabetes mellitus with prliferative diabetic retinpathy with macular edema, right eye Type 1 diabetes mellitus with prliferative diabetic retinpathy with macular edema, left eye Type 1 diabetes mellitus with prliferative diabetic retinpathy with macular edema, bilateral Type 1 diabetes mellitus with prliferative diabetic retinpathy with macular edema, unspecified eye Type 1 diabetes mellitus with prliferative diabetic retinpathy with tractin retinal detachment invlving the macula, right eye Type 1 diabetes mellitus with prliferative diabetic retinpathy with tractin retinal detachment invlving the macula, left eye Type 1 diabetes mellitus with prliferative diabetic retinpathy with tractin retinal detachment invlving the macula, bilateral Type 1 diabetes mellitus with prliferative diabetic retinpathy with tractin retinal detachment invlving the macula, unspecified eye Type 1 diabetes mellitus with prliferative diabetic retinpathy with tractin retinal detachment nt invlving the macula, right eye Type 1 diabetes mellitus with prliferative diabetic retinpathy with tractin retinal detachment nt invlving the macula, left eye Type 1 diabetes mellitus with prliferative diabetic retinpathy with tractin retinal detachment nt invlving the macula, bilateral Immune Glbulin (IVIG and SCIG) Page 13 f 34

14 ICD-10 Diagnsis Cde E E E E E Descriptin Type 1 diabetes mellitus with prliferative diabetic retinpathy with tractin retinal detachment nt invlving the macula, unspecified eye Type 1 diabetes mellitus with prliferative diabetic retinpathy with cmbined tractin retinal detachment and rhegmatgenus retinal detachment, right eye Type 1 diabetes mellitus with prliferative diabetic retinpathy with cmbined tractin retinal detachment and rhegmatgenus retinal detachment, left eye Type 1 diabetes mellitus with prliferative diabetic retinpathy with cmbined tractin retinal detachment and rhegmatgenus retinal detachment, bilateral Type 1 diabetes mellitus with prliferative diabetic retinpathy with cmbined tractin retinal detachment and rhegmatgenus retinal detachment, unspecified eye E Type 1 diabetes mellitus with stable prliferative diabetic retinpathy, right eye E Type 1 diabetes mellitus with stable prliferative diabetic retinpathy, left eye E Type 1 diabetes mellitus with stable prliferative diabetic retinpathy, bilateral E E E E E Type 1 diabetes mellitus with stable prliferative diabetic retinpathy, unspecified eye Type 1 diabetes mellitus with prliferative diabetic retinpathy withut macular edema, right eye Type 1 diabetes mellitus with prliferative diabetic retinpathy withut macular edema, left eye Type 1 diabetes mellitus with prliferative diabetic retinpathy withut macular edema, bilateral Type 1 diabetes mellitus with prliferative diabetic retinpathy withut macular edema, unspecified eye E10.36 Type 1 diabetes mellitus with diabetic cataract E10.37X1 E10.37X2 E10.37X3 E10.37X9 Type 1 diabetes mellitus with diabetic macular edema, reslved fllwing treatment, right eye Type 1 diabetes mellitus with diabetic macular edema, reslved fllwing treatment, left eye Type 1 diabetes mellitus with diabetic macular edema, reslved fllwing treatment, bilateral Type 1 diabetes mellitus with diabetic macular edema, reslved fllwing treatment, unspecified eye E10.39 Type 1 diabetes mellitus with ther diabetic phthalmic cmplicatin E10.40 Type 1 diabetes mellitus with diabetic neurpathy, unspecified E10.41 Type 1 diabetes mellitus with diabetic mnneurpathy E10.42 Type 1 diabetes mellitus with diabetic plyneurpathy E10.43 Type 1 diabetes mellitus with diabetic autnmic (ply)neurpathy E10.44 Type 1 diabetes mellitus with diabetic amytrphy E10.49 Type 1 diabetes mellitus with ther diabetic neurlgical cmplicatin E10.51 Type 1 diabetes mellitus with diabetic peripheral angipathy withut gangrene E10.52 Type 1 diabetes mellitus with diabetic peripheral angipathy with gangrene E10.59 Type 1 diabetes mellitus with ther circulatry cmplicatins E Type 1 diabetes mellitus with diabetic neurpathic arthrpathy E Type 1 diabetes mellitus with ther diabetic arthrpathy E Type 1 diabetes mellitus with diabetic dermatitis E Type 1 diabetes mellitus with ft ulcer E Type 1 diabetes mellitus with ther skin ulcer E Type 1 diabetes mellitus with ther skin cmplicatins E Type 1 diabetes mellitus with peridntal disease E Type 1 diabetes mellitus with ther ral cmplicatins Immune Glbulin (IVIG and SCIG) Page 14 f 34

15 ICD-10 Diagnsis Cde Descriptin E Type 1 diabetes mellitus with hypglycemia with cma E Type 1 diabetes mellitus with hypglycemia withut cma E10.65 Type 1 diabetes mellitus with hyperglycemia E10.69 Type 1 diabetes mellitus with ther specified cmplicatin E10.8 Type 1 diabetes mellitus with unspecified cmplicatins E10.9 Type 1 diabetes mellitus withut cmplicatins E31.0 Autimmune plyglandular failure G04.81 Other encephalitis and encephalmyelitis G04.90 Encephalitis and encephalmyelitis, unspecified G05.3 Encephalitis and encephalmyelitis in diseases classified elsewhere G05.4 Myelitis in diseases classified elsewhere G11.3 Cerebellar ataxia with defective DNA repair G25.82 Stiff-man syndrme G35 Multiple sclersis G36.0 Neurmyelitis ptica [Devic] G Lennx-Gastaut syndrme, nt intractable, with status epilepticus G Lennx-Gastaut syndrme, nt intractable, withut status epilepticus G Lennx-Gastaut syndrme, intractable, with status epilepticus G Lennx-Gastaut syndrme, intractable, withut status epilepticus G61.0 Guillain-Barré syndrme G61.81 Chrnic inflammatry demyelinating plyneuritis G61.89 Other inflammatry plyneurpathies G61.9 Inflammatry plyneurpathy, unspecified G62.89 Other specified plyneurpathies G62.9 Plyneurpathy, unspecified G65.0 Sequelae f Guillain-Barré syndrme G70.00 Myasthenia gravis withut (acute) exacerbatin G70.01 Myasthenia gravis with (acute) exacerbatin G70.80 Lambert-Eatn syndrme, unspecified G70.81 Lambert-Eatn syndrme in disease classified elsewhere G73.1 Lambert-Eatn syndrme in neplastic disease H20.00 Unspecified acute and subacute iridcyclitis H Primary iridcyclitis, right eye H Primary iridcyclitis, left eye H Primary iridcyclitis, bilateral H Primary iridcyclitis, unspecified eye H Recurrent acute iridcyclitis, right eye H Recurrent acute iridcyclitis, left eye H Recurrent acute iridcyclitis, bilateral H Recurrent acute iridcyclitis, unspecified eye H Secndary nninfectius iridcyclitis, right eye H Secndary nninfectius iridcyclitis, left eye H Secndary nninfectius iridcyclitis, bilateral H Secndary nninfectius iridcyclitis, unspecified eye J45.51 Severe persistent asthma with (acute) exacerbatin J45.52 Severe persistent asthma with status asthmaticus L10.0 Pemphigus vulgaris Immune Glbulin (IVIG and SCIG) Page 15 f 34

16 ICD-10 Diagnsis Cde Descriptin L10.2 Pemphigus fliaceus L12.0 Bullus pemphigid L12.1 Cicatricial pemphigid L12.30 Acquired epidermlysis bullsa, unspecified L12.35 Other acquired epidermlysis bullsa L13.8 Other specified bullus disrders L50.8 Other urticaria L51.1 Stevens-Jhnsn syndrme L51.2 Txic epidermal necrlysis [Lyell] L51.3 Stevens-Jhnsn syndrme-txic epidermal necrlysis verlap syndrme M05.00 Felty's syndrme, unspecified site M Felty's syndrme, right shulder M Felty's syndrme, left shulder M Felty's syndrme, unspecified shulder M Felty's syndrme, right elbw M Felty's syndrme, left elbw M Felty's syndrme, unspecified elbw M Felty's syndrme, right wrist M Felty's syndrme, left wrist M Felty's syndrme, unspecified wrist M Felty's syndrme, right hand M Felty's syndrme, left hand M Felty's syndrme, unspecified hand M Felty's syndrme, right hip M Felty's syndrme, left hip M Felty's syndrme, unspecified hip M Felty's syndrme, right knee M Felty's syndrme, left knee M Felty's syndrme, unspecified knee M Felty's syndrme, right ankle and ft M Felty's syndrme, left ankle and ft M Felty's syndrme, unspecified ankle and ft M05.09 Felty's syndrme, multiple sites M05.20 Rheumatid vasculitis with rheumatid arthritis f unspecified site M Rheumatid vasculitis with rheumatid arthritis f right shulder M Rheumatid vasculitis with rheumatid arthritis f left shulder M Rheumatid vasculitis with rheumatid arthritis f unspecified shulder M Rheumatid vasculitis with rheumatid arthritis f right elbw M Rheumatid vasculitis with rheumatid arthritis f left elbw M Rheumatid vasculitis with rheumatid arthritis f unspecified elbw M Rheumatid vasculitis with rheumatid arthritis f right wrist M Rheumatid vasculitis with rheumatid arthritis f left wrist M Rheumatid vasculitis with rheumatid arthritis f unspecified wrist M Rheumatid vasculitis with rheumatid arthritis f right hand M Rheumatid vasculitis with rheumatid arthritis f left hand M Rheumatid vasculitis with rheumatid arthritis f unspecified hand M Rheumatid vasculitis with rheumatid arthritis f right hip Immune Glbulin (IVIG and SCIG) Page 16 f 34

17 ICD-10 Diagnsis Cde Descriptin M Rheumatid vasculitis with rheumatid arthritis f left hip M Rheumatid vasculitis with rheumatid arthritis f unspecified hip M Rheumatid vasculitis with rheumatid arthritis f right knee M Rheumatid vasculitis with rheumatid arthritis f left knee M Rheumatid vasculitis with rheumatid arthritis f unspecified knee M Rheumatid vasculitis with rheumatid arthritis f right ankle and ft M Rheumatid vasculitis with rheumatid arthritis f left ankle and ft M Rheumatid vasculitis with rheumatid arthritis f unspecified ankle and ft M05.29 Rheumatid vasculitis with rheumatid arthritis f multiple sites M05.30 Rheumatid heart disease with rheumatid arthritis f unspecified site M Rheumatid heart disease with rheumatid arthritis f right shulder M Rheumatid heart disease with rheumatid arthritis f left shulder M Rheumatid heart disease with rheumatid arthritis f unspecified shulder M Rheumatid heart disease with rheumatid arthritis f right elbw M Rheumatid heart disease with rheumatid arthritis f left elbw M Rheumatid heart disease with rheumatid arthritis f unspecified elbw M Rheumatid heart disease with rheumatid arthritis f right wrist M Rheumatid heart disease with rheumatid arthritis f left wrist M Rheumatid heart disease with rheumatid arthritis f unspecified wrist M Rheumatid heart disease with rheumatid arthritis f right hand M Rheumatid heart disease with rheumatid arthritis f left hand M Rheumatid heart disease with rheumatid arthritis f unspecified hand M Rheumatid heart disease with rheumatid arthritis f right hip M Rheumatid heart disease with rheumatid arthritis f left hip M Rheumatid heart disease with rheumatid arthritis f unspecified hip M Rheumatid heart disease with rheumatid arthritis f right knee M Rheumatid heart disease with rheumatid arthritis f left knee M Rheumatid heart disease with rheumatid arthritis f unspecified knee M Rheumatid heart disease with rheumatid arthritis f right ankle and ft M Rheumatid heart disease with rheumatid arthritis f left ankle and ft M Rheumatid heart disease with rheumatid arthritis f unspecified ankle and ft M05.39 Rheumatid heart disease with rheumatid arthritis f multiple sites M05.40 Rheumatid mypathy with rheumatid arthritis f unspecified site M Rheumatid mypathy with rheumatid arthritis f right shulder M Rheumatid mypathy with rheumatid arthritis f left shulder M Rheumatid mypathy with rheumatid arthritis f unspecified shulder M Rheumatid mypathy with rheumatid arthritis f right elbw M Rheumatid mypathy with rheumatid arthritis f left elbw M Rheumatid mypathy with rheumatid arthritis f unspecified elbw M Rheumatid mypathy with rheumatid arthritis f right wrist M Rheumatid mypathy with rheumatid arthritis f left wrist M Rheumatid mypathy with rheumatid arthritis f unspecified wrist M Rheumatid mypathy with rheumatid arthritis f right hand M Rheumatid mypathy with rheumatid arthritis f left hand M Rheumatid mypathy with rheumatid arthritis f unspecified hand M Rheumatid mypathy with rheumatid arthritis f right hip M Rheumatid mypathy with rheumatid arthritis f left hip Immune Glbulin (IVIG and SCIG) Page 17 f 34

18 ICD-10 Diagnsis Cde Descriptin M Rheumatid mypathy with rheumatid arthritis f unspecified hip M Rheumatid mypathy with rheumatid arthritis f right knee M Rheumatid mypathy with rheumatid arthritis f left knee M Rheumatid mypathy with rheumatid arthritis f unspecified knee M Rheumatid mypathy with rheumatid arthritis f right ankle and ft M Rheumatid mypathy with rheumatid arthritis f left ankle and ft M Rheumatid mypathy with rheumatid arthritis f unspecified ankle and ft M05.49 Rheumatid mypathy with rheumatid arthritis f multiple sites M05.50 Rheumatid plyneurpathy with rheumatid arthritis f unspecified site M Rheumatid plyneurpathy with rheumatid arthritis f right shulder M Rheumatid plyneurpathy with rheumatid arthritis f left shulder M Rheumatid plyneurpathy with rheumatid arthritis f unspecified shulder M Rheumatid plyneurpathy with rheumatid arthritis f right elbw M Rheumatid plyneurpathy with rheumatid arthritis f left elbw M Rheumatid plyneurpathy with rheumatid arthritis f unspecified elbw M Rheumatid plyneurpathy with rheumatid arthritis f right wrist M Rheumatid plyneurpathy with rheumatid arthritis f left wrist M Rheumatid plyneurpathy with rheumatid arthritis f unspecified wrist M Rheumatid plyneurpathy with rheumatid arthritis f right hand M Rheumatid plyneurpathy with rheumatid arthritis f left hand M Rheumatid plyneurpathy with rheumatid arthritis f unspecified hand M Rheumatid plyneurpathy with rheumatid arthritis f right hip M Rheumatid plyneurpathy with rheumatid arthritis f left hip M Rheumatid plyneurpathy with rheumatid arthritis f unspecified hip M Rheumatid plyneurpathy with rheumatid arthritis f right knee M Rheumatid plyneurpathy with rheumatid arthritis f left knee M Rheumatid plyneurpathy with rheumatid arthritis f unspecified knee M Rheumatid plyneurpathy with rheumatid arthritis f right ankle and ft M Rheumatid plyneurpathy with rheumatid arthritis f left ankle and ft M Rheumatid plyneurpathy with rheumatid arthritis f unspecified ankle and ft M05.59 Rheumatid plyneurpathy with rheumatid arthritis f multiple sites M05.60 Rheumatid arthritis f unspecified site with invlvement f ther rgans and systems M Rheumatid arthritis f right shulder with invlvement f ther rgans and systems M Rheumatid arthritis f left shulder with invlvement f ther rgans and systems M Rheumatid arthritis f unspecified shulder with invlvement f ther rgans and systems M Rheumatid arthritis f right elbw with invlvement f ther rgans and systems M Rheumatid arthritis f left elbw with invlvement f ther rgans and systems M Rheumatid arthritis f unspecified elbw with invlvement f ther rgans and systems M Rheumatid arthritis f right wrist with invlvement f ther rgans and systems M Rheumatid arthritis f left wrist with invlvement f ther rgans and systems M Rheumatid arthritis f unspecified wrist with invlvement f ther rgans and systems M Rheumatid arthritis f right hand with invlvement f ther rgans and systems M Rheumatid arthritis f left hand with invlvement f ther rgans and systems Immune Glbulin (IVIG and SCIG) Page 18 f 34